Pregnancy, delivery and the intensive care unit: need, outcome and management

Peripartum Maternal Admission to the Intensive Care Unit: An Observational Study over a 15-Year Period at a Tertiary Center in Austria

Peripartum maternal admission to the intensive care unit is challenging for anesthesiologists, obstetricians, and all personnel involved. An understanding of altered maternal physiology, fetal considerations, and acute peripartum emergencies is required to ensure adequate maternal and neonatal outcomes. In this study, we analyzed data of peripartum maternal admissions to the intensive care unit at our large tertiary referral center in order to define trends and changes over time. This study retrospectively analyzed maternal morbidity, admission diagnoses, treatments, and outcomes of women with peripartum admission to the intensive care unit at our tertiary care center over a 15-year period. We found that patient characteristics and admission diagnoses remained remarkably consistent over the observational period; however, there was a significant increase in postpartum hemorrhage (r = 0.200, p < 0.001) and cesarean hysterectomy (r = 0.117, p = 0.027) over time. Moreover, we found a reduction in preterm births (r = -0.154, p = 0.004) and a decreased peripartum neonatal intensive care unit admission rate (r = -0.153, p = 0.006) among women who were transferred to the intensive care unit. Based on our long-term observational data, there is consistent need for intensive care in obstetrics due to a small number of different etiologies. Specialized training for the predominant diagnoses involved as well as multidisciplinary care of the affected patients are both warranted.

Epidemiology of acute kidney injury and the role of urinary [TIMP-2]·[IGFBP7]: a prospective cohort study in critically ill obstetric patients

BACKGROUND

There are few data regarding acute kidney injury in critically-ill obstetric patients. A combination of urinary cell cycle arrest markers, tissue inhibitor of metalloproteinase-2 (TIMP-2) and insulin-like growth factor binding protein7 (IGFBP7), is validated for the early prediction of acute kidney injury in non-obstetric patients.

METHODS

We evaluated the epidemiology of acute kidney injury in critically-ill obstetric patients and the role of the biomarker combination in predicting acute kidney injury and mortality. Acute kidney injury, its severity and risk factors, were assessed using Kidney Disease: Improving Global Outcomes (KDIGO) guidelines during the intensive care unit stay. An ELISA technique measured TIMP-2 and IGFBP7 in urine samples collected at the time of admission there.

RESULTS

Results for 66 patients showed an overall incidence of acute kidney injury of 40/66 (61%), with 50%, 10% and 40% being in stage 1, 2 and 3 respectively. Patients with acute kidney injury showed significantly greater sepsis and shock; longer stay and higher mortality during intensive care (33% vs 0%) and in hospital (38% vs 0%) compared to those without (P <0.05). The area-under-the receiver operating characteristics curve was <0.5 for urinary [TIMP-2]·[IGFBP7] as a predictor of kidney injury and mortality (P >0.05).

CONCLUSIONS

Acute kidney injury is common in critically-ill obstetric patients, increasing mortality and duration of hospitalization. It was significantly more common in patients with septic shock. Previously validated results of urinary [TIMP-2]·[IGFBP7] that successfully predict early acute kidney injury or mortality are not applicable to obstetric patients.

Indications and characteristics of obstetric patients admitted to the intensive care unit: a 22-year review in a tertiary care center

Objective

Reviewing indications and characteristics of obstetric patients admitted to the intensive care unit (ICU) of a tertiary care center, comparing those patients by time period and place of delivery, and to verify clinical utility of acute physiology and chronic health evaluation (APACHE) II score in ICU-admitted women.

Methods

Retrospective analyses were carried out for parturients admitted to the ICU of our institution from 1994 to 2015. Clinical characteristics were compared between time period (period 1: 1994-2004; period 2: 2005-2015) and place of delivery (our institution and local hospitals). Receiver operating characteristic (ROC) curve analysis was used to evaluate the usefulness of APACHE II score to predict maternal mortality.

Results

During 22-year period, 176 women required ICU admission, showing the incidence of 2.2 per 1,000 deliveries. The most common reason for ICU admission was postpartum hemorrhage (56.3%), followed by hypertensive disorders (19.3%), sepsis (3.4%), and pulmonary and amniotic fluid embolism (2.3%). Period 2 showed older maternal age (32.7±4.8 vs. 30.8±4.4 years, P=0.006, higher embolization rate (26.4% vs.1.2%, P<0.001), and lower hysterectomy rate (30.8% vs. 49.4%, P=0.012). Cases from local hospitals showed significantly higher proportion of postpartum hemorrhage (84.5% vs. 42.2%, P<0.001). Overall maternal death occurred in 5.1% (9/176) including 6 direct maternal deaths. The APACHE II score showed area under the ROC curve of 0.813 (confidence interval [CI], 0.607-1.000) for prediction of maternal mortality.

Conclusion

The incidence of obstetric ICU admission was 2.2 per 1,000 deliveries and the most common reason was postpartum hemorrhage followed by hypertensive disorders. APACHE II score could be used to predict mortality in obstetric ICU admission.

Obstetric admissions to an integrated general intensive care unit in a quaternary maternity facility

BACKGROUND

Monash Medical Centre (MMC) is a university-affiliated tertiary referral hospital in Melbourne, Victoria, Australia. The hospital has a large obstetric service and is the only quarternary obstetric unit in Victoria. The intensive care unit (ICU) is a busy 21-bed general unit with a broad casemix. While there is no designated state service obstetric ICU in Victoria, MMC ICU has increasingly tried to accept all obstetric patients referred, from both MMC and externally.

AIM

To provide a local perspective on obstetric intensive care in Australia.

METHODS

A retrospective audit of obstetric ICU admissions over 2 years.

RESULTS

Sixty women were admitted, of whom 46 were postpartum. Twenty-nine women were transferred from external sites. Mean maternal age was 30.7 years, mean gestational age 34.5 weeks and mean Acute Physiology and Chronic Health Evaluation (APACHE) version IIIj score 33. Obstetric haemorrhage was the most common admission diagnosis, followed by hypertensive spectrum disorders. Three women were admitted for induction of labour. Median length of stay was 35 h. Twenty-seven women (45%) required mechanical ventilation. No woman died in the ICU, although one died in hospital post-ICU discharge. No data were collected on neonatal outcomes.

CONCLUSIONS

Critically ill obstetric patients can be managed successfully in a general ICU with obstetric input. It may be sensible to cluster these patients into units that are best equipped to deal with them, especially in the ante- and peripartum period.

Obstetric admissions to the intensive care unit in a tertiary referral hospital

PURPOSE

The present study was conducted to evaluate the obstetric admissions to the intensive care unit (ICU) in the setting of a tertiary referral hospital in an attempt to identify the risk factors influencing maternal outcome.

MATERIALS AND METHODS

All of the obstetric patients who seeked care for delivery at the emergency department and who were admitted to the ICU between January 2006 to July 2009 were retrospectively identified. The Simplified Acute Physiology Score (SAPS II) was calculated and the maternal mortality rate was estimated for each patient. The mean SAPS II scores and the mean estimated maternal mortality rates for the surviving patients and the nonsurviving patients were compared.

RESULTS

Seventy-three obstetric patients were admitted to the ICU. There were 9 maternal deaths and 24 fetal deaths. For the surviving group of patients, the mean SAPS II score was 34 and estimated maternal mortality rate was 20%, whereas for the nonsurviving group of patients, the SAPS II score was 64 and estimated maternal mortality rate was 73%. The difference between the surviving group of patients and the nonsurviving group of patients was statistically significant regarding both the mean SAPS II scores and the mean estimated maternal mortality rates.

CONCLUSIONS

Pregnancy-induced hypertensive disorders and hemorrhage appear as the major risk factors influencing maternal outcome in obstetric patients. Considering that the use of the SAPS II scores have enabled the reliable estimation of the mortality rates in the present study, the attempts at defining the focus of care for the obstetric patients who bear the major risk factors and who are admitted to the ICU should be carried out under the guidance of the ICU scoring systems such as the SAPS II.

Clinical characteristics and outcomes of obstetric patients requiring ICU admission

OBJECTIVES

To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death.

DESIGN

Retrospective cohort.

SETTING

Medical-surgical ICU in a university-affiliated hospital.

PATIENTS

Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014).

CONCLUSIONS

Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.