Framework for Critical Care in Obstetrics

Design, construction, and validation of obstetric risk classification systems to predict intensive care unit admission

INTRODUCTION

To develop and validate a support tool for healthcare providers, enabling them to make precise and critical decisions regarding intensive care unit (ICU) admissions for high-risk pregnant women, thus enhancing maternal outcomes.

METHODS

This retrospective study involves secondary data analysis of information gathered from 9550 pregnant women, who had severe maternal morbidity (any unexpected complication during labor and delivery that leads to substantial short-term or long-term health issues for the mother), collected between 2009 and 2010 from the Brazilian Network for Surveillance of Severe Maternal Morbidity, encompassing 27 obstetric reference centers in Brazil. Machine-learning models, including decision trees, Random Forest, Gradient Boosting Machine (GBM), and Extreme Gradient Boosting (XGBoost), were employed to create a risk prediction tool for ICU admission. Subsequently, sensitivity analysis was conducted to compare the accuracy, predictive power, sensitivity, and specificity of these models, with differences analyzed using the Wilcoxon test.

RESULTS

The XGBoost algorithm demonstrated superior efficiency, achieving an accuracy rate of 85%, sensitivity of 42%, specificity of 97%, and an area under the receiver operating characteristic curve of 86.7%. Notably, the estimated prevalence of ICU utilization by the model (11.6%) differed from the prevalence of ICU use from the study (21.52%).

CONCLUSION

The developed risk engine yielded positive results, emphasizing the need to optimize intensive care bed utilization and objectively identify high-risk pregnant women requiring these services. This approach promises to enhance the effective and efficient management of pregnant women, particularly in resource-constrained regions worldwide. By streamlining ICU admissions for high-risk cases, healthcare providers can better allocate critical resources, ultimately contributing to improved maternal health outcomes.

Maternal Transport, What Do We Know: A Narrative Review

Objective

This review examines the initial development of a transport system for neonates, followed by a subsequent evolution of a transportation system for the maternal/fetal unit, and then a maternal transport system (antepartum, intrapartum, and postpartum) to specifically address maternal morbidity/mortality.

Methods

A literature search was undertaken using the electronic databases PubMed, Embase, and CINAHL. The search terms used were "maternal transport" AND "perinatal care" OR "labor" "obstetrics" OR "delivery". The years searched were 1960-2023.

Results

There were 260 abstracts identified and 52 of those are the basis of this review. The utilization of a transportation system with the regionalization of levels of care has resulted in a significant reduction in neonatal, perinatal, and maternal morbidity and mortality. Although preterm delivery remains a concern in women transported, the number of deliveries that have occurred during transport is relatively small. Reimbursement for transportation continues to be a problem in several states.

Conclusion

A state-of-the-art transportation system has evolved that transfers neonates, maternal/fetal dyad, and pregnant women (antepartum, intrapartum, postpartum) to the appropriate level of care facility to ensure the best maternal/fetal/neonatal outcomes.

Role of Critical Care Units in the management of obstetric patients (Review)

Pregnancy is considered a natural process for the majority of women. However, a limited proportion of pregnancies and deliveries can present with a broad variety of complications that may require admission to a Critical Care Unit (CCU). In the present review, the indications of admission of obstetrical and postpartum patients to CCUs were critically evaluated with a particular focus on the management of their complications. The management of critically ill obstetric patients remains challenging due to the physiological changes that occur during pregnancy, pregnancy-related diseases and the need to carefully consider the well-being of the fetus before any intervention can be recommended/performed. Indications for admission to CCUs include both obstetric and non-obstetric conditions that may require continuous monitoring and further interventions. Hypertensive disorders of pregnancy and mass hemorrhage are amongst the most common causes of admission to CCUs in pregnant and postpartum women. The establishment of a diagnostic and care algorithm based on the contribution of a multidisciplinary team is of critical importance to aid in the determination of which patients will require intensive care, and to assist in deciding what type of critical care each critically ill patients receives.

Obstetric protocols in the setting of a pandemic

The purpose of this article is to review key areas that should be considered and modified in our obstetric protocols, specifically: 1) Patient triage, 2) Labor and delivery unit policies, 3) Special considerations for personal protective equipment (PPE) needs in obstetrics, 4) Intrapartum management, and 5) Postpartum care.