Obstetric patients requiring intensive care: a one year retrospective study in a tertiary care institute in India

Clinical Characteristics and Outcomes of an Intensive Maternal Care Unit in a Tertiary Hospital in the Philippines

Objectives

This is the first study that provides an overview of the characteristics of a specialized Intensive Maternal Care Unit (IMU) that caters to obstetric-related conditions in the Philippines. This study aims to describe the different kinds of cases admitted into this facility, the different medical and surgical interventions employed, length of hospital stay, and maternal and fetal outcomes of these patients.

Methods

This is a cross-sectional descriptive study based on a chart review of medical records and admission charts of patients admitted to the Intensive Maternal Unit of a tertiary hospital in Manila from January 2017 to December 2019.

Results

There were a total of 17,185 obstetric admissions from 2017-2019. There were a total of 841 admissions (4%) into the Intensive Maternal Unit, with an average of 280 admissions per year. The average length of Intensive Maternal Unit stay was 10.46 days and the average length of hospital stay was 12.98 days. Maternal outcomes were the following: 56.89% were discharged undelivered while 38.92% delivered on their initial admission. The maternal mortality rate was 2.39% among those admitted to the IMU. Among those discharged undelivered, 43% were re-admitted, 6% were admitted twice, and 4% were admitted three times. The most common reason for admission was pregnancy-related hypertensive diseases (34%). Blood transfusion (2.4%), the use of ventilator support (0.6%), and the use of inotropic drugs (0.6%) were the major medical interventions. Cesarean section was the most common surgical intervention, seen in 54.49% of patients. Most neonates were admitted to the neonatal ICU (23.95%), at an average pediatric age of 33 weeks, with an average length of stay in the Neonatal ICU of 12.33 days.

Conclusion

Pregnant women are a special group of patients with different needs compared to the general patient population. Pregnancy-associated hypertensive disease is the most common cause of admission to the IMU and hospitals should be able to cater to these patients who will present in their institutions, as this may lead to poor maternal and neonatal outcomes. An Intensive Care Unit dedicated to complicated obstetric care in institutions is recommended to cater to high-risk pregnancies.

Evaluation of critically ill obstetric patients treated in an intensive care unit during the COVID-19 pandemic

BACKGROUND

Although obstetric morbidity and mortality have decreased recently, rates are still high enough to constitute a significant health problem. With the COVID-19 pandemic, many obstetric patients have required treatment in intensive care units (ICU).

OBJECTIVES

Evaluate critical obstetric patients who were treated in an ICU for COVID-19 and followed up for 90 days.

DESIGN

Medical record review SETTING: Intensıve care unit PATİENTS AND METHODS: Obstetric patients admitted to the ICU between 15 March 2020 and 15 March 2022 and followed up for at least 90 days were evaluated retrospectively. Patients with and without COVID-19 were compared by gestational week, indications, comorbidities, length of stay in the hospital and ICU, requirement for mechanical ventilation, blood transfusion, renal replacement therapy (RRT), plasmapheresis, ICU scores, and mortality.

MAIN OUTCOME MEASURES

Clinical outcomes and mortality.

SAMPLE SIZE AND CHARACTERISTICS

102 patients with a mean (SD) maternal age of 29.1 (6.3) years, and median (IQR) length of gestation of 35.0 (7.8) weeks.

RESULTS

About 30% (n=31) of the patients were positive for COVID-19. Most (87.2%) were cesarean deliveries; 4.9% vaginal (8.7% did not deliver). COVID-19, eclampsia/preeclampsia, and postpartum hemorrhage were the most common ICU indications. While the 28-day mortality was 19.3% (n=6) in the COVID-19 group, it was 1.4% (n=1) in the non-COVID-19 group (P<.001). The gestational period was significantly shorter in the COVID-19 group (P=.01) while the duration of stay in ICU (P<.001) and mechanical ventilation (P=.03), lactate (P=.002), blood transfusions (P=.001), plasmapheresis requirements (P=.02), and 28-day mortality were significantly higher (P<.001). APACHE-2 scores (P=.007), duration of stay in ICU (P<.001) and mechanical ventilation (P<.001), RRT (P=.007), and plasmapheresis requirements (P=.005) were significantly higher in patients who died than in those who were discharged.

CONCLUSION

The most common indication for ICU admission was COVID-19. The APACHE-2 scoring was helpful in predicting mortality. We think multicenter studies with larger sample sizes are needed for COVID-19 obstetric patients. In addition to greater mortality and morbidity, the infection may affect newborn outcomes by causing premature birth.

LIMITATIONS

Retrospectıve, single-center, small population size.

CONFLICT OF INTEREST

None.

Determinants of maternal mortality in a critical care unit: A prospective analysis

Introduction:

An admission of a pregnant woman to an intensive care unit (ICU) is considered as an objective marker of maternal near miss. Only a few studies from the Indian subcontinent have reported on the ability of ICU scoring systems in predicting the mortality in obstetric patients.

Methods:

A prospective analysis of all critically ill obstetric patients admitted to the critical care department was done.

Results:

In the period between April 2013 and September 2017, there were 101 obstetric admissions to the critical care ICU. Of these, 82 patients (81.2%) were discharged from the hospital, 18 patients (17.8%) died, and one left against medical advice. The common diagnoses seen in these patients were cardiac failure (n = 39; 38.6%); pregnancy-induced hypertension (n = 26; 25.7%); acute respiratory distress syndrome (n = 20; 19.8%); intra-abdominal sepsis (n = 19; 18.8%); tropical diseases (n = 19; 18.8%); and tuberculosis (n = 13; 12.9%). When we compared the survivors with the nonsurvivors, a higher severity of illness score and a low PaO₂/FiO₂ were found to increase the odds of death. The area of distribution under the receiver operator characteristic curve was 0.726 (95% confidence interval [CI] = 0.575–0.877), 0.890 (95% CI = 0.773–1.006), 0.867 (95% CI = 0.755–0.979), and 0.850 (95% CI = 0.720–0.980) for the PaO₂/FiO₂, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation (APACHE) II score, respectively, for predicting mortality. The standardized mortality ratio was better with SAPSII than with APACHE II.

Conclusions:

Cardiac dysfunction is a leading cause of ICU admission. Obstetric patients frequently require ventilatory support, intensive hemodynamic monitoring, and blood transfusion. The APACHE II score is a good index for assessing ICU outcomes.

Profile of Obstetric Patients in Intensive Care Unit and Untold Stories behind Maternal Deaths and Life-threatening Complications

How to cite this article: Bandyopadhyay, S. Profile of Obstetric Patients in Intensive Care Unit and Untold Stories behind Maternal Deaths and Life-threatening Complications. Indian J Crit Care Med 2021;25(4):362-363.

Profile of Obstetric Patients in Intensive Care Unit: A Retrospective Study from a Tertiary Care Center in North India

Background

Critically ill obstetric patients constitute a small number of intensive care unit (ICU) admissions. Physiological changes in pregnancy along with certain pregnancy-specific diseases may cause a rapid worsening of the health status of the patient necessitating ICU care. The present study aims to study the clinical profile of the obstetric patients requiring ICU care.

Materials and methods

It was a retrospective analysis of pregnant/postpartum (up to 6 weeks) admissions over a period of 18 months.

Results

Over these 18 months, 127 women required ICU admission. The most common reasons for ICU admission were obstetric hemorrhage (37.79%) and (pre)eclampsia (28.35%). Ten patients presented with antepartum hemorrhage (placenta previa, placenta accreta, placenta increta). The rest of the patients (n = 38) had atonic postpartum hemorrhage with five having severe anemia. Among the nonobstetric causes (n = 26/127), ICU admission was the most common among those with preexisting heart diseases (n = 10; 7.87%). Forty-nine patients were ventilated mechanically (38.58%), with eclampsia being the most common primary diagnosis (n = 23). We observed 10 maternal deaths (7.87%) with septicemia being the most important cause of death.

Conclusions

Maternal and child health has become an important measure of human and social development. Early diagnosis and prompt treatment of high-risk obstetric patients in a dedicated obstetric ICU in tertiary hospitals can prevent severe maternal morbidity and improve maternal care.

How to cite this article

Gupta H, Gandotra N, Mahajan R. Profile of Obstetric Patients in Intensive Care Unit: A Retrospective Study from a Tertiary Care Center in North India. Indian J Crit Care Med 2021;25(4):388–391.

Critically Ill Obstetric Patients and Fetomaternal Outcome

Reduction in the maternal mortality ratio (MMR) continues to be a worldwide challenge. With repeated analytical studies done over decades, it has become possible to identify the significant contributors to this challenge. Right from low socioeconomic status to the availability of recent technological advances, many factors need attention and prioritization. Obstetric hemorrhage remains an important cause followed by hypertensive disorders of pregnancy and sepsis. In this issue of IJCCM, Miglani et al. have highlighted the various levels of the delays, which are significant contributors to the high MMR. In other preventive strategies, efforts will be needed to improve patient education, infrastructure, availability of trained manpower, blood storage facilities, timely referrals, transport facilities, etc., at peripheral levels. In the tertiary care centers, there is an increased need for trained manpower in critical care, the obstetric medical emergency team as a new concept, aggressive teamwork in intensive care unit (ICU) and operation theaters, the use of advanced technologies and newer drugs, etc. It will remain a tough challenge to reduce global MMR to 70 per 100,000 live births, as per plans by the United Nations, by the year 2030.

A Prospective Study of Clinical Characteristics and Interventions Required in Critically Ill Obstetric Patients

Introduction

Obstetric patients are a special group of patients whose management is challenged by concerns for fetal viability, altered maternal physiology, and diseases specific to pregnancy.

Materials and methods

A prospective analysis of all obstetric patients admitted to the critical care department was done to assess reasons for transfer to the critical care unit (CCU) and the interventions required for management of these patients.

Results

Between June 2013 and September 2017, obstetric admission comprised 95 women (5.9%) of the total critical care admissions. There were 77 patients (81.1%) who were discharged from the hospital and 18 patients (18.9%) died. In most of the cases, the primary reasons for shifting the patient to the CCU were severe preeclampsia with pulmonary edema (22.1%), eclampsia (8.4%), acute respiratory distress syndrome (ARDS) (14.7%), and hypovolemic shock in antepartum hemorrhage (APH) and postpartum hemorrhage (PPH) (10.5 and 13.7%, respectively). It was seen that 73 patients (76.8%) required ventilator support, 58 patients (57.4%) required vasopressor support, and intensive hemodynamic monitoring and blood/blood products were transfused in 55 patients (54.5%). The need for ventilator support was more in patients with a lower PaO₂/FiO₂ and a higher APACHE II score. Patients with a high severity of illness score and a lower PaO₂/FiO₂ had higher odds of requiring vasopressors. Low hemoglobin at the time of transfer to the CCU and a prolonged hospital stay were found to predict the need for blood transfusion.

Conclusion

Obstetric patients are susceptible to critical illnesses but timely management improves the outcome of these young women.

How to cite this article

Suri J, Kumar R, Gupta A, Mittal P, Suri JC. A Prospective Study of Clinical Characteristics and Interventions Required in Critically Ill Obstetric Patients. Indian J Crit Care Med 2020;24(8):677–682.

Pregnancy-Related ICU Admissions From 2008 to 2016 in China: A First Multicenter Report

Objectives:

To identify the key points for improving severe maternal morbidity by analyzing pregnancy-related ICU admissions in Beijing.

Design:

This was a retrospective, multicenter cohort study.

Setting:

Three ICUs in tertiary hospitals in Beijing.

Patients:

A total of 491 severe maternal cases in any trimester of pregnancy or within 42 days of delivery were reviewed between January 1, 2008, and December 31, 2016.

Interventions:

None.

Measurements and Main Results:

Among 491 obstetric ICU admissions (median Sequential Organ Failure Assessment score, 2) out of 87,850 hospital deliveries (a frequency of 5.6 admissions per 1,000 deliveries), the leading diagnoses were postpartum hemorrhage (170; 34.62%), hypertensive disorders of pregnancy (156; 31.77%), and cardio-cerebrovascular diseases (78; 15.9%). Comparing 2008–2011 to 2012–2016, the rates of maternal mortality (2.5% vs 1.9%; p = 0.991) and fetal loss (8.5% vs 8.6%; p = 0.977) did not decrease significantly, whereas the rates of ICU admission (3.05% vs 7.85%; p trends < 0.001) and postpartum hemorrhage (23% vs 38.5%; p = 0.002) increased. Hypertensive disorder (150/156; 96.2% transferred to the ICU postpartum, 24/28 women with fetal loss transferred from lower-level hospitals) was an independent maternal factor associated with fetal loss, and infections were the leading cause of maternal death (6/10) in the ICU.

Conclusions:

Our study highlights the increasing rate of intensive care admissions for postpartum hemorrhage. Improving prenatal care quality for pregnancy-induced hypertension and sepsis at lower-level hospitals may improve maternal and fetal outcomes. Specifically, providing more effective regional cooperation before transfer and shifting patients who require continuous surveillance but not necessarily intensive care to a transitional ward in a tertiary hospital would provide more ICU beds for more prenatal intensive care for the most complex medical conditions.

The ICU Is Becoming a Main Battlefield for Severe Maternal Rescue in China: An 8-Year Single-Center Clinical Experience

OBJECTIVES

To review the characteristics of and to identify the reasons for severe maternal admissions to the ICU.

DESIGN

This was an analytical, observational, open, and retrospective study.

SETTING

In our ICU.

PATIENTS

A total of 487 severe maternal cases were reviewed during the 8-year study period of January 2009 to December 2016.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

A total of 487 severe maternal cases (12.6%) among the 3,867 patients admitted to ICU were reviewed. Of these, 361 patients were admitted for obstetric reasons, mainly pregnancy-induced hypertension (58.7%) and postpartum hemorrhage (36.8%). The remaining 126 patients were admitted for nonobstetric reasons, including cardiac-related disease (31.0%), immune-related disease (24.6%), and sepsis (20.6%). A total of 249 patients experienced combined comorbidities: the most common was a scarred uterus (100 patients; 40.2%), followed by endocrine-related disease (25.3%), immune-related disease (21.3%), and cardiac-related disease (18.1%). Central venous insertion (90.6%) was the most common intervention, followed by arterial catheter insertion (33.7%), mechanical ventilation (11.7%), blood purification (5.7%), and invasive hemodynamic monitoring (3.7%). Nine patients died during the study period, of which the death of four could have been avoided.

CONCLUSIONS

The number of severe maternal cases has increased annually in our ICU. Although obstetric causes remained the most common reason for admission, the nonobstetric causes and basic complications were too complex, dangerous, and beyond the reach of the obstetrician with regard to monitoring and treatment. We call for a multidisciplinary team mainly composed of ICU staff to improve severe maternal outcomes.

Evaluation of Admission Indications, Clinical Characteristics and Outcomes of Obstetric Patients Admitted to the Intensive Care Unit of a Teaching Hospital Center: A Five-Year Retrospective Review

Background

Care of obstetric patients has always been a challenge for critical care physicians, because in addition to their complex pregnancy-related disease, fetal viability is considered.

Objectives

The aim of this study was to review the admission indications, clinical characteristics and outcomes of obstetric patients, admitted to the intensive care unit of Alzzahra teaching hospital affiliated to Guilan University of Medical Sciences, Rasht, Iran.

Methods

This retrospective cohort study was conducted on pregnant /post-partum (up to 6 weeks) patients admitted to the ICU over a 5-year period from April 2009 to April, 2014.

Results

Data from 1019 subjects were analyzed. Overall, 90.1% of the patients were admitted in the postpartum period. The most common indications for admission were pregnancy related hypertensive disorders (27.5%) and obstetric hemorrhage (13.5%). Epilepsy (5.4%) and cardiac disease (5.2%) were the most common non-obstetric indications.

Conclusions

Pregnancy-related hypertensive disorders and obstetric hemorrhage were the main reasons for admission, and epilepsy and cardiac disease were the most common non-obstetric indications. Efforts must be concentrated on increasing antenatal care.

Critically Ill Obstetric Patients in a General Critical Care Unit: A 5 Years' Retrospective Study in a Public Teaching Hospital of Eastern India

Background:

Critical care services are essential for the subset of obstetric patients suffering from severe maternal morbidity. Studies on obstetric critical care are important for benchmarking the issues which need to be addressed while managing critically ill obstetric patients. Although there are several published studies on obstetric critical care from India and abroad, studies from Eastern India are limited. The present study was conducted to fill in this lacuna and to audit the obstetric critical care admissions over a 5 years’ period.

Settings and Design:

Retrospective cohort study conducted in the general critical care unit (CCU) of a government teaching hospital.

Materials and Methods:

The records of all obstetric patients managed in the CCU over a span of 5 years (January 2011-December 2015) were analyzed.

Results:

During the study, 205 obstetric patients were admitted with a CCU admission rate of 2.1 per 1000 deliveries. Obstetric hemorrhage (34.64%) was the most common primary diagnosis among them followed by pregnancy-induced hypertension (26.83%). Severe hemorrhage leading to organ failure (40.48%) was the main direct indication of admission. Invasive ventilation was needed in 75.61% patients, and overall obstetric mortality rate was 33.66%. The median duration (in days) of invasive ventilation was 2 (interquartile range [IQR] 1-7), and the median length of CCU stay (in days) was 5 (IQR 3-9).

Conclusions:

Adequate number of critical care beds, a dedicated obstetric high dependency unit, and effective coordination between critical care and maternity services may prove helpful in high volume obstetric centers.

Study of Obstetric Admissions to the Intensive Care Unit of a Tertiary Care Hospital

PURPOSE

To analyze obstetric admissions to intensive care unit and to identify the risk factors responsible for intensive care admission.

METHODS

This is a retrospective study of all obstetric cases admitted to the intensive care unit over a period of 3 years. Data were collected from case records. The risk factors responsible for ICU admission were analyzed.

RESULTS

There were 765 obstetric admissions to ICU accounting for 1.24 % of all deliveries. 56.20 % were in the age group of 20-25 years. 38.43 % were in their first pregnancy. 36.48 % of cases were at 37-40 weeks of gestation. Postpartum admissions were 80.91 %. Major conditions responsible were obstetric hemorrhage in 44.05 %, hypertensive disorders of pregnancy in 28.88 %, severe anemia in 14.37 %, heart disease in 12.15 %, and sepsis in 7.97 % of ICU cases. 40.39 % cases required high dependency care. Maternal mortality was seen in 15.55 % of ICU cases. Commonest cause of mortality was hemorrhagic shock (26.89 %) and multiorgan dysfunction syndrome (26.05 %).

CONCLUSION

Commonest risk factors for ICU admissions are obstetric hemorrhage and hypertensive disorders of pregnancy. Other major risk factors are severe anemia, heart disease, sepsis, more than one diagnosis on admission, and the need for cesarean delivery.