Variability in intensive care unit admission among pregnant and postpartum women in Canada: a nationwide population-based observational study

Critical care admissions and outcomes in pregnant and postpartum women: a systematic review

PURPOSE

To synthesise evidence for the incidence of intensive care unit (ICU) admission, characteristics and mortality of pregnant and postpartum women with a focus on differences between high-income countries (HICs) and low-middle-income countries (LMICs) and report changes in reported findings since the last review by Pollock et al. (2010).

METHODS

We searched Ovid Medline, EMBASE, and CINAHL (2010-2023), following best practice guidelines for abstract screening for large-evidence systematic reviews. Patient and study characteristics of extracted studies were analysed descriptively. Multivariable meta-regression analysis, employing mixed-effects models, was conducted for assessing ICU admission and mortality. Studies reviewed by Pollock et al. were included to perform an overall analysis, including each study period and geographic region in a model.

RESULTS

Seventy-one eligible studies reported data on 111,601 women admitted to ICU, with 41,291,168 deliveries reported in 65 studies. Fifty-six studies were retrospective. Case definitions, admission criteria, and causes of mortality reported were heterogeneous. The pooled ICU admission rate was 1.6% (95% confidence interval [CI] 1.28-1.99; I2 = 99.8%), 0.4% (95% CI 0.32-0.48, I2 = 99.9%) in HICs versus 2.8% (95% CI 0.65-6.4, I2 = 99.9%) in LMICs (p < 0.0001). The pooled ICU mortality rate among 140,780 admissions reported in 63 studies was 6.5% (95% CI 5.2-7.9; I2 = 98.7%), with mortality in HICs 1.4% (95% CI 0.8-2.1, I2 = 98.04%) lower than LMICs 12.4% (95% CI 8.1-17.5, I2 = 98.9%) (p < 0.0001). Multivariable meta-regression analysis found a significant association between the ICU admission rates (p = 0.0001) and mortality (p = 0.0003) with geographic region (HIC vs LMIC). Compared to the earlier study of Pollock et al. in 2010, there was an increase in reported studies (71 vs 40 in Pollock et al. study) and reported admissions (111,601 vs 7887 Pollock et al. study), particularly from LMICs'.

CONCLUSIONS

Mortality for critically ill peripartum women is substantial and the gap in reported ICU admissions and mortality for critically ill peripartum women between HIC and LMICs remains unacceptably high. The reports are often small and heterogeneous using many case definitions. Reporting standards focusing on critical care processes and outcomes and large multinational prospective studies are necessary to better understand and mitigate maternal and child health challenges as sustainable development goals in LMICs and HICs.

Using multi-level regression to determine associations and estimate causes and effects in clinical anesthesia due to patient, practitioner and hospital or health system practice variability

In this research methods tutorial of clinical anesthesia, we will explore techniques to estimate the influence of a myriad of factors on patient outcomes. Big data that contain information on patients, treated by individual anesthesiologists and surgical teams, at different hospitals, have an inherent multi-level data structure (Fig. 1). While researchers often attempt to determine the association between patient factors and outcomes, that does not provide clinicians with the whole story. Patient care is clustered together according to clinicians and hospitals where they receive treatment. Therefore, multi-level regression models are needed to validly estimate the influence of each factor at each level. In addition, we will explore how to estimate the influence that variability-for example, one anesthesiologist deciding to do one thing, while another takes a different approach-has on outcomes for patients, using the intra-class correlation coefficient for continuous outcomes and the median odds ratio for binary outcomes. From this tutorial, you should acquire a clearer understanding of how to perform and interpret multi-level regression modeling and estimate the influence of variable clinical practices on patient outcomes in order to answer common but complex clinical questions. Fig. 1 Infographics.

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.

Critical Care Services for Pregnant Patients in Ontario: A Province-Wide Survey

Critically ill pregnant patients require advanced critical care support, but access to these services is variable. We surveyed active Ontario obstetric facilities regarding critical care access. Responses were received from 44 of 80 obstetric units (55%), 13 (30%) being rural. Transport to another facility was required by 59% (majority >1 hour transport time), and differences were noted in the availability of specialty support services such as anesthesia and internal/obstetric medicine, as well as radiology and laboratory facilities, and use of massive transfusion protocols. Training in early supportive care of obstetric complications and optimized facility transport are areas for potential improvement.

Trends in maternal ICU admissions at a quaternary centre in Montreal, Canada, and impact of maternal age on critical care outcomes

Background

Advancing maternal age is increasingly prevalent and is associated with severe maternal morbidity often requiring intensive care unit (ICU) admission.

Objectives

To describe maternal ICU admissions at a quaternary care hospital in Montreal, Canada, and evaluate the association between maternal age and composite of: need for invasive interventions, ICU stay > 48 h, or maternal death.

Methods

Chart review of ICU admissions during pregnancy/postpartum (2006-2016); logistic regressions to evaluate the impact of age on outcomes.

Results

With 5.1 ICU admissions per 1000 deliveries, we included 187 women (mean age 32 ± 6.3 years; 20 (10.7%) ≥ 40 years). The composite outcome occurred in 105 (56.2%) patients; there were two maternal deaths. Age ≥ 40 years increased the odds of invasive interventions (OR 4.03; 95% confidence interval [CI] 1.15-14.1) but not of the composite outcome (OR 2.30; 95% CI 0.66-8.02).

Conclusion

Peripartum women aged ≥ 40 years had worse outcomes in ICU, with an increased need for invasive interventions.

Perioperative outcomes and causes of postpartum hemorrhage in patients undergoing cesarean delivery in Thailand: A comprehensive retrospective study

BACKGROUND

This study aimed to identify the characteristics, causes, perioperative anesthetic, and obstetric outcomes of patients experiencing postpartum hemorrhage (PPH) after cesarean delivery.

METHODS

We retrospectively analyzed patients who underwent cesarean delivery at the largest university hospital in Bangkok, Thailand, during a 5-year period (January 1, 2016-December 31, 2020). PPH was defined as an estimated blood loss (EBL) of ≥ 1000 ml within 24 hours postpartum.

RESULTS

Of 17 187 cesarean deliveries during the study period, 649 patients were included for analysis. The mean EBL was 1774.3 ± 1564.4 ml (range: 1000-26 000 ml). Among the patients, 166 (25.6%) experienced massive PPH (blood loss > 2000 ml). Intraoperative blood transfusions were necessary for 264 patients (40.7%), while 504 individuals (77.7%) needed intraoperative vasopressors. The analysis revealed uterine atony as the leading cause of PPH in 62.7% (n = 407) of the patients, with abnormal placentation following at 29.3% (n = 190). Abnormal placentation was associated with a significantly higher mean EBL of 2345.0 ± 2303.9 ml compared to uterine atony, which had a mean EBL of 1504.0 ± 820.7 ml (P < 0.001). Abnormal placentation also significantly increased the likelihood of blood transfusions and hysterectomies (P < 0.001 for both) and led to more intensive care unit admissions (P = 0.032). The risk of EBL exceeding 2000 ml was markedly higher in patients with abnormal placentation (odds ratio [OR] 5.12, 95% confidence interval [CI] 3.45-7.57, P < 0.001) and in cases involving trauma to the internal organs (OR 2.33, 95% CI 1.16-4.71, P = 0.018) than in patients with uterine atony. The study documented three instances of perioperative cardiac arrest, one of which was fatal.

CONCLUSIONS

These findings highlight the importance of comprehensive perioperative management strategies, including the ready availability of adequate blood and blood products, particularly in scenarios predisposed to significant hemorrhage.

TRIAL REGISTRATION

Clinical trial registration: Clinicaltrial.gov registration number NCT04833556 (April 6, 2021).

Placenta accreta spectrum care infrastructure: an evidence-based review of needed resources supporting placenta accreta spectrum care

The incidence of placenta accreta spectrum, the deeply adherent placenta with associated increased risk of maternal morbidity and mortality, has seen a significant rise in recent years. Therefore, there has been a rise in clinical and research focus on this complex diagnosis. There is international consensus that a multidisciplinary coordinated approach optimizes outcomes. The composition of the team will vary from center to center; however, central themes of complex surgical experts, specialists in prenatal diagnosis, critical care specialists, neonatology specialists, obstetrics anesthesiology specialists, blood bank specialists, and dedicated mental health experts are universal throughout. Regionalization of care is a growing trend for complex medical needs, but the location of care alone is just a starting point. The goal of this article is to provide an evidence-based framework for the crucial infrastructure needed to address the unique antepartum, delivery, and postpartum needs of the patient with placenta accreta spectrum. Rather than a clinical checklist, we describe the personnel, clinical unit characteristics, and breadth of contributing clinical roles that make up a team. Screening protocols, diagnostic imaging, surgical and potential need for critical care, and trauma-informed interaction are the basis for comprehensive care. The vision from the author group is that this publication provides a semblance of infrastructure standardization as a means to ensure proper preparation and readiness.

Social determinants and exposure to intimate partner violence in women with severe acute maternal morbidity in the intensive care unit: a systematic review

BACKGROUND

Studying severe acute maternal morbidity in the intensive care unit improves our understanding of potential factors affecting maternal health.

AIM

To review evidence on maternal exposure to intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit.

METHODS

The protocol for this review was registered in PROSPERO (registration number CRD42016037492). A systematic search was performed in MEDLINE, CINAHL, ProQuest, LILACS and SciELO using the search terms "intensive care unit", "intensive care", "critical care" and "critically ill" in combination with "intimate partner violence", "social determinants of health", "severe acute maternal morbidity", pregnancy, postpartum and other similar terms. Eligible studies were (i) quantitative, (ii) published in English and Spanish, (iii) from 2000 to 2021, (iv) with data related to intimate partner violence and/or social determinants of health, and (v) investigating severe acute maternal morbidity (maternity patients treated in the intensive care unit during pregnancy, childbirth or within 42 days of pregnancy termination). Of 52,866 studies initially identified, 1087 full texts were assessed and 156 studies included. Studies were independently assessed by two reviewers for screening, revision, quality assessment and abstracted data. Studies were categorised into high/middle/low-income countries and summarised data were presented using a narrative description, due to heterogenic data as: (i) exposure to intimate partner violence and (ii) social determinants of health.

RESULTS

One study assessed intimate partner violence among mothers with severe acute maternal morbidity in the intensive care unit and found that women exposed to intimate partner violence before and during pregnancy had a nearly four-fold risk of severe acute maternal morbidity requiring ICU admission. Few social determinants of health other than age were reported in most studies.

CONCLUSION

This review identified a significant gap in knowledge concerning intimate partner violence and social determinants of health in women with severe acute maternal morbidity in the intensive care unit, which is essential to better understand the complete picture of the maternal morbidity spectrum and reduce maternal mortality.

Factors associated with severe maternal outcome in patients admitted to an intensive care unit in northeastern Brazil with postpartum hemorrhage: a retrospective cohort study

BACKGROUND

Postpartum hemorrhage (PPH) is the leading cause of maternal death worldwide, particularly in low- and middle-income countries; however, the majority of these deaths could be avoided with adequate obstetric care. Analyzing severe maternal outcomes (SMO) has been a major approach for evaluating the quality of the obstetric care provided, since the morbid events that lead to maternal death generally occur in sequence. The objective of this study was to analyze the clinical profile, management, maternal outcomes and factors associated with SMO in women who developed PPH and were admitted to an obstetric intensive care unit (ICU) in northeastern Brazil.

METHODS

This retrospective cohort study included a non-probabilistic, consecutive sample of postpartum women with a diagnosis of PPH who were admitted to the obstetric ICU of the Instituto de Medicina Integral Prof. Fernando Figueira (IMIP) between January 2012 and March 2020. Sociodemographic, biological and obstetric characteristics and data regarding childbirth, the management of PPH and outcomes were collected and analyzed. The frequency of maternal near miss (MNM) and death was calculated. Multiple logistic regression analysis was performed to determine the adjusted odd ratios (AOR) and their 95% confidence intervals (95% CI) for a SMO.

RESULTS

Overall, 136 cases of SMO were identified (37.9%), with 125 cases of MNM (34.9%) and 11 cases of maternal death (3.0%). The factors that remained associated with an SMO following multivariate analysis were gestational age ≤ 34 weeks (AOR = 2.01; 95% CI: 1.12-3.64; p < 0.02), multiparity (AOR = 2.20; 95% CI: 1.10-4.68; p = 0.02) and not having delivered in the institute (AOR = 2.22; 955 CI: 1.02-4.81; p = 0.04).

CONCLUSION

Women admitted to the obstetric ICU with a diagnosis of PPH who had had two or more previous deliveries, gestational age ≤ 34 weeks and who had delivered elsewhere were more likely to have a SMO.

Obstetric admission to intensive care units in Japan: a cohort study using the Japanese Intensive care PAtient Database

PURPOSE

This study aimed to describe the epidemiology and annual trends of obstetric patients using a multicenter intensive care database.

METHODS

This multicenter, retrospective cohort study used the Japanese Intensive care PAtient Database (JIPAD). We included obstetric patients registered in the JIPAD between 2015 and 2020. We investigated the proportion of obstetric patients among all patients in the intensive care unit (ICU). We also described the characteristics, procedures, and outcomes of obstetric patients. In addition, the annual trends were examined by nonparametric tests for trends.

RESULTS

Of the 184,705 patients enrolled in the JIPAD, 750 (0.41%) were obstetric patients from 61 facilities. The median age was 34 years, the number of post-emergency surgeries was 450 (60.0%), and the median APACHE III score was 36. Mechanical ventilation was the most common procedure performed in 247 (32.9%) patients. There were five (0.7%) in-hospital deaths. The proportion of obstetric patients in the ICU did not change between 2015 and 2020 (P for trend = 0.32). However, there was a trend for a significant decrease in the severity of illness and length of hospital stay on an annual basis between 2015 and 2020. Most patients were admitted to the ICU because of a pregnancy-related disorder postoperatively.

CONCLUSION

The proportion of obstetric patients was 0.41% of all ICU admissions. The proportion of obstetric patients admitted to the ICU did not change from 2015 to 2020, but the patients' severity of illness and length of hospital stay significantly decreased over time.

Novel Antithrombotic Agents in Pregnancy Anticoagulants and Antiplatelet Agents

Increasing rates of thromboembolic complications have required increasing use of anticoagulant and antiplatelet agents during and after pregnancy. Furthermore, thromboembolism is both a cause and a complication of severe maternal morbidity requiring intensive care. As a consequence, almost all patients admitted to intensive care units receive an anticoagulant or an antiplatelet agent (or both) for either treatment or prevention of thromboembolism. In this review, we summarize commonly used anticoagulants and antiplatelet agents and outline the potential role of newly developed (novel) antithrombotic agents for pregnant and postpartum patients.

Association of Endometriosis and Severe Maternal Morbidity

OBJECTIVE

To evaluate the association between endometriosis and risk of severe maternal morbidity (SMM).

METHODS

We conducted a population-based retrospective cohort study of 2,412,823 deliveries at hospitals in Quebec, Canada, between 1989 and 2019. The exposure was surgically confirmed endometriosis. Patients were classified as having active endometriosis during pregnancy, inactive endometriosis during pregnancy, a diagnosis of endometriosis postpregnancy, or no endometriosis. The outcome was SMM, including by a range of life-threatening maternal conditions during pregnancy or up to 42 days postdelivery. We computed rates of SMM and used log binomial regression to assess the association with endometriosis (risk ratio [RR]; 95% CI), adjusted for maternal characteristics.

RESULTS

Severe maternal morbidity occurred in 46.2 of 1,000 patients with endometriosis, compared with 30.7 of 1,000 patients without endometriosis. Relative to no exposure, endometriosis was associated with 1.43 times the risk of SMM (95% CI 1.36-1.51). Patients with endometriosis that was active during pregnancy had a greater risk of SMM (RR 1.93; 95% CI 1.76-2.11). Active endometriosis was associated with the risk of severe preeclampsia and eclampsia, severe hemorrhage, hysterectomy, cardiac complications, embolism, shock, sepsis, and intensive care unit admission. Inactive endometriosis was less strongly associated with these outcomes.

CONCLUSION

Pregnant patients with endometriosis, especially active endometriosis, have a greater risk of SMM and may benefit from closer follow-up to prevent severe complications of pregnancy.

Utilisation of Janani Shishu Suraksha Karyakaram Services in the State of Telangana: A Rural–Urban Comparison

Background:

Maternal and infant mortality remains one of the concerns in India, even in high-performing states like Telangana. However, the urban–rural divide in the maternal and child health service provided and utilisation by the population is more concerning. The Government of India launched schemes like Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK) to improve institutional delivery and reduce the out-of-pocket expenditure of users seeking service at public institutions and private institutions facilities. This study aims to study the utilisation of one such service, that is, JSSK, and compare it in urban and rural areas of Telangana state.

Methodology:

A cross-sectional study was conducted in Warangal and Ranga Reddy districts in the state of Telangana with an interview schedule administered to mothers who had at least one child at the time of the interview and were beneficiaries of JSY and JSSK from the previous delivery. A multistage cluster random sampling was used to select the study area, and a total of 408 respondents were chosen to participate in the study.

Results:

The study found that most facility characteristics related to maternal and child health, JSSK service availability and JSSK service satisfaction and awareness were significantly different across the urban and rural areas.

Conclusion:

The study found that crucial factors affecting respondents’ services utilisation differed across urban and rural areas. This study shows there is still a margin of improvement in services provided under the JSY and JSSK, especially in service availability and awareness of the population on their entitlements under these schemes.

An Integrated Review of Obstetric Admissions in the Intensive Care Unit

BACKGROUND

Critically ill expectant mothers are regularly transferred from obstetrics units to an intensive care unit (ICU), placing one specialty population in an environment designed for another.

OBJECTIVE

The purpose of this study is to examine the rates of admission, admitting diagnoses, and mortality of obstetric intensive care patients in the United States and peer nations, and discuss implications to the critical care nurse.

METHODS

Relevant studies were identified in PubMed and Cumulative Index of Nursing and Allied Health Literature following strict eligibility criteria, including peer reviewed primary research, from 2010-2021, that examined rates of admissions, diagnoses, morbidity, and mortality of peripartum women requiring intensive care. Specialty ICU and countries with an overall performance score from the World Health Organization that placed them in the lower two-thirds deciles of all member countries were excluded. Fourteen articles, representing 9 countries, were reviewed by a single doctoral student.

RESULTS

Few obstetrics patients required intensive care. The majority of admissions and deaths occurred within the postpartum period. The most common admitting diagnoses were hemorrhage, hypertensive disorders of pregnancy, and sepsis. Mean mortality ranged from 0.2% to 9.7%. The most common causes of death were cardiovascular diseases and postpartum hemorrhage.

DISCUSSION

These women represent a truly specialized subset within the critical care population. Limitations include possible selection, confounding, and chronology biases; use of a single data extractor, and a relative dearth of relevant studies, originating in developed nations.

CONCLUSIONS

This review provided information on characteristics of the obstetric critical care population. Education and instituting early warning systems, formal debriefings, and standardization of protocols may assist in preparing critical care nurses in confidently caring for this population.

Associations between ethnicity and admission to intensive care among women giving birth: a cohort study

OBJECTIVE

To determine the association between ethnic group and likelihood of admission to intensive care in pregnancy and the postnatal period.

DESIGN

Cohort study.

SETTING

Maternity and intensive care units in England and Wales.

POPULATION OR SAMPLE

A total of 631 851 women who had a record of a registerable birth between 1 April 2015 and 31 March 2016 in a database used for national audit.

METHODS

Logistic regression analyses of linked maternity and intensive care records, with multiple imputation to account for missing data.

MAIN OUTCOME MEASURES

Admission to intensive care in pregnancy or postnatal period to 6 weeks after birth.

RESULTS

In all, 2.24 per 1000 maternities were associated with intensive care admission. Black women were more than twice as likely as women from other ethnic groups to be admitted (odds ratio [OR] 2.21, 95% CI 1.82-2.68). This association was only partially explained by demographic, lifestyle, pregnancy and birth factors (adjusted OR 1.69, 95% CI 1.37-2.09). A higher proportion of intensive care admissions in Black women were for obstetric haemorrhage than in women from other ethnic groups.

CONCLUSIONS

Black women have an increased risk of intensive care admission that cannot be explained by demographic, health, lifestyle, pregnancy and birth factors. Clinical and policy intervention should focus on the early identification and management of severe illness, particularly obstetric haemorrhage, in Black women, in order to reduce inequalities in intensive care admission.

TWEETABLE ABSTRACT

Black women are almost twice as likely as White women to be admitted to intensive care during pregnancy and the postpartum period; this risk remains after accounting for demographic, health, lifestyle, pregnancy and birth factors.

A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient

Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.

Acute kidney injuries induced by thrombotic microangiopathy following severe hemorrhage in puerperants: a case series and literature review

BACKGROUND

Acute kidney injury in puerperants is generally caused by acute tubular necrosis and occasionally by thrombotic microangiopathy (TMA) following post-partum hemorrhage. However, TMA leads to worse clinical outcomes and is rarely reported in the literature. Therefore, this study aimed to evaluate the pathological mechanism behind the development of TMA in puerperants to improve the diagnosis and treatment of this condition.

METHODS

Three patients diagnosed with severe postpartum hemorrhage and TMA from 2014 to 2017 at a nephrology center were retrospectively investigated.

RESULTS

All patients had severe hemorrhage during delivery with a mean blood loss, 4.0 L (range, 2.7-5.0 L). AKI developed rapidly in these patients and was treated with hemodialysis. Following treatment, the mean volume of packed red blood cells was 2.3 L (range, 1.2-3.6 L), and the mean volume of resuscitation fluid was 3.7 L (range, 3.5-4.0 L). All patients had renal biopsy specimens with typical TMA and ATN changes on light microscopy. Two patients required a hysterectomy while another two patients received respiratory support. Only one patient received plasma exchange. None of the patients had recovered normal kidney function by the final follow-up (26-61 months), with two patients having stage 3 chronic kidney disease, and one patient having an end-stage renal disease requiring maintenance hemodialysis.

CONCLUSION

Severe postpartum hemorrhage could lead to TMA, in addition to the common finding of ATN. Renal histology revealed that poor renal outcomes could be attributed to TMA coexisting with ATN. The potential mechanism was ischemia-reperfusion, which was followed by endothelial cell injury and activation of the alternative complement pathway.

Maternal Intensive Care Unit Admission as an Indicator of Severe Acute Maternal Morbidity: A Population-Based Study

BACKGROUND

Severe acute maternal morbidity (SAMM) accounts for any life-threatening complication during pregnancy or after delivery. Measuring and monitoring SAMM seem critical to assessing the quality of maternal health care. The objectives were to explore the validity of intensive care unit (ICU) admission as an indicator of SAMM by characterizing the profile of women admitted to an ICU and of their ICU stay, according to the association with other SAMM criterion.

METHODS

We performed a secondary analysis of the 2540 women with SAMM included in the epidemiology of severe acute maternal morbidity (EPIMOMS) multiregional prospective population-based study (2012-2013, n = 182,309 deliveries). The EPIMOMS definition of SAMM, based on national experts' consensus, is a combination of diagnosis, organ dysfunctions, and intervention criteria, including ICU admission. Among women with SAMM, we identified characteristics associated with maternal ICU admission with or with no other SAMM criterion compared with ICU admission, by using multivariable multinomial logistic regression models.

RESULTS

Overall, 511 women were admitted to an ICU during or up to 42 days after pregnancy, for a population-based rate of 2.8 of 1000 deliveries (511/182,309; 95% confidence interval [CI], 2.6-3.1); 15.5% of them (79/511; 95% CI, 12.4-18.9) had no other SAMM criterion compared with ICU admission. Among women with SAMM, the odds of ICU admission with no other morbidity criterion were increased in women with preexisting medical conditions (adjusted odds ratio (aOR), 2.13; 95% CI, 1.17-3.86) and cesarean before labor (aOR, 3.12; 95% CI, 1.47-6.64). Women admitted to ICU with no other SAMM criterion had more often decompensation of a preexisting condition, no interventions for organ support, and a shorter length of stay than women admitted with other SAMM criteria.

CONCLUSIONS

Among women with SAMM, 1 in 5 is admitted to an ICU; 15.5% of those admitted in ICU have no other SAMM criterion and a less acute condition. These results challenge the use of ICU admission as a criterion of SAMM.

Impact of SARS-CoV-2 on the clinical outcomes and placental pathology of pregnant women and their infants: A systematic review

Pregnant women are susceptible to viral infections due to physiological changes such as cell-mediated immunity. No severe adverse pregnancy or neonatal outcomes have been consistently reported in 2019 novel coronavirus disease (COVID-19) positive pregnancy cases. There are controversies around the role of COVID-19 in pregnancy. A systematic review was conducted to examine clinical maternal and neonatal clinical outcomes. Studies were included if they reported SARS-CoV-2 infection among pregnant women and/or COVID-19 positive neonates as validated by positive antibody testing or viral testing using polymerase chain reaction. Case series, case reports, case-control studies, and comparative studies were included. Eight hundred and thirty-seven records were identified, resulting in 525 records for level I screening. Forty-one were included after full-text review. Results suggest elevated rates of intensive care unit (ICU) admission, gestational diabetes, preeclampsia, C-sections, pre-term birth, and C-reactive protein (CRP) in comparison to pregnant women without SARS-CoV-2. Careful monitoring of pregnancies with SARS-CoV-2 is recommended.

Determining Associations and Estimating Effects with Regression Models in Clinical Anesthesia

There are an increasing number of "big data" studies in anesthesia that seek to answer clinical questions by observing the care and outcomes of many patients across a variety of care settings. This Readers' Toolbox will explain how to estimate the influence of patient factors on clinical outcome, addressing bias and confounding. One approach to limit the influence of confounding is to perform a clinical trial. When such a trial is infeasible, observational studies using robust regression techniques may be able to advance knowledge. Logistic regression is used when the outcome is binary (e.g., intracranial hemorrhage: yes or no), by modeling the natural log for the odds of an outcome. Because outcomes are influenced by many factors, we commonly use multivariable logistic regression to estimate the unique influence of each factor. From this tutorial, one should acquire a clearer understanding of how to perform and assess multivariable logistic regression.

Obstetric admissions to intensive care units in Australia and New Zealand: a registry-based cohort study

OBJECTIVE

Describe the epidemiology of obstetric patients admitted to an Intensive Care Unit (ICU).

DESIGN

Registry-based cohort study.

SETTING

One hundred and eighty-three ICUs in Australia and New Zealand.

POPULATION

Women aged 15-49 years, admitted to ICU between 2008 and 2017, classified as pregnant, postpartum or with an obstetric-related diagnosis.

METHODS

Data were extracted from the Australia and New Zealand Intensive Care Society (ANZICS) Adult Patient Database and national agencies.

MAIN OUTCOME MEASURES

Incidence of ICU admission, cohort characteristics, maternal outcomes and changes over time.

RESULTS

The cohort comprised 16 063 patients. The annual number of obstetric ICU admissions increased, whereas their proportion of total ICU admissions (1.3%) did not change (odds ratio 1.02, 95% CI 0.99-1.04, P = 0.14). There were 10 518 (65%) with an obstetric-related ICU diagnosis, and 5545 (35%) with a non-obstetric ICU diagnosis. Mean (SD) age was 31 (6.4) years, 1463 (9.1%) were Indigenous, 2305 (14%) were transferred from another hospital, and 3008 (19%) received mechanical ventilation. Median [IQR] length of stay in hospital was 5.2 [3.1-7.9] days, which included 1.1 [0.7-1.8] days in ICU. There were 108 (0.7%) maternal deaths, most (n = 97, 90%) having a non-obstetric diagnosis. There was no change in risk-adjusted length of stay or mortality over time.

CONCLUSIONS

Obstetric patients account for a stable proportion of ICU admissions in Australia and New Zealand. These patients typically have a short length of ICU stay and low hospital mortality.

TWEETABLE ABSTRACT

Obstetric patients in Australia/New Zealand ICUs have a short length of ICU stay and low mortality.