Hemodynamic Monitoring in High-Risk Obstetrics Patients, II

Severity of shock, rate of physiological stabilization and organ failure in healthy women admitted to the intensive care unit following major peripartum hemorrhage: A retrospective, descriptive study

PURPOSE

To describe shock severity, physiological stabilization and organ failure in healthy women admitted to the intensive care unit (ICU) after major peripartum hemorrhage (PPH).

MATERIALS AND METHODS

Retrospective, descriptive, single center study.

RESULTS

Twenty-nine women median age 33 years (interquartile range [IQR] 30-36) and gravidity 5 pregnancies (IQR 3-9) were studied. One woman died. The median maternal admission hematocrit was 28.8 (IQR 25.7-32.4). Median transfusion rates were nine units of packed red blood cells (IQR 7-12.25), eight fresh frozen plasma (IQR 6-12), 17 platelets (IQR 10-22) and 15 cryoprecipitate (IQR 9.75-20). Blood pressure dropped significantly in the six hours following ICU admission. Nonetheless, lactate decreased from 3.23 mmol/L to 1.54 mmol/L within 24 h of ICU admission, renal and pulmonary function were unaffected and coagulopathy was never observed. Two-thirds of the women underwent hysterectomy. One-third underwent repeated surgery. The median length of ICU stay was <48 h and that of mechanical ventilation was <24 h. Increased transfusion rates correlated with lengthier ICU admission (p ≤ 0.01 regardless of blood product).

CONCLUSIONS

Ongoing hemorrhage in women with severe PPH manifests subtly and often requires active intervention. Hemorrhage control is required to achieve physiological stabilization and minimize organ damage.

Sepsis during pregnancy or the postpartum period

Sepsis is an important cause of maternal morbidity and mortality worldwide. Early recognition and timely treatment are the key to ensuring a favourable outcome. This article reviews recent literature about definitions, pathophysiology, incidence, diagnosis, management, treatment, prevention and outcome of sepsis during pregnancy and the postpartum period.

ICU nurses' experiences and perspectives of caring for obstetric patients in intensive care: a qualitative study

AIMS AND OBJECTIVES

The aim of this study was to gain an understanding of the experiences and perspectives of intensive care nurses caring for critically ill obstetric patients.

BACKGROUND

Current literature suggests critically ill obstetric patients need specialised, technically appropriate care to meet their specific needs with which many intensive care nurses are unfamiliar. Furthermore, there is little research and evidence to guide the care of this distinct patient group.

DESIGN

This study used a descriptive qualitative design.

METHODS

Two focus groups were used to collect data from 10 Australian intensive care units nurses in May 2007. Open-ended questions were used to guide the discussion. Latent content analysis was used to analyse the data set. Each interview lasted no longer than 60 minutes and was recorded using audio tape. The full interviews were transcribed prior to in-depth analysis to identify major themes.

RESULTS

The themes identified from the focus group interviews were competence with knowledge and skills for managing obstetric patients in the intensive care unit, confidence in caring for obstetric patients admitted to the intensive care unit and acceptance of an expanded scope of practice perceived to include fundamental midwifery knowledge and skills.

CONCLUSION

The expressed lack of confidence and competence in meeting the obstetric and support needs of critically ill obstetric women indicates a clear need for greater assistance and education of intensive care nurses. This in turn may encourage critical care nurses to accept an expanded role of clinical practice in caring for critically ill obstetric patients.

RELEVANCE TO CLINICAL PRACTICE

Recognition of the issues for nurses in successfully caring for obstetric patients admitted to an adult intensive care setting provides direction for designing education packages, ensuring specific carepaths and guidelines are in place and that support from a multidisciplinary team is available including midwifery staff.

Sepsis during pregnancy

OBJECTIVES

To provide a current review of the literature regarding the assessment and management of sepsis during pregnancy.

DESIGN

A comprehensive review of current English-language literature search was performed with Ovid MEDLINE using the Medical Subject Headings pregnancy and sepsis, with Medical Subject Headings or keywords seeking randomized controlled trials and clinical reports, and by reviewing the bibliographies of clinical practice guidelines.

RESULTS

Sepsis-related maternal morbidity and mortality is a significant and persistent problem in the modern critical care obstetric unit. The management of sepsis during pregnancy is challenging. The obstetric intensivist must simultaneously discern the effect of maternal physiologic changes on fetal vulnerability and the effect of the fetus on maternal status throughout the various phases of pregnancy. Little direct evidence exists to validate the extrapolation of some sepsis treatment modalities from other nonpregnant patient populations. Nevertheless, early detection, accurate diagnosis, and aggressive appropriate treatment strategies may significantly improve outcome. Approaches like the Surviving Sepsis Campaign guidelines are unproven but seem reasonable and practical.

CONCLUSIONS

Sepsis during pregnancy is uncommon yet potentially fatal. Diagnostic and therapeutic guidelines should predominantly pattern those currently utilized for nonpregnant patients.