The critically ill obstetric patient - Recent concepts

Factors Affecting ICU Stay and Length of Stay in the ICU in Patients with HELLP Syndrome in a Tertiary Referral Hospital

Objective

The study aimed to compare patients with HELLP syndrome who require intensive care and who do not require intensive care and evaluate the factors affecting the length of stay in the intensive care unit.

Methods

Patients were divided into two groups as follows: requiring intensive care (group 1) and not requiring intensive care (group 2). The data of both groups were compared in terms of demographic characteristics, transfusion amounts, length of stay in the intensive care unit, maternal complications, and mortality.

Results

14032 births in a tertiary center between 2011 and 2018 were evaluated in this study. During the study period, 342 patients were diagnosed with HELLP, and 32 (9.4%) of these were followed up in the intensive care unit. The length of stay in the intensive care unit was determined as 8.1 (7.2) days on average. Fresh frozen plasma, erythrocyte suspension, apheresis, and random thrombocyte transfusion were observed to be significantly more in group 1 patients. In the regression analysis, the most effective factor was found to be erythrocyte suspension and the length of stay in the intensive care unit was significantly longer in patients who had erythrocyte suspension transfusion. The receiver operating characteristic curve showed that the area under the curve value for erythrocyte transfusion was 70.6%. When the cutoff value of erythrocyte suspension was 450 (95% CI: 365–681) ml, the sensitivity was 43.8% and the specificity was 91.6%.

Conclusion

We think that physicians should be careful that maternal morbidity and mortality may increase as the need for erythrocyte suspension transfusion increases in patients with HELLP syndrome. Minimum transfusion to hemodynamically stable patients can be more suitable in terms of morbidity and mortality in managing patients with HELLP syndrome requiring erythrocyte suspension transfusion. Precautions and measures should be taken in this regard.

ST2 and galectin-3 as novel biomarkers for the prediction of future cardiovascular disease risk in preeclampsia

The aim of this study was to investigate known cardiovascular disease (CVD) risk biomarkers galectin-3 (Gal-3) and human stromelysin-2 (ST2) levels in preeclampsia (PE) and normotensive pregnancies. A case-control study was conducted in a teaching and research hospital. We performed data analysis involving 45 pregnant women with PE and gestational week (GW) matched 35 normotensive pregnant women. The Gal-3 and ST2 levels were determined by using ELISA kit. Gal-3 values did not differ statistically between PE and control groups (535.1 ng/mL vs. 615.2 ng/mL) (p> .05). ST2 value in the PE group was statistically significantly lower than the control group (33.3 pg/mL vs. PE, 54.5 pg/mL, p ˂ .05). >34 GW patients (late-onset PE) had statistically significantly lower Gal-3 values than the ≤34 GW patients (early-onset PE) (507.1 ng/mL vs. 769.6 ng/mL, p ˂ .05). Late-onset PE patients had significantly lower ST2 values than early-onset patients (26.4 pg/mL vs. 57.9 pg/mL, p ˂ .05). We assume that low Gal-3 values in early-onset PE show a higher risk of cardiac fibrosis although both early and late-onset PE patients had an increased CVD risk later in life. We found the superiority of ST2 levels to Gal-3 levels in PE pregnancies for CVD risk assessment.Impact StatementWhat is already known about this subject? Preeclampsia (PE) in pregnancy is a known risk factor for future cardiovascular disease (CVD) and is also associated with increased mortality from ischaemic heart disease later in life. Studies that investigate patients with a higher risk for CVD in PE pregnancies are lacking.What do the results of this study add? We found different levels of two novel cardiac markers with PE and normotensive pregnancies, and also with early and late-onset PE pregnancies.What are the implications of these findings for clinical practice and/or further research? Different adaptive responses from patients during PE pregnancies via altered levels of cardiac markers could help clinicians to identify women with a higher risk of CVD.

Critical Care Management of the Parturient with Cardiac Disease

Parturient with heart disease forms a challenging group of patients and requires specialized critical care support in the peripartum period. Maternal heart disease may remain undiagnosed till the second trimester of pregnancy, presenting frequently after 20 weeks of gestation, due to increased demands imposed on the cardiovascular system and pose a serious risk to the life of mother and fetus. Management of critically ill parturient with heart disease must be tailored according to individual assessment of the patient and requires a strategic, multidisciplinary, and protocol-based approach. A dedicated obstetric intensive care unit (ICU) and team effort are the need of the hour.

HOW TO CITE THIS ARTICLE

Garg R, Hariharan UR, Malik I. Critical Care Management of the Parturient with Cardiac Disease. Indian J Crit Care Med 2021;25(Suppl 3):S230-S240.

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.

Impact of violence against women on severe acute maternal morbidity in the intensive care unit, including neonatal outcomes: a case-control study protocol in a tertiary healthcare facility in Lima, Peru

INTRODUCTION

Preventing and reducing violence against women (VAW) and maternal mortality are Sustainable Development Goals. Worldwide, the maternal mortality ratio has fallen about 44% in the last 25 years, and for one maternal death there are many women affected by severe acute maternal morbidity (SAMM) requiring management in the intensive care unit (ICU). These women represent the most critically ill obstetric patients of the maternal morbidity spectrum and should be studied to complement the review of maternal mortality. VAW has been associated with all-cause maternal deaths, and since many women (30%) endure violence usually exerted by their intimate partners and this abuse can be severe during pregnancy, it is important to determine whether it impacts SAMM. Thus, this study aims to investigate the impact of VAW on SAMM in the ICU.

METHODS AND ANALYSIS

This will be a prospective case-control study undertaken in a tertiary healthcare facility in Lima-Peru, with a sample size of 109 cases (obstetric patients admitted to the ICU) and 109 controls (obstetric patients not admitted to the ICU selected by systematic random sampling). Data on social determinants, medical and obstetric characteristics, VAW, pregnancy and neonatal outcome will be collected through interviews and by extracting information from the medical records using a pretested form. Main outcome will be VAW rate and neonatal mortality rate between cases and controls. VAW will be assessed by using the WHO instrument. Binary logistic followed by stepwise multivariate regression and goodness of fit test will assess any association between VAW and SAMM.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the La Trobe University, Melbourne-Australia and the tertiary healthcare facility in Lima-Peru. This research follows the WHO ethical and safety recommendations for research on VAW. Findings will be presented at conferences and published in peer-reviewed journals.

Critical care in obstetrics

Pregnancy is a normal physiologic process with the potential for pathologic states. Pregnancy has several unique characteristics including an utero-placental interface, a physiologic stress that can cause pathologic states to develop, and a maternal–foetal interface that can affect two lives simultaneously or in isolation. Critical illness in pregnant women may result from deteriorating preexisting conditions, diseases that are co-incidental to pregnancy, or pregnancy-specific conditions. Successful maternal and neonatal outcomes for parturients admitted to a maternal critical care facility are largely dependent on a multidisciplinary input to medical or surgical condition from critical care physicians, obstetric anaesthesiologists, obstetricians, obstetric physicians, foetal medicine specialists, neonatologists, and concerned specialists. Pregnant women requiring maternal critical care unit admission are relatively low in developed nations and range from 0.9% to 1%; but in our country, the admission rates of critically ill parturients range from 3% to 8%. Two-thirds of pregnant women requiring critical care are often unanticipated at the time of conception. In this review, we will look at critical illnesses in pregnant women with a specific focus on pregnancy-induced illnesses.

Intensive Care Unit issues in eclampsia and HELLP syndrome

Preeclampsia, eclampsia and HELLP syndrome are life-threatening hypertensive conditions and common causes of ICU admission among obstetric patients The diagnostic criteria of preeclampsia include: 1) systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg on two occasions at least 4 hours apart and 2) proteinuria ≥300 mg/day in a woman with a gestational age of >20 weeks with previously normal blood pressures. Eclampsia is defined as a convulsive episode or altered level of consciousness occurring in the setting of preeclampsia, provided that there is no other cause of seizures. HELLP syndrome is a life-threatening condition frequently associated with severe preeclampsia-eclampsia and is characterized by three hallmark features of hemolysis, elevated liver enzymes and low platelets. Early diagnosis and management of preeclampsia, eclampsia and HELLP syndrome are critical with involvement of a multidisciplinary team that includes Obstetrics, Maternal Fetal Medicine and Critical Care. Expectant management may be acceptable before 34 weeks with close fetal and maternal surveillance and administration of corticosteroid therapy, parenteral magnesium sulfate and antihypertensive management. Worsening condition requires delivery. Complications that can be related to this spectrum of disease include disseminated Intravascular coagulation (DIC), acute respiratory distress syndrome, stroke, acute renal failure, hepatic dysfunction with hepatic rupture or liver hematoma and infection/sepsis.

Management of severe dengue hemorrhagic fever and bleeding complications in a primigravida patient: a case report

Background

The incidence of dengue hemorrhagic fever is increasing among the adult population living in endemic areas. The disease carries a 0.73% fatality rate for the general population, but what happens when the disease strikes a special subpopulation group, the obstetrics? Perhaps the important question specific to this special subpopulation revolves around the right time and mode of delivery under severe coagulopathy and plasma leakage in conditions of imminent delivery.

Case presentation

A 24-year-old primigravid Sundanese woman presented to our intensive care unit due to acute pulmonary edema secondary to massive plasma leakage caused by severe dengue. She tested positive for both immunoglobulin G and immunoglobulin M dengue serology indicating she had secondary dengue infection, which placed her at risk for an exaggerated cytokine response as was evident clinically. She had to undergo an emergency cesarean section which was later complicated by rebleeding and hemodynamic instability due to an atypical defervescence period. She was successfully managed by multiple blood transfusions and was discharged from our intensive care unit on day 8 without any negative sequel.

Conclusions

Fever, thrombocytopenia, and hemoconcentration are the classical symptoms of dengue hemorrhagic fever observed in adult, pediatric, and obstetric populations. However, a clinician must be particularly watchful in treating a pregnant dengue-infected patient as physiologic hematology changes provide greater volume compensation and the advent of shock marks significant volume loss. In conclusion, an important principle in the management of dengue hemorrhagic fever in pregnancy is to prioritize maternal well-being prior to addressing fetal issues.

Anaesthesia for non-obstetric surgery during pregnancy

Non-obstetric surgery during pregnancy posts additional concerns to anaesthesiologists. The chief goals are to preserve maternal safety, maintain the pregnant state and achieve the best possible foetal outcome. The choice of anaesthetic technique and the selection of appropriate anaesthetic drugs should be guided by indication for surgery, nature, and site of the surgical procedure. Anaesthesiologist must consider the effects of the disease process itself and inhibit uterine contractions and avoid preterm labour and delivery. Foetal safety requires avoidance of potentially dangerous drugs and assurance of continuation of adequate uteroplacental perfusion. Until date, no anaesthetic drug has been shown to be clearly dangerous to the human foetus. The decision on proceeding with surgery should be made by multidisciplinary team involving anaesthesiologists, obstetricians, surgeons and perinatologists. This review describes the general anaesthetic principles, concerns regarding anaesthetic drugs and outlines some specific conditions of non-obstetric surgeries.

Acute respiratory failure and mechanical ventilation in pregnant patient: A narrative review of literature

Physiological changes of pregnancy imposes higher risk of acute respiratory failure (ARF) with even a slight insult and remains an important cause of maternal and fetal morbidity and mortality. Although pregnant women have different respiratory physiology and different causes of ARF, guidelines specific to ventilatory settings, goals of oxygenation and weaning process could not be framed due to lack of large-scale randomized controlled trials. During the 2009 H1N1 pandemic, pregnant women had higher morbidity and mortality compared to nonpregnant women. During this period, alternative strategies of ventilation such as high-frequency oscillatory ventilation, inhalational of nitric oxide, prone positioning, and extra corporeal membrane oxygenation were increasingly used as a desperate measure to rescue pregnant patients with severe hypoxemia who were not improving with conventional mechanical ventilation. This article highlights the causes of ARF and recent advances in invasive, noninvasive and alternative strategies of ventilation used during pregnancy.

Prospective evaluation of maternal morbidity and mortality in post-cesarean section patients admitted to postanesthesia intensive care unit

BACKGROUND AND AIMS

Critical illness may complicate any pregnancy. Timely intensive care management of critically ill obstetric patients has better outcomes than expected from the initial severity of illness. The aim was to study the indications of transfer of post-cesarean section patients to post-anesthesia intensive care unit (PACU). (PACU transfer indicated that the patient required intensive care).

MATERIALS AND METHODS

This was a prospective observational study carried out in the PACU of a tertiary care teaching public hospital over a period of 2 years. Sixty-one postoperative lower segment cesarean section (LSCS) females admitted consecutively in PACU were studied. The study included obstetric PACU utilization rate, intensive care unit interventions, outcome of mother, Acute Physiology and Chronic Health Evaluation (APACHE II) score, and its correlation with mortality.

RESULTS

Postanesthesia intensive care unit admission rate was 2.8% and obstetric PACU utilization rate was 3.22%. Of 61 patients, four had expired. Obstetric indications (67.2%) were the most common cause of admission to PACU. Among the obstetric indications hemorrhage (36.1%) was found to be a statistically significant indication for PACU admission followed by hypertensive disorder of pregnancy (29.5%). Cardiovascular disease (16.4%) was the most common nonobstetric indication for PACU transfer and was associated with high mortality. The observed mortality was 6.557%, which was lower than predicted mortality by APACHE II Score.

CONCLUSION

Obstetric hemorrhage, hypertensive disorders of pregnancy and cardiovascular diseases are the leading causes of PACU admission in post LSCS patients. Prompt provision of intensive care to critically ill obstetric patients can lead to a significant drop in maternal morbidity and mortality.