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Rojas-Suarez J, Paruk F. Maternal high-care and intensive care units in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 93:102474. [PMID: 38395025 DOI: 10.1016/j.bpobgyn.2024.102474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
Despite notable advancements in minimizing maternal mortality during recent decades, a pronounced disparity persists between high-income nations and low-to middle-income countries (LMICs), particularly in intensive and high-care for pregnant and postpartum individuals. This divergence is multifactorial and influenced by factors such as the availability and accessibility of community-based maternity healthcare services, the quality of preventive care, timeliness in accessing hospital or critical care, resource availability, and facilities equipped for advanced interventions. Complications from various conditions, including human immunodeficiency virus (HIV), unsafe abortions, puerperal sepsis, and, notably, the COVID-19 pandemic, intensify the complexity of these challenges. In confronting these challenges and deliberating on potential solutions, we hope to contribute to the ongoing discourse around maternal healthcare in LMICs, ultimately striving toward an equitable health landscape where every mother, regardless of geographic location or socioeconomic status, has access to the care they require and deserve. The use of traditional and innovative methods to achieve adequate knowledge, appropriate skills, location of applicable resources, and strong leadership is essential. By implementing and enhancing these strategies, limited-resource settings can optimize the available resources to promptly recognize the severity of illness in obstetric individuals, ensuring timely and appropriate interventions for mothers and children. Additionally, strategies that could significantly improve the situation include increased investment in healthcare infrastructure, effective resource management, enhanced supply chain efficiency, and the development and use of low-cost, high-quality equipment. Through targeted investments, innovations, efficient resource management, and international cooperation, it is possible to ensure that every maternal high-care and ICU unit, regardless of geographical location or socioeconomic status, has access to high-quality critical care to provide life-saving care.
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Affiliation(s)
- José Rojas-Suarez
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Colombia; GINUMED Research Group, Corporación Universitaria Rafael Núñez, Cartagena, Colombia.
| | - Fathima Paruk
- Department of Critical Care, Steve Biko Academic Hospital and Faculty of Health Science University of Pretoria, South Africa.
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Buowari DY, Owoo C, Gupta L, Schell CO, Baker T. Essential Emergency and Critical Care: A Priority for Health Systems Globally. Crit Care Clin 2022; 38:639-656. [PMID: 36162903 DOI: 10.1016/j.ccc.2022.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided, and the potential for reversibility. An estimated 45 million adults become critically ill each year. While some are treated in emergency departments or intensive care units, most are cared for in general hospital wards. We outline a priority for health systems globally: the first-tier care that all critically ill patients should receive in all parts of all hospitals: Essential Emergency and Critical Care. We describe its relation to other specialties and care and opportunities for implementation.
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Affiliation(s)
- Dabota Yvonne Buowari
- Department of Accident and Emergency, University of Port Harcourt Teaching Hospital, Along East West Road, Alakahia, Port Harcourt, Rivers State 23401, Nigeria
| | - Christian Owoo
- Department of Anaesthesia, University of Ghana Medical School, College of Health Sciences, Guggisberg Avenue, Korle Bu, GA-029-4296 Accra, Ghana; Department of Anaesthesia, Korle Bu Teaching Hospital, Guggisberg Avenue, Korle Bu, GA-029-4296 Accra, Ghana; Ghana Infectious Disease Centre, Kwabenya, Ga East, Municipal Hospital, GE-255-9501 (PQ47+FGV), Accra, Ghana; University of Ghana Medical Centre, Indian Ocean Link, University of Ghana, GA-337-6980 (JRJ7+WJP) Accra, Ghana
| | - Lalit Gupta
- Department of Anaesthesia and Critical Care, Maulana Azad Medical College, 2 Bahadur Shah Zafar Marg, New Delhi 110002, India
| | - Carl Otto Schell
- Department of Global Public Health, Karolinska Institutet, Solna Väg, Stockholm, 171 77, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Sveavägen entré 9 Mälarsjukhuset, Eskilstuna, 631 88 Sweden; Department of Medicine, Nyköping Hospital, Nyköping 61185, Sweden
| | - Tim Baker
- Department of Global Public Health, Karolinska Institutet, Solna Väg, Stockholm, 171 77, Sweden; Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, United Nations Road, Dar es Salaam, P.O. Box 65001, Tanzania; Department of Clinical Research, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK; Ifakara Health Institute, 5 Ifakara Street, Plot 463 Mikocheni, Dar es Salaam, P.O. Box 78 373, Tanzania.
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Kumar R, Gupta A, Suri T, Suri J, Mittal P, Suri JC. Determinants of maternal mortality in a critical care unit: A prospective analysis. Lung India 2022; 39:44-50. [PMID: 34975052 PMCID: PMC8926236 DOI: 10.4103/lungindia.lungindia_157_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Rohit Kumar
- Department of Pulmonary, Critical Care and Sleep Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Ayush Gupta
- Departement of Pulmonary, Critical Care and Sleep Medicine, JCS Institute of Pulmonary, Critical Care and Sleep Medicine, New Delhi, India
| | - Tejus Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jyotsna Suri
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Pratima Mittal
- Department of Obstetrics and Gynaecology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Jagdish Chander Suri
- Departement of Pulmonary, Critical Care and Sleep Medicine, JCS Institute of Pulmonary, Critical Care and Sleep Medicine, New Delhi, India
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Kannaujia A, Srivastava U, Dwivedi Y, Verma S, Ambasta S, Lalramthara I. Sequential organ failure assessment score for predicting outcome of severely ill obstetric patients admitted to intensive care unit. JOURNAL OF OBSTETRIC ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.4103/joacc.joacc_15_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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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; 25:388-391. [PMID: 34045804 PMCID: PMC8138638 DOI: 10.5005/jp-journals-10071-23775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Heena Gupta
- Department of Anesthesiology and Critical Care, Government Medical College, Jammu, Jammu and Kashmir, India
| | - Nikita Gandotra
- Department of Obstetrics and Gynaecology, Government Medical College, Jammu, Jammu and Kashmir, India
| | - Ruhi Mahajan
- Department of Biochemistry, Government Medical College, Jammu, Jammu and Kashmir, India
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Magar JS, Rustagi PS, Malde AD. Retrospective analysis of patients with severe maternal morbidity receiving anaesthesia services using 'WHO near miss approach' and the applicability of maternal severity score as a predictor of maternal outcome. Indian J Anaesth 2020; 64:585-593. [PMID: 32792734 PMCID: PMC7413348 DOI: 10.4103/ija.ija_19_20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/05/2020] [Accepted: 05/09/2020] [Indexed: 11/23/2022] Open
Abstract
Background and Aims: Risk stratification of severely morbid obstetric patients receiving anaesthesia services can be helpful in improving maternal outcomes. This study was undertaken to analyse these patients using the WHO near-miss (NM) approach and to assess the applicability of maternal severity score (MSS) to predict maternal mortality. Methodology: This is a one-year retrospective cohort analysis at a tertiary care centre. Of all the obstetric patients receiving anaesthesia, those with 'potentially life-threatening conditions' (PLTC) were identified. Amongst women with PLTC, those fulfilling the WHO NM criteria were grouped into either maternal near miss (MNM) or maternal death (MD) depending on final survival outcome. The MSS was assessed upon admission to post-anaesthesia ICU. The cases of “near miss” were compared to maternal death to determine the factors and WHO NM criteria significantly associated with mortality. Area under ROC curve (AUROC) was used to assess the accuracy of MSS to predict maternal mortality. Results: Of the 4351 anaesthetised obstetric patients, 301 were PLTC, 59 MNM and 11 MD. Obstetric haemorrhage was the commonest PLTC with the highest risk for MNM and MD. Preoperative organ dysfunction, referral from other centres, intra-uterine fetal death (IUFD) and WHO cardiovascular and respiratory NM criteria were significantly associated with mortality. MSS had excellent accuracy for the prediction of mortality (AUROC was 0.986 and 95% CI 0.966–0.996). Conclusion: Haemorrhage is the leading cause of MNM and MD. MSS is reliable in stratifying the severity of maternal morbidity and in predicting maternal mortality. Thus it can be used as an effective prognostic tool.
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Affiliation(s)
- Jyoti Sandeep Magar
- Department of Anesthesia, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Preeti Sachin Rustagi
- Department of Anesthesia, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
| | - Anila D Malde
- Department of Anesthesia, Lokmanya Tilak Municipal Medical College and General Hospital, Sion, Mumbai, Maharashtra, India
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Einav S, Leone M. Epidemiology of obstetric critical illness. Int J Obstet Anesth 2019; 40:128-139. [PMID: 31257034 DOI: 10.1016/j.ijoa.2019.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 10/26/2022]
Abstract
Obstetric intensive care unit (ICU) admissions comprise only a small part of severe maternal morbidity. The incidence rate of both remains relatively unclear due to inconsistent definitions across publications, although this has begun to be addressed. There is a relative paucity of information regarding disease-specific survival following obstetric ICU admission, but outcomes are clearly related to the cause of admission and the quality of care. The ratio between maternal near-miss cases (many of whom are admitted to ICUs) and maternal death may provide insight into the preventability of death. Hemorrhage and pre-eclampsia constitute the leading causes of ICU admission and have relatively low mortality rates, perhaps demonstrating the impact of informed care in managing obstetric critical illness. Obstetric sepsis, heart disease and anesthesia complications should be the focus of future research. The incidence of obstetric sepsis has been increasing in the last decade, with mortality rates remaining relatively high. The incidence of obstetric heart disease is increasing and maternal complications have been attributed to fractionated care of mothers within this category. Anesthesia complications remain a predominant cause of maternal death and likely intensive care admission. Data are lacking regarding the relative proportion of cases per disease that remain treated outside the ICU; and the outcomes of various management strategies. The only study of the health status of survivors of obstetric ICU admission revealed that six months after hospital discharge, one in five women still had a poorer health-related quality of life than those of a reference age- and sex-matched cohort.
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Affiliation(s)
- S Einav
- Intensive Care Unit, Shaare Zedek Medical Center and Hebrew University School of Medicine, Jerusalem, Israel.
| | - M Leone
- Department of Anesthesiology and Intensive Care Medicine, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Aix Marseille University, Marseille, France
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Sailaja K B, Mk R. Critically Ill Obstetric Admissions to an Intensive Care Unit: A Prospective Analysis from a Tertiary Care University Hospital in South India. Indian J Crit Care Med 2019; 23:78-82. [PMID: 31086451 PMCID: PMC6487612 DOI: 10.5005/jp-journals-10071-237121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Critically ill obstetric patients represent a small proportion of intensive care unit (ICU) admissions. Physiological changes of pregnancy along with pregnancy specific diseases may lead to rapid deterioration of the health status of the parturient warranting ICU care. The present study aims to study the clinical profile and outcomes of the obstetric patients requiring ICU care. Study design and settings Prospective observational study in the multidisciplinary ICU of a tertiary care teaching hospital conducted for a period of 2 years. Materials and methods Demographic details, indication for ICU admission, severity of illness scores, interventions, complications and outcomes of the consecutive obstetric patients transferred to ICU were studied. Results Ninety-one patients were admitted (26 per 1000 deliveries) to the ICU. Majority of them were postpartum (84.6%) and unbooked or referred (63.8%). Hypertensive disorders (24.2%) and obstetric hemorrhage (23.1%) were the major cause for admission to ICU. Forty three patients (47.3%) underwent cesarean delivery. Mechanical ventilation (54.9%), blood transfusion (46%), vasopressor therapy (22%) and dialysis (9.9%) were the various interventions provided in the ICU. Patients with sepsis had high mortality accounting for one third of ICU mortality. The ICU mortality rate was 9.9%. Conclusion The present study showed a clinical profile and outcomes similar to the current scenario of critically ill obstetric patients nationwide. Further studies with a larger sample size may provide a better insight in this population. How to cite this article Sailaja B, Renuka MK, et al. Critically Ill Obstetric Admissions to an Intensive Care Unit: A Prospective Analysis from a Tertiary Care University Hospital in South India. Indian J of Crit Care Med 2019;23(2):78-82.
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Affiliation(s)
- Baby Sailaja K
- Department of Critical Care Medicine, Sriramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India
| | - Renuka Mk
- Department of Anaesthesiology, Sriramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India, e-mail:
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