Outcomes of Antepartum and Postpartum Obstetric Admissions to the Intensive Care Unit of A Tertiary University Hospital: An 8-Year Review

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.

Prediction of mechanical ventilation greater than 24 hours in critically ill obstetric patients: ten years of data from a tertiary teaching hospital in mainland China

Background

Maternal admission to the intensive care unit (ICU) during pregnancy or in the postpartum period is a marker of severe acute maternal morbidity. Mechanical ventilation is an important and basic method of maintaining life support in the ICU, but prolonged mechanical ventilation (PMV) is associated with a prolonged length of hospital stay and other adverse outcomes. Therefore, we conducted this retrospective study to describe morbidity and further try to identify the risk factors for PMV in critically ill obstetric women.

Methods

The clinical data were obtained from a single-centre retrospective comparative study of 143 critically ill obstetric patients at a tertiary teaching hospital in mainland China between January 1, 2009, and December 31, 2019. PMV was defined as a mechanical ventilation length of more than 24 h. Clinical and obstetric parameters were collected to analyse the risk factors for PMV. Patients were separated into groups with and without PMV. Potential risk factors were identified by univariate testing. Multivariate logistic regression was used to evaluate independent predictors of PMV.

Results

Out of 29,236 hospital deliveries, 265 critically ill obstetric patients entered the ICU. One hundred forty-five (54.7%) of them were treated with mechanical ventilation. Two were excluded because of death within 24 h. Sixty-five critically ill obstetric patients (45.5%) underwent PMV. The independent risk factors for PMV included estimated blood loss (odds ratio (OR) =1.296, P=0.029), acute kidney injury (AKI) (OR=4.305, P=0.013), myocardial injury (OR=4.586, P=0.012), and PaO₂/FiO₂ (OR=0.989, P< 0.001). The area under the receiver operating characteristic (ROC) curve based on the predicted probability of the logistic regression was 0.934.

Conclusions

Estimated blood loss, AKI, myocardial injury, and PaO₂/FiO₂ were independent risk factors for PMV in critically ill obstetric patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03524-4.

Epidemiology of obstetric critical illness

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.