A fifteen-year retrospective review of obstetric patients requiring critical care

Background

Maternal mortality is a rare occurrence in developed nations. Given the low maternal mortality rate, other markers must be used to assess maternal risk and quality of obstetric care. One such is admission to critical care.

Aims

To determine the rate of admission, diagnosis and management of women from conception and up to 6 weeks postpartum to critical care units including coronary care (CCU), high dependency unit (HDU) and intensive care units (ICU).

Methods

We performed a retrospective review of obstetric patients requiring critical care admission from January 1995 to August 2010. Demographic details, obstetric history, place of admission (CCU, HDU or ICU) and fetal/neonatal outcomes were examined as were initial indication for critical care admission, final diagnosis and treatment administered.

Results

Data were available from 308 admission incidents. There were 259 (84%) admissions to ICU and 49 (15.9%) to CCU. More than a third of women were transferred from another institution. Those women transferred were more unwell and had a higher mortality rate than local women. Primary diagnoses: obstetric haemorrhage (ICU 30.9%), hypertensive disorders of pregnancy (ICU 16.2%, CCU 12.2%), infection (ICU 14.2%, CCU 6.1%), pre-existing cardiac disease (ICU 9.3%, CCU 55.1%).

Conclusions

The obstetric population represents only a small percentage of critical care utilisation and overall morbidity and mortality. However, this population is an important and growing group. Increased surveillance peripartum in a critical care facility allows earlier detection of maternal compromise and detailed management. Analysis of these 'near misses' in obstetrics aims to improve pregnancy outcomes.

Managing cardiovascular collapse in severe flecainide overdose without recourse to extracorporeal therapy

Flecainide overdose can rapidly result in profound cardiovascular collapse, and is associated with a relatively high mortality. A case is described where a woman with major toxicity and high serum levels was managed without recourse to invasive modalities such as cardiopulmonary bypass or extracorporeal therapies. Hypertonic sodium bicarbonate is recognized as effective therapy for hypotension and arrhythmias. More recent case reports have concentrated on the use of cardiopulmonary bypass. In this report and other reports describing successful resuscitation, the total dose of sodium bicarbonate is conspicuously higher than in reports describing extracorporeal interventions. Sodium bicarbonate should be given early in the resuscitation, and re-administered as frequently as required, targeting an alkaline pH and improved cardiac output, while accepting hypernatraemia. This case demonstrates the maxim that the correct dose of hypertonic sodium bicarbonate is 'enough'. Cardiopulmonary bypass support can be considered as a salvage therapy.

Femorofemoral bypass through the perineum for infection complicating arterial revascularization of the lower limb

Of 587 prosthetic arterial constructions performed between 1980 and 1984 on the aorta and lower limbs, 25 patients were operated on for sepsis. A total of 37 operations were performed, six of which were femorofemoral crossover bypasses through the perineum. Prosthetic material was used in one case and vein in five. The host vessel was the contralateral iliac or femoral artery, the contralateral limb of an aortobifemoral bypass, or the contralateral limb of an axillofemoral bypass in two cases each. The recipient vessel was the profunda femoris artery in four cases, the popliteal artery in one case, and the profunda femoris and popliteal arteries sequentially in one case. Indications for perineal bypass included an infected pseudoaneurysm in the femoral triangle following a femoropopliteal (one case) or aortofemoral bypass (five cases). In two instances, sepsis was bilateral and also required an axillofemoral bypass. Excepting one postoperative death, early results were satisfactory as infection disappeared and arterial reconstructions remained patent in all other cases. This technique should have its place in the armamentarium of extraanatomic bypasses along with other techniques such as the axillofemoral, prepublic femorofemoral crossover, and obturator bypasses. The best indication for perineal bypass is when vascularization of a lower limb from the contralateral side is necessary because of infection in the femoral triangle.

[Iatrogenic phlebitis of the upper limb and thoracic outlet syndrome]

Classically, the primary forms of phlebitis of the upper limb due to venous compression in the thoracic outlet have been radically contrasted with the secondary phlebitis, always iatrogenic, occurring after peripheral venipuncture. However, this distinction is perhaps not as clear as all that. In this paper, the authors report 3 cases of iatrogenic phlebitis of the upper limb. In all 3 cases, phlebography demonstrated venous compression at the thoracic outlet. Consequently, the development of phlebitis in the upper limb after a nervous puncture should always suggest the possibility of a thoracic outlet syndrome and is an indication for phlebography. Conversely, a corollary to the diagnosis of thoracic outlet syndrome should be the formal contraindication of intravenous infusion on the affected side. The treatment of these iatrogenic forms of phlebitis involves the use of anticoagulants followed by surgical resection of the 1st rib to decompress the collateral venous circulation.

[Costo-clavicular syndromes (thoracic outlet syndrome) (author's transl)]

During a 5-year period, 156 patients were followed with symptoms representative of costo-clavicular compression. Surgical treatment has been rejected in 80 patients. One hundred and five (20 bilateral) resections of the first rib were performed according to the technique as described by Roos. The surgical indication depends mainly on the severity of symptoms, clinical signs and the presence of complications (45 major complications). In 88% of the cases, a satisfactory result was obtained at the expense of a small incision, a hospital stay averaging 7 days and a few reversible complications of no significance.

[Cervical ribs. Therapeutic deliberations apropos of 10 cases]

The authors report ten cases of cervical ribs operated upon in 7 patients. The predominantly neurological symptoms and signs were associated with vascular problems in 3 cases, with intermittent compression of the sub-clavian vessels. Treatment consisted of resection of the cervical rib and the first rib via an extra-pleural axillary approach using the technique described by Roos. It gave 10 good results with a follow-up of 6 months to 3 years. The authors emphasise the fact that this pathology falls within the context of compressive syndromes of the root of the upper limb or thoracic outlet syndrome. Such a conception justifies associated resection of the first rib which should give better long term results than simple resection of the extra rib.

[Phlebitis of effort and venous edema of the upper limbs. Compressions of the subclavian vein]

The authors present a series of 18 cases (13 patients) of a venous syndrome of the arm. Three were cases of phlebitis due to effort and 15 were cases of intermittent or permanent oedema of the arms. Four of the patient also presented homo- or contralateral arterial disorders. Dynamics and multiposition phlebography gave evidence on 18 occasions of a branchial compression syndrome. Twelve patients were operated upon. On 16 occasions resection of the first rib was carried out by the axillary route (in 1 case this was combined with the ablation of one cervical rib). All the patients were cured without complications.

[Approach to the dorso-lumbar joint by sub-pleuro-peritoneal route]

The authors expose an access to the dorsal-lumbar spine through sub pleuro-peritoneal way. There are two interesting points to it: - A very wide open access allowing every surgical gesture from D9 to L3 according to the necessities. - The relative mildness of post-operative sequels, regarding the extra serous form of this way. The use of this access should allow to widden the surgical informations relative to the dorso-lumbar articulation.