Risk factors for maternal deaths in unplanned obstetric admissions to the intensive care unit-lessons for sub-Saharan Africa

This study was undertaken to determine the risk factors for maternal deaths in unplanned or unbooked obstetric admissions to the intensive care unit of a tertiary health centre. Hospital records of unbooked obstetric admissions to the intensive care unit of the hospital from January 1997 to December 2006 were retrospectively reviewed. Data collected included patients' demographics, diagnosis, duration of stay in the ICU and patient outcome. The intensive care unit records showed that there were 25 unbooked obstetric admissions. Major diagnoses for unplanned admissions to the ICU were preeclampsia/eclampsia (41.1%), obstetric haemorrhage (37.5%), and respiratory distress (12.5%). There were 12 deaths (48%). Organ dysfunction on admission, massive blood loss and late presentation were the risk factors for mortality. The high maternal mortality was mainly due to limited supply of blood products and inadequate prenatal care resulting in disease severity.     

Epidemiologic profile,survival, and maternal prognosis factors among women at an obstetric intensive care unit

Objective

To identify the epidemiologic profile, maternal survival, and prognosis factors that might affect survival rates in the obstetric intensive care unit (ICU).

Methods

A prospective cohort study was conducted between January 2007 and February 2009 in a tertiary referral ICU, Belo Horizonte, Brazil. Critical patients during pregnancy and puerperium were followed from admission until discharge or death. Maternal survival was assessed in association with the cause of ICU admission, grouped into direct or indirect obstetric causes, by Kaplan–Meier curves and log-rank tests.

Results

Among 298 patients admitted to the ICU during the study period, mortality was 4.7% (n = 14). Hypertensive disorders (46.0%), hemorrhage (15.9%), sepsis (14.2%), and heart disease (5.7%) were the main causes of admission. Half of the patients who died were admitted for direct obstetric reasons (n = 7). Survival was statistically linked to the cause of admission: most survivors were admitted for a direct obstetric cause (75.5%; P = 0.044). Maternal survival rates of patients admitted for indirect obstetric causes were lower than those admitted for direct obstetric causes (27.8 and 19.6 days, respectively; P = 0.019).

Conclusion

The main cause of admission was a decisive factor for maternal survival in the obstetric ICU. Direct obstetric complications had a better prognosis.     

Obstetric admissions to the intensive care unit.

OBJECTIVE: To determine whether obstetric admissions to the intensive care unit (ICU) are useful quality-assurance indicators. METHODS: We analyzed retrospectively obstetric ICU admissions at two tertiary care centers from 1991 to 1997. RESULTS: The 131 obstetric admissions represented 0.3% of all deliveries. The majority (78%) of women were admitted to the ICU postpartum. Obstetric hemorrhage (26%) and hypertension (21%) were the two most common reasons for admission. Together with cardiac disease, respiratory disorders, and infection, they accounted for more than 80% of all admissions. Preexisting medical conditions were present in 38% of all admissions. The median Acute Physiology and Chronic Health Evaluation II score was 8.5. The predicted mortality rate for the group was 10.0%, and the actual mortality rate was 2.3%. CONCLUSION: The most common precipitants of ICU admission were obstetric hemorrhage and uncontrolled hypertension. Improved management strategies for these problems may significantly reduce major maternal morbidity.     

Maternal mortality in a maternal-fetal medicine intensive care unit

Maternal mortality in a large, tertiary-care, intensive care, referral center was reviewed for a six-year period. The first three years of the review were prior to the institution of a maternal-fetal medicine intensive care unit, located in the labor-and-delivery suite. The subsequent three years encompassed a period during which an intensive care unit staffed by maternal-fetal medicine specialists and obstetric anesthesiologists was established in the labor-and-delivery suite. The maternal mortality rate was 21.7/100,000, or 10 maternal deaths in 45,984 deliveries, prior to establishment of the unit and 22.1/100,000, or 11 maternal deaths in 49,700 deliveries, after establishment of the unit. The major causes of maternal mortality were pregnancy-induced hypertension, hemorrhage and infection. It appears that a multi-disciplinary team composed of maternal-fetal medicine specialists and obstetric anesthesiologists can provide the same level of care for critically ill obstetric patients that traditionally would be provided by medical intensive care specialists.     

Course and outcome of obstetric patients in a general intensive care unit

BACKGROUND: To characterize the course, interventions required to achieve predetermined end-points and outcome of obstetric patients admitted to a general intensive care unit. METHODS: A retrospective case series study was performed including all pregnant patients admitted to an 8-bed general intensive care unit at a tertiary care university-affiliated hospital over a 4-year period. All patients referred by the obstetricians were admitted. Patients were divided into two groups: group 1, (n = 19) those requiring mechanical ventilatory support and group 2, (n = 27) those requiring intensive monitoring. Data collected included demographics, reason for admission, admission diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE II) and Therapeutic Intervention Scoring System (TISS) scores, intensive care unit course, types of interventions used and outcome. End-points of therapy included systolic blood pressure 110-150 mmHg, urine output > or = 1 cc/kg/h and oxygen saturation > 95%. RESULTS: Over the study period, 46 obstetric patients were admitted to the intensive care unit, representing 0.2% of all deliveries and an intensive care unit utilization rate of 2.3%. Commonest admission diagnoses were pregnancy-induced hypertension and hemorrhage. Reason for admission was mechanical ventilation in 41% while 59% were admitted for monitoring. Median length of stay was 25 +/- 80.9 (mean 48.8) hours. The median APACHE II score was 6 +/- 3.9 (mean 7.24) and the TISS score was > 20 in both groups. Only one patient died (mortality rate 2.3%). CONCLUSION: Despite a short length of stay and low APACHE score, the high TISS score in obstetric patients admitted for both ventilation and monitoring suggests that these patients require a level of intervention and care typically provided by a general intensive care unit.     

Transfer of obstetric patients in a pregnant and postpartum condition to an intensive care unit: eighty-two cases in Burkina Faso

OBJECTIVE: To review all obstetric admissions to an intensive care unit (ICU) of an African hospital. PATIENTS AND METHODS: Retrospective analysis of the records of all obstetric patients admitted to the ICU of Souro Sanou Hospital in Burkina Faso, from January 1st, 1996, to June 30, 1998. RESULTS: Eighty-two patients out of 6119 deliveries were transferred to the ICU, which meant a 1.34% transfer rate. These transfers concerned young patients (mean age of 24 years), coming originally from outlying maternities in 52.4% and having already given birth in 64.63% of the cases. The two main diagnoses at the ICU were: eclampsia and septic shock. The large majority of the patients (73 out of 82) had at least one bad prognosis factor at admission at the ICU. A maternal mortality rate of 60% was noted, the main risk factors for mortality being acute respiratory condition and severe anemia. CONCLUSION: Mortality of obstetric patients admitted to ICUs is very high in our setting. Establishing an ICU within the obstetric unit or early detection of cases to be transferred (scoring system?) should improve the prognosis.     

Obstetric intensive care admissions: a 12-year review in a tertiary care centre

OBJECTIVE: To review all pregnant women who required admission to an Intensive Care Unit (ICU) during pregnancy, childbirth or puerperium. STUDY DESIGN: Retrospective follow-up study in a tertiary care centre in The Netherlands. The files of all obstetric ICU admissions over the period 1990-2001 were reviewed. RESULTS: Over these 12 years, 142 women required ICU admission (0.76% of all deliveries, 0.70% of all adult ICU admissions). The most common reasons for ICU admission were (pre)eclampsia (62.0%) and obstetric haemorrhage (18.3%). Twenty-seven out of 142 women (19.0%) were of non-caucasian origin. The most common therapeutic interventions were transfusion of erythrocytes (66.2%), caesarean section (50.7%) and artificial ventilation (44.4%). We observed seven maternal deaths (4.9%). CONCLUSION: We need better information about high-risk obstetric patients in order to prevent severe maternal morbidity and to improve maternal care. The high number of non-caucasian women requiring ICU admission indicates the need for a study into the role of ethnicity. We have initiated a nationwide confidential enquiry into the causes of severe maternal morbidity.     

Emergency obstetric care in developing countries: impact of guidelines implementation in a community hospital in Senegal

OBJECTIVE: To evaluate, with volunteer professionals in a resource-poor setting, an approach of audit and feedback to promote local implementation of emergency obstetric guidelines. DESIGN: Triple cohort observational time series study. SETTING: A 46-bed obstetric unit in an academic-affiliated community hospital in Senegal. POPULATION: All pregnant women with haemorrhagic and hypertensive complications who were admitted to the maternity unit during the study periods. METHODS: To assess the benefits of guidelines implementation, maternal outcomes during the intervention period were compared with those occurring in two one-year periods when staff daily supervision was the main potentially effective action on clinical management. MAIN OUTCOME MEASURES: The intervention strategy was criteria-based audits with regular feedback over a one-year period. The clinical focus was haemorrhage and hypertension the most frequent causes of maternal death in the study population. Hospital charts were audited by external reviewers. The primary outcome was the case fatality rate (CFR) among patients with haemorrhage and hypertension. RESULTS: There was an increase in morbidity diagnoses during the intervention period. In addition, there was a marked increase in obstetric interventions, especially for transfusions and caesarean deliveries. Patients characteristic-adjusted case fatality decreased by 53% between baselines I and II and during the intervention period by 33% and 24%, compared with baseline periods I and II, respectively. Outcome improvements were different for haemorrhage and hypertension. CONCLUSION: While staff daily supervision may have improved maternal outcome before the intervention period, audit and feedback produced marked effects on emergency obstetric care, specially for complications requiring highly trained management (e.g. pre-eclampsia). Audit and feedback are one of the potentially effective guidelines implementation strategies that should be considered for further studies in resource-poor health facilities.     

Obstetric patients in a surgical intensive care unit: prognostic factors and outcome.

The objective of this study was to assess the incidence, prognostic factors and the outcome of obstetric patients admitted in a surgical intensive care unit (SICU) during the ante-partum or postpartum period (within 6 weeks of delivery). Between 1995 and 2002, the patients transferred from the department of obstetrics were retrospectively included into the study. Demographics included: obstetric data, medical and surgical histories, diagnosis, simplified acute physiology score (SAPS II), acute physiology and chronic health evaluation system APACHE II score; and the occurrence of organ failure, therapeutic interventions, length of stay in the SICU and outcome were recorded. During the study period, 364 obstetric patients were admitted to the SICU. Obstetric admissions to the SICU represented 0.6% of all deliveries and the SICU utilisation rate was 14.96%. The main indications for admission were eclampsia (70.6%) and postpartum haemorrhage (16.2%). The overall mortality rate was 16.7% (n = 61). In a logistic regression model, risk factors for death included organ system failure (odds ratio (OR) = 3.95 confidence interval (CI) [1.84 - 8.48], bilirubin >12 mg/l (OR = 1.017 CI [1.00 - 1.03]), and prolonged prothrombin time (OR = 0.97 CI [0.95 - 0.99]). Median length of stay was longer in non- survivors (6.5 +/- 7.3 vs 5.5 +/- 4.6 days). Maternal condition on admission and associated complications are the major determinant of maternal outcome.     

Indications and outcome for intensive care unit admission during puerperium

Background: A significant decrease of maternal mortality related to improvement in diagnosis and prevention of disorders in pregnancy has been observed without a similar reduction of puerperal morbidity. Objective of this study was to identify risk factors and outcome of patients, which required intensive care during puerperium. Methods: During the period 1987–1998 all pregnant patients, which were transferred from Department of Obstetrics and Gynecology to Intensive Care Unit (ICU) of University of Bari, were retrospectively included into the study. Several risk factors (age, preexisting diseases, gestational age, medical complication of pregnancy, mode of delivery, surgical additional procedure, fetal outcome, intrapartum transfusions, and puerperal complications) and the indications for transfer were evaluated. Results: The overall incidence of admission into Intensive Care Unit was 0.17% (41/23.694) of deliveries. Indications for admission into ICU were: worsening of preeclampsia in 75.6% of cases, severe bleeding in 14.7% of cases, maternal cardiac disease stage III AHA in 4.9% of cases, pulmonary embolism and acute pulmonary oedema respectively in 2.4% of cases. Conclusions: Transfer of patients to ICU due to hypovolemic postraumatic shock seems progressively declining thanks to modern criteria of obstetric management; on the contrary we assist to a prevalence of serious intrinsic maternal diseases often preexisting pregnancy or late consequence of preeclampsia, pulmonary embolism and sequelae of abnormal insertion of placenta. Received: 8 November 2000 / Accepted: 6 December 2000     

Critical care in pregnancy—Is it different?

In the first part of this review, the epidemiology of obstetric critical care is discussed. This includes the incidence of severe morbidity in pregnancy, identification of critically ill and potentially critically ill patients, the incidence of obstetric ICU admissions, the type of critical illness by stage of pregnancy, ICU admission diagnoses, the severity of illness in obstetric ICU patients compared to non-obstetric patients, ICU mortality of obstetric patients, the ICU proportion of total maternal mortality, and the causes of death for obstetric patients in ICU. In the second part, the management of obstetric patients who happen to be admitted to a general ICU is discussed. Rather than focusing on the management of particular obstetric conditions, general principles of ICU management will be discussed as applied to obstetric ICU patients. These include drug safety, monitoring the fetus, management of the airway, sedation, muscle relaxation, ventilation, cardiovascular support, thromboprophylaxis, and radiology and ethical issues.     

Risk factors for obstetric admissions to the intensive care unit in a tertiary hospital: a case-control study

Objective The objective was to review all obstetric admissions to the intensive care unit (ICU) at the Royal Free Hospital, London, UK, and to identify the risk factors for obstetric admissions to the ICU.Method We carried out a retrospective case-control study. The cases consisted of women admitted to the ICU during pregnancy and up to 42 days postpartum between 1 January 1993 and 31 December 2003. Controls were women who delivered immediately before and after the indexed case. Demographic data, medical and surgical histories, pregnancy, and intrapartum and postpartum data were collected. Statistical analysis was done using SPSS software.Results Thirty-three obstetric patients were admitted to the ICU, representing 0.11% of all deliveries. The ICU utilization rate was 0.81%. Eighty percent of the admissions were postpartum. The main indications for admission were hypertensive disorders (39.4%), and obstetric haemorrhage (36.4%). There was no difference between cases and controls in, age, parity, smoking and employment status. Compared with controls, women admitted to the ICU were significantly more likely to be black (P<0.05), have a shorter mean duration of pregnancy (36.6 vs. 39.2 weeks; P=0.006), delivered by emergency caesarean section (P<0.001), and have higher mean blood loss at delivery (1,173 vs. 296 ml; P<0.001). The risk factors for obstetric ICU admission were black race (odds ratio [OR] =2.8, 95% confidence interval [CI] 1.05–6.28), emergency caesarean section (OR=14.9, 95% CI 5.38–41.45) and primary postpartum haemorrhage (OR=5.4, 95% CI 1.79–4.35).Conclusion Women of black race, those delivered by emergency caesarean section and those with primary postpartum haemorrhage are more likely to be admitted to the ICU.     

Severe maternal morbidity in a tertiary care centre of northern Italy: a 5-year review

Objective: To assess prevalence and causes of severe acute maternal morbidity cases and evaluate their impact on feto-maternal wellbeing and on facility resources. Study Design: Observational retrospective study adopting management-based criteria in a tertiary care public hospital during a 5-year period. Criteria adopted were: intensive care unit admission, blood transfusion?≥ 4 units, emergency peripartum hysterectomy and arterial embolization at any time during pregnancy. Results: A total of 80 cases were identified, most of them (97.5%) through a combination of two criteria, ICU admission and blood transfusion. Commonest severe obstetric morbidities were major obstetric haemorrhage (48.8%) and hypertensive disorders (27.5%). Immigrant status (OR 1.68, 95% CI 1.03–2.7), pre-term birth (OR 4.15, 95% CI 2.5–6.8), Caesarean section (OR 7.74,95% CI 4.2–14.3) were factors significantly associated with SAMM cases. Major abdominal surgery was necessary in 26 women (32.5%), with emergency peripartum hysterectomy in 11 (13.5%). These events led to an average blood consumption per woman of 6.5?±?12.8 units and a mean hospital stay of 8.9?±?5.0 days, significantly longer (p?<?0.001) than the average duration of post-delivery care. Maternal mortality to morbility ratio was 1:80. Conclusions: An integrated intervention-based approach proved to be effective in finding severe acute maternal morbidity cases. Information on underlying causes and associated risk factors may improve prevention and treatment of obstetric morbidities, thus reducing feto-maternal adverse effects and hospital expenditures.     

Feto-maternal outcomes in obstetric patients with near miss morbidity: an audit of obstetric high dependency unit

Aim: To evaluate and compare the feto-maternal outcomes of pregnant women with potentially life-threatening complications (PLTC) and near miss events admitted to the obstetric high dependency units (OHDU).

Methods: Pregnant women with PLTC admitted to the OHDU were enrolled. Feto-maternal outcomes, need for NICU admission and neonatal mortality, were compared between women without near miss events (controls) and those with near miss events.

Results: Of the 1505 admissions to the obstetric department during the study period, 1127 delivered at our hospital. Among the deliveries 125 (11%) women were admitted to the OHDU and 19 (15%) of them were referred to the intensive care unit (ICU) of the hospital. The incidence of near miss morbidity (n?=?46) was 37% among the mothers admitted to OHDU and 4.1% among the deliveries. The outcomes were similar in both groups for mean birth weight (among live births), neonatal death and still birth or intra-uterine deaths. The mean duration of ICU stay, proportion of ICU admission, and the mean duration of hospital stay were significantly higher for women with near miss events.

Conclusion: In the presence of standardized OHDU and an ICU, the feto-maternal outcomes of women with PLTC and near miss event are similar to those without near miss events.     

Maternal deaths audit in four Benin referral hospitals: quality of emergency care causes and contributing factors

OBJECTIVE: Analyse evolution of maternal deaths and quality of emergency obstetric care provided to the women admitted in four Benin referral maternities thus causes and reasons of deficiencies contributing to maternal death. A transversal retrospective study was conducted in two stage: evolution of maternal death ratio added to living births was analysed from 1994 to 2003, followed by extensive analysis of maternal death in 2003. Different hospital data recording and individual interviews were the main sources of data collecting. Maternal mortality ratio in hospitals didn't evolve since 10 years. The poor quality of care was noticed in 59 % of cases. Direct obstetric causes were prevailing in 74% of cases and the leading specific causes were haemorrhage (32,2%), infection (31,60%). Deficiencies in health system, medicals errors in treatment and monitoring, patients' financial unavailability and inadequate management of septic abortions were the main contributing factors. Maternal deaths continue to happen unacceptably in Benin. The drastic solutions have to be taken at all levels to improve maternal health.     

Prevalence and risk factors of severe obstetric haemorrhage

Objective  To determine the prevalence, causes, risk factors and acute maternal complications of severe obstetric haemorrhage.
Design  Population-based registry study.
Population  All women giving birth (307 415) from 1 January 1999 to 30 April 2004 registered in the Medical Birth Registry of Norway. Information about socio-economic risk factors was obtained from Statistics Norway.
Methods  Cross-tabulation was used to study prevalence, causes and acute maternal complications of severe obstetric haemorrhage. Associations of severe obstetric haemorrhage with demographic, medical and obstetric risk factors were estimated using multiple logistic regression models.
Main outcome measure  Severe obstetric haemorrhage (blood loss of > 1500 ml or blood transfusion).
Results  Severe obstetric haemorrhage was identified in 3501 women (1.1%). Uterine atony, retained placenta and trauma were identified causes in 30, 18 and 13.9% of women, respectively. The demographic factors of a maternal age of ≥30 years and South-East Asian ethnicity were significantly associated with an increased risk of haemorrhage. The risk was lower in women of Middle Eastern ethnicity, more than three and two times higher for emergency caesarean delivery and elective caesarean than for vaginal birth, respectively, and substantially higher for multiple pregnancies, von Willebrand's disease and anaemia (haemoglobin <9 g/dl) during pregnancy. Admissions to an intensive care unit, postpartum sepsis, hysterectomy, acute renal failure and maternal deaths were significantly more common among women with severe haemorrhage.
Conclusion  The high prevalence of severe obstetric haemorrhage indicates the need to review labour management procedures. Demographic and medical risk factors can be managed with extra vigilance.     

Maternal mortality in health institutions with emergency obstetric care facilities in Enugu State, Nigeria.

In order to assess the current level of maternal mortality in health institutions with comprehensive emergency obstetric care in Enugu State, South Eastern Nigeria, a retrospective analysis of maternal deaths for the years 1999-2003 was carried out to establish the maternal mortality ratios in the eligible health institutions. Each maternal death was studied in detail to establish the socio-demographic characteristics of the women who died; their referral sources, type of delay (if any), medical causes of death and their preventability. In-depth interviews of the service providers were carried out to throw more light on the maternal mortality situation in the state. Five out of seven eligible health institutions were studied. Within the 5-year period (1999-2003), there were 141 maternal deaths and 18,257 live births giving a maternal mortality ratio of 772 maternal deaths per 100,000. The folders of 89 out of the 141 women who died were retrieved. Of these 89 maternal deaths, 51.7% of them were unemployed, 52.4% were referred from private hospitals; type 3 delay was the commonest type of delay encountered in the care of the women. Referral delay was the main cause of delay accounting for 46.4% of all cases of type 3 delay. The leading causes of maternal deaths among the women were obstetric haemorrhage (19.1%), sepsis (18.0%), prolonged obstructed labour/ruptured uterus (16.9%) and pre-eclampsia/eclampsia (16.9%). The in-depth interviews corroborated the high maternal mortality ratio recorded and the type 3 delays in tackling obstetric emergencies. It also showed some discrepancies between reality and the health providers' perception of the magnitude of maternal mortality situation in the state. It was concluded that in health institutions in Enugu State with comprehensive emergency obstetric care facilities, the maternal mortality ratio remains high due to type 3 delays. Most of the referrals come from private hospitals, hence the need to retrain the private practitioners in emergency obstetric care.     

Epidemiology of obstetric critical care

In the last 20 years, in developed countries, maternal mortality rates have fallen such that analysis of cases of severe maternal morbidity is necessary to provide sufficient numbers to give a clinically relevant assessment of the standard of maternal care. Different approaches to the audit of severe maternal morbidity exist, and include need for intensive care, organ system dysfunction and clinically defined morbidities. In both developed and developing countries, the dominant causes of severe morbidity are obstetric haemorrhage and hypertensive disorders. In some low-resource regions, obstructed labour and sepsis remain significant causes of severe maternal morbidity. The death to severe morbidity ratio may reflect the standard of maternal care. Audits of severe maternal morbidity should be complementary to maternal mortality reviews.