Treatment in an obstetric intensive care unit

A three-bed intensive care unit was opened in the labor and delivery area of a city-county hospital having approximately 7500 deliveries annually. The utilization rate of 0.9% and the severity of illness were sufficient to justify such a unit. Main indications for admission were hypertensive disorders (46%), massive hemorrhage (10%), and medical problems of pregnancy (44%). Identifiable benefits of the unit were as follows: (1) Intensive observation and organization allowed for prevention of early recognition and treatment of complications; (2) familiarity with invasive monitoring permitted personnel to exert prompt, rational treatment of hemodynamically unstable patients; (3) continuity of care was improved before and after delivery; (4) residents and fellows learned a great deal about intensive care and the management of rare medical complications of pregnancy. We conclude not only that critically ill pregnant women can be managed successfully in an obstetric intensive care unit but also that critical care is a bona fide part of obstetric practice and has been incorporated into our training program.     

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.     

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.     

心理护理对提高重症监护病房患者护理配合度的价值分析

目的：探讨心理护理对提高重症监护病房患者护理配合度的价值。方法：选取于2012年10月至2013年10月在我院进行治疗的40例重症监护病房患者,对患者采用心理护理,观察患者护理前后的护理配合度及其护理满意度。结果：患者的护理配合度从75.00%增加到了95.00%,护理满意度也从78.22±3.13分增加到了94.66±5.51分,护理前后结果对比有显著性差异。结论：心理护理改善了患者对疾病的认识,取得了较高的护理配合度,值得在临床上推广应用。     

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.     

Obstetric admissions to the intensive care unit: a 12-year review

Objective The objective was to ascertain the prevalence, causes and outcome of critically ill obstetric patients admitted to the intensive care unit (ICU). Design The design was a retrospective collection of data. Settings The setting was a multidisciplinary ICU in a University hospital. Patients All obstetric patients admitted to the ICU over a 12-year period from May 1992 to April 2004 were reviewed. Results The incidence of obstetric admissions to the ICU represented 0.22% of all deliveries during the study period. The majority (84.4%) of patients were admitted to the ICU postpartum. Obstetric haemorrhage (32.8%) and pregnancy-induced hypertension (17.2%) were the two main obstetrical reasons for admission. The remainder included medical disorders (37.5%) and other causes (6.2%). Associated major complications included adult respiratory distress syndrome (ARDS) and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome. The perinatal mortality rate was 20% and the maternal mortality rate 9.4%. Conclusions A team approach consisting treatment by obstetricians, intensive care specialists and anaesthesiologists provided optimal care for the patients. Improved management strategies for obstetric haemorrhage and hypertension may significantly reduce maternal morbidity.     

Intrapartum maternal and fetal monitoring: the obstetric intensive care unit.

The Obstetric Intensive Care Unit (OBICU) at Bellevue Hospital in New York City has adapted intensive care and coronary care models to the care of patients in labor. During the past 3 years, 519 of the most serious of 2 250 high-risk obstetric patients treated at the hospital were monitored in the OBICU. There were two maternal and six perinatal deaths. The perinatal mortality rate of the very high risk population of the OBICU was 11.6/1 000, compared to 14.7/1 000 for all deliveries performed at the hospital. Our findings indicate that the OBICU system provides the ideal mechanism for the rapid and continuous control of symptoms in very high risk gravidas which is essential for stabilizing the patient, both for prompt delivery and for optimal maternal and fetal survival.     

The evidence for emergency obstetric care.

PURPOSE: We searched for evidence for the effectiveness of emergency obstetric care (EmOC) interventions in reducing maternal mortality primarily in developing countries. METHODS: We reviewed population-based studies with maternal mortality as the outcome variable and ranked them according to the system for ranking the quality of evidence and strength of recommendations developed by the US Preventive Services Task Force. A systematic search of published literature was conducted for this review, including searches of Medline, PubMed, Cochrane Database of Systematic Reviews, the Cochrane Pregnancy and Childbirth Database and the Cochrane Controlled Trials Register. RESULTS: The strength of the evidence is high in several studies with a design that places them in the second and third tier in the quality of evidence ranking system. No studies were found that are experimental in design that would give them a top ranking, due to the measurement challenges associated with maternal mortality, although many of the specific individual clinical interventions that comprise EmOC have been evaluated through experimental design. There is strong evidence based on studies, using quasi-experimental, observational and ecological designs, to support the contention that EmOC must be a critical component of any program to reduce maternal mortality.     

Emergency obstetric care: impact on emerging issues.

Access to Emergency obstetric care (EmOC) remains a challenge for women. This paper presents a summary of issues and suggestions from one of the working groups at the FIGO precongress workshop on access of sexual and reproductive health care in November, 2006, in Kuala Lumpur.     

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.     

Ten-year survey of positive blood cultures among admissions to a neonatal intensive care unit

A 10-year survey of positive blood cultures was conducted among 6,616 infants admitted to an intensive care unit from 1974-1983. Group B streptococci (59) and E. coli (32) were the most common pathogenic organisms isolated from the early onset group (less than 72 hours of age). The percentage of infants with bacteremia, the birth weight distribution of infected infants, and the organisms isolated did not change in the early onset group throughout the study period. Coagulase negative staphylococci (471), S. aureus (126), E. coli (33), Klebsiella sp. (30), and enterococci (30) were the most frequent organisms isolated from the late onset group. The frequency of infection in the late onset group did not change as a function of time but was associated with decreasing birth weight during the study period. Methicillin and gentamicin resistance among coagulase negative staphylococci preceded that of S. aureus by one to three years, suggesting interspecies transfer of bacterial resistance among staphylococci. The data indicate that whereas the epidemiology of early-onset septicemia has remained relatively stable during the study period, the incidence of late onset bacteremia is increasing with improved survival rates of low birth weight infants. Antibiotic administration in the late onset group should include consideration of hospital-acquired, multiply antibiotic resistant organisms as well as maternally-acquired bacterial flora.     

Global patterns in availability of emergency obstetric care.

OBJECTIVE: This paper examines the availability of basic and comprehensive emergency obstetric care (EmOC), interventions used to treat direct obstetric complications. Determining what interventions are provided in health facilities is the first priority in analyzing a country's capabilities to treat obstetric emergencies. There are eight key interventions, six constitute basic EmOC and all eight comprehensive EmOC. METHODS AND RESULTS: Based on data from 24 needs assessments, the following global patterns emerge: comprehensive EmOC facilities are usually available to meet the recommended minimum number for the size of the population, basic EmOC facilities are consistently not available in sufficient numbers, both in countries with high and moderate levels of maternal mortality, and the majority of facilities offering maternity services provide only some interventions indicating an unrealized potential. CONCLUSION: Upgrading maternities, health centers and hospitals to at least basic EmOC status would be a major contributing step towards maternal mortality reduction in resource-poor countries.     

Pain relief in maternity care and the role of the obstetric anaesthetist

Pain is a common and treatable symptom in all stages of pregnancy. All agents must be prescribed considering the perceived benefits whilst acknowledging the potential fetal adverse effects. Oral agents can be used safely and effectively during the antenatal period, and management must be tailored for each individual. Intrapartum analgesia should be multi-modal with consideration for complimentary therapies including continuous labour support and water immersion. Epidural anaesthesia is the gold standard for pain management in labour, with inhalation anaesthetic offering excellent adjunct analgesia. A combined spinal/epidural anaesthesia acts rapidly compared to traditional epidural. Pudendal nerve blocks are effective methods of analgesia with decreasing popularity. Transversus abdominis plane blocks and wound infiltration of local anaesthetic reduces post-operative requirement for opioids. The obstetric anaesthetist plays a significant role in the multidisciplinary team in identifying and planning care for high-risk individuals. Furthermore, anaesthetic intervention at the time of delivery is not infrequent and can be optimized.     

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.     

Availability and quality of emergency obstetric care in Shanxi Province, China

Objective

To investigate the availability and quality of emergency obstetric care (EmOC) received by women in a rural Chinese province.

Methods

The study was conducted in 7 rural counties and townships in Shanxi Province, China. Data sources included interviews with 7 hospital leaders, 5 maternal and child health workers, and 7 obstetricians; 118 records of complicated delivery were audited, 21 Maternal and Child Health Annual Reports analyzed, and observations conducted of facilities and advanced labor care.

Results

The number of comprehensive EmOC facilities was adequate in all counties. Three counties had fewer basic EmOC facilities than recommended and only 4 counties reached the recommended level. Most of the existing township hospitals did not provide birthing services. All the county hospitals could perform cesarean deliveries with rates from 6.8%-40.8%. The management of complications was not evidence-based. For example, women with pre-eclampsia and eclampsia were given too little magnesium sulfate; women were not closely monitored for hemorrhage after birth and the partograph was used incorrectly with consequences for obstructed labor.

Conclusion

Basic EmOC facilities are not adequate and township hospitals should be upgraded to provide birthing services. The quality of EmOC is poor and needs improvement.