Critical illness during pregnancy and the peripartum period
- Peter F Clardy, MD
Peter F Clardy, MD
- Assistant Professor of Medicine
- Harvard Medical School
- Christine C Reardon, MD
Christine C Reardon, MD
- Associate Professor of Medicine
- Boston University School of Medicine
- Section Editors
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- David L Hepner, MD
David L Hepner, MD
- Section Editor — Obstetric Anesthesia
- Associate Professor of Anaesthesia
- Harvard Medical School
Although fewer than 2 percent of women require admission to an intensive care unit (ICU) during pregnancy or the peripartum period (the last month of gestation and the first few weeks after delivery), both maternal and fetal mortality are high when such care is required [1-8].
The disorders that are most common among women admitted to the ICU during pregnancy or the peripartum period are reviewed here. Issues related to acute respiratory failure during pregnancy and the peripartum period are discussed separately. (See "Acute respiratory failure during pregnancy and the peripartum period".)
INCIDENCE AND MORTALITY
The incidence of ICU admission for pregnant and postpartum women ranges from 0.7 to 13.5 per 1000 deliveries [2,9,10]. The most common indications for ICU admission are postpartum hemorrhage and the hypertensive disorders (severe preeclampsia or eclampsia) . However, all medical conditions that can complicate pregnancy can be encountered in the ICU.
Maternal mortality is high when critical care is required, with estimates ranging from 3.4 to 14 percent [8,11]. In the United States, the leading cause of maternal mortality is death due to cardiovascular disease and cardiomyopathy, which may relate to rising maternal age and high incidence of obesity, diabetes, and hypertension [8,12]. Other common causes of pregnancy-related mortality include venous thromboembolic disease, hemorrhage, infection, and amniotic fluid embolism. In one observational study, as many as 18 percent of maternal deaths were considered preventable . Causes of preventable maternal death included postpartum hemorrhage, preeclampsia, medication errors, and some infections. (See "Overview of maternal mortality and morbidity".)
Fetal mortality is also high when critical care is required [2,14-16]. Early gestational age, severe maternal illness, maternal shock, the need for maternal blood transfusions, and the absence of prenatal care are associated with fetal mortality.
- Zwart JJ, Dupuis JR, Richters A, et al. Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study. Intensive Care Med 2010; 36:256.
- Pollock W, Rose L, Dennis CL. Pregnant and postpartum admissions to the intensive care unit: a systematic review. Intensive Care Med 2010; 36:1465.
- Porreco RP, Barkey R. Peripartum intensive care. J Matern Fetal Neonatal Med 2010; 23:1136.
- Madan I, Puri I, Jain NJ, et al. Characteristics of obstetric intensive care unit admissions in New Jersey. J Matern Fetal Neonatal Med 2009; 22:785.
- Muench MV, Baschat AA, Malinow AM, Mighty HE. Analysis of disease in the obstetric intensive care unit at a university referral center: a 24-month review of prospective data. J Reprod Med 2008; 53:914.
- Wanderer JP, Leffert LR, Mhyre JM, et al. Epidemiology of obstetric-related ICU admissions in Maryland: 1999-2008*. Crit Care Med 2013; 41:1844.
- Orsini J, Butala A, Diaz L, et al. Clinical Profile of Obstetric Patients Admitted to the Medical-Surgical Intensive Care Unit (MSICU) of an Inner-City Hospital in New York. J Clin Med Res 2012; 4:314.
- Callaghan WM. Overview of maternal mortality in the United States. Semin Perinatol 2012; 36:2.
- Chantry AA, Deneux-Tharaux C, Bonnet MP, Bouvier-Colle MH. Pregnancy-related ICU admissions in France: trends in rate and severity, 2006-2009. Crit Care Med 2015; 43:78.
- Guntupalli KK, Hall N, Karnad DR, et al. Critical illness in pregnancy: part I: an approach to a pregnant patient in the ICU and common obstetric disorders. Chest 2015; 148:1093.
- Vasquez DN, Das Neves AV, Vidal L, et al. Characteristics, Outcomes, and Predictability of Critically Ill Obstetric Patients: A Multicenter Prospective Cohort Study. Crit Care Med 2015; 43:1887.
- Small MJ, James AH, Kershaw T, et al. Near-miss maternal mortality: cardiac dysfunction as the principal cause of obstetric intensive care unit admissions. Obstet Gynecol 2012; 119:250.
- Clark SL, Belfort MA, Dildy GA, et al. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 2008; 199:36.e1.
- Vasquez DN, Estenssoro E, Canales HS, et al. Clinical characteristics and outcomes of obstetric patients requiring ICU admission. Chest 2007; 131:718.
- Cartin-Ceba R, Gajic O, Iyer VN, Vlahakis NE. Fetal outcomes of critically ill pregnant women admitted to the intensive care unit for nonobstetric causes. Crit Care Med 2008; 36:2746.
- Aoyama K, Seaward PG, Lapinsky SE. Fetal outcome in the critically ill pregnant woman. Crit Care 2014; 18:307.
- American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. Practice Bulletin No. 170: Critical Care in Pregnancy. Obstet Gynecol 2016; 128:e147.
- MacKAy AP, Berg CJ, Liu X, et al. Changes in pregnancy mortality ascertainment: United States, 1999-2005. Obstet Gynecol 2011; 118:104.
- Baskett TF. Epidemiology of obstetric critical care. Best Pract Res Clin Obstet Gynaecol 2008; 22:763.
- Leung NY, Lau AC, Chan KK, Yan WW. Clinical characteristics and outcomes of obstetric patients admitted to the Intensive Care Unit: a 10-year retrospective review. Hong Kong Med J 2010; 16:18.
- Usta IM, Sibai BM. Emergent management of puerperal eclampsia. Obstet Gynecol Clin North Am 1995; 22:315.
- Mushambi MC, Halligan AW, Williamson K. Recent developments in the pathophysiology and management of pre-eclampsia. Br J Anaesth 1996; 76:133.
- Magann EF, Martin JN Jr. Complicated postpartum preeclampsia-eclampsia. Obstet Gynecol Clin North Am 1995; 22:337.
- Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000; 183:S1.
- Committee on Obstetric Practice. Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstet Gynecol 2015; 125:521.
- Duley L, Meher S, Jones L. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database Syst Rev 2013; :CD001449.
- Witlin AG, Sibai BM. Magnesium sulfate therapy in preeclampsia and eclampsia. Obstet Gynecol 1998; 92:883.
- Duley L, Henderson-Smart DJ, Walker GJ, Chou D. Magnesium sulphate versus diazepam for eclampsia. Cochrane Database Syst Rev 2010; :CD000127.
- Duley L, Henderson-Smart DJ, Chou D. Magnesium sulphate versus phenytoin for eclampsia. Cochrane Database Syst Rev 2010; :CD000128.
- Yundt KD, Diringer MN. The use of hyperventilation and its impact on cerebral ischemia in the treatment of traumatic brain injury. Crit Care Clin 1997; 13:163.
- Frontera JA, Ahmed W. Neurocritical care complications of pregnancy and puerperum. J Crit Care 2014; 29:1069.
- Guntupalli KK, Karnad DR, Bandi V, et al. Critical Illness in Pregnancy: Part II: Common Medical Conditions Complicating Pregnancy and Puerperium. Chest 2015; 148:1333.
- Bauer ME, Bateman BT, Bauer ST, et al. Maternal sepsis mortality and morbidity during hospitalization for delivery: temporal trends and independent associations for severe sepsis. Anesth Analg 2013; 117:944.
- Al-Ostad G, Kezouh A, Spence AR, Abenhaim HA. Incidence and risk factors of sepsis mortality in labor, delivery and after birth: population-based study in the USA. J Obstet Gynaecol Res 2015; 41:1201.
- Paruk F. Infection in obstetric critical care. Best Pract Res Clin Obstet Gynaecol 2008; 22:865.
- Barton JR, Sibai BM. Severe sepsis and septic shock in pregnancy. Obstet Gynecol 2012; 120:689.
- Sheffield JS, Cunningham FG. Community-acquired pneumonia in pregnancy. Obstet Gynecol 2009; 114:915.
- Almoujahed MO, Khatib R, Baran J. Pregnancy-associated pyogenic sacroiliitis: case report and review. Infect Dis Obstet Gynecol 2003; 11:53.
- Liu XQ, Li FC, Wang JW, Wang S. Postpartum septic sacroiliitis misdiagnosed as sciatic neuropathy. Am J Med Sci 2010; 339:292.
- Mulvey JM. Postpartum septic sacroiliitis coincident with labour epidural analgesia. Anaesth Intensive Care 2008; 36:875.
- Knowles SJ, O'Sullivan NP, Meenan AM, et al. Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study. BJOG 2015; 122:663.
- Rouphael NG, O'Donnell JA, Bhatnagar J, et al. Clostridium difficile-associated diarrhea: an emerging threat to pregnant women. Am J Obstet Gynecol 2008; 198:635.e1.
- Neligan PJ, Laffey JG. Clinical review: Special populations--critical illness and pregnancy. Crit Care 2011; 15:227.
- Clark SL, Cotton DB, Lee W, et al. Central hemodynamic assessment of normal term pregnancy. Am J Obstet Gynecol 1989; 161:1439.
- Hay JE. Liver disease in pregnancy. Hepatology 2008; 47:1067.
- Pereira SP, O'Donohue J, Wendon J, Williams R. Maternal and perinatal outcome in severe pregnancy-related liver disease. Hepatology 1997; 26:1258.
- Knox TA, Olans LB. Liver disease in pregnancy. N Engl J Med 1996; 335:569.
- Kang AH, Graves CR. Herpes simplex hepatitis in pregnancy: a case report and review of the literature. Obstet Gynecol Surv 1999; 54:463.
- Frederick DM, Bland D, Gollin Y. Fatal disseminated herpes simplex virus infection in a previously healthy pregnant woman. A case report. J Reprod Med 2002; 47:591.
- Riediger C, Sauer P, Matevossian E, et al. Herpes simplex virus sepsis and acute liver failure. Clin Transplant 2009; 23 Suppl 21:37.
- Graham WJ. Now or never: the case for measuring maternal mortality. Lancet 2002; 359:701.
- Martin JN Jr, Bailey AP, Rehberg JF, et al. Thrombotic thrombocytopenic purpura in 166 pregnancies: 1955-2006. Am J Obstet Gynecol 2008; 199:98.
- Esplin MS, Branch DW. Diagnosis and management of thrombotic microangiopathies during pregnancy. Clin Obstet Gynecol 1999; 42:360.
- Allford SL, Hunt BJ, Rose P, et al. Guidelines on the diagnosis and management of the thrombotic microangiopathic haemolytic anaemias. Br J Haematol 2003; 120:556.
- Collop NA, Sahn SA. Critical illness in pregnancy. An analysis of 20 patients admitted to a medical intensive care unit. Chest 1993; 103:1548.
- Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med 1996; 334:494.
- Wagner SJ, Acquah LA, Lindell EP, et al. Posterior reversible encephalopathy syndrome and eclampsia: pressing the case for more aggressive blood pressure control. Mayo Clin Proc 2011; 86:851.
- Staykov D, Schwab S. Posterior reversible encephalopathy syndrome. J Intensive Care Med 2012; 27:11.
- Doelken M, Lanz S, Rennert J, et al. Differentiation of cytotoxic and vasogenic edema in a patient with reversible posterior leukoencephalopathy syndrome using diffusion-weighted MRI. Diagn Interv Radiol 2007; 13:125.
- Bartynski WS. Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol 2008; 29:1036.
- Finocchi V, Bozzao A, Bonamini M, et al. Magnetic resonance imaging in Posterior Reversible Encephalopathy Syndrome: report of three cases and review of literature. Arch Gynecol Obstet 2005; 271:79.
- Servillo G, Bifulco F, De Robertis E, et al. Posterior reversible encephalopathy syndrome in intensive care medicine. Intensive Care Med 2007; 33:230.
- Striano P, Striano S, Tortora F, et al. Clinical spectrum and critical care management of Posterior Reversible Encephalopathy Syndrome (PRES). Med Sci Monit 2005; 11:CR549.
- Ramin KD. Diabetic ketoacidosis in pregnancy. Obstet Gynecol Clin North Am 1999; 26:481.
- Carroll MA, Yeomans ER. Diabetic ketoacidosis in pregnancy. Crit Care Med 2005; 33:S347.
- Cullen MT, Reece EA, Homko CJ, Sivan E. The changing presentations of diabetic ketoacidosis during pregnancy. Am J Perinatol 1996; 13:449.
- Lapinsky SE, Kruczynski K, Slutsky AS. Critical care in the pregnant patient. Am J Respir Crit Care Med 1995; 152:427.
- Motoyama EK, Rivard G, Acheson F, Cook CD. The effect of changes in maternal pH and P-CO2 on the P-O2 of fetal lambs. Anesthesiology 1967; 28:891.
- Ivankovic AD, Elam JO, Huffman J. Effect of maternal hypercarbia on the newborn infant. Am J Obstet Gynecol 1970; 107:939.
- Ralston DH, Shnider SM, DeLorimier AA. Uterine blood flow and fetal acid-base changes after bicarbonate administration to the pregnant ewe. Anesthesiology 1974; 40:348.
- Clark RB, Stephens SR, Greifenstein FE. Fetal and maternal effects of bicarbonate administration during labor. Anesth Analg 1971; 50:713.
- Cravey RH, Reed D. Placental transfer of narcotic analgesics in man. Clin Toxicol 1981; 18:911.
- Johnson RF, Herman N, Arney TL, et al. The placental transfer of sufentanil: effects of fetal pH, protein binding, and sufentanil concentration. Anesth Analg 1997; 84:1262.
- Hawkins JL, Johnson TD, Kubicek MA, et al. Vecuronium for rapid-sequence intubation for cesarean section. Anesth Analg 1990; 71:185.
- Iwama H, Kaneko T, Tobishima S, et al. Time dependency of the ratio of umbilical vein/maternal artery concentrations of vecuronium in caesarean section. Acta Anaesthesiol Scand 1999; 43:9.
- Bacon RC, Razis PA. The effect of propofol sedation in pregnancy on neonatal condition. Anaesthesia 1994; 49:1058.
- Hilton G, Andrzejowski JC. Prolonged propofol infusions in pregnant neurosurgical patients. J Neurosurg Anesthesiol 2007; 19:67.
- Price LC, Slack A, Nelson-Piercy C. Aims of obstetric critical care management. Best Pract Res Clin Obstet Gynaecol 2008; 22:775.
- Ko R, Mazur JE, Pastis NJ, et al. Common problems in critically ill obstetric patients, with an emphasis on pharmacotherapy. Am J Med Sci 2008; 335:65.
- Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation, Williams and Wilkins, Baltimore 1986.
- Rochow N, Küster H, Bandt C, et al. Case 1: Unexpected muscular hypotonia and need for mechanical ventilation in a preterm infant. Prolonged effect of diazepam. Acta Paediatr 2008; 97:1602.
- Morgan J, Roberts S. Maternal sepsis. Obstet Gynecol Clin North Am 2013; 40:69.
- Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med 2017.
- Van Nimwegen D, Dyer DC. The action of vasopressors on isolated uterine arteries. Am J Obstet Gynecol 1974; 118:1099.
- Lee A, Ngan Kee WD, Gin T. A quantitative, systematic review of randomized controlled trials of ephedrine versus phenylephrine for the management of hypotension during spinal anesthesia for cesarean delivery. Anesth Analg 2002; 94:920.
- Shnider SM, de Lorimier AA, Holl JW, et al. Vasopressors in obstetrics. I. Correction of fetal acidosis with ephedrine during spinal hypotension. Am J Obstet Gynecol 1968; 102:911.
- GREISS FC, CRANDELL DL. THERAPY FOR HYPOTENSION INDUCED BY SPINAL ANESTHESIA DURING PREGNANCY: OBSERVATIONS ON GRAVID EWES. JAMA 1965; 191:793.
- Clark RB, Brunner JA 3rd. Dopamine for the treatment of spinal hypotension during cesarean section. Anesthesiology 1980; 53:514.
- Moran DH, Perillo M, LaPorta RF, et al. Phenylephrine in the prevention of hypotension following spinal anesthesia for cesarean delivery. J Clin Anesth 1991; 3:301.
- Ngan Kee WD, Khaw KS, Tan PE, et al. Placental transfer and fetal metabolic effects of phenylephrine and ephedrine during spinal anesthesia for cesarean delivery. Anesthesiology 2009; 111:506.
- Fujitani S, Baldisseri MR. Hemodynamic assessment in a pregnant and peripartum patient. Crit Care Med 2005; 33:S354.
- Dennis AT. Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness. Int J Obstet Anesth 2011; 20:160.
- INCIDENCE AND MORTALITY
- MANAGEMENT OF SPECIFIC DISEASES
- Cardiovascular disease
- Venous thromboembolism
- Preeclampsia or eclampsia
- Acute respiratory failure
- Liver disease
- TTP and HUS
- Posterior reversible encephalopathy syndrome
- Diabetic ketoacidosis
- SUPPORTIVE CARE
- Mechanical ventilation
- SUMMARY AND RECOMMENDATIONS