Medline ® Abstracts for References 2,14-16
of 'Critical illness during pregnancy and the peripartum period'
Pregnant and postpartum admissions to the intensive care unit: a systematic review.
Pollock W, Rose L, Dennis CL
Intensive Care Med. 2010;36(9):1465. Epub 2010 Jul 15.
PURPOSE: To determine the incidence and characteristics of pregnant and postpartum women requiring admission to an intensive care unit (ICU).
METHODS: Medline, PubMed, EMBASE and CINAHL databases (1990-2008) were systematically searched for reports of women admitted to the ICU either pregnant or up to 6 weeks postpartum. Two reviewers independently determined study eligibility and abstracted data.
RESULTS: A total of 40 eligible studies reporting outcomes for 7,887 women were analysed. All studies were retrospective with the majority reporting data from a single centre. The incidence of ICU admission ranged from 0.7 to 13.5 per 1,000 deliveries. Pregnant or postpartum women accounted for 0.4-16.0% of ICU admissions in study centres. Hypertensive disorders of pregnancy were the most prevalent indication for ICU admission [median 0.9 cases per 1,000 deliveries (range 0.2-6.7)]. There was no difference in the profile of ICU admission in developing compared to developed countries, except for the significantly higher maternal mortality rate in developing countries (median 3.3 vs. 14.0%, p = 0.002). Studies reporting patient outcomes subsequent to ICU admission are lacking.
CONCLUSIONS: ICU admission of pregnant and postpartum women occurs infrequently, with obstetric conditions responsible for the majority of ICU admissions. The ICU admission profile of women was similar in developed and developing countries; however, the maternal mortality rate remains higher for ICUs in developing countries, supporting the need for ongoing service delivery improvements. More studies are required to determine the impact of ICU admission for pregnant and postpartum women.
School of Nursing and Midwifery, La Trobe University/Mercy Hospital for Women, Level 4, Mercy Hospital for Women, 163 Studley Rd, Heidelberg, VIC, 3084, Australia. email@example.com
Clinical characteristics and outcomes of obstetric patients requiring ICU admission.
Vasquez DN, Estenssoro E, Canales HS, Reina R, Saenz MG, Das Neves AV, Toro MA, Loudet CI
OBJECTIVES: To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death.
DESIGN: Retrospective cohort.
SETTING: Medical-surgical ICU in a university-affiliated hospital.
PATIENTS: Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005.
MEASUREMENTS AND RESULTS: We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014).
CONCLUSIONS: Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.
The Intensive Care Unit, Hospital Interzonal General de Agudos Gral, San Martín, La Plata, Buenos Aires, Argentina. Electronic address: firstname.lastname@example.org.
Fetal outcomes of critically ill pregnant women admitted to the intensive care unit for nonobstetric causes.
Cartin-Ceba R, Gajic O, Iyer VN, Vlahakis NE
Crit Care Med. 2008;36(10):2746.
INTRODUCTION: The outcome of the fetus in critically ill mothers has been briefly reported as a part of descriptive studies focusing on maternal risk factors for admission to the intensive care unit. We evaluated the risk factors for adverse fetal outcomes in critically ill pregnant women admitted to the intensive care unit for nonobstetrical reasons.
DESIGN: Retrospective cohort study of all critically ill pregnant patients>18 yr; admitted to four (medical, surgical, trauma, and mixed medical-surgical) intensive care units at the Mayo Clinic in Rochester, MN; during the period of January 1995 to December 2005. Only pregnant women admitted to the intensive care unit in the antepartum period for nonobstetrical indications were included. Main predictors for fetal outcomes included: maternal comorbidities, obstetrical history, intensive care unit interventions, and intensive care unit complications. Fetal outcomes were defined as spontaneous abortions, neonatal mortality, fetal deaths, admission to the neonatal intensive care unit, neonatal intensive care unit length of stay, and neonatal intensive care unit complications.
RESULTS: A totalof 153 adult women (>18 yr) with a diagnosis of pregnancy were admitted to the intensive care unit, of whom 93 pregnant women met the inclusion criteria. Median maternal age was 26 yr (interquartile range 22-33) and median gestational age was 25 wk (interquartile range 8-33). The median maternal Acute Physiologic and Chronic Health Evaluation III score was 27 (interquartile range 17-38). There were 32 fetal losses; 18 were spontaneous abortions and 14 were fetal deaths. Ten neonates required neonatal intensive care unit admission, five for respiratory distress syndrome; and only one neonate died. The median neonatal intensive care unit length of stay was 34 days (interquartile range 15-87). After multivariable logistic regression analysis, the risk factors associated with fetal loss were: presence of maternal shock, odds ratio 6.85 (95% confidence interval 1.16-58, p = 0.04); maternal transfusion of blood products, odds ratio 7.24 (95% confidence interval 1.4-49, p = 0.02); and gestational age, odds ratio 1.2 for every gestational week below 37 wk (95% confidence interval 1.1-1.3, p<0.001).
CONCLUSIONS: Nonobstetrical critical illness in pregnant women significantly affects fetal and neonatal outcomes. Maternal shock, maternal requirement of allogenic blood product transfusion and lower gestational age were associated with an increased risk of fetal loss.
Mayo Clinic of Medicine, Rochester, MN, USA. email@example.com
Fetal outcome in the critically ill pregnant woman.
Aoyama K, Seaward PG, Lapinsky SE
Crit Care. 2014;18(3):307. Epub 2014 5 27.
Management of the critically ill pregnant woman is complicated by potential adverse effects of both maternal illness and ICU interventions on the fetus. This paper reviews the potential risks to the fetus of maternal critical illness, including shock, hypoxemia, and fever, as well as the effects of critical care management, such as drug therapy and radiological investigations. The authors' recommended approach to management is provided. Prior publications and new data presented identify that there is insufficient information to prognosticate accurately on fetal outcome after maternal critical illness, although maternal shock, hypoxemia and early gestational age are likely significant risk factors.