Ž .International Journal of Gynecology & Obstetrics 68 2000 257]258

Brief communication

Intensive care for critically ill obstetric patients

R. TripathiU, A.M. Rathore, S. SaranMaulana Azad Medical College, New Delhi, India

Received 16 June 1999; received in revised form 19 October 1999; accepted 4 November 1999

Keywords: Intensive care; Critically ill obstetric patients; Maternal mortality and morbidity

Care of the critically ill pregnant patient is animportant aspect of obstetric services delivered ina tertiary care hospital. This study presents aretrospective case record analysis of obstetricpatients who required shifting to the Intensive

Ž .Care Unit ICU over a 5-year period fromSeptember 1993 to August 1998 at Maulana AzadMedical College and associated Lok Nayak Hos-pital, New Delhi. A total of 50 patients wereshifted to ICU over the study period, with a totalof 26 986 deliveries during this period, the rate ofICU admissions was 1 per 540 deliveries. Ofthese, 6% were teenage pregnancies, 22% wereelderly gravidas, with the majority of 72% in the20]34-year age group.

The indication for ICU admission was shock in46% of the patients. Hemorrhagic shock was thepredominant cause in 28% of the patients,whereas endotoxic shock accounted for 16% ofthe cases. Other causes were hypertensive dis-

Ž .orders of pregnancy 18% , medical disorders

U Corresponding author.

Ž .complicating pregnancy 10% and anestheticŽ .complications 26% .

All patients had continuous monitoring by pulseoximeter. Blood gas analysis was done intermit-tently when indicated. Respiratory support byassisted ventilation was provided to 64% of thepatients and by ventimask to the remaining 24%.Ten percent of the patients required cardiac mon-itoring and CVP line was inserted in 4%. More

Ž .than half of the patients 60% required transfu-sion of blood andror blood products.

The average duration of stay in ICU was 33.6 hand in the hospital was 15.3 days. Of the patientsadmitted to ICU, 28% died. Causes of maternaldeath are depicted in Table 1. In this study, therequirement for ICU care was 1 per 540 deliver-ies, as compared to 1 per 1000 by Graham et al.w x w x1 , and 0.7 per 1000 by Baskett et al. 2 . Thehigher incidence is probably due to the poorquality of antenatal care received by the patients,and also the referral nature of our teaching hos-pitals offering tertiary level care.

Hemorrhagic shock tops the list of indicationsfor ICU admission at 28% in this study, compared

0020-7292r00r$20.00 Q 2000 International Federation of Gynecology and Obstetrics.Ž .PII: S 0 0 2 0 - 7 2 9 2 9 9 0 0 2 0 0 - 3

( )R. Tripathi et al. r International Journal of Gynecology & Obstetrics 68 2000 257]258258

Table 1Causes of maternal deaths

Diagnosis No. %

Hemorrhagic shock 2 14.3D.I.C. 3 21.4

Amniotic fluid embolismDengue feverEclampsia

Eclamptic hepatorenal shutdown 2 14.3Endotoxic shock 3 21.4Pulmonary embolism 2 14.3Cerebral malaria 1 7.1Sudden intra-operative cardiac arrest 1 7.1due to anesthetic complication

w xto 22% by Baskett et al. 2 , 20% by Lewinsohn etw x w xal. 3 , 17.3% by Graham et al. 1 and 10.5% by

w xMabie et al. 4 . Hypertensive disorders con-tributed to only 18% of ICU admissions in this

w xstudy compared to 56.5% by Graham et al. 1 ,w x w x46% by Mabie et al. 4 , 25% by Baskett et al. 2

w xand 17% by Lewinsohn et al. 3 . This contrastshould not be misconstrued to suggest that hyper-tensive disorders in pregnancy are infrequentlyseen in India. In actual numbers, these are, infact, quite large, but are overshadowed by theubiquitous problem of anemia. This is almostuniversally present, especially in the socio-economically disadvantaged group of women thatthis government hospital largely caters for.

Ž .Anesthetic complications 26% were an impor-tant indication for transfer to ICU in this study as

w xcompared to 13% by Graham et al. 1 and 7% byw xLewinsohn et al. 3 . Medical and surgical compli-

cations during pregnancy, contributed to only 10%of ICU admissions in our study, whereas there

Ž .was a high percentage 43.5% of similar patientsw xreported by Mabie et al. 4 and 38% by Baskett

w xet al. 2 .Maternal mortality in this study was 28% of

ICU admissions, which is many times the 3.5%w xreported by Mabie et al. 4 . This is a reflection of

Ž .the high maternal mortality rate MMR in ourcountry and is due to lack of proper antenataland intranatal care, late referral, poor transportfacilities and inadequate emergency obstetric careat centers close to the patient’s residence.

The major contributors to maternal mortalityand severe acute maternal morbidity still con-tinue to be hemorrhage, sepsis and hypertensivedisorders. It is a poor reflection on the healthservices of our country that the causes of mater-nal death at the end of the millenium continue tobe almost the same as at the start of the twenti-eth century. A multi-pronged approach to de-crease maternal mortality and morbidity is re-quired and provision of ICU care for obstetricpatients could be an important component ofmeasures aimed to decrease MMR.

References

w x1 Graham SG, Luxton MC. The requirement for intensivecare support for pregnant population. Anaesthesia1989;44:581.

w x2 Baskett TF, Sternadel J. Maternal intensive care andnear-miss mortality in obstetrics. Br J Obstet Gynaecol1998;105:981]984.

w x3 Lewinsohn G, Herman A, Leonov Y, Linowski E. Criti-cally ill obstetrical patients: outcome and predictability.Crit Care Med 1994;22:1412.

w x4 Mabie WC, Sibai BM. Treatment in an obstetric intensivecare unit. Am J Obstet Gynecol 1990;162:1.