Introduction

Obstetric patients in intensive care unit (ICU) show significant differences from average ICU patients. Due to the altered physiological status and special medical problems, this group of patients is a challenge for ICU specialists. The altered physiological parameters stress the body and may suppress the response needed to overcome this situation. In addition to the diseases at the admission, diseases specific to pregnancy such as peripartum hemorrhage, hypertensive disorders of pregnancy, acute fatty liver of pregnancy, embolic and infectious problems can be seen in this group of patients (1).

Prevalence of ICU admission among obstetric patients varies between 100 and 900 in 100000 pregnancies (2). Obstetric patients make up a small portion of ICU admissions in developed countries (<2%) whereas it may rise up to 10% or higher in developing countries (3).

According to literature, need for intensive care and mortality of pregnant women differ in a wide range, 0.1-0.9% and 0-36% respectively (2). For Turkish Republic, Ministry of Health has declared maternal mortality to be 19.4 for 100000 live births in 2008 and among all women who died in hospitals, peripartum maternal deaths accounted for 1% (4). According to this report, the most frequent reasons for maternal deaths consist of hemorrhage (30.3%), hypertensive disorders of pregnancy (15.5%), infections (9.6%) and complications related to abortion (4.0%). 

The aim of this study is to review the obstetric cases followed up and treated in our ICU and to determine the reasons for ICU admissions and maternal mortality.

Materials and Methods

The study was conducted under ethical principles for medical research. A total of 94 obstetric patients in need of intensive care were included in this study that were followed up and treated in Department of ICU of Akdeniz University Hospital within the 10-years period.

Data were reviewed retrospectively and following were recorded: age, vital parameters at the time of admission (heart rate, respiratory rate, body temperature, systolic and diastolic blood pressures), gestational age, gestational stage at the time of ICU admission (prepartum or postpartum), admission source (floor, emergency room, operation room or other hospitals), preexisting medical disorders, obstetric complications, reason for ICU admission (eclampsia, preeclampsia, hemorrhage, cardiac problems, pulmonary problems, hemolysis, elevated liver enzyme levels, and low platelet syndrome, APACHE II and Glasgow coma scale scores, interventions performed in ICU (mechanical ventilation, transfusion of blood and blood products, renal support therapy, arterial cannulation, central venous catheterization, use of intravenous inotropic and antihypertensive agents), type of delivery (normal or caesarean section) and blood tests for glucose, lactate, creatinine, blood urea nitrogen, sodium, potassium, bicarbonate, hemoglobin (Hb), hematocrit, leucocyte, platelet, pH and arterial blood gases.

Presence of disseminated intravascular coagulopathy (DIC) was recorded and DIC was defined as presence of low platelets (<100x109/L), decreased fibrinogen (<3 mg="</p">

Results

Patient files of 94 obstetric patients that were followed up and treated in ICU within the 10-year period were analyzed. Mean age of the patients was 29.1±5.5 years (range 18-40 years) and mean gestational age was 32.30±6.50 weeks (range 10-40 weeks). Nine patients (9.6%) were in prepartum period and the rest (85 of 94, 90.4%) were in postpartum period during the admission. Caesarean section was performed in 83 out of 85 patients that were admitted in postpartum period. Mean Hb level was 10.2±2.3 g/dL at the time of ICU admission. In 37 patients, Hb levels were below 10 g/dL and in 8 patients serious anemia was present (<7 g="</p">

Discussion

Most of the pregnant women overcome this period of pregnancy without any problem despite a group of physiological alterations. But in a group of patients, life-threating complications may occur and due to these complications, intensive care support may be needed. Studies have shown that care of critical obstetric patients is easier in ICUs (8,9). Obstetric patients generate a small portion of ICU admissions and mortality is lower in this group compared to non-obstetric patient population (10). Majority of obstetric patients are admitted to ICU in postpartum period. Studies indicate that antepartum admissions account for 12-45% of all obstetric admissions (2,11-13). Compatible with other studies, 90.4% of patients were postpartum admissions in our study. The leading cause of ICU admission in postpartum patients was urgent caesarean section and a great amount of these patients were transferred from other hospitals.

Obstetric patients followed in ICU’s generally have lower mortality rates compared with other groups of patients. It is expressed that maternal mortality in ICU’s is between 0-36% (2,14,15). Maternal mortality rate in ICU was 5.2% in our study. Deficient or inadequate antenatal care seriously rises up the risk of mortality related to pregnancy (16). Of our patients, majority were among patients getting inadequate antenatal care or were urgent cases (62 cases, 66%).

Studies have shown that prognosis may be predicted by use of APACHE II scores in obstetric patients followed up in ICU’s (17,18). On the other side, Lapinsky et al. (19) suggested that pregnancy rises acute physiological scores and therefore physiological scoring systems such as Simplified Acute Physiology Score II, APACHE II and APACHE III may not predict mortality accurately. In our study, APACHE II scores were 17.4±4.7 and 12.8±4.7 in non-survivors and survivors, respectively. However, as non-survivor group contained only 5 patients, statistical evaluation was not performed.

Many investigators reported that pregnant patients with complications have been transferred to more advanced hospitals (2,8,14,15). It is suggested that transfer of patients to other hospitals correlate with higher mortality rates (20,21). But unfortunately, studies on pregnant patients are small both in number and sample size (2,9). In this study, 34 out of 94 patients (36%) were transferred from other hospitals because of ICU follow up demand. Mortality rate in transferred group was 9% whereas the rate was 3% in patients who were followed up and treated in our hospital.

The most common reason for ICU admission is suggested to be preeclampsia/eclampsia and postpartum hemorrhage (8,14,22,23). Eclampsia (24 cases, 25.5%) and hemorrhage (19 cases, 20%) were the most common reasons for ICU admission in our study too.

Preexisting systemic diseases may worsen during pregnancy and this situation may be the cause of ICU admission. Medical disorders resulting in ICU admission are reported in a variety of ranges (24). These diseases consist of cardiovascular problems, diabetes mellitus, asthma bronchiale and chronic renal failure (24). The most common problems among cardiovascular diseases are valvular diseases (25). We admitted 24 cases (26%) with preexisting medical disease to ICU and as compatible with literature, valvular diseases were at top in frequency.Indications for intubation and mechanical ventilation are well defined in literature for obstetric patients (26). Indications are the same as non-obstetric patients and include inadequate oxygenation, respiratory failure and protection of airways. Need for mechanical ventilation in pregnancy derive from different origins. Most common reasons are complications related to pregnancy (27). The ratio of mechanically ventilated patients in our study was 79.8% (75 patients) and was significantly higher than the need reported in literature (between 19-60%) (9,28). The need for higher mechanical ventilation and longer LOS in ICU may be attributed to higher urgent admissions, inadequate antenatal care and higher incidence of transfers from other hospitals. LOMV and LOS in ICU were 1.9±2.8 and 4.1±4.4 days in our hospital whereas they were 4.7±7.1 and 8.8±10.0 days in patients transferred from other hospitals, respectively. When compared for LOMV and LOS in ICU, there was a significant difference between the patients treated in our hospital and the patients transferred from other hospitals (p=0.03 for LOMV and p=0.01 for LOS in ICU).

Hemorrhage is a common problem seen during pregnancy (12,15). Despite the progress in medical technology and transfusion practice, it is still among the most encountered reasons of maternal mortality (29). Massive obstetrical hemorrhage is often seen in intrapartum or early postpartum period and is usually a result of uterine atony. The range for ICU admissions due to hemorrhage related to pregnancy is wide (15). When the studies are reviewed, it can be seen that few studies report exact values for blood loss. Nineteen patients (20.2%) were admitted to ICU for hemorrhage in our study and 17 of them were treated for intrapartum or early postpartum hemorrhage. The other two patients had gastrointestinal bleeding or intraventricular bleeding. Placental abnormality (placental retention, ablatio placenta, placenta previa, placenta accreata) was responsible for hemorrhage in 5 cases. Hysterectomy was performed in 4 cases. Four of the patients admitted due to unceasable uterine bleeding were transferred from other hospitals. All the patients admitted for hemorrhage were discharged from ICU without any problem.

Blood or blood products were given to 38 patients (40%). In 16 cases, the amounts of products transfused were more than 10 units. Although not significant statistically, transfusion rate was higher for patients transferred from other hospitals (53% vs. 33%, p<0.06). When investigated in details, the use of FFP was significantly higher in patients transferred from other hospitals (44% vs. 23%, p=0.036).

This study has two limitations. Firstly, it has a retrospective design. Depending on this fact, some data were not available due to inadequate records. Second, it is a single center study.

Although critically ill obstetric patients account for a small portion of general ICU patients, treatment and follow up is challenging due to physiological alterations during pregnancy.

Conclusion

In conclusion, we found that transfer from one center to another is a risk factor for maternal mortality and morbidity due to delayed management of obstetric patients. Physicians in the ICU should be familiar with the complications of obstetric patients and should work closely with obstetricians in order to improve maternal outcome.

Ethics

Ethics Committee Approval: Retrospective study.

Informed Consent: Retrospective study.

Peer-review: Internally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: M.Y., A.R., M.C., Concept: M.Y., Design: M.Y., A.R., Data Collection or Processing: Y.Ç., S.K., Analysis or Interpretation: M.Y., A.R., Y.Ç., Literature Search: Y.Ç., S.K., Writing: M.Y., Y.Ç., M.C.,Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.