Maternal Morbidity - ICU Admissions Resources

Using a provincial perinatal database for 15 years, 1988-2002. Cases were identified with one or more of the following markers of severe maternal morbidity: blood transfusion > or = 5 units, emergency hysterectomy, uterine rupture, eclampsia, intensive care (ICU) admission. There were 159,896 mothers delivered of whom 313 (2.0/1000) had 385 markers of severe morbidity (257 had one, 42 had two, 12 had three, and two had four). The following rates of morbidity were recorded: blood transfusion > or = 5 units 119 (0.74/1000); emergency hysterectomy 88 (0.55/1000); uterine rupture 49 (0.31/1000); eclampsia 46 (0.28/1000); ICU 83 (0.52/1000). There was a statistically significant association between multiparity > or = 1, and emergency hysterectomy and uterine rupture; between age > or = 35 years, and emergency hysterectomy, uterine rupture and ICU; and between caesarean delivery and blood transfusion > or = 5 units, emergency hysterectomy, uterine rupture, eclampsia and ICU. The main contributing obstetric complications were haemorrhage (64.7%) and complications of hypertensive disorders (16.8%).

OBJECTIVE: To determine the level of near-miss maternal mortality and morbidity due to severe obstetrical complications or maternal disease in a tertiary maternity hospital.
DESIGN: Retrospective review.
SETTING: A free-standing maternity hospital delivering 5500 infants per year.
METHODS: The information coded in the perinatal database concerning women who had required transfer for critical care to a general hospital was reviewed for the 14 year period 1980 to 1993. The complications necessitating transfer and the specialised consultants and services required were noted.
RESULTS: Over 14 years there were 76,119 women delivered with two maternal deaths (2.6/100,000). Fifty-five women required transfer for critical care (0.7/1000). The main reasons for transfer were hypertensive disease (25%), haemorrhage (22%) and sepsis (15%). Transfer to an intensive care unit was required by 80%, and the remainder were transferred to specialised medical or surgical units. Twenty different specialist groups were consulted. The 55 patients spent 280 days in critical care and 464 days hospital after-care (mean 13 days, range 3-92).
CONCLUSION: A review of near-miss maternal mortality helps delineate the continuing threats to maternal health and the type of support services most commonly required.

OBJECTIVE: This investigation aimed to identify pregnancy complications and risk factors for women who experienced severe maternal morbidity during the delivery hospitalization and to estimate severe maternal morbidity rates. STUDY DESIGN: We used the National Hospital Discharge Survey for 1991-2003 to identify delivery hospitalizations with maternal diagnoses and procedures that indicated a potentially life-threatening diagnosis or life-saving procedure. RESULTS: For 1991-2003, the severe maternal morbidity rate in the United States was 5.1 per 1000 deliveries. Most women who were classified as having severe morbidity had an ICD-9-CM code for transfusion, hysterectomy, or eclampsia. Severe morbidity was more common at the extremes of reproductive age and for black women, compared with white women. CONCLUSION: Severe maternal morbidity is 50 times more common than maternal death. Understanding these experiences of these women potentially could modify the delivery of care in healthcare institutions and influence maternal health policy at the state and national level.

STUDY OBJECTIVE: To evaluate the predictive ability of three scoring systems, acute physiology and chronic health evaluation (APACHE II), simplified acute physiology score (SAPS II), and mortality probability models (MPM II) in critically ill obstetric patients compared to a control group of non-obstetric female patients of similar age group (range, 17 to 41 years).
DESIGN: A retrospective medical chart review of obstetric and nonobstetric female patients between 17 and 41 years of age.
SETTING: Two university hospitals.
PATIENTS: Ninety-three obstetric patients and 96 nonobstetric female patients were identified from 12,740 consecutive ICU admissions.
RESULTS: The actual mortality of the obstetric and the nonobstetric group was 10.8% (95% confidence interval [CI], 5.3 to 19.0%) and 12.5% (95% CI, 6.6 to 21.0%), respectively. The observed mortality was not statistically different from the mortality predicted by APACHE II, SAPS II, and MPM II (14.7%, 7.8%, and 9.1% for the obstetric group and 10.9%, 9.0%, and 9.9% for the nonobstetric group). Predictive accuracy was assessed by the c-index, which is equivalent to the area under the receiver operator characteristic (ROC) curve. There were no significant differences in the c-index for APACHE II, SAPS II, and MPM II within or between the obstetric group ([mean +/- SE], 0.93 +/- 0.02, 0.90 +/- 0.04, and 0.91 +/- 0.04, respectively) and the nonobstetric group (0.97 +/- 0.02, 0.95 +/- 0.03, and 0.96 +/- 0.02, respectively).
CONCLUSIONS: We conclude that APACHE II, SAPS II, and MPM II assess the ICU outcome of critically ill obstetric patients as accurately as nonobstetric critically ill female patients of similar age group.

OBJECTIVES: To identify pregnant and postpartum patients admitted to intensive care units (ICUs), the cause for their admission, and the proportion that might be appropriately managed in a high-dependency environment (HDU) by using an existing database. To estimate the goodness-of-fit for the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the APACHE III scoring systems in the obstetrical population.
DESIGN: Retrospective analysis of demographic, diagnostic, treatment, and severity of illness data.
SETTING: Fourteen ICUs in Southern England.
PATIENTS: Pregnant or postpartum (<42 days) admissions between January 1, 1994, and December 31, 1996.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: We identified 210 patients, constituting 1.84% (210 of 11,385) of all ICU admissions and 0.17% (210 of 122,850) of all deliveries. Most admissions followed postpartum complications (hypertensive disease of pregnancy [39.5%] and major hemorrhage [33.3%]). Seven women were transferred to specialist ICUs. There was considerable variation between ICUs with respect to the number and type of interventions required by patients. Some 35.7% of patients stayed in ICU for <2 days and received no specific ICU interventions; these patients might have been safely managed in an HDU. There were seven maternal deaths (3.3%); fetal mortality rate was 20%. The area under the receiver operator characteristic curve and the standardized mortality ratio were 0.92 (confidence interval [CI], 0.85-0.99) and 0.43 for the Simplified Acute Physiology Score II, 0.94 (CI, 0.86-1.0) and 0.24 for APACHE II, and 0.98 (CI, 0.96-1.0) and 0.43 for APACHE III, respectively.
CONCLUSIONS: Existing databases can both identify critically ill obstetrical patients and provide important information about them. Obstetrical ICU admissions often require minimal intervention and are associated with low mortality rates. Many might be more appropriately managed in an HDU. The commonly used severity of illness scoring systems are good discriminators of outcome from intensive care admission in this group but may overestimate mortality rates. Severity of illness scoring systems may require modification in obstetrical patients to adjust for the normal physiologic responses to pregnancy.

OBJECTIVE: The purpose of this study was to describe the characteristics and outcomes of obstetric patients who require mechanical ventilation. STUDY DESIGN: A review was conducted of obstetric patients who required mechanical ventilation and who received care at our institutions between 1990 and 1998. Data that were collected included maternal demographics, medical condition that necessitated ventilation, delivery status, duration of ventilation, onset of parturition while receiving ventilation, mode of delivery, and maternal and early neonatal morbidity or death. RESULTS: Fifty-one women were identified; 43 women(84%) received care in the labor and delivery setting. The most common admission diagnoses were preeclampsia/eclampsia (44%), labor/preterm labor (14%), and pneumonia (12%). Forty-three women (86%) were undelivered on admission (mean gestational age, 31.6 weeks). Delivery occurred in 37 women (86%) during their admission; 24 women (65%) underwent cesarean delivery. Eleven women began labor while receiving ventilation; 6 were delivered vaginally. The maternal mortality rate was 14% (7/51 women), and the perinatal mortality rate was 11% (4/37 fetuses). CONCLUSION: A large number of obstetric patients who receive mechanical ventilation will require delivery because of their condition. Centers that care for such women should form a treatment strategy to coordinate obstetric and medical care for this unique population

Obstetric patients are a small but important group of patients in the intensive care unit (ICU). Their problems are unique and need specialized attention. Decision making may be confounded by physiologic changes in pregnancy. In developed countries with good antenatal care, comparatively fewer obstetric patients are admitted to ICUs, but the maternal mortality rate remains high in the developing countries. Medical disorders and organ dysfunction caused by critical illness of pregnancy differ from region to region. With improvement in antenatal care, the number of ICU admissions for obstetric disorders would decline in developing countries; however, this number may increase gradually in developed countries because of increasing maternal age and pregnancies in women with complicated chronic medical disorders.

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.

BACKGROUND: During childbirth, the maternal need for intensive care unit (ICU) services is not well-defined. This information could influence the decision whether to incorporate ICU services into the labor and delivery suite.
METHODS: This study reports (1) ICU use and mortality rates in a statewide population of obstetric patients during their hospital admission for childbirth, and (2) the risk factors associated with ICU admission and mortality. A case-control design using patient records from a state-maintained anonymous database for the years 1984-1997 was used. Outcome variables included ICU use and mortality rates.
RESULTS: Of the 822,591 hospital admissions for delivery of neonates during the study period, there were 1,023 ICU admissions (0.12%) and 34 ICU deaths (3.3%). Age, race, hospital type, volume of deliveries, and source of admission independently and in combination were associated with ICU admission (P < 0.05). The most common risk factors associated with ICU admission included cesarean section, preeclampsia or eclampsia, and postpartum hemorrhage (P < 0.001). Black race, high hospital volume of deliveries, and longer duration of ICU stay were associated with ICU mortality (P < 0.05). The most common risk factors associated with ICU mortality included pulmonary complications, shock, cerebrovascular event, and drug dependence (P < 0.05).
CONCLUSIONS: This study shows that ICU use and mortality rate during hospital admission for delivery of a neonate is low. These results may influence the location of perinatal ICU services in the hospital setting.