Critical care challenges in obstetrics: An acute need for dedicated and co-ordinated teamwork.

Despite the recent progress in the field of medicine, the developing countries lag far behind in providing good maternal care and obstetric intensive care facilities. The maternal mortality has steeply come down in the developed nations while developing nations are still struggling as they contribute 99% of the total global maternal deaths. The incidence of intensive care unit (ICU) admission of an obstetric patient in developed countries is 2-4/1000 deliveries, whereas in the developing nations it is as high as 2-13.5/1,000 deliveries.[1]

Critically, ill-parturient poses a unique challenge to the obstetrician, Anesthesiologist as well as to the intensivists.[2] The systematic review in the current issue (September to December) of Anesthesia, Essays and Researches has comprehensively described not only anesthetic management in parturients with severe co-morbidities, but also has raised a serious concern regarding the challenges faced during obstetrical critical care. These facts assume significant dimensions when considering maternal morbidity and mortality as these are objective markers and are considered to be an important quality assurance indicators.[3]

The process of childbirth from conception to puerperium can be complicated anytime by severe maternal morbidity necessitating critical care support and admission into an ICU. The medical management of the critically ill-obstetric patient requires a complete knowledge of the altered physiology of pregnancy as well as the superimposed acute pathological insult, demanding a cohesive coordinated care from an obstetrician as well as the Intensivists/Anesthesiologist.

As per the statement of World Health Organization “there is a story behind every maternal death or life-threatening complications and understanding the lessons to be learnt can help to avoid such outcomes.”[4]

The need for admission of a parturient to an ICU can arise because of obstetric complications (47-93%)[5] as well as non-obstetric indications. Antepartum and postpartum hemorrhage, hypertensive disease of pregnancy and puerperal sepsis are the most frequent obstetric complications necessitating ICU admission. The common non-obstetric indications include maternal cardiac disease, trauma, anesthetic complications, cerebrovascular accidents and drug overdose. Presence of other co-morbidities such as diabetes, renal diseases, viral infections and others also contribute negatively in maternal outcome.[678] In these circumstances, a closed ICU is more suitable for imparting focused training to medical professionals and paramedics and can ensure a good teamwork as well.[9] Antenatal services have to be strengthened at grass root level and more specialists have to be recruited so as to identify parturients with co-morbid diseases so as to timely refer them to a tertiary care center. These services can possibly be boosted by providing recreational, academic for children and other essential facilities for specialists in rural areas.

The wider gap between critical care services and outcome among developed and developing nations is largely due to in-coordination of various administrative/clinical initiatives and failed alignment of these health services with the universal guidelines.[1011] Delegation of financial and administrative power at lower levels, formulation of policies to enhance close co-ordination among various health sectors, improving means of transport and communications and improving the overall health infrastructure can significantly improve critical care services.

Invasive monitoring may be essential in few patients besides minimum mandatory monitoring, widely practiced in developing countries, which may not be sufficient to guide the therapeutic interventions in such patients both during surgical procedures and during the ICU stay. The choice of central venous pressure (CVP) monitoring is largely based on guiding fluid administration while pulmonary artery (PA) catheter may be used rarely especially during the need for monitoring CVP, pulmonary capillary wedge pressure (PCWP), systemic vascular resistance, cardiac output, PA pressure and mixed venous oxygen saturation. Such needs are necessitated due to wide variations and discrepancies between the estimation of various invasive pressures such as CVP, PCWP, intra-abdominal pressure and others due to altered physiological status of pregnancy.[1213]

There is a need for increased awareness amongst women of child bearing age about the need and benefits of good antenatal care and training of the midwives and the staff at the peripheral health centers for early recognition and timely referral of the parturients with obstetric complications to higher tertiary care centers with intensive care facilities. This can be achieved by spreading literacy among masses and opening of new evening schools for elderly people in all villages. The light of education will tide over the pseudo-control exerted by various traditional beliefs, superstitions and obsolete cultural practices.

Now-a-days, women being more professional plan for the family at higher age groups resulting in an increase in the complications rate as well. With the advancement in the field of medicine and obstetrics, more women with underlying chronic medical illnesses are able to conceive and carry a fetus to term. Such parturients require a greater degree of medical care and counseling during the antenatal as well as the post-partum period. Management of such parturients during labor, delivery and in the postpartum period may require a period of observation in ICU. However, education of such women folk is not that difficult and they can be made aware anytime during a hospital visit.

The medical emergency team (MET) system has been introduced successfully world-wide. However, there is no literary evidence of successful obstetric MET implementation in any of the developing countries. The introduction of MET in obstetric practice can help in recognition and timely transfer of patients requiring intensive care services. There is a need to design and establish an obstetric MET for implementation in developing countries where the resources are scarce and the number of unbooked high risk patients is high. Though the concept of emergency medicine is new in developing nations, it will definitely bring down the maternal morbidity and mortality in these nations. The most common indications for ICU admission, i.e., antepartum and postpartum hemorrhage, hypertensive disease of pregnancy, expected and emergency difficult obstetric procedures should be the main focus of MET alert criteria.

Moreover, there is a need to develop dedicated obstetric ICU or obstetric high-dependency care units for the management of critically ill-parturients. Few successful initiatives have been taken, but the need of the hour is adoption of such measures at large scales. Even the scoring patterns for these critically ill-obstetric patients are not uniform and are highly subjectively biased. Different scoring systems like Acute Physiology and Chronic Health Evaluation II, Mortality Probability Model and Simplified Acute Physiology Score II have been used in various studies to predict the hospital mortality. These scores do not take into consideration the altered physiological state of pregnancy and tend to overestimate mortality in obstetric patients.[141516] A uniform scoring system, best adapted to socio-economic and health scenario in developing nations so as to predict the morbidity and mortality rate in obstetric patients admitted in ICU should be developed keeping in view the altered physiology in pregnancy.

Besides scoring systems, other important aspects need to be stressed while caring for critically ill-obstetric patients in ICU. The nutritional assessment, accurate estimation and administration of various nutrients, enteral and parenteral nutrition is as equally essential as other therapeutic regimens.[1718]

With the joint efforts focusing on enhanced antenatal care, timely recognition and referral of the critically ill-patients and cohesive coordinated management by maternal fetal medicine specialist or obstetrician and intensivists, the maternal mortality rate can be curtailed in the developing countries as well.