Obstetric admissions to tertiary level intensive care unit - Prevalence, clinical characteristics and outcomes.

BACKGROUND AND AIMS: Obstetric admissions to the intensive care unit (ICU) are a subject of increasing interest, as it is an indirect indicator of maternal morbidity and mortality. The studies from areas reported to have a higher maternal mortality rate are lacking. Thus, we undertook this study to determine the prevalence pattern, clinical characteristics and outcome of obstetric patients admitted to the ICU of a tertiary care hospital.
METHODS: All obstetric patients (up till 42 days of delivery) admitted to the ICU from 1st October 2015 to 30th September 2016 and from 1st October 2010 to 30th September 2015 were included. Data collected for our study included demographic characteristics, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at the time of admission, obstetric and medical history, provisional diagnosis, the reason for ICU admission, interventions required in ICU and the outcome.
RESULTS: The third trimester (46.79%) and postpartum period (40.37%) were the most common time of admission with conditions such as severe pre-eclampsia, eclampsia, HELLP syndrome (Haemolysis, elevated liver enzymes, low platelet count), antepartum haemorrhage, postpartum haemorrhage and anaemia. The mean APACHE II score was 16.89 ± 7.48 with a mortality rate of 17.76%. The mean length of stay in ICU was 3.47 ± 3.16 days, and mean length of stay in our hospital was 8.78 ± 6.76 days.
CONCLUSION: Obstetric patients recover well if treated early. A good ICU care with monitoring can save a young productive life.

INTRODUCTION

Obstetric admissions to the intensive care unit (ICU) require special care and attention by a multidisciplinary team.[1] The number of obstetric care admissions to an ICU is more in a developing nation when compared with the developed nation, and often this demand is not adequately met. This is attributed to various reasons such as differences in the healthcare system, socio-cultural background and ethnicity.[2] The admission of obstetric patients to the ICU is a challenging task for an intensivist as these patients recover in a short period of time if their management is carried out at the earliest. Thus, it is of utmost importance to keep a continuous vigilance so as to ensure maternal safety. Maternal obstetric morbidity is defined as morbidity arising from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.[3] The areas where high maternal mortality rates have been reported are the ones from where studies are lacking.[4] It is important to fill these lacunae. Obstetric patients require quality care immediately, at the time of delivery and after delivery as the leading cause of maternal morbidity is obstetric haemorrhage. A detailed analysis of such group of patients is an important step for maternal well-being. Hence, this study was undertaken to study the prevalence pattern, clinical characteristics, reasons for admission to the ICU and the interventions required in ICU with their subsequent outcome.

METHODS

This study was conducted in multidisciplinary ICU at a 750-bed tertiary care hospital in northern India. The ICU is a semi-open unit managed by anaesthesiologists round-the-clock, in consultation with relevant departments, and admits approximately 700–800 critically ill patients per year. The obstetric services provide antenatal care to approximately 1300 patients annually and conduct about 1500 deliveries per year.

After due approval from the Institutional Research Committee and with an informed consent, all obstetric patients (pregnant or within 42 days of delivery) admitted to the ICU from 1st October 2015 to 30th September 2016 were enrolled in this study. Data were also collected from the medical records of obstetric patients admitted to the ICU in the past 5 years, that is, from 1st October 2010 to 30th September 2015. As our institute is a high-risk obstetric centre, the case mix was different.

Data collected include demographic characteristics, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score at the time of admission, obstetric and medical history, provisional diagnosis, the reason for ICU admission and interventions required in ICU (monitoring only, non-invasive or invasive ventilator support, inotrope/vasopressor support, cardiovascular support, transfusion of blood or blood products or renal replacement therapy). The outcome measures were recorded in terms of the duration of mechanical ventilation (if applicable), length of stay in ICU, length of stay in the hospital and any mortality in the ICU or hospital, if applicable. All the patients who were included in the prospective and retrospective period were followed up to note their outcome from the ICU (discharged/Leave against medical advice (LAMA)/death).

Categorical variables were presented in number and percentage (%), and continuous variables were presented as mean ± standard deviation and median. Qualitative variables were correlated using Chi-square test. A P value of <0.05 was considered statistically significant. Data were entered in MS Excel spreadsheet, and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0 (IBM, Chicago, USA).

RESULTS

In our study, a total of 109 patients were included, of which 26 patients were admitted during the prospective period and 83 patients in the retrospective time period. Baseline characteristics of these patients are summarised in Table 1.

Table 1

Baseline characteristics of patients

We found that the mean age group of our obstetric patients admitted to ICU was 27.17 ± 5.14 years, and the most common time of admission to our ICU was during the third trimester (46.79%) followed by postpartum period (40.37%). The mean APACHE II score that was calculated on patients on admission to ICU was 16.89 ± 7.48. The number of booked cases was 69 out of 109 patients (63.3%), and 93 out of 109 (85.32%) patients were referred from peripheral centres.

The most common mode of delivery among the obstetric patients admitted to our ICU was caesearean section (51.3%), and all these were done as an emergency, followed by vaginal delivery in 34.86% of the patients.

We found that the most common diagnoses on admission in our patients were pre-eclampsia with eclampsia and HELLP syndrome (Haemolysis, elevated liver enzymes, low platelet count) followed by anaemia and antepartum haemorrhage. We had a total of 42 out of 109 (38.5%) patients admitted with severe pre-eclampsia, eclampsia and HELLP syndrome followed by 30 out of 109 (27.52%) patients with anaemia and 21 of 109 (19.27%) patients with antepartum haemorrhage.

It was observed that severe anaemia was the primary reason for ICU admission in our study. The non-obstetric causes (67.89%) also contributed to admission of these patients in our ICU and these were acute kidney injury, coagulopathy, infections such as post partum H1N1, miliary tuberculosis, dengue with shock and typhoid fever. The provisional diagnosis on admission is illustrated in Table 2, and the non-obstetric causes of admission are represented in Table 3. The most common indication for ICU admission was for respiratory insufficiency and for the requirement of subsequent ventilator support. About 59.63% of the patients were admitted for respiratory insufficiency [Table 4].

Table 2

Provisional diagnosis on admission

Table 3

Non-obstetric causes of admission

Table 4

Indication for ICU admission

The maternal mortality rate in our study was found to be 17.76%. The causes of mortality with APACHE II score of 10–19 were cardiorespiratory arrest following 8 days of ICU admission with severe mitral regurgitation in atrial fibrillation, septic shock with disseminated intravascular coagulation after 5 days of ICU admission, postpartum haemorrhage in hypovolaemic shock on admission to ICU and cardiac arrest with pre-eclampsia. The causes of mortality with APACHE II score of 20–29 were postpartum haemorrhage with multiple-organ dysfunction syndrome, respiratory arrest following suction evacuation for molar pregnancy and purperial sepsis with fulminant hepatic failure after 3 days of ICU admission.

The mean duration of mechanical ventilation was 2.44 ± 2.26 days. The mortality rate in our study was 17.43%. The relationship between APACHE II score and outcome of patients in our study is shown in Figure 1.

Figure 1

Correlation between APACHE II score and outcome

DISCUSSION

As the outcome of critically ill obstetric patients is an indirect indicator of health status in our country, so is the admission rate of these patients to a critical care unit. They give us a foresight as to what has been missed out previously and help us take decisions regarding additional interventions required to guide us for better management in the future.[5] It is an essential part of our healthcare system to conduct studies in the field of obstetric critical care as they highlight the areas where necessary action has to be taken for improvement of the health status in a country. It has been seen that an early and elective transfer of patients to the ICU by identifying the risk factors can help us in achieving the goal of decreasing maternal mortality.[6]

The study conducted by Pollock W et al. reviewed available literature with regard to obstetric admissions in ICU and it showed that a majority of studies highlight ICU admission with scarce data on the outcome, follow-up and multidisciplinary management. Thus, it is necessary to carry out studies wherein the outcome of this group of patients is studied in detail.[7]

The characteristics of patients admitted to ICU are a useful tool to help us in determining their clinical course. An indepth comparison of our patients in the prospective and retrospective group is given in Table 5. We found that age is an important prognostic factor for critically ill obstetric patients. It was inferred from our study that 70.64% of the obstetric patients admitted to our ICU were in the age group of 21–30 years. Bhadade et al. and Cleary Goldman et al. found that increased maternal age is associated with hypertensive disorders of pregnancy, eclampsia, placental problems and maternal mortality.[89] We had one patient in the age group of 40–50 years admitted with molar pregnancy to our ICU. The maximum number of admissions was seen during the third trimester (46.79%) and the postpartum period (40.37%). This finding highlights the importance of early detection and treatment of life-threatening conditions during the third trimester and postpartum period. The importance of antenatal checkups cannot be overemphasised as they help us detect any abnormal conditions at the earliest. The finding of increased number of booked cases requiring ICU when compared with unbooked cases is attributed to the referral of these booked cases during complicated stages to the hospital. The patients who are referred are at an increased risk of complications as precious time is lost in their transport.

Table 5

Comparison between prospective and retrospective group

It has been found that the scoring systems such as APACHE II and III, simplified acute physiological score (SAPS) and mortality prediction model (MPM) are not being used as a routine to assess severity of illness in developing nations.[10] An early detection of clinical deterioration can be done with the help of these scoring systems as they help us in defining admission criteria to the ICU. An APACHE II score between 10 and 19 was calculated in 66.97% of the patients admitted to our ICU. An APACHE II score of more than 30 is associated with increased mortality, and it was observed in our study that five of eight patients who had an APACHE II score of more than 30 had expired in our study. Thus, a patient with a higher APACHE II score should be managed in an ICU, whereas a patient with a lower score can be treated with close observation in an obstetric high-dependency unit. Hence, with these scoring systems we can also use resources in a better way.

The primary diagnosis on admission to the hospital was considered important, and we observed from our study that the most prevalent provisional diagnoses on admission to the hospital were severe pre-eclampsia, eclampsia, postpartum haemorrhage, antepartum haemorrhage, anaemia and for medical reasons.

The study done by Karnad et al. reported that 24% of their admissions to ICU were in view of obstetric haemorrhage, and 53 of 67 patients who survived were diagnosed with postpartum haemorrhage. They also reported that the predicted mortality rate with APACHE II score was higher when compared with the actual observed mortality rate even though the APACHE II scores were higher among the non-survivors. This was attributed to the exclusion of normal physiological changes during pregnancy while calculating the APACHE II scores.[11]

The primary reason for ICU admission was in view of the respiratory insufficiency (59.63%) and subsequent need for mechanical ventilation. This was followed by cardiac and renal insufficiency secondary to the already co-existing obstetric conditions. Karnad et al. also reported that respiratory insufficiency was the most common reason for non-survival.[11] We observed that invasive ventilatory support was the most common intervention (73.39%), and the average duration of patients on ventilator was found to be 2.44 ± 2.26 days. Rathod et al. in their study observed that 40.5% of their patients required invasive ventilator support.[12] The requirement for haemodynamic monitoring was of utmost importance in this group of patients with significant blood loss and altered physiology secondary to pregnancy. About 31.1% of our patients were admitted for haemodynamic monitoring to the ICU. Karnad et al. found that the associated mortality was higher in patients with sepsis when compared with those with pre-eclampsia.[11]

The mean length of stay in ICU was 3.47 ± 3.16 days, and mean length of stay in our hospital was 8.78 ± 6.76 days. As an anaesthesiologist, we should always remember that these group of patients recover well from their critical state if treated at the earliest. A good ICU care with monitoring can save a young productive life.

CONCLUSION

Obstetric morbidity and mortality continues to be an important predictor of the healthcare system in a country, and a continuous vigilance is required to assess the drawbacks and rectify them at the earliest.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.