Soumya Ranjan Panda He has passed his MS (Obstetrics and Gynecology) from VSS MCH, Burla, Odisha, in 2014. At present, he is a senior resident in the Department of Obstetrics and Gynecology, IMS, BHU, Varanasi
Background: The critically ill obstetric patient represents a
challenge that usually requires a multidisciplinary
approach. Lack of awareness and the absence of regular
antenatal care make the critically ill patients to be referred
late and sometimes in moribund conditions. The objective
of the present study is to determine the incidence, predictors
and outcome of obstetric ICU admissions.
Methods: This retrospective study was conducted over a
period of 2 year from July 2015 to June 2017 in Department of Obstetrics and Gynecology at Institute of
Medical Sciences, BHU, Varanasi, India.
Results: Out of a total of 4986 deliveries, 756 patients
underwent HDU admission, while 92 obstetric patients
were admitted to ICU during this study period. Maximum
number of patients (73.91%) were in the age-group of
20–35 years, 64.13% of patients constitute lower socioeconomic
status group, 68.47% of patients reside in rural
area and there was inadequacy in receiving antenatal care
in case of 60.86% of patients. Maximum number of
patients were admitted for a period of 4–7 days. Blood
transfusion (64.1%), the use of inotropic drugs (45.6%),
central line placement (44.5%) and mechanical ventilation
(26.08%) were the major interventions performed in ICU.
Obstetric hemorrhage was found to be the most frequent
clinical diagnosis leading to ICU admission (31.5%) followed
by hypertensive disorders (25%).
Conclusion: In addition to timely referral, health education
and training of health professionals may improve clinical
outcome and better obstetric practice, especially in countries like India. Obstetric ICU dedicated for the
management of only obstetric patients should be constructed
in order to compensate for heavy burden critically
ill women.
Keywords: Obstetric ICU HDU Maternal mortality
Pregnancy is a special physiological condition in a woman’s life but sometimes could have detrimental effect to the extent of severe maternal morbidity or mortality. The critically ill obstetric patient represents a challenge that usually requires a multidisciplinary approach. Lack of awareness and the absence of regular antenatal care make the critically ill patients to be referred late and sometimes in moribund conditions. In order to provide them specialized care and reduce maternal mortality and morbidity, specialized obstetric intensive care units and high dependency units need to be established. Evaluation of obstetric admissions to intensive care unit (ICU) is one of the ways to approach surveillance of critically ill women in pregnancy in a tertiary care facility [1]. Data from developed countries show an ICU admission rate of 0.1–1.7% [2].
Objective: The objective of the present study is to determine the incidence, predictors and outcome of obstetric ICU admissions.
This retrospective study was conducted over a period of 2
year from July 2015 to June 2017 in Department of
Obstetrics and Gynecology at Institute of Medical Sciences,
BHU, Varanasi, India. It is a tertiary care center
getting referrals not only from nearby cities and hospitals
but also from major cities of neighbor states like eastern
Uttar Pradesh, Bihar and Madhya Pradesh. It has one
16-bedded ICU with facilities for intubation, ventilation,
CVP monitoring and establishment of arterial lines. During
this time frame, a total of 4986 deliveries have taken place,
756 women were admitted to HDU, while 92 cases were
admitted to ICU.
Data were collected from previous hospital records. All
pregnant women admitted to the hospital (antenatal and
postnatal up to 6 weeks) were included in the study. The
number of above women who needed ICU admission was
noted. The demographic details, indications for ICU admission, any inadequacy of antenatal care, comorbidities,
obstetric features (antepartum history, gestational age,
antenatal abnormalities, mode of delivery, vital signs and
other pregnancy complications) were noted on admission
to the ICU. The causes of admission to ICU were classified
as obstetric and non-obstetric causes. Obstetric disorders
were defined as pregnancy-related condition which occurred
during pregnancy or within 42-days postpartum period.
Non-obstetric conditions were defined as other medical or
surgical conditions that were not pregnancy related. For
each patient, data pertaining to ICU interventions like
mechanical ventilation, the use of blood and blood products,
the use of inotropes, anticonvulsants and antihypertensives
were noted. ICU scoring system like APACHE
and SAPS was not used as the obstetric patients are relatively
young and physiological alterations during pregnancy can cause false higher scores because of any
pathology.
Table 1 shows out of a total of 4986 deliveries 756 patients underwent HDU admission, while 92 obstetric patients were admitted to ICU during this study period. Table 2 shows the demographic parameters of patients being admitted to ICU. Maximum number of patients (73.91%) were in the age-group of 20–35 years, 64.13% of patients constitute lower socioeconomic status group, 68.47% of patients reside in rural area, and there was inadequacy in receiving antenatal care in case of 60.86% of patients. There was a delay in seeking treatment and getting admitted to ICU for most of the patients. We found a delay of > 12 h of duration in case of 52.17% of patients. Maximum number of patients were admitted for a period of 4–7 days as evidenced in Table 3. Blood transfusion (64.1%), the use of inotropic drugs (45.6%), central line placement (44.5%) and mechanical ventilation (26.08%) were the major interventions performed in ICU (Table 4). As depicted in Table 5, obstetric hemorrhage was found to be the most frequent clinical diagnosis leading to ICU admission (31.5%) followed by hypertensive disorders (25%). Non-obstetric disorders contribute to about 18.4% of ICU admission. A total of 32 (34.78%) maternal mortalities were noted among all ICU admissions. Out of 32 deaths, 24 (75%) were among the group of women admitted for obstetric causes, and 8 (25%) were among those admitted for non-obstetric causes.
In the present study, out of total obstetric admissions to
hospital, 1.84% were admitted to ICU. Some reports from
previous studies show an ICU admission rate that ranges
from 0.1 to 1.7% [2–5], while other studies show an
admission rate of 3.3% [6]. Similarly, HDU admission rate
in our institute was found to be 15.16%. HDU constitutes
an intermediate level of care between general ward and
ICU. It involves triage of patients and step-up or step-down
support between ward and ICU. However, procedures such
as intubation with mechanical ventilation for advanced
respiratory support, invasive investigations and monitoring
(beyond central venous and long arterial lines) or multiple
organ support are usually not the remit of HDU. In fact, the
presence of a HDU can reduce the number of ICU
admissions by 53%, thus making ICU beds available to
more needy women well in time [4].
Table 2 depicts that those women from lower to middle
socioeconomic status, from rural areas of residency and
having inadequate antenatal care comprise the major bulk
of patients that got admitted to ICU. Most of these women
are unbooked for antenatal visit. Previous studies also have
reported that unbooked women may have more complications,
resulting in an increased need for ICU care [7].
Involvement of more than one organ systems was seen in
94.58% women. The reason for such high percentage of women with multiorgan dysfunction among ICU admissions
is the fact that most of the women with single-organ
system involvement are being managed in the HDU
available in our institute. This is very high in comparison
with previous studies where more than one organ system
was involved in around 20% cases [8]. This reflects on to
the poor health status of our women and the advanced stage
of disease by the time they reach ICU. Criteria for the
transfer of patients to ICU have been described in Table 4.
Most of the patients were having multiorgan dysfunction.
Obstetric complications accounted for the majority of
ICU admissions (n = 75, 81.6%) as compared to non-obstetric
conditions (n = 17, 18.4%). Previous studies [9, 10]
also reported obstetric complications to be a major cause of
admission to ICU. As depicted in Table 5, obstetric hemorrhage
was found to be the most frequent clinical diagnosis
leading to ICU admission (31.5%) followed by hypertensive
disorders (25%). Also worse prognosis was seen with hemorrhagic
disorders with the mortality of around 37.93% as
compared to 28% in hypertensive disorders. Hemorrhagic
complications constituted greater danger to life of affected
woman reflecting need for aggressive treatment. Similar
results were seen in other studies from the literature [11].
The incidence of mortality in cases admitted to ICU was
34.78% which is higher than reported 15–20% from other
developing countries [12]. However, a study conducted in
New Delhi reported a similarly high mortality rate of 40%
[13]. Increased maternal mortality rates reported have been
attributed to treatment by quacks, low socioeconomic status,
poor antenatal care, low hematocrit and undernutrition
of obstetric patients [14].
Most common intervention in ICU was the need for
oxygen and blood transfusion along with intensive monitoring
and care of patient. Authors from other parts of the
world also observed that hemodynamic and respiratory
complications needing inotropic or ventilatory support
remain the most important reasons for ICU admissions, and
the need for support may predict poor outcome [9, 12].
Very few women could present to health facility without
any delay. Study conducted by Bajwa et al. in Banur, India,
also found poor transport facilities, poor rural health
infrastructure, customs and traditions of local community
to be contributing toward an increased ICU admission [15].
Conflict of interest: The authors declare that they have no competing
interests.
Ethical Approval: This article does not contain any study involving
human participants or animal performed by any of the authors, as it’s
a retrospective analysis from the hospital records.
Informed consent: We have obtained the required informed consents.
