Critical Pregnancy Care
Childbirth is a major event in the lives of mothers and their families. Critical pregnancy is uncommon but may arise from conditions unique to pregnancy, conditions exacerbated by pregnancy, and coincidental conditions. Hypertensive disorders in pregnancy and hemorrhage remains a leading direct cause of mortality. However, there has been an increase in mortality due to indirect causes. The obstetric population has changed over past decade and we are caring for much older mothers with pre-existing disorders and advanced chronic medical conditions. It is therefore essential to adopt an early multidisciplinary approach for the care of these women. With birth rates increasing, complex caseloads and changes in training of both medical and nursing staff, the challenge of caring for critically ill obstetric patients requires urgent attention. Although some women with severe hypertensive disorders of pregnancy will require admission to adult critical care units, the majority receive care within the maternity unit.
Critical Pregnancy Care
A multidisciplinary team including the intensivist, obstetrician, maternal-fetal medicine specialist, anesthesiologist, neonatologist, nursing specialist, and transfusion medicine expert is key to optimize outcomes. Severe preeclampsia and its complications, hemolysis, elevated liver enzymes, and low platelets syndrome, and amniotic fluid embolism, which cause significant organ failure, are reviewed. Obstetric conditions that were not so common in the past are increasingly seen in the ICU. Massive hemorrhage from adherent placenta is increasing because of the large number of pregnant women with scars from previous cesarean section. With more complex fetal surgical interventions being performed for congenital disorders, maternal complications are increasing. Ovarian hyper-stimulation syndrome is also becoming common because of treatment of infertility with assisted reproduction techniques.
Other indirect causes are on the increase. The reason for this is that the obstetric population has changed over the decades. The obstetric population is much older, with co-morbidities including essential hypertension, type 2 diabetes and even coronary heart disease. Obesity is a major concern and in pregnancy provides numerous challenges. We are encountering women with chronic medical conditions that previously precluded them from pregnancy. Improved medical care and assisted reproductive techniques now enable them to become pregnant. Women from socially deprived areas and recent immigrants may present late with advanced medical problems. All of these factors add up to a more complex, high-risk caseload with an increasing need for specialist input by obstetric physicians, intensive care and above all early multidisciplinary teamwork.
Majority of obstetric admissions to the intensive therapy unit are postnatal, antenatal cases (the majority of whom are not suffering from conditions directly related to pregnancy) present particular challenges. With birth rates increasing, complex caseloads and changes in training for both medical and midwifery staff, the challenge of caring for critically ill obstetric patients will become greater. Simulation, skills and drills training, and reinforcement of medical guidelines have been shown to improve aspects of crisis resource management such as communication, teamwork and leadership. Sharing medical and nursing expertise with experience from other high-dependency and intensive care areas is essential to optimise the care of the critically ill pregnant patient.