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Hospitalary Complex of Pontevedra Pontevedra, Spain University Hospital La Paz Madrid, Spain
Correspondence to: José Olarra, MD, C/Dr Cadaval, 4 BIS, 8-A 36202 Vigo, Pontevedra, Spain; e-mail: Jolarra{at}terra.es
To the Editor:
We read with interest the article by Afessa and colleagues (October 2001)1 about obstetric patients needing critical care. We would like to comment on our experience after a retrospective study developed in a tertiary hospital, from 1991 to 1998. During this period, out of 49,717 delivery patients, we admitted 149 patients (0.3%) to the ICU.
Contrary to the Afessa study, where the prevalence of African American women was 64%, most of our patients (85%) were white women, and only 45% had long-term underlying medical conditions. This may explain the different reasons for admission to the ICU between the two studies. In the study by Afessa, the most common reasons for admission to the ICU were respiratory failure (45%) and hemodynamic instability (32%); in our series, however, obstetric conditions (70.4%), especially pregnancy hypertensive disease (50.4%), were the most common reasons for ICU admission. Our most frequent complications were disseminated intravascular coagulation (38%), acute renal failure (19%), and ARDS (14%). The incidence of ARDS in our study was similar to that described by Afessa (15%).
We were surprised by the high incidence of pulmonary edema that developed in patients after emergent cesarean section, as described by Afessa (31%), because we have not found any case of this respiratory complication. We also found it curious that hypertension was listed as the cause for only 5% of the ICU admissions. In their description of complications, Afessa et al referred to as many as 33 cases of eclampsia, preeclampsia, and the syndrome of hemolytic anemia, elevated liver enzymes and low platelet count (HELLP).
In our study, only 35% of patients were treated with mechanical ventilation, fewer than the 45% referred by Afessa. This is probably related to our lower incidence of respiratory failure.
Finally, when comparing fetal and maternal mortality rates, Afessa described a maternal mortality rate of only 2.7%, and eight perinatal deaths (11%); we experienced a maternal mortality rate of 7.5% and a fetal mortality rate of 13%. Although our study would seem to have had high mortality rates, they were quite low compared with those described by Platteau et al2 (21%), Collop and Sahn3 (20% and 35% respectively), Monaco et al4 (18% and 12% respectively), or Kilpatrick and Matthay5 (25%). This is why we were surprised by the even lower incidence found in the Afessa study.
In conclusion and after reading a recent article by Waterstone et al,6 we think future studies should try to estimate the predictor factors of severe obstetric morbidity, in order to improve prenatal care, perinatal management, and anesthetic procedures. With reliable predictor factors, we could reduce the number of obstetric patients who require critical care, and we could lower the rates of maternal and fetal morbidity and mortality.
References
Mayo Clinic and Foundation Rochester, MN
Correspondence to: Bekele Afessa, MD, FCCP, Division of Pulmonary and Critical Care, Mayo Clinic and Foundation, 200 First St, SW, Rochester, MN 55905; e-mail: afessa.bekele{at}mayo.edu 
To the Editor:
In the experience related by Olarra et al, 0.3% of the obstetric patients were admitted to the ICU. This rate of ICU admission is similar to the rate reported in the literature. The authors mentioned some differences between their findings and ours.1 We are not surprised by these differences, because variations are likely to exist between our hospital and theirs with regard to patient mix, ICU admission criteria, and hospital settings. Similar to the observation by Olarra et al, others have reported hypertensive diseases of pregnancy to be the most common reason for ICU admission.2 3 Like the study by Lapinsky et al,4 respiratory failure and hemodynamic instability were responsible for ICU admission of 80% of the patients in our study.1 Eclampsia, preeclampsia, the syndrome of hemolytic anemia, elevated liver enzymes, and low platelet count (HELLP) were present in 33 of our patients.1 Although these 33 patients may have had coexistent hypertension, that condition was the reason for ICU admission in only 5 patients. Our obstetric unit has equipment and staff to provide care to noncomplicated cases of hypertension without ICU admission, explaining this observation. Although there was no significant difference in the incidence of pulmonary edema between patients who did and did not undergo emergent cesarean section, pulmonary edema was the most common reason for ICU admission in our study.1 A large, earlier study had also shown that pulmonary edema is a common occurrence in obstetric patients admitted to ICU.5 We are surprised by the absence of any case of pulmonary edema in the study by Olarra et al.
The reported mortality rate of obstetric patients admitted to ICU ranges between 0% and 36%.1 The mortality rate reported by Olarra et al is within this range. Heterogeneity of the patient population and differences in disease severity may account for the differences in the reported mortality rates of critically ill obstetric patients. We agree with Olarra et al on the need for future studies to identify the risk factors for obstetric-associated critical illness, in order to decrease the associated morbidity and mortality.
References
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