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doi:10.1378/chest.06-2388
(Chest. 2007; 131:718-724)
© 2007 American College of Chest Physicians
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Clinical Characteristics and Outcomes of Obstetric Patients Requiring ICU Admission*

Daniela N. Vasquez, MD; Elisa Estenssoro, MD; Héctor S. Canales, MD; Rosa Reina, MD; María G. Saenz, MD; Andrea V. Das Neves, MD; María A. Toro, MD and Cecilia I. Loudet, MD

* From the Intensive Care Unit, Hospital Interzonal General de Agudos Gral, San Martín, La Plata, Buenos Aires, Argentina.

Correspondence to: Daniela N. Vasquez, MD, Intensive Care Unit, Hospital Interzonal General de Agudos Gral, San Martín, 1 y 70, 1900 La Plata, Buenos Aires, Argentina; e-mail: danielavasquez73{at}yahoo.com.ar

Abstract

Objectives: To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death.

Design: Retrospective cohort.

Setting: Medical-surgical ICU in a university-affiliated hospital.

Patients: Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005.

Interventions: None.

Measurements and results: We studied 161 patients (age, 28 ± 9 years; mean gestational age, 29 ± 9 weeks) [mean ± SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 ± 8, with 24% predicted mortality; sequential organ failure assessment score was 5 ± 3; and therapeutic intervention scoring system at 24 h was 25 ± 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014).

Conclusions: Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.

Key Words: acute physiology and chronic health evaluation II • antenatal care • ARDS • critical illness • intracranial hemorrhage • obstetrics • organ failure • septic abortion

Critically ill obstetric patients represent an interesting group with unique characteristics, whose management is challenged by the presence of a fetus, an altered maternal physiology, and diseases specific to pregnancy.123 Pregnant patients account for a small number of ICU admissions in developed countries (≤ 2%), but they can reach up to 10% or more in developing countries.45 Although there have been several studies67891011121314 on critically ill obstetric patients, there is only one study15 coming from South America. Additional reports might help to increase information about this group of patients and, especially, about preventable factors that adversely affect maternal/fetal outcomes in undeveloped regions. Therefore, our objectives were as follows: (1) to review a series of critically ill obstetric patients admitted to our ICU in order to assess the spectrum of diseases, acuity, interventions required, and fetal/maternal mortality; and (2) to identify conditions associated with maternal death.

Materials and Methods

This retrospective cohort study took place in an 8-bed, medical-surgical ICU in a 449-bed, university-affiliated public hospital in La Plata, Province of Buenos Aires, Argentina. The Obstetric Service of the hospital provides antenatal care for 9,000 patients annually, of which 16% constitute high-risk pregnancies. Maternal-fetal specialists are available 24 h/d. The Ethics Committee of the hospital approved the study, and anonymity of patients was preserved. All pregnant and < 42-day postpartum patients admitted to the ICU between January 1, 1998, and September 30, 2005, were included. Patients were managed by the ICU team, and the obstetric team was consulted daily.

Data Collection
For each patient, the following data were recorded: age; admission diagnosis; severity of acute illness (acute physiology and chronic health evaluation [APACHE] II score)16; level of interventions during the first day (therapeutic intervention scoring system [TISS] 24-h score)17; organ dysfunction (sequential organ failure assessment [SOFA] score)18; comorbid conditions (presence of underlying diseases such as chronic hypertension, diabetes, HIV infection, asthma, others); obstetric history (gestational age in weeks at hospital admission or at delivery, gravidity, and appropriateness of antenatal care); use of mechanical ventilation (MV); presence of shock and ARDS; maternal and fetal mortality; and ICU length of stay (LOS). Expected maternal mortality was calculated according to APACHE II categories of disease.16

Shock was defined as a reduction of 40 mm Hg of systolic BP from baseline despite adequate fluid resuscitation, along with presence of perfusion abnormalities that might include oliguria, lactic acidosis, or acute altered mental status. ARDS was diagnosed according to the American-European Consensus Conference on ARDS.19 Sepsis and septic shock were identified by the definition of the American College of Chest Physicians and the Society of Critical Care Medicine.20 Organ dysfunctions were evaluated with SOFA score (≥ 3 points per item of characterized organ failure). Maternal mortality was considered as death occurring during pregnancy or within 6 weeks of delivery, in agreement with the International Classification of Diseases version 10.21 Perinatal death was considered to have occurred if happened prior or within 6 weeks of birth.8 Antenatal care was deemed adequate when five or more visits per pregnancy were accomplished.22

Acute diseases leading to ICU admission were grouped into obstetric and nonobstetric. Obstetric disorders were those occurring only during pregnancy or in the postpartum period, and were diagnosed using previously defined criteria.123 Nonobstetric disorders were those that could also occur in nonpregnant women. Obstetric status on hospital admission was recorded as antepartum or postpartum.

Data Analysis
All data were collected prospectively as part of the ICU database. Categorical data are displayed as percentages. Continuous data are reported as mean ± SD, or as median and interquartile range (IQR) according to presence or not of a normal data distribution.

Comparisons were performed with an unpaired t test for continuous, normally distributed data, or with a Wilcoxon signed-rank test for continuous nonnormally distributed data. For multiple comparison procedures, one-way analysis of variance or the nonparametric Kruskal-Wallis test were used. Post hoc comparisons were performed with unpaired t test and Wilcoxon rank-sum test as required, followed by Bonferroni correction. Categorical variables were analyzed by {chi}2 test or Fisher exact test, as appropriate. Multiple comparisons of categorical variables were performed with multiple {chi}2 tests, with Bonferroni correction. A two-sided {alpha} < 0.05 was considered as significant. Statistical software (STATA 8.0; StataCorp; College Station, TX) was used for data analysis.

Results

During the recorded period, 161 obstetric patients were admitted to the ICU (10% of 1,571 ICU admissions, and 0.7% of 23,044 deliveries occurring in the hospital). This is equivalent to 699 ICU admissions per 100,000 deliveries. General characteristics, ICU interventions, and obstetric histories are shown in Table 1 .


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  		Table 1. General Characteristics of Patients and Principal Diagnoses*

 
Of the 161 patients, 102 were admitted in the postpartum period and 59 were admitted in the antepartum period. Diagnoses leading to ICU admission are displayed in Table 2 . In terms of obstetric history, women admitted with septic abortion had a mean gravidity record of 7 ± 2 pregnancies (mean ± SD), compared to 3 ± 3 in the rest (p = 0.0007).


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  		Table 2. Admission Diagnoses (n = 161)*

 
Fifty-four patients had underlying diseases (34%),with chronic hypertension, diabetes, and HIV infection as the most frequent. Specifically, one third of patients with community-acquired pneumonia (CAP) had HIV infection.

The ICU maternal mortality rate was 11%, or 78 deaths per 100.000 deliveries. Causes of death are shown in Table 3 .


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  		Table 3. Causes of Maternal Death in 18 Patients

 
Obstetric and nonobstetric causes of admission had similar death rates (9% vs 17%, p = 0.15). APACHE II scores were 13 ± 8 and 15 ± 8, respectively (p = 0.12), with predicted mortality rates of 24% and 27%. Neonatal mortality rate was 32%. Antenatal care was provided to only 48 patients, and was deemed adequate in just 25 patients. Only 1 of 18 nonsurvivors, vs 47 of 143 survivors, received some kind of antenatal care (6% vs 33%, p = 0.014). This was most evident in the largest admission subgroup (hypertensive disorders of pregnancy) in which antenatal care was totally absent in nonsurvivors.

Almost half of patients presented one or more organ failures, with distributions and outcomes described in Table 4 . Cardiovascular plus respiratory failure was the most common pattern of multiple organ failure.


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  		Table 4. Distribution of Organ Failures

 
The most frequent indications for MV were acute respiratory failure (39%) and hemodynamic failure (38%), followed by impaired consciousness (17%) and postoperative ventilation (6%). ARDS developed in 30 patients, and its risk factors are shown in Table 5 . ARDS not only worsened prognosis (33% mortality, compared to 6% in patients without ARDS; p < 0.0001) but lengthened ICU LOS from 5 days (IQR, 3 to 8 days) to 13 days (IQR, 7 to 24 days) [p < 0.0001].


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  		Table 5. ARDS in Obstetric Patients (n = 30)*

 
Shock developed in 25% of patients, equally distributed between major hemorrhage and septic causes. Main causes of septic shock were septic abortion (42%), urinary tract infection (16%), and CAP (16%). Although patients with shock were different from patients without shock with respect to age (31 ± 1 years vs 27 ± 1 years, p = 0.009), APACHE II (17 ± 1 vs 13 ± 1, p = 0.001), TISS at 24 h (32 ± 2 vs 23 ± 1, p < 0.0001), and SOFA (7 ± 1 vs 4 ± 0.5, p < 0.0001), it did not affect mortality (13% vs 11%, shock vs nonshock; p = 0.76) nor ICU LOS (7 days [IQR, 4 to 18 days] vs 5 days [IQR, 3 to 9 days]; p = 0.08). Septic shock patients were sicker than those with hypovolemic shock (APACHE II score, 20 ± 8 vs 15 ± 7, p = 0.02; SOFA, 8 ± 3 vs 6 ± 4, p = 0.02; MV duration, 13 days [IQR, 5 to 25 days] vs 3 days [IQR, 2 to 7 days], p = 0.047; and ICU LOS, 11 days [IQR, 6.5 to 24.5 days] vs 4.5 days [IQR, 3 to 11.25 days], p = 0.03). Septic shock displayed a trend toward higher mortality (20%, vs 5% in nonseptic shock; p = 0.34).

Discussion

The main findings of our study are as follows: (1) the high number of septic abortions as obstetric causes of admission; (2) the different types of nonobstetric causes of hospital admission in comparison to other developing countries, with pneumonia as the prevalent single clinical entity; (3) the high ICU admission and the low mortality rates in comparison to other developing countries, with similar outcomes to some developed countries; (4) the poor performance of APACHE II score in the ICU obstetric subpopulation; and (5) the identification of preventable risk factors for maternal/fetal mortality as the lack of antenatal care, together with other conditions associated with maternal mortality, as illegal abortion practices. Little is known about critically ill obstetric patients in South America.414 So far, the only available report comes from Brazil and includes 68 patients.15 However, the ICU admission rate of pregnant patients in our study (699 ICU admissions per 100,000 deliveries) is higher than in Brazil, and also than in India (140 admissions and 548 admissions per 100,000 deliveries, respectively).1511 Our hospital acts as the largest referral center in the Province of Buenos Aires (14,000,000 inhabitants), which can explain these high figures.

Consistent with previous studies,1671012 most hospital admissions occurred in the postpartum period, with hypertensive disorders of pregnancy and major hemorrhage as the main obstetric causes.56711 Patients with hypertensive disorders of pregnancy were less acutely ill, required lower levels of MV, and had fewer organ failures than the rest, except for patients with major hemorrhage. Mortality in patients with hypertensive disease of pregnancy was only 8%; however, all deaths occurred in patients not receiving antenatal care.

Sepsis of pelvic origin was very frequent on hospital admission, with septic abortion as the leading cause. This is unique to this group, and causes might be tracked to poverty, unequal access to health care, inefficient or absent birth control policies and, essentially, illegality of abortion practice in Argentina. Some remarkable characteristics distinguish this subset of patients: severity of illness on hospital admission, as shown by high APACHE II score, presence of multiple organ dysfunction syndrome (MODS), and increased use of MV. Septic abortion was the second cause of mortality in the whole group of obstetric patients. Nevertheless, the low frequency of comorbidities (16%) indicates a healthy previous condition and the possibility of full recovery. Finally, a mean age of 31 years, together with a mean gravidity of 7 ± 2 prior pregnancies, suggests an adult decision regarding terminating pregnancy, as well as an economic underlying reason.

Nonobstetric causes of hospital admission display a wide geographic variation.7891011 In this study, the principal disorders were nonobstetric sepsis, respiratory failure, and intracranial hemorrhage (ICH). CAP and urinary tract infection were the most common single causes of sepsis, as in most developed regions,7891024 and differs from reports from other developing countries, where malaria and viral hepatitis prevail.1115 These diseases are uncommon in Argentina. The presence of CAP was associated with high APACHE II score, number of failing organs and requirement of MV, longer ICU LOS, and a high incidence of ARDS and shock. One third of the patients had HIV infection. CAP is a well-known risk factor for maternal mortality, onset of preterm labor, and low birth weight at delivery, and in some cases can be prevented by pneumococcal vaccine, usually recommended to women with underlying diseases.225

As previously shown in most reports610111213 of critically ill obstetric patients, APACHE II score overpredicted mortality. Different factors could account for this: first, normal physiologic changes occurring in pregnancy may misleadingly increase scoring points, as high heart rate and respiratory frequency, or low hematocrit counts. Second, the original database of APACHE II might have not included enough obstetric patients to calibrate properly for this population. Finally, reversibility of many conditions leading to ICU admission could decrease the score predictability in obstetric patients.34626

In the present study, maternal ICU mortality was 11%, which compares fairly to the 0 to 12% mortality rate in developed countries.479 This acceptable performance—even within a medical-surgical unit, which tends to have sicker patients than the obstetric units—might be due to the 24-h presence of critical care specialists,512 a 24 h/d available obstetric team, and an aggressive obstetric approach.1424 There were no differences in mortality between patients admitted for nonobstetric vs obstetric reasons, nor in their APACHE II observed/predicted mortality ratio. This differs with the study by Karnad et al,11 who found higher mortality and closer observed/predicted rate in patients with nonobstetric causes of admission.

Main causes of death were MODS (44%) and ICH (39%). The relative risk for ICH during pregnancy and 6 weeks after delivery is 5.6 times compared to nonpregnant patients.27 The incidence of ICH, a well-known risk factor for mortality in the peripartum period,5791112 has decreased in the last decades in developed countries but is still an important cause of death in developing regions. And, above all, ICH can be prevented or timely controlled. For example, hypertension control is key to prevent ICH in severe preeclampsia.2 In our study, patients presenting with ICH were the most acutely ill, had the maximal requirements of MV, and had the highest incidence of ARDS and organ dysfunction.

MODS was quite prevalent. Similarly to developed countries, respiratory, cardiovascular and hematologic failures were the most common. In developing regions, neurologic and renal failures usually prevail.341014 In this study, neurologic and hematologic failures had the highest incidence of mortality. MODS was especially frequent (84%) in patients with septic abortion.

MV use was frequent (41% of patients), similar to other studies,6101315 and different to data from developing countries like India (18.5%).11 There is a paucity of information about indications of MV in pregnancy.828 We found that the most frequent causes of its initiation were acute respiratory and hemodynamic failures.

ARDS developed in 19% of patients. As in a general ICU population, ARDS was mainly associated with sepsis, with CAP and septic abortion as the underlying causes in half of the population. ARDS increased ICU LOS and mortality (13 days [IQR, 7 to 24 days] vs 5 days [IQR, 3 to 8 days] and 33% vs 6%, respectively, compared with patients without ARDS). Nevertheless, mortality related to ARDS in this group of patients still remains lower than in general ICU populations (40 to 60%).72930 Lower age, fewer underlying diseases and, in some cases, rapid resolution of illness after delivery might explain these differences.11

Twenty-five percent of patients had shock, equally distributed between major hemorrhage and septic causes. Patients with shock were older, sicker, and required more interventions; however, it had no effect on outcome. The mortality of 13% is strikingly different from that reported in a general population.3132 Rapidly reversible causes of shock (major hemorrhage and septic abortion) in two thirds of patients might explain this unexpected finding. Nevertheless, septic shock displayed a tendency toward a worse outcome.

Antenatal care was clearly deficient in this cohort. Similarly to the report of Karnad et al,11 only 30% of patients received some kind of antenatal care, which was adequate in, roughly, half of the patients. In addition, antenatal care was strikingly less frequent among nonsurvivors. This is an important and modifiable risk factor for a bad outcome.34111314 Perinatal mortality was 32%. Although lower than in other developing countries,11 where it can reach 52%,11 it is still far from data (10 to 14%) reported from developed countries.933

This study has certain limitations. First, it has a retrospective design. However, data were prospectively collected, as part of the ICU standard operating protocol. Second, a multivariate predictive model could not be built since there were too few deaths. Notwithstanding it, sample size is large, and so is adequate to draw meaningful conclusions. Finally, this is a single-center study.

In summary, this study underlines the unique characteristics of critically ill obstetric patients, in comparison to the rest of ICU population. Despite the elevated incidences of ARDS, shock, and organ dysfunctions, and the high levels of intervention and MV, obstetric patients had better outcomes than those predicted by APACHE II scores. These results also support the poor performance of the APACHE II score in this subpopulation. And very importantly, this study identifies risk factors for mortality that are clearly modifiable. The great proportion of septic abortions highlights the urgent need of improved birth control policies, which might include the legalization of abortion. However, the absence or inadequacy of antenatal care remains a public health debt. Government efforts should concentrate in reducing morbidity and mortality in these patients, mostly considering that they can return to full productivity.

Footnotes

Abbreviations: APACHE = acute physiology and chronic health evaluation; CAP = community-acquired pneumonia; ICH = intracranial hemorrhage; IQR = interquartile range; LOS = length of stay; MODS = multiple organ dysfunction syndrome; MV = mechanical ventilation; SOFA = sequential organ failure assessment; TISS = therapeutic intervention scoring system

The authors have no conflicts of interest to disclose.

Received for publication September 28, 2006. Accepted for publication November 22, 2006.

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