Non-obstetric causes of admission in obstetric intensive care unit

Abstract

The Millennium Development Goal (MDG) is to reduce Maternal mortality rate by three-fourth between 1990 and 2015. In 1990 the estimated global maternal mortality ratio (MMR) was 400 deaths per 100,000 live births, which has come down to 210 (-47%) in 2010, but the progress of individual countries has been variable. The major direct causes of maternal mortality are estimated to be responsible for 75-80% of maternal deaths and result from the complications of pregnancy like eclampsia, high blood pressure (HBP), postpartum haemorrhage (PPH), infection/sepsis, unsafe abortion and prolonged/obstructed labour in addition to indirect and other contributory/social causes. These major direct causes mainly haemorrhage, and hypertensive disorders are also the leading causes of near-miss events. Due to these near-miss events, the patients are labelled as critically ill and require intensive care. In a study published in 2006 analyzing the profile of ob¬stetric admissions to the ICU, the three leading causes of ad¬mission were hypertensive and hemorrhagic disorders of pregnancy, and puerperal infections, while non-obstetric diseases accounted for 5.7% of causes of hospitalization. Most women admitted at the ICU have an obstetric diagnosis as cause of hospitalization (50-80%); however, these women tend to have a better prognosis when com-pared to women admitted to the ICU for clinical reasons. The most frequently found clinical conditions were: heart diseases, venous thromboembolism, sepsis and septic shock, severe asthma, acute pulmonary edema, pneumonia (community-acquired and hospital-acquired), stroke, diabetic ketoacidosis. In women with heart disease, maternal mortality is reported to be much higher than average and the risk appears to be increasing such that in western countries heart disease is the major cause of maternal death. However, we do not fully understand what the impact of pregnancy is on the progression of heart disease or how heart disease affects the outcome of pregnancy. The full spectrum of structural heart disease including congenital heart disease (CHD), valvular heart disease (VHD), and cardiomyopathy (CMP), and also ischaemic heart disease (IHD) may be encountered in pregnant women. In developing countries that still struggle with a high prevalence of rheumatic fever, acquired VHD dominates, whereas in developed countries, CHD is the main diagnostic group. In addition, over the last few years, the incidence of an acute coronary event during pregnancy has increased, due to older child-bearing age, and changes in lifestyle with more hypertension, smoking, and obesity in women. Pregnancy in patients with heart disease results in a maternal mortality of 1%, which is a hundred times higher than in normal pregnant patients. However, clear differences were found in pregnancy outcomes with respect to the underlying diagnosis and between patients in developed and developing countries. Most patients with adequate counselling and optimal care should not be discouraged and can go safely through pregnancy. Hypertensive disorders in pregnancy contribute to significant mortality and morbidity worldwide, and affect 5% of pregnancies. Rapid onset interstitial fluid accumulation in the lungs, acute pulmonary oedema (APO), is a potential complication of maternal hypertension, seen particularly in women with preeclampsia and eclampsia. APO has also been linked to increased maternal age, delivery via Caesarean section, body mass index, parity, undiagnosed cardiomyopathy, multiple gestation, corticosteroid use, colloid therapy and magnesium sulphate (MgSO4) use. Medical therapies to treat pulmonary edema should be optimized to expedite treatment results. Bladder catheterization allows for accurate measurement of urine output. Most patients will respond to initial diuresis therapy. Oxygen saturation should be monitored using a pulse oximeter, and oxygen supplementation using a nonrebreather facemask can be used to treat maternal hypoxemia. In addition to these standard measures, it is appropriate to follow the patient’s blood pressure, electrocardiogram, and fetal heart rate tracing.