|Year : 2017 | Volume
| Issue : 3 | Page : 381-386
Obstetric critical care requirements felt by the obstetricians: An experience-based study
Mohan Deep Kaur1, Jyoti Sharma2, Prasoon Gupta1, Tarun Deep Singh3, Saurav Mitra Mustafi1
1 Department of Anaesthesiology and Intensive Care, PGIMER, Dr. RML Hospital, New Delhi, India
2 Department of Anaesthesiology, PGIMS, Rohtak, Rajasthan, India
3 Intern MGMC, Jaipur, Rajasthan, India
|Date of Web Publication||11-Sep-2017|
H.NO. 313, First Floor, Sector 14, Rohtak - 124 001
Source of Support: None, Conflict of Interest: None
Background and Aims: Pregnancy is a state of physiological stress to a woman's health. Concomitant complications and infections during pregnancy may necessitate intensive monitoring and management of such patients in critical care settings. This study aims to determine the perceptions about the requirement of obstetric critical care based on the experience of obstetricians.
Material and Methods: An observational, questionnaire-based study was conducted in 200 obstetricians working in various settings, who were approached during obstetric conferences. The questionnaire consisted of twenty items and was designed to determine the views of obstetricians, based on their clinical experience, regarding problems at the time of medical or surgical crisis in obstetric patients due to nonavailability of the intensive care services.
Results: Seventeen percent of the participating obstetricians had a facility of dedicated obstetric Intensive Care Unit (ICU) at their institution. In the opinion of 62% of the respondents, ICU bed was made available in cases of crisis. Forty-two percent of the obstetricians reported that it took <10 min for the intensivist to reach the critically ill parturient. According to 32% of respondents, the intensivist could not reach within 20 min. There was a delay of more than 30 min in providing critical care services according to almost half (49%) of the respondents. Postpartum hemorrhage (24%) was the leading cause of ICU admission, followed by pregnancy-induced hypertension (14%) and acute respiratory distress syndrome (12%). A majority (87%) of the obstetricians were strongly in favor of a dedicated obstetric ICU.
Conclusions: Need for a dedicated obstetric ICU is felt by most of the obstetricians to improve patient care.
Keywords: Dedicated obstetric Intensive Care Unit, multidisciplinary team approach, physiological changes
|How to cite this article:|
Kaur MD, Sharma J, Gupta P, Singh TD, Mustafi SM. Obstetric critical care requirements felt by the obstetricians: An experience-based study. J Anaesthesiol Clin Pharmacol 2017;33:381-6
|How to cite this URL:|
Kaur MD, Sharma J, Gupta P, Singh TD, Mustafi SM. Obstetric critical care requirements felt by the obstetricians: An experience-based study. J Anaesthesiol Clin Pharmacol [serial online] 2017 [cited 2018 Jan 20];33:381-6. Available from: http://www.joacp.org/text.asp?2017/33/3/381/214309
| Introduction|| |
Dedicated obstetric critical care is lacking in most of the obstetric centers of developing countries. Obstetric patients are often young and mostly healthy. Pregnancy is a stressful physiological state for the woman. It unmasks or at times worsens the underlying comorbidities. There may be certain superimposed issues such as concomitant obstetric complications and infections. These clinical situations necessitate the requirement of intensive monitoring and management of such patients in critical care settings. In developed countries, the incidence of Intensive Care Unit (ICU) admission of an obstetric patient is 2–4/1000 deliveries as compared to developing countries where it is as high as 2–13.5/1000 deliveries. The incidence of maternal deaths due to critical illness varies from 1% to up to 25% in different developing countries. The majority of these deaths are caused by postpartum hemorrhage (PPH).,,
This study aims to determine the requirement of critical care based on the experience of the obstetricians and the problems experienced by them due to complete lack or delay in accessing these facilities.
| Material and Methods|| |
After getting approval from the Institutional Ethical Committee, we conducted an observational questionnaire-based study. The questionnaire consisted of twenty questions [Appendix 1]. Two hundred obstetricians working in various settings such as government hospitals, corporate medical centers, or individual nursing homes in different cities were interviewed during obstetric conferences. The questionnaire was designed to determine the views of obstetricians based on their clinical experience, the kind of set up in which the obstetricians participating in this study were working, as well as to describe various problems faced by the patients at the time of medical crisis due to nonavailability or delayed availability of intensive care services.
The study was completed over a period of 1 year in which the authors collected data from delegates attending obstetric conferences held in different cities including the capital New Delhi, after seeking appropriate permission/s from the organizers. We tried to collect maximum data points in each conference and were able to complete the data collection in three conferences.
Data comprised 200 questionnaires filled by 200 obstetricians. The data were compiled in Microsoft Excel and analyzed using SPSS version 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) The percentages were calculated for most of the data. Association between various factors and experience of obstetricians was found using Chi-square test, and P value was calculated.
| Results|| |
Baseline data of the participants are presented in [Table 1]. Experience with obstetric complications requiring critical care has been presented in [Table 2]. Seventeen percent of the participating obstetricians had a dedicated obstetric ICU facility at their workplace. ICU bed was made available in case of a medical crisis for 62% of the respondents while the patients of the remaining 38% of respondents did not receive ICU care due to the lack or shortage of facilities. Forty-two percent of the obstetricians reported that it took <10 min for the intensivist or the anesthesiologist to reach the site of the critically ill parturient. In rest of the 58% cases, there was a delay of more than 10 min.
|Table 2: Experience with obstetric complications requiring critical care|
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PPH (24%) was found to be the leading cause of ICU admission. This was followed by pregnancy-induced hypertension (14%) and acute respiratory distress syndrome (12%). Other important but rarer causes included pulmonary embolism, sepsis, disseminated intravascular coagulation, antepartum hemorrhage, and shock as well as medical conditions which mainly include cardiac diseases and severe anemia. Operative complications, postoperative injury, poor antenatal care, and delayed help and referral system at their centers were among the other causes mentioned by the obstetricians for the deterioration of the condition of their patients and requirement of intensive care services [Table 3].
Suggestions for improvement and better management of critically ill obstetric patients and lacunae in the management have been summarized in [Table 4]. Association between the number of complications and the years of experience of the participants has been shown in [Table 5]. No significant difference was found between the number of complications observed over last 2 years and the number of years of experience of the obstetrician (P = 0.190). Association of the time of delay of arrival of the intensivist and years of experience of attending obstetricians has been shown in [Table 5]. Data were suggestive of an association between these two factors, but it failed to achieve a statistical significance (P = 0.065).
|Table 4: Suggestions for improvement and better management of critically ill obstetric patients and lacunae in the management|
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|Table 5: Association of number of obstetric complications and delay in time of intensivist with years of experience of obstetrician|
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A few of the participants suggested that strengthening of antenatal services should be done at grass root level. This can be done by creating awareness among women of childbearing age and training of midwives. A few others focused on a multidisciplinary approach and a more coordinated teamwork within various departments while giving suggestions to improve obstetric critical care.
| Discussion|| |
Obstetric patients are a special group of patients as their care requires caring for two lives. In addition, these women have altered physiology. During pregnancy, they develop physiological anemia, hypercoagulability, generalized edema, and blood vessel fragility. The gravid uterus compresses the inferior vena cava. Due to these factors, these women are prone to decompensate in the presence of medical insults such as hypoxemia, hypotension, and anemia. Furthermore, their airway may be difficult to manage due to estrogen and weight gain-mediated airway edema. Critically ill obstetric patients pose a challenging situation for the intensivist, obstetrician, and the pediatrician. A multidisciplinary team approach is required for their management. However, the role of the obstetrician is of utmost importance whose supervision, vigilance, skill, and knowledge of critical events of obstetric patients can decrease maternal morbidity and mortality to a great extent.
Maternal safety has always been given priority. However, as far as possible fetal well-being should also be kept in mind and interventions which are safe for both mother and child should be considered. Acquisition of special procedural skills and knowledge of the pathophysiological changes of the underlying disease is essential for providing high-quality intensive care. The prime requirement for this is the supervision and cooperation of the obstetrician in addition to continuous vigilance and care by the intensivist. Therefore, the round-the-clock availability of dedicated obstetric critical care services is the need of the hour.
Government and corporate hospitals have got critical care setups though not dedicated obstetric critical care. It is only the obstetricians working in the nursing homes that represent the true segment of obstetric practice devoid of critical care arrangements. Provision of ICU attachments is mandatory for these nursing homes to have complete obstetric care facility. Hence, this segment of obstetricians was also included in the study.
We did not fix specific numbers for interviewing obstetricians working in different hospital settings such as government, corporate, or nursing homes, so our results do not point to any specific health care setting.
For best delivery of obstetric critical care, a closed ICU is preferable over an open ICU. Open ICU implies that the physician-in-charge of the patient is responsible for the patient's admission to the ICU as well as her treatment. The intensivist does not have the primary responsibility of the patient whereas in a “closed” ICU the patient is admitted to the ICU directly under the intensivist. Closed ICUs of various specialties have been associated with a lower ICU mortality as compared to open ICUs.
In developed countries, only 0.2–0.9% of parturients require critical care. However, in developing countries like India, empirically speaking, this figure seems high and has not actually been calculated. The incidence of maternal deaths due to critical illness varies from 1% to as high as 25% in different developing countries. PPH is one of the leading causes of maternal mortality in developing countries. It was found in a systematic review conducted by the World Health Organization that PPH is the leading cause of maternal mortality in Africa and Asia, accounting for approximately 50% of the total number of maternal deaths in this region., Overall PPH accounts for an estimated 25% of maternal mortality worldwide. Tang et al. in their series of patients also reported PPH to be consistently the most common indication for ICU admission. The obstetricians who participated in this study also observed that PPH was the leading cause of ICU admission in 23.6% cases. Early detection and timely and appropriate intervention can avoid or reduce the effects of PPH. Due to the lack of dedicated obstetric ICUs and nonavailability of ICU beds in general ICUs, the patient may clinically deteriorate as there is a delay in delivery of intensive care. Massive transfusion of blood products may be required which has its inherent complications. Hence, this should best be done under intensive monitoring in the intensive care settings. Another area of concern in managing these patients is the availability of a blood bank. Dedicated obstetric hospitals, nursing homes, and clinics are mostly equipped with their own blood banks. Smaller setups/nursing homes get approval by the government for obstetric practice only after ensuring the availability of essential requirements, one of which is a liaison with a dedicated blood bank in its vicinity. However, prior availability of specific blood and emergency blood bank facility should be ensured in elective cases. For emergencies, blood bank facility should be available round the clock.
Lack of proper and uniform ICU scoring systems has also led to poor management of critically ill obstetric patients. The criteria used in scoring systems which are routinely used such as Acute Physiology and Chronic Health Evaluation, Mortality Probability Models II, and Simplified Acute Physiology Score II do not differentiate the physiological changes of pregnancy from the pathological changes in this group of patients. This leads to an overestimation of mortality in critically ill parturients., A uniform scoring system needs to be designed for obstetric patients, taking into consideration the altered physiology during pregnancy. Such a system will work best if there is a dedicated ICU that deals only with obstetric patients.
Family health care is woman oriented in developing countries. Greater morbidity and mortality of obstetric patients becomes a liability for the family as well as the society. Hence, availability of ICU for obstetric patients will lead to a reduction in their morbidity and mortality and improve the family care and resources.
Similar studies if done in different parts of the country may help determine the incidence of various problems in those regions and may also point out to the problems analyzed our study in a wider perspective.
Limitations of the study
There are two major limitations of this study. First, it is a questionnaire-based study. The results tell us about what the obstetricians remember about the complications and not the facts regarding the incidence of obstetric complications or ICU admissions. Second, the obstetricians attending the conferences were interviewed. Therefore, the participants are not the true representatives of all the obstetricians leading to selection bias of the participants.
| Conclusions|| |
In spite of the limitations, some conclusions can be drawn from the present study. The majority of the obstetricians feel a need of dedicated obstetric ICU at their institution and the earliest possible help from the intensivist to manage critically ill patients. It also needs to be focused that the training and curriculum of obstetricians need to be modified so that they can themselves carry out intensive care procedures by the time specialist help is reached.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bajwa SJ, Kaur J. Critical care challenges in obstetrics: An acute need for dedicated and co-ordinated teamwork. Anesth Essays Res 2014;8:267-9. [Full text]
Ramachandra Bhat PB, Navada MH, Rao SV, Nagarathna G. Evaluation of obstetric admissions to intensive care unit of a tertiary referral center in coastal India. Indian J Crit Care Med 2013;17:34-7.
Gombar S, Ahuja V, Jafra A. A retrospective analysis of obstetric patient's outcome in intensive care unit of a tertiary care center. J Anaesthesiol Clin Pharmacol 2014;30:502-7.
] [Full text]
Khan KS, Wojdyla D, Say L, Gülmezoglu AM, Van Look PF. WHO analysis of causes of maternal death: A systematic review. Lancet 2006;367:1066-74.
Snelgrove JW. Postpartum haemorrhage in the developing world a review of clinical management strategies. Mcgill J Med 2009;12:61.
Singh Bajwa SJ. Emergency and critical care challenges during pregnancy. J Pain Relief 2012; S1:e001.
Chittawatanarat K, Pamorsinlapathum T. Effects of a closed ICU model on a general surgical ICU. Crit Care 2009;13 Suppl 1:P479.
Bajwa SJ, Bajwa SK. Critical care in obstetrics: Essentiality, initiatives, and obstacles in Indian scenario. J Anaesthesiol Clin Pharmacol 2014;30:459-61.
] [Full text]
Tang LC, Kwok AC, Wong AY, Lee YY, Sun KO, So AP. Critical care in obstetrical patients: An eight-year review. Chin Med J (Engl) 1997;110:936-41.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]