Critical Illness In Pregnancy Research Articles

Patient-reported outcomes in research on critically ill obstetric patients

Background Research benefits from the incorporation of patient-important outcomes. We interviewed individuals after a critical illness during pregnancy to identify outcomes for the development of a core outcome set (COS). Methods Participants were identified through intensive care unit (ICU) admissions in Toronto, Canada, and Barranquilla, Colombia. Interviewers used a semi-structured guide, and discussions were recorded and transcribed. Transcripts underwent inductive thematic analysis to delineate themes and patient-important outcomes. Results Twelve individuals were interviewed. Twenty-six patient-important outcomes were elicited, which represented the core outcome areas of mortality ( n = 1), physiological/clinical outcomes ( n = 7), functioning and life impact ( n = 13), resource use ( n = 4) and adverse events ( n = 1). These related to five identified themes of mental well-being, quality of care delivered, clinicians’ communication, regaining functional independence and mother–newborn separation. Conclusions This qualitative study identified patient-important outcomes from persons with lived experience of critical illness in pregnancy which will inform the development of a COS.

INTRAABDOMINAL PRESSURE AND PREGNANCY

IAP was dened in 2006 by the World Society of Abdominal Compartment Syndrome consensus denition as the steady state pressure concealed within the abdominal cavity. There are few studies that measures inuence, and management of intra-abdominal pressure (IAP) and Intra-abdominal hypertension (IAH) in pregnancy. Preeclampsia, supine hypotension syndrome are common cause of signicant morbidity and mortality in both mother and new-born. During critical illness in pregnancy, little importance is given to the possible impact of intra-abdominal pressure (IAP) and intra-abdominal hypertension (IAH) on such conditions.

COVID-19 critical illness in pregnancy.

Although the pregnant population was affected by early waves of the COVID-19 pandemic, increasing transmission and severity due to new viral variants has resulted in an increased incidence of severe illness during pregnancy in many regions. Critical illness and respiratory failure are relatively uncommon occurrences during pregnancy, and there are limited high-quality data to direct management. This paper reviews the current literature on COVID-19 management as it relates to pregnancy, and provides an overview of critical care support in these patients. COVID-19 drug therapy is similar to that used in the non-pregnant patient, including anti-inflammatory therapy with steroids and IL-6 inhibitors, although safety data are limited for antiviral drugs such as remdesivir and monoclonal antibodies. As both pregnancy and COVID-19 are thrombogenic, thromboprophylaxis is essential. Endotracheal intubation is a higher risk during pregnancy, but mechanical ventilation should follow usual principles. ICU management should be directed at optimizing maternal well-being, which in turn will benefit the fetus.

Development of a Core Outcome Set for research on critically ill obstetric patients: A study protocol.

Current data on critical illness during pregnancy are insufficient for evidence-based decision making. Core outcome sets are promoted to improve reporting of outcomes important to decision makers. We aim to develop a Core Outcome Set for research on critically ill obstetric patients (COSCO study). We will perform a systematic review of studies on critical illness in pregnancy and focus groups or interviews with women who were critically ill while being pregnant. These data will inform an international Delphi survey where stakeholders will rank proposed outcomes. Selected outcomes will be brought forward to a consensus meeting where core outcomes will be defined. We will then complete a second consensus process to define measures for each core outcome. The Core Outcome Set on Critically ill Obstetric patients study aims to develop a set of core outcomes to be part of all studies on critically ill obstetric patients. Implementation of this core outcome set will help improve future research efforts.Trial registration: This study is registered on the COMET-initiative website (COS #916). This systematic review is registered on PROSPERO (CRD #42017071944).

Pulmonary Disease and Critical Illness in Pregnancy.

Pregnancy is a unique and exciting period in a woman's or a couple's life. Though the vast majority of pregnancies are healthy and uncomplicated, some can be quite complicated and even catastrophic. Maternal mortality remains a major burden around the world. The World Health Organization made the reduction of maternal, infant, and child mortality a priority in its healthy people 2020 campaign. As expected, maternal mortality rates are much lower in the Western world than in underdeveloped countries and decreasing in most. However, mortality rates have been on the rise in the United States in the 21st century and continue to show significant racial discrepancies. It has been hypothesized that the rise in mortality may be due to the obesity epidemic having impacted the United States earlier than other Western countries. It is also possible that the high rates of racial inequality, the higher percentage of poor people, and a good proportion of pregnancies occurring at an advanced maternal age may all play a role in the relatively higher rates of maternal mortality. Finding effective solutions to maternal mortality continues to be a challenge.

Critical Illness in Pregnancy: Part II: Common Medical Conditions Complicating Pregnancy and Puerperium

The first of this two-part series on critical illness in pregnancy dealt with obstetric disorders. In Part II, medical conditions that commonly affect pregnant women or worsen during pregnancy are discussed. ARDS occurs more frequently in pregnancy. Strategies commonly used in nonpregnant patients, including permissive hypercapnia, limits for plateau pressure, and prone positioning, may not be acceptable, especially in late pregnancy. Genital tract infections unique to pregnancy include chorioamnionitis, group A streptococcal infection causing toxic shock syndrome, and polymicrobial infection with streptococci, staphylococci, and Clostridium perfringens causing necrotizing vulvitis or fasciitis. Pregnancy predisposes to VTE; D-dimer levels have low specificity in pregnancy. A ventilation-perfusion scan is preferred over CT pulmonary angiography in some situations to reduce radiation to the mother's breasts. Low-molecular-weight or unfractionated heparins form the mainstay of treatment; vitamin K antagonists, oral factor Xa inhibitors, and direct thrombin inhibitors are not recommended in pregnancy. The physiologic hyperdynamic circulation in pregnancy worsens many cardiovascular disorders. It increases risk of pulmonary edema or arrhythmias in mitral stenosis, heart failure in pulmonary hypertension or aortic stenosis, aortic dissection in Marfan syndrome, or valve thrombosis in mechanical heart valves. Common neurologic problems in pregnancy include seizures, altered mental status, visual symptoms, and strokes. Other common conditions discussed are aspiration of gastric contents, OSA, thyroid disorders, diabetic ketoacidosis, and cardiopulmonary arrest in pregnancy. Studies confined to pregnant women are available for only a few of these conditions. We have, therefore, reviewed pregnancy-specific adjustments in the management of these disorders.

Critical Illness in Pregnancy: Part I: An Approach to a Pregnant Patient in the ICU and Common Obstetric Disorders

Managing critically ill obstetric patients in the ICU is a challenge because of their altered physiology, different normal ranges for laboratory and clinical parameters in pregnancy, and potentially harmful effects of drugs and interventions on the fetus. About 200 to 700 women per 100,000 deliveries require ICU admission. A systematic five-step approach is recommended to enhance maternal and fetal outcomes: (1) differentiate between medical and obstetric disorders with similar manifestations, (2) identify and treat organ dysfunction, (3) assess maternal and fetal risk from continuing pregnancy and decide if delivery/termination of pregnancy will improve outcome, (4) choose an appropriate mode of delivery if necessary, and (5) optimize organ functions for safe delivery. 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, HELLP (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. Thrombotic thrombocytopenic purpura of pregnancy is being diagnosed more frequently. 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 hyperstimulation syndrome is also becoming common because of treatment of infertility with assisted reproduction techniques. Part II will deal with common medical disorders and their management in critically ill pregnant women.

Maternal critical care: what can we learn from patient experience? A qualitative study

ObjectiveFor every maternal death, nine women develop severe maternal morbidity. Many of those women will need care in an intensive care unit (ICU) or high dependency unit (HDU). Critical care...

Critical care in pregnancy

Childbirth is a major event in the lives of mothers and their families. Critical illness in pregnancy is uncommon but may arise from conditions unique to pregnancy, conditions exacerbated by pregnancy and coincidental conditions. According to the latest Confidential Enquiry into Maternal Deaths in the UK, haemorrhage 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 the 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 midwifery staff, the challenge of caring for critically ill obstetric patients requires urgent attention.

Perinatal and Maternal Outcomes in Critically ill Obstetrics Patients With Pandemic H1N1 Influenza A

BackgroundDuring the influenza pandemic of spring 2009, Manitoba had a disproportionate number of pregnant women who became critically ill. Information about these cases will be useful to help us understand the potential impact of future outbreaks and review critical illness in pregnancy. MethodsWe describe the clinical details of six critically ill pregnant women with pandemic H1N1 2009 influenza virus admitted to two ICUs in Manitoba between March 1 and August 31, 2009. ResultsThirty adult pregnant women tested positive for pandemic H1N1 2009 virus in Manitoba. Six women were admitted to the ICU. The time from onset of symptoms to life-threatening deterioration was on average five days. Most patients presented with worsening fever and cough and had H1N1-positive contacts. Five of six patients (83%) were Aboriginal. Four of six cases occurred in the third trimester. These patients frequently required non-conventional ventilatory support such as high frequency ventilation or extracorporeal membrane oxygenation (ECMO). All patients received oseltamivir. Two patients died while in the ICU. Three of six patients had adverse perinatal outcomes, and there was one spontaneous abortion and one early preterm delivery. ConclusionPandemic H1N1 2009 influenza virus has the potential to cause severe illness in pregnant patients. Those patients requiring ICU admission for respiratory support have a high risk for poor fetal and neonatal outcome. The experience of this cohort underscores the appropriateness of public health measures directed at prevention and early treatment of H1N1 infection in pregnancy.

Pathologie obstétricale en réanimation. Des généralités aux principes

Critical illness in pregnancy requires a multidisciplinary approach and special skills for the intensivist. Cardio circulatory, respiratory, and neurological failures are the main causes of admission in the ICU, the maternal mortality ranging from 2 to 10% in European countries. In this setting, the pregnancy-induced physiological changes and the particular evolution of many specific diseases increase the risk of diagnostic errors or delay. Fœtal mortality remains very high due to severe prematurity. Physical and psychological maternal morbidity should be decreased by a specific management during the ICU stay, favoring non invasive procedures and facilitating mother and child reunion.

Critical illness in pregnancy: An overview

To provide an overview of the critical illnesses that afflict the pregnant patient. A comprehensive review of the literature was performed with Pubmed Medline using medical subject headings of pregnancy, critical care, epidemiology, prognostic score, dyspnea, fever, and jaundice. Although pregnant women constitute a small number of admissions to an intensive care unit, they pose a challenge to the health care team. The physiological changes that occur in pregnancy stress and limit the compensatory response required to adapt to a superimposed acute illness. Although a number of conditions are uniquely associated with pregnancy, other medical conditions may complicate the course of pregnancy. The pregnant state also increases susceptibility to a number of illnesses. In this overview, we reviewed the epidemiology and different clinical presentations of critical illness in a pregnant patient. The critically ill pregnant patient presents a challenge to the critical care physician due to unique physiology and specific medical disorders in this population.

Critical Illness in Pregnancy

I read with interest the article entitled “Critical Illness in Pregnancy” by Nancy A. Collop and Steven A. Sahn, which was published in the May, 1993, issue of Chest. 1. Collop N.A. Sahn S.A. Critical illness in pregnancy: an analysis of 20 patients admitted to a medical intensive care unit. Chest. 1993; 103: 1548-1552 Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar I agree with them that the pregnant patient with medical complications represents a unique challenge to the intensive care specialist. In their review of patients who were pregnant and admitted to the medical ICU (MICU), in almost 3 years of time, there were only 20 obstetric patients. Our facility is smaller, but our per capita admission rate to the MICU for obstetric patients is about equal. At a previous facility, Truman Medical Center, East, I was the intensivist. Our numbers were strikingly similar when adjusted for deliveries. My impression on reading the article was the strikingly high rate of pulmonary artery and arterial catheters placed when compared with their general MICU patients. I was struck by this fact, and then I wondered whether this was possibly a result of the fact that in most cases, a pulmonary artery (Swan-Ganz) catheter is not placed by an obstetrician or a maternal/fetal medicine expert but, more than likely, by an intensivist, pulmonologist, or cardiologist. It could be a confluence of two uncomfortable situations for the practicing physicians. One would be a critically ill obstetric patient, which, by and large, does not occur with frequency in the obstetric population, therefore, not frequently presenting to the obstetrician. The second would be a critically ill patient who happened to be pregnant, presenting to the intensivist who infrequently sees pregnant patients. Could it be that the higher rate of Swan-Ganz catheterization in Collop and Sahn's 1. Collop N.A. Sahn S.A. Critical illness in pregnancy: an analysis of 20 patients admitted to a medical intensive care unit. Chest. 1993; 103: 1548-1552 Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar population was a result of this confluence of uncomfortable situations of these practicing physicians?

Critical Illness in Pregnancy: An Analysis of 20 Patients Admitted to a Medical Intensive Care Unit

There is a paucity of literature with regard to the need for intensive care treatment of critically ill obstetric patients. In this review, the findings from 20 obstetric patients admitted to a medical ICU (MICU) over a 40-month period were analyzed. Demographics, preexistent medical problems, diagnoses, days in the hospital and the MICU, need for mechanical ventilation, maternal and fetal mortality, and invasive procedures were reviewed. (For comparison, a limited analysis of nonobstetric admissions to the MICU over the same time period were included.) Fifty percent (10) of the patients had preexisting medical problems. Maternal mortality was 20 percent (4 patients), with a fetal mortality of 35 percent (7). In all of the maternal deaths, adult respiratory distress syndrome was present. Although mortality and the need for mechanical ventilation did not differ between the obstetric and nonobstetric patients, pulmonary artery and arterial catheters were placed at a higher rate in the obstetric patients. Critically ill obstetric patients, although younger than general MICU patients, appear to have as great a risk of dying of their critical illness and have a high infant mortality.