Obstetric Critical Care Research Articles

Posterior reversible encephalopathy syndrome: An emerging clinical entity in adult, pediatric, and obstetric critical care

To describe the signs, symptoms, causative factors, and treatment for posterior reversible encephalopathy syndrome (PRES), an emerging clinical neuroradiologic entity which may be encountered by nurse practitioners in almost any clinical setting. Extensive review of worldwide literature, including peer-reviewed medical specialty journals, supplemented by an actual case study. Currently, a paucity of information exists in the nursing literature. PRES occurs as a result of disordered cerebral circulatory autoregulation and/or endothelial dysfunction, usually as a result of acute, intermittent hypertension. Clinical manifestations include mental status change, headache, visual disturbance, and seizures. Characteristic abnormalities in the posterior cerebral white matter, seen best on diffusion-weighted magnetic resonance imaging, confirm the presence of the syndrome. PRES has been documented worldwide among a diverse patient population, yet many clinicians are still unfamiliar with this diagnosis. PRES is a clinical-radiographic diagnosis that requires close collaboration between the clinician and interpreting radiologist. Rapid identification and appropriate diagnostics are essential, as prompt treatment usually results in reversal of symptoms; permanent neurologic injury or death can occur with treatment delay.

Challenges in critical care obstetrics in West Africa

The need for critical care facilities in obstetrics has become increasingly important in West Africa. At present 47% of global maternal mortality occurs in Africa, 1 with the highest rate in sub-Saharan Africa. Sadly, 85% of all maternal deaths are the direct result of complications arising during pregnancy, delivery or the puerperium. 1 Nigeria, with 37 000 maternal deaths per year has the second highest number of maternal deaths in the world after India (160 000/year). 2 It has been estimated that between 0.1% and 0.9% of women develop complications during pregnancy that require admission to intensive care (ICU). 3 Due to poorly developed health care delivery systems this figure should be higher in West Africa as demonstrated by studies from Nigeria 4 and Burkina Faso. 5 There are, however, limited critical care obstetric facilities, equipment and staff. Various studies in sub-Saharan African countries, including four in West Africa (Benin, Burkina Faso, Ivory Coast and Mali), have revealed that hemorrhage (30%), sepsis (18%), eclampsia (13%) and abortion (10%) are the major causes of maternal mortality. 1 Such patients would benefit from ICU admission but unfortunately many are still nursed on general wards. 6 An additional problem is that patients present late to hospital, even to those with ICU facilities, as women may visit traditional medicine practitioners before hospital presentation. Consequently they may be moribund by the time they reach hospital. In West Africa, most ICUs are to be found in teaching or regional hospitals in urban areas. This effectively means that women from rural areas, who are poorer and suffer more from pregnancy-related complications, do not have easy access to ICU services. This is disappointing as critical care obstetric patients often need ICU admission for organ support and greater medical and nursing care. 5 Most ICUs in West Africa have fewer than ten beds and in Nigeria units are mainly limited to the 16 federal government funded teaching hospitals. Current practice is compounded by poor road networks, inadequate ambulance services and imperfect referral systems. An important impediment to the improvement of critical care obstetrics in West Africa is the paucity of anesthetists with necessary ICU experience. In West Africa, ICUs are usually run by anesthetists but due to the economic problems in the region, some specialist and trainee anesthetists have emigrated to more favorable climes, compounding an already precarious situation. 7,8 In some regions, consultant anesthetists regularly cover two or more hospitals, increasing their workload leading to reduced efficiency because of fatigue. To improve critical care services political will is paramount. Governments should provide funds to build and equip more ICUs, build and repair roads and improve the remuneration of staff to prevent their loss to other countries. Nigeria, the world’s most populous black nation, spends less than one percent of her gross national product on health care. Presently, only eight of the federal government funded teaching hospitals are to be upgraded to international standard, with three hospitals already beneficiaries. Economic empowerment programs and health education will help reduce poverty and ignorance, known contributing factors to poor utilization of health facilities. ICU admission is expensive with some centers charging US $40-160 per day. This is excessive in nations where the minimum monthly wage is less than US $80. The recently introduced National Health Insurance Scheme (NHIS) in Nigeria may enable more patients to meet the financial obligation of ICU care. This initiative re-emphasizes the need for maternal health insurance schemes in West Africa. The assistance of Western aid organizations has helped greatly by way of donated equipment and drugs to some ICUs in the region. Sadly, however, because of a shortage of biomedical engineers, poor maintenance limits the life span of equipment. While Western help is needed and appreciated, a nation’s health care plans should not depend on charity and governments should invest in their people. Though a significant number of pregnancy-related complications can be reduced by efficient primary health care, complications still develop even in women who attend antenatal services. When these complications arise, the resulting need for ICU admission is rarely met in West Africa due to a combination of factors. An improvement in ICU facilities may help reverse this sad trend.

Obstetric critical care: A blueprint for improved outcomes

Obstetric patients are generally young and healthy. However, the potential for catastrophic complications is real, and despite the therapeutic advances of the last few decades, maternal morbidity and mortality continue to occur. This may be related to the pregnancy itself, aggravation of a preexisting illness, or complications of the (operative) delivery. The purpose of this review is two-fold: first, to provide an update on currently available reports pertaining to important critical care issues of the obstetric patient population and, second, to present current comprehensive treatment options for preeclampsia and massive obstetric hemorrhage because both are responsible for the majority of maternal mortality and morbidity worldwide. The most common reasons for intensive care unit admission are hypertensive disorders and massive obstetric hemorrhage. Timely delivery and prompt initiation of antihypertensive therapy for severe hypertension form the mainstay of care in preeclampsia. Restoration of circulating blood volume and rapid control of bleeding and impaired coagulation are the main factors in the management of massive obstetric hemorrhage. Puerperal morbidity has become the main topic of quality of care issues in maternity care. Although the Acute Physiology and Chronic Health Evaluation II score is commonly used in the intensive care unit, it does not seem to be appropriate for pregnant women because it overestimates their mortality rates. A high-dependency care unit suits the needs for at least half of the obstetric patient population in need of higher acuity care and will save considerable cost. Emphasis on early detection of maternal problems and prompt referral to tertiary centers with intensive care unit facilities to provide optimum care of the circulation, blood pressure, and respiration at an early stage could minimize the prevalence of multiple organ failure and mortality in critically ill obstetric patients.

Intensive care in obstetrics: An evidence-based review

The necessity for critical care support and admission to an intensive care unit (ICU) is a relatively infrequent occurrence during pregnancy and the postpartum period. The exact incidence is unclear because of the variety of reporting methods and definitions, with estimates that range from 0.17% to 1.1% of pregnant patients. 1-9 All of the published series to date are small; the largest series includes 131 obstetric critical care patients. 8 Zeeman et al 10 described their experience with 483 patients who were treated in an obstetric intermediate care unit. This series represented 1.7% of deliveries during a 2-year period, which is a substantially higher rate than reported in other studies. This high percentage likely reflects the inclusion of some patients with lower acuity who were admitted for ‘‘intermediate care’’ who otherwise would not have required transfer to a traditional ICU. Of the 34 patients who were transferred to the ICU, most patients (71%) required ventilatory support. Obstetric complications account for most ICU admissions in pregnant patients, which range from 47% to 93%. 1,4-6,10 Hemorrhage and hypertensive disorders

Managing pre-eclampsia 2: charting patient records

The audit of the regional guidelines for pre-eclampsia by the Yorkshire Obstetric Critical Care Group (YOCCG) regional link midwifery network in Yorkshire highlighted the need for a better mechanism for recording care in these high risk cases. Midwives have undertaken the development and implementation of the chart as they are the main recorders of care in these cases and are well placed to guide other members of the multidisciplinary team in the use of the new chart. The new chart was developed in consultation with all the units it has been introduced to. The initial response has been extremely favourable with all clinicians appreciating the one stop documentation tool for these cases and the lack of duplication required. The most important gain has been the freeing up of time to spend with the woman and her family during this period of time whilst the condition is so acute.

A blueprint for obstetric critical care

Objective: The purpose of this study was to describe our 2-year experience with 483 critically ill peripartum women and to propose a blueprint for obstetric critical care. Study design: This was a prospective study to evaluate all admissions to the Obstetric Intermediate Care Unit and obstetric admissions to medical/surgical intensive care units. Our findings are followed by general recommendations for the organization of obstetric critical care. Results: Almost two thirds of the women had obstetric complications that included pregnancy-associated hypertension and obstetric hemorrhage. Medical disorders were most common in the other one third of the women. Conclusion: An Obstetric Intermediate Care Unit allows for the continuation of care by obstetricians and results in fewer transfers to medical/surgical intensive care units. Patient treatment depends on hospital size and available resources. In most tertiary centers, the critically ill pregnant woman is best cared for by obstetricians in an Obstetric Intermediate Care Unit. In smaller hospitals, transfer to a medical or surgical intensive care unit may be preferable. (Am J Obstet Gynecol 2003;188:532-6.)

Two Lives on the Line: A Case Study in Obstetric Critical Care

Two Lives on the Line: A Case Study in Obstetric Critical Care

Critical care obstetrics: 13 years of experience in a community practice setting

Critical care obstetrics: 13 years of experience in a community practice setting

Book Reviews

Book reviewed in this article: Basic Sciences for Obstetrics and Gynaecology Fifth Edition. Edited by: Tim Chard, Richard Lilford. Published by Springer Primary Care in Obstetrics and Gynaecology: A Handbook for Clinicians. Edited by: Joseph S. Sanfilippo and Roger P. Smith. Published by Springer Problems in Early Pregnancy: Advances in Diagnosis and Management. Edited by J.G. Grudsinskas and P.M.S. O'Brien. Published by RCOG Press. Critical Care Obstetrics, 3rd Edition. Edited by Steven L. Clark MD, David B. Cotton MD, Gary D.V. Hankins MD, Jeffrey P. Phelan MD. Published by Blackwell Scientific‐Publications Sports Gynaecology: Problems and Care of the Athletic Female. Edited by Michelle P. Warren, Mona M. Shangold. Published by Blackwell Science Inc Practical Procedures for the Gynaecological Oncologist. Edited by A. Peter, M. Henitx and David G. Allen. Published by Elsevier Science BV 1998 Endometrium and Endometriosis. Edited by Michael P. Diamond and Kevin G. Osteen. Published by Blackwell Science 1997 A Clinician's Guide to Menopause. Edited by Donna E. Stewart, Gail Erlick Robinson. Published by Health Press International Hysterectomy and HRT. Edited by John Studd and Linda Edwards. Published by RCOG Press The Yearbook of the Royal College of Obstetricians and Gynaecologists 1996. John Studd. Published by RCOG Press Obstetric Intensive Care. M.R. Foley, T.H. Strong. Published by Harcourt Brace & Co Australia Chromosome Abnormalities and Genetic Counselling. R.J.M. Gardner and G.R. Sutherland. Published by Oxford University Press Atlas of Gynecologic Surgery‐3rd Edition. H.A. Hirsch, O. Kaser, F.A. Lkle. Published by Georg Thieme Verlag Practical Manual of Operative Laparoscopy and Hysteroscopy. Ricardo Azziz, Ana Alvarez Murphy. Published by Springer‐Verlag GmbH & Co Kg Invasive Outpatient Procedures in Reproductive Medicine. Mark I. Evans, Mark P. Johnson and Kamran S. Moghissi. Published by MacLennan & Petty Neonatology for the MRCOG. Peter Dear and Simon Newell. Published by RCOG Press

Obstetric critical care

Despite advances in healthcare, maternal morbidity and mortality rates have been rising over the last three decades. Potential contributors to this alarming trend include advances in assisted reproductive technologies allowing women to conceive at older ages than previously possible, an increasing number of pregnancies affected by chronic diseases, a rising cesarean delivery rate resulting in complications such as abnormal placentation, and medical advances allowing women with complex illnesses to conceive. Expert consensus has endorsed simulation over traditional teaching methods for improving learner skill and patient outcomes, particularly in a setting of rarely encountered illnesses and increasingly complex patients. Maternal cardiac arrest simulations are one of the more extensively studied obstetrical critical care scenarios, and participation has been associated with improved learner performance. With such promising data in the setting of growing numbers of obstetrical simulation programs, a logical next step is the incorporation of obstetric critical care scenarios into simulation curricula. This chapter will discuss the use of simulation for teaching critical care obstetrics.

Is It Time To Upgrade My Credentials?

I am a clinical nurse specialist with a master's degree in critical care obstetrics. Available roles for advanced practice nurses in perinatal care are expanding to including perinatal clinical nurse specialists, perinatal nurse practitioners, and others. Would you explain the different advanced practice roles and the educational background required for each?

Book Reviews

Book reviewed in this article:Introduction to Obstetrics and Gynaecology. Edited by Cynthia Farquahar and Murray Jamieson. Published by National Women's Hospital, Auckland.Management of Common Problems in Obstetrics and Gynecology. Edited by D. R. Mishell, Jr. and P. F. Brenner.High Risk Pregnancy ‐ Management Options. Edited by D. K. James, P. J. Steer, C. P. Weiner and B. Gonik.Handbook of Critical Care Obstetrics. Edited by Steven L. Clark, David B. Cotton, Gary D. V. Hankins and Jeffrey P. Pheian.Magnetic Resonance Imaging in Obstetrics & Gynaecology. Martin C. Powell, Brian S. Worthington and E. Malcolm Symonds.MRI of the Female Pelvis. Kaori Togashi. Igaku‐Shoin Ltd, Tokyo.The Endometrium ‐ A Clinico‐Pataologic Approach. Ed. Debra S. Heller. Igaku‐Shoin, New York‐Tokyo.Cytopathology of the Endometrium. Liang‐Cheo Tao, MD, FRACOG. Raven Press, New York.Handbook of Placental Pathology. Vijay V. Joshi, Butterworth‐Heineman, Australia.Laboratory Testing in Ob/Gyn. Gerald D. Willett. Blackwell.Considerations Regarding the Unintended Radiation Exposure of the Embryo, Fetus or Nursing Child. NCRP Commentary No. 9. National Council on Radiation Protection and Measurements, U.S.A.Development Toxicology. Edited by Carole A. Kimmel and Judy Buelke‐Sam. Raven Press, New York.Psychological Aspects of Women's Health Cart Donna E. Stewart, Nada L. Stotland Eds. American Psychiatric Press, Washington.Postnatal Depression: Towards a Research Agenda for Human Services and Health. Edited by Jan Carter.Contraceptive Method Mix ‐ Guidelines for Policy and Service Delivery. World Health Organization, Geneva.Manual of Pelvic Surgery. Edited by Maurice J. Webb. Springer‐Verlag Publications, Berlin.Complications in Gj naecologk Surgery. Prevention, Recognition and Management. James W. Orr and Hugh M. CunninghamThe Management of Adnexal Cysts. Edited by Professor M Abruhat. Biackwell Scientific Publications.What an Abnormal Pap Smear Means ‐ Living for Tomorrow series. Margaret Wilson. Hill of Content Publishing Co, Melbourne.

A curriculum to develop critical care obstetric nursing staff

Orientation of perinatal nursing staff to critical care obstetrics is vital to provide comprehensive, high-quality care for high-risk populations. One approach is to offer an intensive critical care obstetrics program in house that offers theoretical and practical experience and makes use of resources and talents within the institution.

Strategies for establishing a critical care obstetric service.

Critical care obstetrics is gaining increased recognition as a subspecialty of perinatal medicine. As the specialty continues to expand, many institutions may consider establishing a critical care obstetric service. However, implementing such a service is not feasible for every institution because of space limitations, budgetary constraints, lack of necessary resources, and/or a limited number of critically ill obstetric patients. This article explores strategies for examining the feasibility of establishing a critical care obstetric service, suggests methods of implementation, and offers an alternative when establishing a critical care obstetric service is not feasible.

Critical care obstetrics: The role of advanced practice nursing

The role of the advanced practice nurse in the specialty of critical care obstetric nursing is emerging to meet the dynamic needs of health care under reform. Advanced practice components, including case management, research utilization, collaborative consultation, and advanced educational preparation, give light to a new model of caregiver. This article details the educational preparation and specific roles of the advanced practice nurse in the specialty of critical care obstetrics.

Ultrasonographically guided subclavian vein catheterization in critical care obstetrics and gynecologic oncology

Ultrasonographically guided subclavian vein catheterization in critical care obstetrics and gynecologic oncology

Ultrasonographically guided subclavian vein catheterization in critical care obstetrics and gynecologic oncology

Invasive hemodynamic monitoring has become an integral part of intensive care management. Whereas the pulmonary artery catheter is the mainstay for determination of the hemodynamic profile and differentiation between cardiogenic and noncardiogenic forms of pulmonary edema, immediate central venous access in itself is of importance in rapid volume replacement in cases complicated by severe hypovolemia. Central venous catheters are also the preferred route of administration of total parenteral nutrition to patients with cancer. We present our experience with real-time ultrasonographic guidance during subclavian vein catheterization in critical care obstetrics and gynecologic oncology.

Legal and Professional Issues in Critical Care Obstetrics

The practice of critical care obstetrics is a challenging specialty that presents unique problems and issues in providing perinatal care. With the emergence of critical care obstetrics comes increased accountability and expanded responsibilities. This article addresses the legal and professional issues related to critical care obstetrics.

Obstetric Critical Care Issues in Prematurity

Typically, obstetric critical care issues focus on the management of the patients whose pregnancies are complicated by severe preeclampsia and oliguria. Here, the focus is on the expectant management of the preterm pregnancy complicated by severe preeclampsia, HELLP syndrome, or eclampsia. Then, the emphasis shifts to tocolytic and severe preeclampsia-related pulmonary edema and its clinical management.

BOOK REVIEWS

Birthrights. Law and Ethics at the Beginnings of Life edited by Robert Lee & Derek Morgan. Critical Care Obstetrics edited by S. L. Clark, J. P. Phelan & D. B. Cotton. Perinatal Events and Brain Damage in Surviving Children edited by F. Kubli, N. Patel, W. Schmidt & O. Linderkamp. Atlas of Fetal Skeletal Radiology edited by Asher Ornoy, Zvi Borochowitz, Ralph Lachman & David L. Rimoin. The Developing Human by Keith L. Moore. Diabetes Complicating Pregnancy. The Joslin Clinic Method edited by John W. Hare. Controversies in Diabetes and Pregnancy (Vol. 2 in the series Endocrinology and Metabolism, Progress and Research in Clinical Practice) edited by Lois Jovanovic.