CRITICAL CARE IN OBSTETRICS
Nita Dalal, Vivek Patkar, N Karnik, Yamini Deshmukh, K P Chawla
Dept. of Obstetrics and Gynaecology, LTMG Hospital and LTM Medical College, Sion, Mumbai 400 022.
Care of the critically ill pregnant woman presents a unique challenge to the patients disease and therapy simultaneously affect two individuals with vastly different physiologies. In India 80,000 women lose their lives during their reproductive years with the maternal mortality reaching an appalling high figure of 437 deaths per 100,000 live births. [1,2] The common causes of maternal mortality are anaemia, haemorrhage sepsis and toxaemia of pregnancy. Many of these patients require specialised care which can not be provided in the general wards. Intensive care units have been developed for cardiac, renal, paediatric and neonatal care. An obstetric intensive care unit is a more recent trend still to come to India. Critically ill obstetric patients can now avail of technological advances that provide advanced life support. These are the patients who are at risk of developing multi organ failure.
Patients admitted to the ICU are scored based on numerous criteria to try and predict their outcome. Several scoring systems have emerged over recent years in an attempt to quantify the relationship between the severity of the pathologic disease and outcome. The two most popular scoring systems are the acute physiologic score and chronic health evaluation II (APACHE II) and the therapeautic intervention scoring system (TISS). 
This retrospective study was undertaken in a tertiary teaching institute with the aims and objectives of analysing obstetric patients requiring critical care and to test the predictability of theAPACHE II scoring system.
MATERIAL AND METHODS
All obstetric patients admitted to the MICU (Medical intensive care unit) from 1.1.96 to 31.12.96 were studied retrospectively. There was a total of 34 patients. On admission to the MICU an APACHE II score was calculated, aetiologic factors leading to the need for critical care and the number and type of organ systems affected were analysed. A detailed study was made of their management and outcome.
TABLE 1 Source of patients Number Direct MICU admissions 9 Transfer from other institutes 17 Obstetric dept. transfer to MICU 8 34
TABLE 2 Age in years Number of patients 20 10 21-25 11 26-30 8 31 5 34
Advancing age adversely affects the outcome of critically ill patients. Youth confers an advantage for obstetric patients.
Infections accounted for the majority of patients. Malaria, hepatitis and Koch’s accounted for 10 patients and puerperal sepsis for 5. The secondlargest group had pregnancy induced hypertension.
TABLE 3 Aetiology No. Pts. Eclampisa / Sev. PIH 13 Puerperal sepsis 5 IUFD 8 APH 3 PPH 2 Malaria 5 Anaemia 5 Heart disease 3 Hepatitis 2 Koch’s 3
TABLE 4 No. Organs Affected No. Patients Mortality 1. 9 2 (22%) 2. 13 7 (54%) 3. 9 6 (67%) 4. 2 2 (100%) 5. 1 1 (100%)
As the number of organs failed rises, so does the mortality.
TABLE 5 APACHE II score No. Pts. Predicted Mortality % Actual Mortality % 10-19 4 15-25 25 20-25 8 35 37 30-34 2 74 100
Our hospital being a tertiary referral centre, 26 of the 34 patients were referred from other hospitals, municipal maternity or private nursing homes. Majority are referred late and in a moribund condition. More patients can be salvaged if these referrals are made early and with some of the necessary resuscitative measures initiated early.
44% of the patients had an infectious aetiology, of which puerperal sepsis accounted for 15%. Absence of basic obstetric care including ante, intra and postnatal services for all women largely contribute to this problem. Medical disorders in pregnancy go unrecognised and untreated, adding to the mortality. Malaria alone contributed to 15% of the patients underscoring the importance of asking all pregnant patients with recurrent or persistent fever to consult their obstetricians or physicians. Most of the intra uterine foetal deaths were probably a result of the primary disease process, whereas in a few, the IUDs may have exacerbated the process.
Multi organ failure of MOF results from a cascade of events secondary to the release of inflammatory mediators in any acute illness or shock. In excessive quantities these cause organ damage to systems other than the primary one.
The number of organs failed directly reflects on the mortality. As the number of organs failed increases, so does the mortality with 1, 2 and 3 or more organ failure corresponding to a mortality of 22-41%, 52-58% and 80-100% on day one and day seven of failure. 
The basic principles of intensive care are support of the failing organs while the underlying pathology is dealt with, adequate nutritional support, asepsis, treatment of infection when present and correction of anaemia are some of the goals in the ICU.
The APACHE II score was first devised by Knaus et al (1985)  to stratify prognostic groups of critically ill patients as well as determine the success of different forms of treatment. Clinical and physiologic parameters like the temperature, mean arterial pressure, heart and respiratory rates, oxygen saturation, pH, S.bicarbonate and electrolyte levels, S.creatinine, haematocrit and WBC counts are scored. This gives a reasonable prediction of mortality on admission to the ICU. There is an APACHE III system which is not yet widely used. Here the CNS score, the co-morbidity and wherethe patients came from are also taken into account.
As seen in Table 5 the actual mortality in our study is higher than that predicted by the score. This can be explained by two factors. One is that the number of patients scored is small as the complete data was not available in all the patients. Secondly the scoring system is based on ICUs in the Western World, wherein economics are different.
Availability of good obstetric care is the cornerstone to decreasing maternal mortality. Educating women to avail these facilities is necessary. Medical disorders should be treated in the antenatal period itself by the appropriate specialities. Early recognition of the patient going downhill before one or multiple systems start failing is important as is the importance of good intensive care once this does occur. Mortality increases directly with the number of organs failed and hence prevention is more important than treatment after failure.
The APACHE II score is a good predictor of mortality on admission to the ICU, with a near 100% mortality for 3 or more organs failed. Ethical considerations apart, our limited resources can be more productively utilized and directed to patients with better-predicted outcome.
Lastly a short period of training in the ICU for all residents of obstetrics and gynaecology should be mandatory. Life saving procedures would be useful when managing these patients till an ICU bed is obtained.
1. Roy Chowdhary NN. Maternal and child health care in India - an unmet challenge - Journal of Indian Medical Association 1995; 49-50.
2. National family health survey. International institute for population sciences, Mumbai. 1993; 8 (5) : 226.
3. Keene AR, Cullen DJ. Therapeutic intervention scoring system : update 1983 Critical Care Med 1983; 11 : 1-3.
4. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. Prognosis in acute organ system failure. Annuls of Surgery 1985; 202 : 685-93.
5. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II : A severity of disease classification system. Critical Care Med 1985; 13 : 818-29.