An endless number of medical, surgical, and obstetrical complications may be encountered in pregnancy or the puerperium. Those that are more complex and life threatening can be particularly challenging, especially when a multidisciplinary team is necessary for optimal care. It is axiomatic that obstetricians and other members of the health-care team have a working knowledge of the unique considerations for pregnant women. Some of those discussed in Chapter 46 include pregnancy-induced physiological changes, alterations in normal laboratory values, and finally and importantly, consideration for the second patient—the fetus. Because these severely ill women are usually young and in good health, their prognosis is generally better than that of many other patients admitted to intensive care units.
Obstetrical Intensive Care
In the United States each year, 1 to 3 percent of pregnant women require critical care services, and the risk of death during such admission ranges from 2 to 11 percent (American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, 2012). Those with pregnancy-associated complications—especially hemorrhage and hypertension—have the greatest need for intensive care (Baskett, 2009; Kuklina, 2009; Madan, 2008). That said, many antepartum admissions are for nonobstetrical reasons, and in our experiences from Parkland Hospital, these include diabetes, pneumonia or asthma, heart disease, chronic hypertension, pyelonephritis, or thyrotoxicosis (Zeeman, 2006). In addition to antenatal treatment, intrapartum and postpartum critical care for hypertensive disorders, hemorrhage, sepsis, or cardiopulmonary complications may be required for many. In instances of life-threatening hemorrhage, surgical procedures may be necessary, and close proximity to a delivery-operating room is paramount. For women who are undelivered, fetal well-being is also better served by this close proximity.
Organization of Critical Care
The concept and development of critical care for all aspects of medicine and surgery began in the 1960s. The National Institutes of Health held a Consensus Conference (1983) and the Society of Critical Care Medicine (1988, 1999) subsequently established guidelines for intensive care units (ICUs). Especially pertinent to obstetrics, costly ICUs prompted evolution of a step-down intermediate care unit. These units were designed for patients who did not require intensive care, but who needed a higher level of care than that provided on a general ward. The American College of Critical Care Medicine and the Society of Critical Care Medicine (1998) published guidelines for these units (Table 47-1).
TABLE 47-1Guidelines for Conditions That Could Qualify for Intermediate Care ||Download (.pdf) TABLE 47-1 Guidelines for Conditions That Could Qualify for Intermediate Care
|Cardiac: evaluation for possible infarction, stable infarction, stable arrhythmias, mild-to-moderate congestive heart failure, hypertensive urgency without end-organ damage |
|Pulmonary: stable patients for weaning and chronic ventilation, patients with potential for respiratory failure who are otherwise stable |
|Neurological: stable central nervous system, neuromuscular, or neurosurgical conditions ...|