CHAPTER 47: Critical Care and Trauma

INTRODUCTION

These observations made more than a century ago are less applicable today to critically ill pregnant women because of current intensive care capabilities. For example, severe medical, surgical, and obstetrical disorders complicating pregnancy are frequently managed by a multidisciplinary team for optimal care. It is axiomatic that obstetricians and other members of the health-care team must 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 consideration for the second patient—the fetus. Because these critically 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 (ICUs) (Gaffney, 2014).

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 admissions ranges from 2 to 11 percent (American College of Obstetricians and Gynecologists, 2017b). Those with pregnancy-associated complications—especially hemorrhage and hypertension—have the greatest need for intensive care (Chantry, 2015; Gaffney, 2014; Guntupalli, 2015a,b). That said, many antepartum admissions are for nonobstetrical reasons, and these include diabetes, pneumonia or asthma, heart disease, chronic hypertension, pyelonephritis, and thyrotoxicosis (Guntupalli, 2015b; Zeeman, 2006). Additionally, intrapartum and postpartum critical care for hypertensive disorders, hemorrhage, sepsis, or cardiopulmonary complications is often required. 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, especially because many are delivered preterm (Kilpatrick, 2016).

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 ICUs. Especially pertinent to obstetrics, these costly units prompted the evolution of a step-down intermediate care unit. These latter 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) have published guidelines for these units (Table 47-1).