Treatment of the critically ill pregnant woman has improved over the past three decades with advances in intensive care capabilities. To achieve optimal outcomes, severe medical, surgical, and obstetrical disorders complicating pregnancy are frequently managed by a multidisciplinary team. Importantly, obstetricians and these other health-care team members must have a working knowledge of the unique considerations for pregnancy (Padilla, 2021). Some discussed in Chapter 49 include pregnancy-induced physiological changes, alterations in normal laboratory values, and consideration for the second patient—the fetus. Because critically ill women are usually young and healthy, their prognosis is generally good (Gaffney, 2014).
Despite noted gains, evidence suggests that severe morbidity rates are increasing (Friedman, 2016). In the United States, 1 to 3 percent of pregnant women require critical care services each year. The risk of death during such admissions ranges from 2 to 11 percent (American College of Obstetricians and Gynecologists, 2019a). Black women and Medicaid recipients are disparately affected (Wen, 2020).
Those with pregnancy-associated complications—especially hemorrhage, sepsis, and hypertension—have the greatest need for intensive care (Chantry, 2015; 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). Cardiac disease is the leading non-obstetrical indication for intensive care unit (ICU) admission (Small, 2012). In instances of life-threatening hemorrhage, surgical procedures may be necessary, and close proximity to an operating room is paramount. For women who are undelivered, fetal well-being also is 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. As a part of this effort, the National Institutes of Health held a Consensus Conference (1983) and the Society of Critical Care Medicine (1988, 1999) 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 treatment 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 50-1).
TABLE 50-1Guidelines for Conditions That Could Qualify for Intermediate Care ||Download (.pdf) TABLE 50-1Guidelines 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 |