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Mifepristone and efficacy of Chinese medicine treatment of ectopic pregnancy
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PAGE\*MERGEFORMAT14MifepristoneandefficacyofChinesemedicinetreatmentofectopicpregnancy[Keywords:]mifepristonemedicinestasisofectopicpregnancyEctopicpregnancy(ectopicpregnancy,EPisacommongynecologicaldiseases,theincreasingincidenceinrecentyears,withthedevelopmentofvariousdiagnostictechniques,earlydiagnosisrateshaveincreasedattentionpaidtoconservativetreatment.IappliedMifepristoneChinesemedicinetreatmentofectopicpregnancy,achieveasatisfactoryeffect,arereportedbelow.MaterialsandMethods1.ClinicaldatafromSeptember2000toSeptember2006,theFucheck,urineandbloodHCGandB-ultrasounddiagnosisofEPwhovoluntarilyrequestedatotalof156casesofconservativetreatmentofdrug,theindicationsareinlinewithconservativetreatment[1]:Nodrugtreatmentcontraindications,tounrupturedtubalpregnancyormiscarriage,tubalmassdiameter4bloodHCG&2000U/L,.156casesnoobviousbleedingstoppedafter60daysin15patients59to45daysin42patients,44to40days68cases,“39daysin31cases,thebeginningofpregnancywere47cases,pregnant2to4timesthose109cases,withabortionhistoryormedicalabortionhistoryof94cases,B-Tipsideoftheadnexalmasswere143cases,partoftheuterusrectumfossawitheffusion,positivepre-treatmentof146casesofurinaryHCG,HCGbloodof156patientsweregreaterthan100U/L,100~1000U/L13cases,U/L75cases,U/L45cases,bloodHCG&3000U/L23cases(ofwhich9casesofbloodHCG&5000U/L,2casesofbloodHCGashighasU/L,1BSeeSuperectopicpregnancyfetalheartthrobwithinthemassofabnormallyhighbloodlevelofHCGinpatientshospitalizedmethodisproposedforthesurgery,butconservativedrugtherapyinpatientswithstrongdemandandstablecondition,itistobemonitoredcloselyanddoanysurgerycases,giventheconservativetreatment.2.Methodsofmifepristone25mg/tablets,1,2Tianzaoandeveningemptystomach150mg,total600mg,1day3daysobserved,withoutexception,thefirst4daysplusservicesfromtraditionalChinesemedicine,day1,thebasicrecipeis:Salvia15g,redpeonyroot10g,myrrh10g,peachkernel10g,frankincense10g,Tri10g,Curcuma10g,andthenadditionandsubtractionwiththedise
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50.72 · Columbia University45.48 · Lehigh Valley Health NetworkAbstractIntroductionMaternal mortalityPregnancy-related hospitalizationsPerinatal mortalityIllnesses responsible for obstetric intensive care unit admissionsPregnancy-related intensive care unit admissionsCauses of mortality in obstetric intensive care unit admissionsSummaryPerinatal loss 101th obstetric intensive care unit admissionsReferencesDiscover the world's research13+ million members100+ million publications700k+ research projects
1Critical Care Obstetrics, 5th edition. Edited by M. Belfort, G. Saade, M. Foley, J. Phelan and G. Dildy. (C) 2010 Blackwell Publishing Ltd.
Epidemiology of Critical Illness in Pregnancy
1 Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences, UMDNJ
Robert Wood Johnson Medical School, New Brunswick, NJ, USA
2 Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Lehigh Valley Health Network, Allentown, PA,
Introduction
The successful epidemiologic evaluation of any particular disease or condition has several prerequisites. Two of the most important prerequisites are that the condition should be accurately defi ned and that there should be measurable outcomes of interest. Another requirement is that there must be some systematic way of data collection or surveillance that will allow the measurement of the outcomes of interest and associated risk factors. The epi-demiologic evaluation of critical illness associated with pregnancy has met with mixed success on all of these counts.
Historically, surveillance of pregnancy - related critical illness has focused on the well - defi ned outcome of maternal mortality in order to identify illnesses or conditions that might have led to maternal death. Identifi cation of various conditions associated with maternal mortality initially came from observations by astute clinicians. One of the best examples is the link described by Semmelweiss between hand - washing habits and puerperal fever. In most industrial and many developing countries, there are now population - based surveillance mechanisms in place to track maternal mortality. These often are mandated by law. In fact, the World Health Organization uses maternal mortality as one of the measures of the health of a population
Fortunately, in most industrialized nations the maternal mor-tality rates have fallen to very low levels. Recent statistics for the United States suggest that overall maternal mortality was 11.5 maternal deaths per 100
000 live births during 1991 – 97
[2] . Despite this impressively low rate of maternal mortality, tracking maternal deaths may not be the best way to assess pregnancy - related critical illnesses since the majority of such illnesses do not result in maternal death. As stated by Harmer
“ death represents the tip of the morbidity iceberg, the size of which is unknown. ”
Unlike mortality, which is an unequivocal endpoint, critical illness in pregnancy as a morbidity outcome is diffi cult to defi ne and, therefore, diffi cult to measure and study precisely.
There are many common conditions in pregnancy such as the hypertensive diseases, intrapartum hemorrhage, diabetes, thyroid disease, asthma, seizure disorders, and infection that occur frequently and require special medical care, but do not actually become critical illnesses. Most women with these com-plications have relatively uneventful pregnancies that result in good outcomes for both mother and infant. Nevertheless, each of these conditions can be associated with signifi cant complications that have the potential for serious morbidity, disability and mor-tality. The stage at which any condition becomes severe enough to be classifi ed as a critical illness has not been clearly defi ned. However, it may be helpful to consider critical illness as impend-ing, developing, or established signifi cant organ dysfunction, which may lead to long - term morbidity or death. This allows some fl exibility in the characterization of disease severity since it recognizes conditions that can deteriorate rather quickly in pregnancy.
Maternal mortality data collection is well established in many places, but specifi c surveillance systems that track severe compli-cations of pregnancy not associated with maternal mortality are rare. It has been suggested that most women suffering a critical illness in pregnancy are likely to spend some time in an intensive care unit
[3 – 5] . These cases have been described by some as
“ near - miss ”
Therefore,
examination
of cases admitted to intensive care units can provide insight into the nature of pregnancy - related critical illnesses and can compliment maternal mortality surveillance. However, it should be noted that nearly two - thirds of maternal deaths might occur in women who never reach an intensive care unit
The following sections review much of what is currently known about the epidemiology of critical illness in pregnancy. Some of the information is based
however, much of the data are derived from publicly available data that are collected as part of nationwide surveillance systems in the US.
COPYRIGHTED MATERIAL
Chapter 1 2hospitalizations (3.19%), although the average LOS was shorter for
non - delivery
hospitalizations.
Hospitalizations for preterm labor occurred twice as frequently for non - delivery hospitalizations (21.21%) than for delivery - related hospitalizations (10.28%). This is expected since many preterm labor patients are successfully treated and some of these hospitalizations are for
“ false labor. ”
Liver disorders were uncom-monly associated with hospitalization. However, the mean hos-pital LOS for liver disorders that occurred with non - delivery hospitalizations was over 31 days, compared with a mean LOS of 3 days if the liver condition was delivery related. Coagulation - related defects required 14.9 days of hospitalization if not related to delivery compared with a mean LOS of 4.9 days if the condition was delivery related. Hospitalizations for embolism - related com-plications were infrequent, but generally required extended hos-pital stays.
The top 10 conditions associated with hospital admissions, separately for delivery -
and non - delivery - related events, are pre-sented in Figure
1.1 . The chief cause for hospitalization (either delivery or non - delivery related) was preterm labor. The second most frequent condition was hypertensive disease (7.37% for delivery related and 6.61% for non - delivery related) followed by anemia (7.13% vs 5.05%). Hospitalizations for infection - related conditions occurred twice more frequently for non - delivery periods (11.65%) than during delivery (5.75%). In contrast, hos-pitalization for hemorrhage was more frequent during delivery (4.43%) than non - delivery (3.26%). These data provide impor-tant insights into the most common complications and condi-tions associated with pregnancy hospitalization. The LOS data also give some indication of resource allocation needs. While this is important in understanding the epidemiology of illness in pregnancy, it does not allow a detailed examination of illness severity.
m ortality
The national health promotion and disease prevention objectives of the
Healthy People 2010
indicators specify a goal of no more than 3.3 maternal deaths per 100
000 live births in the US
[12] . The goal for maternal deaths among black women was set at no more than 5.0 per 100
000 live births. As of 1997 (the latest avail-able statistics on maternal deaths in the US) this objective remains elusive. The pregnancy - related maternal mortality ratio (PRMR) per 100
000 live births for the US was 11.5 for 1991 – 97
[13] , with the ratio over threefold greater among black compared with white women
[14] . Several studies that have examined trends in mater-nal mortality statistics have concluded that a majority of preg-nancy - related deaths (including those resulting from ectopic pregnancies, and some cases of infection and hemorrhage) are preventable
[1,15,16] . However, maternal deaths due to other complications such as pregnancy - induced hypertension, placenta previa, retained placenta, and thromboembolism, are considered by some as diffi cult to prevent
Pregnancy -
h ospitalizations
Pregnancy complications contribute signifi cantly to maternal, fetal, and infant morbidity, as well as mortality
[8] . Many women with complicating conditions are hospitalized without being delivered. Although maternal complications of pregnancy are the fi fth leading cause of infant mortality in the US, little is known about the epidemiology of maternal complications associated with hospitalizations. Examination of complicating conditions associated with maternal hospitalizations can provide informa-tion on the types of conditions requiring hospitalized care. In the US during the years 1991 – 92, it was estimated that 18.0% of pregnancies were associated with non - delivery hospitalization with disproportionate rates between black (28.1%) and white (17.2%) women
[9] . This 18.0% hospitalization rate comprised 12.3% for obstetric conditions (18.3% among black women and 11.9% among white women), 4.4% for pregnancy losses (8.1% among black women and 3.9% among white women), and 1.3% for non - obstetric (medical or surgical) conditions (1.5% among black women and 1.3% among white women). The likelihood of pregnancy - associated hospitalizations in the US declined between 1986 – 87
1991 – 92
More recent information about pregnancy - related hospitaliza-tion diagnoses can be found in the aggregated National Hospital Discharge Summary (NHDS) data for 1998 – 99. These data are assembled by the National Center for Health Statistics (NCHS) of the US Centers for Disease Control and Prevention. The NHDS data is a survey of medical records from short - stay, non - federal hospitals in the US, conducted annually since 1965. A detailed description of the survey and the database can be found elsewhere
Briefl y, for each hospital admission, the NHDS data include a primary and up to six secondary diagnoses, as well as up to four procedures performed for each hospitalization. These diagnoses and procedures are all coded based on the International Classifi cation of Diseases, ninth revision, clinical modifi cation. We examined the rates (per 100 hospitalizations) of hospitaliza-tions by indications (discharge diagnoses) during 1998 – 99 in the US,
separately
non - delivery (n
023) hospitalizations. We also examined the mean hos-pital lengths of stay (with 95% confi dence intervals, CIs). Antepartum and postpartum hospitalizations were grouped as non - delivery
hospitalizations.
During 1998 – 99, nearly 7.4% of all hospitalizations were for hypertensive diseases with delivery, and 6.6% were for hyperten-sive diseases not delivered (Table
1.1 ). Mean hospital length of stay (LOS) is an indirect measure of acuity for some illnesses. LOS was higher for delivery - related than for non - delivery - related hospitalizations for hypertensive diseases. Hemorrhage, as the underlying reason for hospitalization (either as primary or secondary diagnosis), occurred much more frequently for delivery -
non - delivery - related
hospitalizations.
Non - delivery hospitalizations for genitourinary infections occurred three times more frequently (10.45%) than for delivery - related
Epidemiology of Critical Illness in Pregnancy3
Rate (per 100 hospitalizations) of delivery and non - delivery hospitalizations, and associated hospital lengths of stay ( LOS )
diagnoses:
1998 – 99.
Hospital admission diagnosis
Delivery hospitalization
7,965,173)
Non - delivery hospitalization
Mean LOS (95% CI)
Mean LOS (95% CI)
Hypertensive
hypertension
Pre - eclampsia/eclampsia
hypertension
pre - eclampsia
Hemorrhage
Hemorrhage
(unassigned
Postpartum
hemorrhage
Infection - related
infections
malaria/rubella)
Genitourinary
infections
Anesthesia - related
complications
Pre - existing
Gestational
dependency
Congenital
cardiovascular
Postpartum
coagulation
Shock/hypotension
Embolism - related
Blood - clot
The diagnoses associated with hospital admissions include both primary and secondary reasons for hospitalizations. Each admission may have had up to six associated diagnoses.
From the 1960s to the mid - 1980s, the maternal mortality ratio in the US declined from approximately 27 per 100
000 live births to about 7 per 100
000 live births (Figure
1.2 ). Subsequently, the mortality ratio increased between
000 live births) and
000 live births). During the period 1991 – 97, the mortality ratio further increased to 11.5 per 100
000 live births – an overall relative increase of 60% between 1987 and 1997. The reasons for the recent increases are not clear.
Several maternal risk factors have been examined in relation to maternal deaths. Women aged 35 – 39 years carry a 2.6 - fold (95%
Chapter 1 4births, followed by embolism - related deaths (PRMR 1.8), and hypertensive diseases (PRMR 1.6). Among all live births, hypertensive diseases (23.8%) were the most frequent cause of death. Among stillbirths (27.2%) and ectopic (94.9%) pregnan-cies, the chief cause of death was hemorrhage, while infections (49.4%) were the leading cause of abortion - related maternal deaths.
Understanding the epidemiology of pregnancy - related deaths is essential in order to target specifi c interventions. Improved population - based surveillance through targeted reviews of all pregnancy - related deaths, as well as additional research to under-stand the causes of maternal deaths by indication will help in achieving the
Healthy People 2010
CI 2.2, 3.1) increased risk of maternal death and those over 40 years are at a 5.9 - fold (95% CI 4.6, 7.7) increased risk. Black maternal race confers a relative risk of 3.7 (95% CI 3.3, 4.1) for maternal death compared with white women. Similarly, women without any prenatal care during pregnancy had an almost twofold increased risk of death relative to those who received prenatal care
The chief cause for a pregnancy - related maternal death depends on whether the pregnancy results in a live born, stillbirth, ectopic pregnancy, abortion, or molar gestation (Table
1.2 ). For the period 1987 – 90, hemorrhage was recorded in 28.8% of all deaths, leading to an overall pregnancy - related mortality ratio (PRMR) for hemorrhage of 2.6 per 100
000 live Non-delivery relatedDelivery relatedThyroidDrug dependencyUterine tumorCardiovascularDiabetesHemorrhageInfectionsAnemiaHypertensionPreterm labor0510Rate (%) of hospitalizations per 100 deliveries20 2515
Figure 1.1
Ten leading causes of delivery -
and non - delivery - related
hospitalizations
1998 – 99.
302520151050Ratio975 987 Year
Figure 1.2
Trends in maternal mortality ratio (number of maternal deaths per 100
000 live births) in
1967 – 96.
“ ratio ”
used instead of
“ rate ”
because the numerator includes some maternal deaths that were not related to live births and thus were not included in the denominator.
Epidemiology of Critical Illness in Pregnancy5these conditions on pregnancy outcomes. Table
shows the results of our examination of perinatal mortality rates among singleton and multiple births (twins, triplets and quadruplets) by gestational age and high - risk conditions. The study population comprises all births in the US that occurred in 1995 – 98. Data were derived from the national linked birth/infant death fi les, assembled by the National Center for Health Statistics of the Centers for Disease Control and Prevention
[20] . Gestational age
m ortality
Perinatal mortality, defi ned by the World Health Organization as fetal deaths plus deaths of live - born infants within the fi rst 28 days, is an important indicator of population health. Examination of the maternal conditions related to perinatal mortality can provide further information on the association and impact of
Perinatal mortality rates among singleton and multiple gestations by gestational age and high - risk conditions:
USA , 1995 – 98.
High - risk conditions
20 – 27 weeks
28 – 32 weeks
33 – 36 weeks
≥ 37 weeks
Relative risk (95% CI)
Relative risk (95% CI)
Relative risk (95% CI)
Relative risk (95% CI)
Singletons
Hypertension
Hemorrhage
complications
(Referent)
(Referent)
(Referent)
(Referent)
Hypertension
Hemorrhage
complications
(Referent)
(Referent)
(Referent)
(Referent)
CI, confi PMR, perinatal mortality rate per 1000 SGA, small for gestational age births.
Hypertension includes chronic hypertension, pregnancy - induced hypertension, and eclampsia.
Hemorrhage includes placental abruption, placenta previa, uterine bleeding of undermined etiology.
No complications include those that did not have any complications listed in the table.
Relative risk for each high - risk condition was adjusted for all other high - risk conditions shown in the table.
Pregnancy - related
underlying
1987 – 90.
Cause of death
All outcomes
Outcome of pregnancy (% distribution)
Live birth
Stillbirth
Undelivered
Hemorrhage
Hypertension
Cardiomyopathy
Anesthesia
Others/unknown
Pregnancy - related
spontaneous
abortions.
Chapter 1 6 related ICU admissions involved 37 maternity hospitals in Maryland and included hospitals at all care levels
[22] . This study found a nearly 30% lower admission rate to ICUs for obstetric patients from community hospitals compared with major teach-ing hospitals. Another source of variation is the different criteria for admission to the ICU used at different institutions. Finally, there are major differences in the inclusion criteria used for these studies that further contributes to the variability in reported ICU utilization
Reported maternal mortality for critically ill obstetric patients admitted to an ICU is approximately 8.4% (Table
1.4 ). This refl ects the true seriousness of the illnesses of these women. The wide range of mortality from 0% to 33% is due to many factors. Most of the studies were small and just a few deaths may affect rates signifi
cantly. The populations studied also differ in underly-ing health status. Reports from less developed countries had much higher mortality rates. The time period of the study can have an impact. In general, earlier studies had higher maternal mortality rates. These earlier studies represent the early stages of development of care mechanisms for critically ill obstetric patients. They probably refl ect part of the
“ learning curve ”
of critical care obstetrics, as well as differences in available technol-ogy
[52] . Regardless, the mortality rate from these ICU admis-sions is several orders of magnitude higher than the general US population maternal mortality rate of 11.5 per 100
000 live births. Therefore, these cases are a good representation of an obstetric population with critical illnesses.
r esponsible for
o bstetric
i ntensive
a dmissions
Examination of obstetric ICU admissions provides some insight into the nature of obstetric illnesses requiring critical care. Data were pooled from 26 published studies that provided suffi cient details about the primary indication for the ICU admission (Table
1.5 ). It is no surprise that hypertensive diseases and obstet-ric hemorrhage were responsible for over 50% of the primary admitting diagnoses. Specifi c organ system dysfunction was responsible for the majority of the remaining admissions. Of those, pulmonary, cardiac, and infectious complications had the greatest frequency. From these reports, it is apparent that both obstetric and medical complications of pregnancy are responsible for the ICU admissions in similar proportions. There were 16 studies that provided information on 1980 patients as to whether the primary admitting diagnosis was related to an obstetric complication or a medical complication
[4,22,23,25,26,36 – 38,40,42,43,46,49 – 51,54]
. The pooled data indicate that approximately 69.3% (n
1373) were classifi ed as obstetric related and 30.7% (n
607) were due to medical complications. These data clearly highlight the complex nature of obstetric critical care illnesses and provide support for a multidisciplinary approach to manage-ment since these patients are quite ill with a variety of diseases.
was predominantly based on the date of last menstrual period
[21] , and was grouped as 20 – 27, 28 – 32, 33 – 36, and
weeks. Perinatal mortality rates were assessed for hypertension (chronic hypertension,
pregnancy - induced hypertension, and eclampsia), hemorrhage (placental abruption, placenta previa, and uterine bleeding of undetermined etiology), diabetes (pre - existing and gestational diabetes), and small for gestational age (SGA) births (defi ned as birth weight below 10th centile for gestational age). We derived norms for the 10th centile birth weight for singleton and multiple births from the corresponding singleton and mul-tiple births that occurred in 1995 – 98 in the US. Finally, relative risks (with 95% CIs) for perinatal death by each high - risk condi-tion were derived from multivariable logistic regression models after adjusting for all other high - risk conditions.
Perinatal mortality rates progressively decline, among both singleton and multiple births, for each high - risk condition with increasing gestational age (Table
1.3 ). Among singleton and mul-tiple gestations, with the exception of SGA births, mortality rates were generally higher for each high - risk condition, relative to the no complications group. Infants delivered small for their gesta-tional age carried the highest risk of dying during the perinatal period compared with those born to mothers without complica-tions. Among singleton births, the relative risks for perinatal death for SGA infants were 2.3, 6.2, 7.8, and 5.5 for those deliv-ered at 20 – 27 weeks, 28 – 32 weeks, 33 – 36 weeks, and term, respec-tively. Among multiple births, these relative risks were similar at 2.0, 6.8, 7.5, and 8.6, respectively, for each of the four gestational age categories.
Pregnancy -
i ntensive
a dmissions
Evaluation of obstetric admissions to intensive care units (ICUs) may be one of the best ways to approach surveillance of critical illnesses in pregnancy. Unfortunately, there are no publicly avail-able population - based databases for obstetric admissions to ICU that provide suffi ciently detailed information to allow in - depth study of these conditions. Therefore, it is reasonable to examine descriptive case series to provide information on these condi-tions. We reviewed 33 studies published between 1990 and 2006 involving 1
111 deliveries and found an overall obstetric - related admission rate to ICU of 0.07 – 0.89% (Table
1.4 ). Some of the variation in the rates may be explained by the nature of the populations studied. Hospitals that are tertiary referral centers for large catchment areas typically receive a more concentrated high - risk population. These facilities would be expected to have higher rates of obstetric admissions to an ICU. However, these studies provided suffi cient data to allow the exclusion of patients trans-ported from outside facilities. Community - oriented facilities are probably less likely to care for critically ill obstetric patients unless the illnesses develop so acutely that they would preclude trans-port to a higher - level facility. The largest study of pregnancy -
Epidemiology of Critical Illness in Pregnancy7
Obstetric admission rates to an intensive care unit ( ICU ) and corresponding maternal mortality rates from 33 studies.
Inclusion criteria
Total deliveries
Obstetric ICU Admissions (rate)
Obstetric ICU deaths (rate)
Fetal/neonatal deaths per ICU admissions
1986 – 89
Kilpatrick
1985 – 90
1988 – 91
1989 – 95
1983 – 90
1984 – 97
Delivering
1991 – 98
1991 – 98
1989 – 97
1992 – 2001
1991 – 97
1980 – 93
& 20 weeks and PP
Hazelgrove
1994 – 96
1985 – 89
Selo - Ojeme
1993 – 2003
1979 – 89
1988 – 95
1985 – 90
1994 – 1999
1993 – 2000
1990 – 2001
Netherlands
Obstetrics
admissions with illness
Bouvier - Colle
1986 – 96
1992 – 2001
1996 – 98
1994 – 98
1987 – 1998
1997 – 2002
Demirkiran
1995 – 2000
1997 – 2002
1992 – 2004
PP, ( – ) indicates data not provided or unable to be calculated (these values excluded from summaries of columns).
calculated
m ortality in
o bstetric
i ntensive
a dmissions
specifi c causes of mortality for the obstetric ICU admis-sions were reviewed, 26 studies gave suffi cient data to assign a primary etiology for maternal death (Table
1.6 ). Of a total of 138 maternal deaths, over 57% were related to complications of hypertensive diseases, pulmonary illnesses, and cardiac diseases. Other deaths were commonly related to complications of hemor-rhage, bleeding into the central nervous system, malignancy, and infection. More importantly, despite an identifi ed primary
Chapter 1 8tality rate of 25.6%. Reported rates ranged from 1.2 – 48.8%. If the large report from India is removed
[31] , there were 272 of these deaths among 1
745 cases, with a mortality rate of 15.6%. These proportions may not refl ect a true perinatal mortality rate since some of the losses may have occurred before 20 weeks gestation. In addition, the denominator includes a number of postpartum admissions for conditions not expected to impact fetal or neona-tal mortality. Nevertheless, the high loss rate highlights the importance of considering the fetus when managing critical ill-nesses in pregnancy.
In summary, understanding the nature of critical illness in preg-nancy is an important and evolving process. We have clearly grown beyond simple mortality reviews for assessment of preg-nancy - related critical illness. However, our currently available tools and databases for examining these patients still need improvement. Reports of critically ill women admitted to the ICU have further refi ned our understanding of these diseases. However, targeted surveillance of obstetric ICU admissions is needed to identify variations in care and disease that may affect management. As our understanding of these conditions contin-ues to mature, we will hopefully gain greater insight into the specifi c nature of these conditions that will lead to improved prevention strategies and better therapies for the diseases when they occur. In our view, these data will improve our ability to plan and allocate the necessary resources to adequately care for these often complex and severe illnesses.
etiology for the maternal deaths, nearly all cases were associated with multiorgan dysfunction, which again emphasizes the complex condition of these critically ill women.
As noted earlier, obstetric and medical complications of preg-nancy are equally represented in all admissions to the ICU (Table
1.5 ). However, nearly 40% of all maternal deaths in the ICU were directly related to obstetric conditions (mainly hypertensive dis-eases, hemorrhage, amniotic fl uid embolism and acute fatty liver of pregnancy) with the remaining deaths due to medical condi-tions
l oss 101th obstetric intensive care unit admissions
When considering the implications of critical illness for obstetric patients, the focus is usually on the mother. However, it is impor-tant to re - emphasize that many of these conditions also may have a signifi cant impact on fetal and neonatal outcomes. There is surprisingly little detailed information available on these perina-tal outcomes in pregnancies complicated by critical illnesses. However, there are data on perinatal outcomes based on specifi c disease conditions. Maternal high - risk conditions associated with perinatal mortality in the US are presented in Table
1.3 . However, these data do not separate outcomes by severity of maternal illness. We were able to identify 18 studies that provided informa-tion on fetal or neonatal mortality rates for obstetric admissions to the ICU (Table
1.4 ). Fetal and/or neonatal deaths were identi-fi ed in 640 of the pooled 2499 cases, resulting in an overall mor-
Complications primarily responsible for admission to the intensive care unit for obstetric patients: data summarized from 26 published studies
[4 – 6,22 – 26,28,31,32,35 – 37,39,40,42 – 51]
Category examples
Percentage
Hypertensive
Eclampsia,
pre - eclampsia,
hypertensive
Hemorrhage
abruption,
postpartum
hemorrhage,
Pulmonary edema, pneumonia, adult respiratory distress syndrome, asthma, thromboembolic diseases, amniotic fl uid embolus
arrhythmia,
cardiomyopathy,
infarction
Sepsis/infection
Chorioamnionitis,
pyelonephritis,
hepatitis,
meningitis,
miscellaneous
Intracranial
hemorrhage,
(non - eclamptic),
arteriovenous
malformation
Anesthesia
complication
intubation,
Gastrointestinal
Pancreatitis,
pregnancy,
gallbladder
Hematologic
Thrombotic thrombocytopenic purpura, sickle cell disease, disseminated intravascular coagulation, aspiration
ketoacidosis,
Malignancy
Insuffi cient information to assign to specifi c organ system but included anaphylaxis, trauma, drug and overdose/poisoning
Epidemiology of Critical Illness in Pregnancy9critically reviewing the manuscript and offering several com-ments that improved its contents. We also appreciate the effi cient and excellent assistance of Susan Fosbre during the preparation of this manuscript and thank Laura Smulian for critically proof-reading the chapter.
References
Organization .
Maternal Mortality: A Global Factbook .
Organization ,
mortal-ity
United States, 1982 – 1996 . US Department of Health and Human Services
Anaesthesia
Murphy - Kaulbeck
Obstetrics admissions to the intensive care unit .
Obstet Gynecol
Hazelgrove
Multicenter
obstetric admissions to 14 intensive care units in southern England .
Crit Care Med
near - miss
mor-tality in obstetrics .
Br J Obstet Gynaecol
mater-nal morbidity: A pilot study of a defi nition for a near - miss .
Br J Obstet Gynaecol
Hospitalizations for severe complications of pregnancy, 1987 – 1992 .
Obstet Gynecol
Kotelchuck
Pregnancy - associated hospitalizations in the United States in 1991 and 1992: A comprehensive review of maternal morbidity .
Am J Obstet Gynecol
Hospitalization for pregnancy complications, United States, 1986 and 1987 .
Am J Obstet Gynecol
Statistics .
the National Hospital Discharge Survey: 1988 redesign . Series I. Programs and collection procedures. US Department of Health and Human Services, CDC
2000 ; DHHS Publication 2001 – 1315 (number 39).
Statistics .
1992 . Hyattsville, MD: US Department of Health and Human Services, Public Health Service, CDC, 1993.
Pregnancy - related deaths among Hispanic, Asian/Pacifi c Islander, and American Indian/Alaska Native women
United States, 1991 – 1997 . US Department
Maternal mortality
United States, 1982 – 1996 . US Department of Health and Human
in Massachusetts: trends and prevention .
N Engl J Med
Pregnancy - related mortality in New York City, 1980 to1984: Causes of death and associated factors .
Am J Obstet Gynecol
Identifi ed primary causes of mortality in obstetric admissions to
[4 – 6,22 – 26,28,31,32,35 – 37,39,40,42 – 51] .
Identifi ed etiology
Percentage
Hypertensive
Hypertensive
complications
complications
hypertensive
complications
complications
respiratory
Eisenmenger ’ s
Myocardial
infarction
Arrhythmia
cardiomyopathy
Hemorrhage
hemorrhage
Arteriovenous
malformation
hemorrhage
Intracranial
hemorrhage
Tuberculosis
meningitis
Malignancy
Hematologic
Thrombotic
thrombocytopenic
Gastrointestinal
Poisoning/overdose
Anesthesia
complication
Acknowledgments
We would like to express our sincere appreciation to Anthony Vintzileos, MD, from the Department of Obstetrics and Gynecology, Winthrop - University Hospital, Mineola, NY, for
Chapter 1 10
critically
obstetric patients: a fi
Int J Obstet Anesthesia
Tyrv ? inen
Saarikoski
mater-nal critical care in obstetrics: a population - based analysis .
Int J Obstet Anesthesia
van Roosmalen . Obstetric intensive care admissions: a 12 - year review in a tertiary care centre .
Eur J Obstet Gynecol Reprod Biol
Bouvier - Colle
patients treated in intensive care units and maternal mortality. Regional teams for the survey .
Eur J Obstet Gynecol Reprod Biol
Cl é ment
Riethmuller
Complications
obst é tricales graves n é cessitant une hospitalization en reanimation:
é tude retro-spective sur 10 ans au CHU de Basan ? on .
Ann Fr Anesth R é anim
high - dependency unit in a regional obstetric hospital .
Anaesthesia
of obstetric patients in a general intensive care unit .
Acta Obstet Gynecol Scand
Critically
obstetri-cal patients: Outcome and predictability .
Crit Care Med
Indications and outcome for intensive care unit admission during puerperium .
Arch Gynecol Obstet
in critical care obstetric patients .
Int J Obstet Anesthesia
Engelhardt
gyn-aecological patients in an intensive care unit: A 1 year review .
Demirkiran
Critically
obstetric patients in the intensive care unit .
Int J Obstet Anesthesia
Weerasinghe
Pregnancy - related admissions to the intensive care unit .
Int J Obstet Anesthesia
Al - Suleiman
Obstetric admissions to the intensive care unit: A 12 - year review .
Arch Gynecol Obstet
evaluation of outcome from intensive care in major medical centers .
Ann Intern Med
Pregnancy - related mortality surveillance
United States, 1987 – 1990 . MMWR, Morbidity
Utility of Acute Physiology, Age, and Chronic Health Evaluation (APACHE III) score in maternal admissions to the intensive care unit .
Am J Obstet Gynecol
Pregnancy - related
New Jersey,
1975 – 1989 .
Am J Public Health
Pregnancy - related
mor-tality in the United States, 1987 – 1990 .
Obstet Gynecol
mortality .
Curr Opin Obstet Gynecol
statistics
the linked birth/infant death data set
1995 period data .
Mon Vital Stat Rep
gesta-tion on birth certifi cates .
Vital Health Stat 2 ,
Am J Obstet Gynecol
Kilpatrick
care. A fi
pregnancy.
20 patients admitted to a medical intensive care unit .
comparison
scoring systems for critically ill obstetrics patients .
intensive care unit: a descriptive analysis .
South Med J
utilization
during hospital admission for delivery: Prevalence, risk factors, and out-comes in a statewide population .
Anesthesiology
infl ammatory response syndrome, organ failure, and outcome in critically ill obstetric patients treated in an ICU .
( Abstract).
admissions to the intensive care unit: demographic and severity of illness analysis .
Am J Respir Crit Care Med
care unit utilization during pregnancy .
Obstet Gynecol
95 (Suppl):
Guntupalli
Critically
obstetric patients in an American and an Indian public hospital: comparison of case - mix, organ dysfunction, intensive care requirements, and out-comes .
Intensive Care Med
Kruczynski
Critical care management of the obstetric patient .
Can J Anaesth
requirement
for the pregnant population .
Anesthesia
Selo - Ojeme
Battacherjee
factors for obstetric admissions to the intensive care unit in a tertiary hospi-tal: a case control study .
Arch Gynecol Obstet
admissions
obstetrical
hospital .
Can J Anaesth
care in obstetrical patients: An eight - year review .
Chinese Med J
Arulkumaran
admissions
to the intensive care unit
a retrospective review .
Ann Acad Med Singapore
CitationsCitations0ReferencesReferences61ABSTRACT: Reprint requests: William C. Mabie, MD, Department of Obstetrics and Gynecology, University of Tennessee, 853 Jefferson Ave., Room E-102, Memphis, TN 38163.Article · Jan 1990 ABSTRACT: Objectives: To assess the serious maternal morbidity during pregnancy, delivery and post partum, which led to an hospitalization in a medical or surgical intensive care unit.Study design: A Retrospective study was carried out on a period of ten years, from July 1986 to July 1996, in the University Teaching Hospital of Besan?on.Patients: The criterious of inclusion come from the definition of the serious maternal morbidity decided by the Inserm: any admission of a pregnant woman in a medical or surgical intensive care unit in the 42 days of the post-partum, whatever the term of the pregnancy and the type of the post-partum, extra uterine pregnancy, spontaneous miscarriage and medical or voluntary abortion.Methods: Forty six patient’s medical file hospitalized in a medical or surgical intensive care unit between July, 1th 1986 and July, 31th 1996, have been studied.Results: The analysis of the cause underline the gravity of the pathologies handled with young patients and initialy healthy, the short lenght of controlled ventilation and hospitalization, the advoidability of great number of transfer in an intensive care unit, and the lack of hospitalization due to anaesthesia. The frequency of hospitalisation in an intensive care unit during and after the pregnancy was estimated at 0.17% of lives births.Conclusion: The serious maternal morbidity could be an indicator of the quality of the obstetrics cares which would complete the study of the maternal mortality. The potential gravity of the complication of the pregnancy and the delivery require better care of this patients.Article · Jun 2000 +1 more author...ABSTRACT: No abstract is available for this article.Article · Feb 1997 ABSTRACT: Objective
To describe trends in pregnancy-related mortality and risk factors for pregnancy-related deaths in the United States for the years 1991 through 1997. Full-text · Article · Feb 2003 ABSTRACT: Objective: To characterize obstetric (OB) and nonobstetric (Non-OB) intensive care unit (ICU) admissions in relation to maternal and perinatal outcomes.Study design: We identified 172 (0.6%) women (15 weeks of gestation to 6 weeks postpartum) admitted to an ICU (medical, cardiovascular, neurosurgical, and surgical) within 30,405 deliveries at our institution from 1989 to
maternal-fetal transports, 6.3%). Obstetric and Non-OB admission outcomes were compared.Results: Of 172 patients, 116 (67%) were maternal transports (63 maternal-fetal, 53 maternal). Common OB conditions were hypertension (22, 12.6%), hemorrhage (17, 9.7%), and cardiopulmonary dysfunction (28, 16%). Non-OB conditions included pneumonia (26, 14.9%), trauma (16, 9.1%), and cerebrovascular accident (11, 6.2%).Conclusions: Maternal and neonatal outcomes were similar between OB and Non-OB ICU admissions. Maternal mortality was appreciable (13%); however, the perinatal mortality of infants delivered in the ICU was low (11%). Selected outcomesOB (N = 92)Non-OB (N = 83)MaternalICU, days (mean ± SD)6.2 ± 11.013.3 ± 32.7Mechanical ventilation (N, %)55 (60)48 (58)Dialysis (N, %)5 (0.5)4 (0.5)Transfusion (N, %)62 (67)48 (58)Maternal death (N, %)12 (13)11 (13)PerinatalICU antepartum (N, %)13 (14)42 (53)Fetus alive (N)1336Admit GA (mean ± SD)26.7 ± 7.026.2 ± 5.9ICU delivery (N)5/1313/36Fetal mortality (N)11Neonatal mortality (N)00Discharged undelivered (N)823Article · Apr 2000 · European Journal of Obstetrics & Gynecology and Reproductive Biology+1 more author...ABSTRACT: Objective: To ascertain the frequency of serious diseases in pregnant women. Study design: A population based survey was performed in France. The cases were all the women admitted for treatment in intensive care unit (ICU). The severity of the cases was measured with the simplified acute physiology score (SAPS) the lethality and the rate of still birth. Results: 435 obstetric patients were included. The estimated frequency of severe diseases was 310 S.D. 36 per 100 000 live births. The most frequent diagnose that motived admission in ICU was hypertensive diseases. The lethality rates differed greatly between specific disorders. The lethality rate was lower when scheduled maternity was located in a teaching hospital. Conclusion: Regarding these results it appears that the majority of obstetric patients with severe diseases are referred to suitable care, but a small proportion of women who had to change their type of care registered a significant higher lethality.Article · Mar 1996 +1 more author...ProjectProjectJournal ProjectProjectArticleFebruary 1952 · International Journal of Legal Medicine · Impact Factor: 2.79ArticleMay 1983ArticleAugust 1958 · Archives of Surgery · Impact Factor: 4.93Hemorrhage into thyroid adenomas is relatively common but usually does not attain clinical significance. Small hemorrhages and the secondary results of hemorrhages, such as necrosis or cystic degeneration in thyroid nodules, are frequently seen by pathologists on gross or microscopic examination. A massive hemorrhage into a thyroid adenoma of sufficient magnitude to produce respiratory... ArticleJanuary 2014 · Medical ChannelIntroduction: Perinatal asphyxia contributes greatly to neonatal mortality and morbidity. In developing countries, the need for risk factor assessment in perinatal asphyxia is obvious because of the high birth rate and limited perinatal resources1. Objectives: To assess risk factors of birth asphyxia in babies born at LUH Hyderabad. Study design: Descriptive. Setting: Department of Peadiatric... Data provided are for informational purposes only. Although carefully collected, accuracy cannot be guaranteed. Publisher conditions are provided by RoMEO. Differing provisions from the publisher's actual policy or licence agreement may be applicable.This publication is from a journal that may support self archiving.Last Updated: 02 Mar 17}