REVIEW

Management of the critically

ill obstetric patient

increasing susceptibility to (e.g. thromboembolism, urinary tract

infection, varicella pneumonia) or deterioration of a condition
unrelated to pregnancy (e.g. asthma, heart disease). Leading
obstetric reasons for patients requiring critical care are pregnancyinduced hypertensive disorders and massive obstetric haemorrhage, with most women being admitted in the postpartum period,
usually for relatively short admissions. Most admissions follow
Caesarean section, and approximately 50% require invasive
ventilation. There are rising numbers of high-risk pregnancies in
mothers with increased age and obesity, with maternal cardiac
disease remaining the commonest cause of maternal death, and
ischaemic heart disease becoming increasingly important. There
are also likely to be more admissions relating to the complications
of assisted reproductive techniques and in-vitro fertilization such
as ovarian hyperstimulation syndrome.
Compared to most patients admitted to ICU, obstetric patients
are younger, and usually have no history of prior medical
conditions. This is reflected in their significantly improved
survival compared to ICU all-comers, with UK mortality due to
obstetric critical illness being about 2e3%, compared to 20% in
the non-obstetric population. Of the 14/100,000 mothers that
died in the UK in the 2003e5 triennium, one third were admitted
to ICU. The commonest reasons for deaths were acute respiratory
distress syndrome (ARDS), intracerebral haemorrhage and
multiple organ failure.
Fetal morbidity and mortality reflect maternal outcome. Even
though the fetus is adapted to living in a relatively hypoxic
environment, perinatal mortality may as high as 25%. If the
mother does become critically ill, preterm delivery may be indicated with the associated neonatal complications of respiratory
distress syndrome, jaundice, intracranial haemorrhage and
necrotizing enterocolitis.
Current estimates are that a typical obstetric unit will send
five patients a year to ICU, and that 1% of deliveries will require
high dependency unit (HDU) care. Maternal admission and
mortality rates will depend on a number of factors, including
admission criteria to level 3 units (providing multiorgan support)
and the co-availability of obstetric HDU facilities, which can
manage patients with single organ failure (level 2 support).
The following points are important when dealing with critically ill obstetric patients:
 Consider the normal physiological changes of pregnancy,
otherwise underlying disease may be over- or underdiagnosed.
 If a test, treatment or procedure is necessary then it should be
carried out (with appropriate protective measures), and not
delayed or disregarded because the woman is pregnant.
 Remember that there are two patients involved, the mother
and the fetus, and the optimal management for one may have
adverse implications for the other. (see Table 2 relating to
drugs in pregnancy).
The Confidential Enquiries into Maternal Deaths repeatedly
make a number of recommendations regarding the management
of critically ill obstetric patients. The 2000e2002 report stressed
the need to get senior obstetric help urgently, as soon as it
becomes apparent that the mother is deteriorating, and to involve
physicians, anaesthetists and intensivists early. The 2003e2005
report encouraged the use of early warning scores to detect the
onset of critical illness in all hospital areas, and made specific

Laura Claire Price

Sarah Germain
Duncan Wyncoll
Catherine Nelson-Piercy

Abstract
Obstetric critical illnesses represent a small but important proportion of
all intensive care unit (ICU) admissions in the UK. They are challenging
to the critical care team because of the unique physiology and specific
medical disorders seen in this population. Maternal mortality is fortunately rare, but devastating when it occurs, with the commonest causes
of death being cardiac disease and venous thromboembolism. Massive
obstetric haemorrhage, pre-eclampsia and genital tract sepsis are also
important causes, and these are reflected in the reasons for ICU admission in the obstetric population. Maternal mortality may be reduced by
prompt recognition of critical illness in the pregnant woman, earlier initiation of intensive care, and increased input from senior clinicians.
ICU management involves resuscitation, monitoring \and assessment
of deranged physiology, and the provision of safe organ support. The
overall aims are to ensure adequate oxygen delivery and tissue perfusion,
and to stabilise the patient while awaiting investigations which may guide
further disease-specific management. The normal physiological adaptations to pregnancy and the effects of any drugs or procedures on the
fetus should be taken into account.

Keywords acute fatty liver of pregnancy; acute respiratory distress

syndrome; amniotic fluid embolus; critical care; fetus; haemorrhage;
intensive care; maternal mortality; obstetrics; pre-eclampsia; pregnancy;
sepsis; shock; systemic inflammatory response syndrome; thromboembolic disease

Introduction
In the UK, less than 2% of ICU admissions relate to obstetric
illnesses, compared to up to 10% in the developing world. Of these
admissions, 50e80% relate to a direct obstetric cause (Table 1),
and the remainder to medical or surgical causes, with pregnancy

Laura Claire Price Department of Obstetrics and Gynaecology,

St.Thomas Hospital, London, UK.
Sarah Germain Department of Obstetrics and Gynaecology, St.Thomas
Hospital, London, UK.
Duncan Wyncoll Department of Obstetrics and Gynaecology,
St.Thomas Hospital, London, UK.
Catherine Nelson-Piercy Department of Obstetrics and Gynaecology,
St.Thomas Hospital, London, UK.

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Obstetric conditions in the Intensive Care National Audit and Research Centre (ICNARC) Coding Method
Haemorrhage

Hypertensive disorder

Other conditions

Antepartum haemorrhage
Peripartum or postpartum haemorrhage

HELLP syndrome
Pre-eclampsia
Eclampsia

Ectopic pregnancy
Amnionitis
Infected retained products of conception
Septic abortion
Intrauterine death
Molar pregnancy
Amniotic fluid embolus

HELLP, haemolysis, elevated liver enzymes and low platelets.

Harrison et al. Critical Care 2005; 9(Suppl. 3): S25.

Table 1

recommendations about ICU management including the adherence to major haemorrhage protocols, early identification and
targeted management of sepsis, and increased resuscitation
training of all obstetric staff. Forward planning for high-risk cases
should involve all multidisciplinary team members, and elective
ICU beds should be booked accordingly. Critical care can often be
initiated in the operating theatre or emergency department prior

to transfer to the ICU to avoid delays. Stabilization and elective

intubation may be necessary prior to transfer.
Obstetric ICU management should aim to adhere to recent
developments in critical care practice including the Surviving
Sepsis Campaign (SSC) guidelines, insulin therapy to avoid
hyperglycaemia, lung protective ventilatory strategies in acute
lung injury, early goal-directed therapy for severe sepsis and

FDA categories of ICU drugs according to fetal risk

FDA category:

A&B
No fetal risk in humans

C
Studies inconclusive. Use
when benefit outweighs risk

D
Evidence of fetal risk but
benefit may outweigh risk

X
Contraindicated in
pregnancy: risk outweighs
any benefit

Cardiovascular

Dobutamine
Methyldopa

ACEI & ARB (in all trimesters)

Amiodarone
Beta blockers (avoid in 1st
trimester and prolonged use)

Analgesic/sedatives

NSAIDS
(1st & 2nd trimesters)
Acyclovir
Cephalosporins
Clindamycin
Macrolides
Penicillins
e
Insulin
Magnesium sulphate

Diazepam
Midazolam
NSAIDS (3rd trimester)
e

Antibiotics

Adenosine
Digoxin
Dopamine
Epinephrine
Norepinephrine
Glyceryl trinatrate
Hydralazine
Milrinone
Nifedipine
Fentanyl
Morphine
Haloperidol
Aminoglycosides
Quinolones (1st trimester)
Trimethoprim (in 1st trimester)
Vancomycin
Heparin
Glucocorticoids
Neuromuscular blockers

e
e

Warfarin
e

Anticoagulants
Other

Abbreviations: FDA, Food & Drug Administration; ACEI, angiotensin converting enzyme inhibitors; ARB, angiotensin receptor blockers; NSAIDS, non-steroidal antiinflammatory drugs.

Table 2

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Cardiovascular & respiratory system changes in normal pregnancy

Cardiovascular

Respiratory

HR (32 weeks) elevated 10e20 beats/min

SVR, PVR reduced 20e30%
Cardiac output (25 weeks) elevated 30e50%

Minute ventilation increased

Tidal volume increased
Respiratory rate unchanged
Mild respiratory alkalosis

Blood volume elevated 40%

Plasma volume elevated 45e50%

Oxygen demand increased

Red cell mass elevated 20e30%

CVP unchanged

FRC reduced
O2 desaturation more common

COP reduced

Difficult intubation more likely

HR, heart rate; SVR, systemic vascular resistance; PVR, pulmonary vascular resistance; CVP, central venous pressure; COP, colloid oncotic pressure; FRC, functional
residual capacity.

Table 3a

septic shock, the use of activated protein C in patients with

severe sepsis and multiple organ failure, and consideration of
corticosteroids for patients with prolonged septic shock.

reduced by positioning in a lateral tilt, and a full left lateral

position is sometimes required.
Respiratory system changes include a progesterone-driven
increase in tidal volume (with minimal change in respiratory
rate), resulting in a mild respiratory alkalosis (decreased PaCO2)
throughout normal pregnancy. The partial pressure of oxygen
(PaO2) increases by the end of the first trimester, then falls in the
following trimesters. An important reduction in functional
residual capacity (FRC) occurs in late pregnancy, and oxygen
desaturation may occur rapidly. Upper airway oedema may make
a difficult intubation more likely, especially in women who have
pre-eclampsia.

Physiological changes during normal pregnancy

Normal pregnancy involves a range of physiological adaptations
(Tables 3a and 3b), which have an impact on diagnostic
assessment and ongoing management in critical illness. Some
cardiovascular signs and symptoms such as mild breathlessness
and peripheral oedema may be normal and are common.
However, resting tachypnoea and metabolic acidosis are always
abnormal, and should prompt further assessment.
Haemodynamic changes begin as early as 5e8 weeks of
pregnancy (Table 3a), and by the second trimester, cardiac
output is increased by up to 50%. At birth, further fluid shifts
are especially challenging in parturients with cardiac disease.
There is also a reduction in plasma colloid oncotic pressure in
normal pregnancy which may increase susceptibility to pulmonary oedema, especially when associated with increased
pulmonary capillary permeability, such as in pre-eclampsia.
After 24 weeks, the supine hypotension syndrome relating to
compression of the inferior vena cava by the gravid uterus and
can lead to a dramatic reduction in preload and cardiac output,
resulting in severe hypotension and bradycardia. It can be

Organ-specific aims of critical care management

The aims of ICU management are to stabilise physiological
parameters and support organ systems, thus allowing time for
recovery and/or implementation of disease-specific therapies.
Supportive ICU management is classically divided by organ
systems, and may be guided by invasive or non-invasive monitoring. The global aim is adequate oxygen delivery to the tissues,
and this is dependent on several steps, at any of which, deficiencies may occur. These steps involve oxygen transfer to the
blood in the lungs (involving alveolar oxygen concentration,
oxygen transfer, the haemoglobin, and the oxyhaemoglobin
dissociation curve), oxygen transport from the lungs to the

Other physiological changes in pregnancy

Haematological

Renal

Gastrointestinal/liver

Increased plasma volume

Haemodilutional anaemia
Hypercoagulable state
Fall in platelet count

Hydronephrosis
Increased renal plasma flow, glomerular filtration rate, and
creatinine clearance
Proteinuria (<300 mg/24 h)
Reduced excretion of sodium and water load with resultant peripheral oedema

Reduced gastrointestinal motility

Increased risk of aspiration
Increased liver metabolism

Table 3b

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tissues, and finally diffusion from capillary blood to tissue

mitochondria.

replacement therapy will be required, using haemofiltration or

haemodialysis. Monitoring may involve measurement of hourly
urine output and fluid balance, and daily serum electrolytes.

Cardiovascular
Cardiovascular support may involve fluid administration (e.g.
crystalloids, colloids and blood products), correction of cardiac
rhythm and electrolyte disturbances, use of inotropes (e.g.
dobutamine, milrinone) and vasopressors (e.g. norepinephrine)
and ventilatory support. The concept of a fluid challenge to
determine a patients fluid status is similar to that in a nonpregnant setting. Fluid therapy in obstetrics should be more
cautious than in the non-obstetric setting because of the
increased risk of pulmonary oedema, especially in patients with
pre-eclampsia.
Invasive monitoring may involve central venous pressure
(CVP) monitoring to assess intravascular volume and cardiac
output (CO) monitoring. Methods for measuring the CO include
pulsed continuous cardiac output (PiCCO), lithium dilution
cardiac output (LiDCO), oesophageal Doppler, and rarely the
pulmonary artery catheter.

Gastrointestinal
Nutritional support is usually required to avoid the complications of malnutrition such as impaired wound healing and
immune function. The enteral route is preferred, using a nasogastric or nasojejunal tube, or occasionally surgical gastrostomy or jejunostomy. Prokinetic agents (such as
metoclopramide or erythromycin) facilitate gastric emptying
and are safe in pregnancy. Sometimes total parenteral nutrition
(TPN) is required via a central venous line, but complications
include line-related sepsis, thrombosis and suppressed T-cell
immunity. Stress ulceration and gastrointestinal bleeding are
reduced by early enteral feeding, however, proton pump
inhibitor prophylaxis is required if patients are not able to be
fed. Avoiding hyperglycaemia has been shown to improve
outcome (see below).
Neurological
Neurological support aims to relieve pain and anxiety, and
prevent secondary brain injury following an initial insult. The
level of sedation required will depend on factors such as the
ventilation mode and need for invasive procedures. Drugs used
include analgesics (paracetamol, opiates) and sedative-anxiolytics (benzodiazepines, propofol, haloperidol, and clonidine).
Sometimes patients will also require neuromuscular blockade,
for example, to facilitate ventilation in ARDS and for initial
intubation. Avoiding oversedation and reviewing the need for
sedation at least on a daily basis is imperative.

Respiratory
As well as enhancing oxygen delivery to the tissues with
supplemental oxygen therapy, respiratory support ensures
effective removal of CO2 by either invasive or non-invasive
ventilation (NIV). NIV includes the use of continuous positive
airway pressure (CPAP) and also bi-level pressure support. In
certain settings, for example pulmonary oedema, NIV is a very
effective as first-line treatment, but requires haemodynamic
stability and no severe acidebase disturbance.
Invasive ventilation is indicated in patients with more severe
respiratory failure such as in ALI/ARDS, and a protective lung
strategy should be employed. This strategy involves optimizing
alveolar recruitment and oxygenation, while avoiding pressureinduced lung damage (barotrauma) or over-distension (volutrauma). This necessitates using low tidal volumes (6e8 ml/kg)
and low peak inspiratory pressures (<30 cmH2O). The inspired
oxygen (FiO2) should be reduced to less than 0.7 as soon as
possible. Hypercarbia often results, which is usually well tolerated if the patient is optimally sedated. The effects of a markedly
increased PaCO2 on fetal wellbeing are not clear; however they
are likely to be detrimental with acidosis leading to reduced
ability of fetal haemoglobin to bind oxygen.
Monitoring may involve measurement of arterial blood gases,
pulse oximetry, central venous oxygen saturation (ScvO2) and
blood lactate as a measure of oxygen delivery and global tissue
perfusion. An indication of oxygenation is calculated using ratio
of partial pressure of oxygen (PaO2)/fractional inspired oxygen
(FiO2), the P/F ratio.

General critical illness disease syndromes

There are several important well-described critical care
syndromes that are the common end pathway of some obstetric
illnesses and are important to recognize and understand.
Acute respiratory distress syndrome (ARDS)
The diagnostic criteria and common obstetric causes of ARDS are
shown in Table 4, with the commonest causes in pregnancy
being haemorrhage and sepsis. Acute lung injury (ALI) is a less
severe form of ARDS, present if the P/F ratio is less than 300 mm
Hg or 40 kPa.
A variety of direct (i.e. alveolar damage) or indirect (i.e.
systemic disease) insults lead to an acute inflammatory lung
injury, with release of inflammatory mediators. The inflammatory response involves sequential exudative, proliferative and
fibrotic phases. The result is progressive hypoxaemia and respiratory failure, and complications include nosocomial pneumonia,
pulmonary hypertension, and ventilator-induced lung injury
(VILI). The latter may be due to barotrauma (e.g. pneumothorax,
surgical emphysema) or volutrauma (e.g. pulmonary oedema
and diffuse alveolar damage). Most deaths occur due to sepsis or
multiple organ failure, rather than respiratory failure. Fortunately, the overall mortality from ARDS is declining, and
obstetric patients who develop ARDS are probably at lower risk
of death than other critically ill patients.

Renal
Early recognition and appropriate management of renal impairment and oliguria is important to avoid the development of acute
kidney injury (AKI). Management will depend on the underlying
cause, but involves careful fluid administration with a fluid
challenge where appropriate, diuretics, correction of electrolyte
imbalances, inotropes, and specific measures to treat the
underlying cause (e.g. antibiotics for sepsis). Low-dose renal
dopamine has no proven benefit. In established AKI, renal

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Diagnostic criteria and obstetric causes of ARDS

ARDS diagnostic criteria

Obstetric causes of ARDS

Severe hypoxaemia
P/F ratio <200 mm Hg (or 27 kPa)

Major haemorrhage
Sepsis
Intrauterine fetal death
Hypertensive disease
Preeclampsia
Eclampsia
Acute fatty liver of pregnancy

Diffuse bilateral infiltrates on chest X-ray

Pulmonary artery occlusion pressure <18 mm Hg (i.e. normal left atrial pressure and
left ventricular function, to exclude cardiogenic pulmonary oedema and heart failure)
P/F ratio: PaO2/FiO2, partial pressure of oxygen in arterial blood/fractional inspired oxygen.

Table 4

The management involves both general respiratory support,

and identification and treatment of the precipitating cause. For
mild ALI this includes oxygen therapy, physiotherapy, and
diuretics (to reduce extravascular lung water). More severe ALI/
ARDS will require non-invasive ventilation (NIV) or intubation
with mechanical ventilation aiming for a protective lung strategy.
Sometimes prone positioning (i.e. placing the patient face down)
enables the posterior consolidated lung to become non-dependent,
thus changing pulmonary blood flow and allowing a more even
distribution of ventilation. Other strategies that are employed to
reduce VILI include high-frequency oscillation, or very rarely
extracorporeal gas exchange, but these remain rescue therapies
and are not yet widely used. Pulmonary vasodilators such as
inhaled nitric oxide or prostacyclin, surfactant replacement, and
corticosteroids have not been shown to reduce mortality.

There are two main types of shock: either warm and dilated
or cold and clammy. Patients with warm and dilated shock, as
seen in early sepsis or anaphylaxis, are peripherally vasodilated
[low systemic vascular resistance (SVR)] with a high CO, they
may have a bounding pulse and are flushed. Conversely, patients
with cold and clammy shock, as in hypovolaemia or cardiogenic shock, are peripherally vasoconstricted (high SVR) with
a low CO, so will be shutdown with a low volume pulse. The
jugular venous pressure (JVP) or CVP may help determine the
cause, as it is often high in cardiogenic and obstructive shock,
and low in hypovolaemic and anaphylactic shock, but can be
high, low or normal in septic shock. Patients do not always
follow these rules though, especially young obstetric patients,
hence the CVP should not be overly relied upon. Irrespective of
the cause, patients with shock are at risk of further complications
because of progressive tissue hypoxia, and ARDS, acute renal
failure and multi-organ failure may follow.
Management needs to be initiated early in patients with shock,
as mortality increases steadily with the duration of time that the
patient remains hypotensive. Management includes oxygen
therapy and assistance with ventilation to improve the hypoxaemia, appropriate fluid management, and inotropic and vasopressor drugs to maintain the circulation. It is important to identify
the underlying cause, as some aspects of management vary
depending on the cause. For example, patients with hypovolaemic

Shock
Shock is a broad term used to describe acute circulatory
collapse, with failure of adequate oxygen delivery to the tissues.
Presenting clinical features in all types of shock may include
hypotension, tachycardia (except in spinal shock), tachypnoea,
oliguria and confusion. The underlying causes of shock can be
grouped into one of five categories according to Table 5, and in
the obstetric population, the commonest causes are sepsis and
hypovolaemia following haemorrhage.

Types of shock and obstetric causes

Type of shock

Pathophysiology

CO

SVR

Obstetric causes

Hypovolaemia
Distributive
Cardiogenic
Obstructive

Loss of circulating volume

Pathological vasodilatation
Severe pump failure
Physical obstruction
within cardiovascular system
Loss of sympathetic tone

Low
High, Low or normal
Low
Low

High
Low
High
High

Low or normal

Low

Massive haemorrhage, DKA

Sepsis, anaphylaxis
Cardiomyopathy, myocarditis, IHD
Pulmonary embolism,
amniotic fluid embolus
Spinal trauma

Neurogenic

Abbreviations: CO, cardiac output; SVR, systemic vascular resistance; DKA, diabetic ketoacidosis; PE, pulmonary embolism; IHD, ischaemic heart disease.

Table 5

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shock may require aggressive fluid replacement, whereas those

with cardiogenic shock require more cautious fluid administration
and an inotrope such as dobutamine to increase CO.

source of infection is usually the pelvis, and potentially more

amenable to intervention.
Conditions associated with an increased risk of sepsis in early
pregnancy (before 24 weeks gestation) include septic miscarriage,
and retained products following a miscarriage. Conditions in later
pregnancy are prolonged rupture of membranes, cervical sutures,
emergency CS, instrumentation of the genital tract, and retained
products of conception or placenta. Endotoxin-producing aerobic
Gram-negative bacilli are the most common cause (60e80%), but
sometimes Gram-positive bacteria, mixed (usually anaerobes such
as Bacteroides or Clostridium) or fungal infections are implicated.
Septic shock with disseminated intravascular coagulation (DIC) is
an ominous sign if it develops.
The immediate management involves circulatory support and
correction of coagulation defects, but should also involve prompt
aggressive treatment with adequate intravenous doses of
appropriate broad-spectrum antibiotics, rather than waiting for
microbiology results. Microbiology advice should be sought
early. The 2004 Surviving Sepsis Campaign guidelines (now
revised in 2008) were produced to improve outcome in severe
sepsis, with particular targets for the first 6 hours of resuscitation. Evidence-based care in sepsis has been divided into bundles
of care, with the first bundle covering resuscitation in the initial
6 hours and the second bundle covering targets for the subsequent 24 hours - see below.

Systemic inflammatory response syndrome and sepsis (SIRS)

SIRS is a basic description of the bodys response to a spectrum
of clinical conditions such as infection. It is defined as the
presence of at least two of the following criteria:
 Temperature >38 or <36 C
 Heart rate >90 beats/min
 Respiratory rate >20/min or PaCO2 <4.3 kPa (32 mm Hg)
 White cell count >12000 or <4000 cells/mm3, or >10%
immature (band) forms.
Non-infective causes include trauma, burns and pancreatitis.
Sepsis is defined as SIRS secondary to an infection, and severe
sepsis is when there are features of organ dysfunction such as
hypotension or oliguria. Septic shock has developed when
hypotension persists despite adequate fluid resuscitation. Sepsis
is the leading cause of multiple organ failure, AKI, and ARDS,
and carries a mortality of 30e50%.

Obstetric conditions requiring ICU

Thromboembolic disease
Pregnancy is a hypercoagulable state due to changes in clotting
factors, and vena caval compression by the gravid uterus
predisposes to lower limb and pelvic venous thromboembolism
(VTE). VTE remains the most common cause of direct maternal
death in pregnancy in the UK, with the puerperium being the
highest risk period. Important additional risk factors are well
summarized in the RCOG green top guideline number 37, revised
2009 (Reducing the risk of thromboembolism during pregnancy,
birth and the puerperium). A full risk assessment should be
carried out in every patient admitted to ICU, especially those
following Caesarean section (CS). Pregnant women at increased
risk of VTE (including previous VTE, thrombophilia, and other
risk factors e.g. increased age, obesity, immobility) should
receive postnatal and/or antenatal thromboprophylaxis. This is
important for critically ill obstetric patients with long periods of
immobility, who will need subcutaneous low molecular weight
heparin (LMWH) (e.g. 40 mg od or bd enoxaparin depending on
level of risk) and graduated compression stockings. Treatment of
VTE involves high-dose LMWH (e.g. 1 mg/kg bd enoxaparin
compared with non-pregnant dose of 1.5 mg/kg od). Thrombolysis has been used in pregnancy for life-threatening pulmonary embolus and should not be withheld in the pregnant or
puerperal patient if otherwise indicated for life threatening PE
with haemodynamic instability.

Massive obstetric haemorrhage

Obstetric haemorrhage is defined as an estimated blood loss level
(EBL) of at least 2500 ml, the transfusion of five or more units of
blood, or the need for treatment of coagulopathy, although definitions may vary. It is a common cause of maternal death worldwide,
with a 1% case fatality rate. It occurs 100 times less frequently in the
UK, in 3.7 per 1000 births in a recent UK study, and remains one of
the most frequent obstetric reasons for admission to an ICU. Postnatal intra-abdominal bleeding must be recognized early, and high
risk features include uterine atony and morbidly adherent
placentas. Initial management is maternal resuscitation, as for any
major bleed, with rapid fluid replacement, and should ideally be
according to well-rehearsed local major obstetric haemorrhage
protocols. The obstetric and haematological management of
obstetric haemorrhage has been recently reviewed.
Disseminated intravascular coagulation
DIC is a secondary phenomenon, following a trigger of generalized coagulation activity. Further consumption of platelets,
clotting factors and fibrin occurs, resulting in a vicious circle of
continuing bleeding and yet consumption of clotting components. DIC is associated with a large number of obstetric conditions including major obstetric haemorrhage, pre-eclampsia and
HELLP syndrome, acute fatty liver, chorioamnionitis, septic
shock, amniotic fluid embolism, and retained dead fetus.
Management is similar to that for obstetric haemorrhage, namely
prompt resuscitation and fluid replacement, with location and
treatment of the underlying cause. Blood products need to be
given as soon as available, including packed red cells, fresh
frozen plasma (FFP), cryoprecipitate, and platelets. More recent
developments include the use of recombinant activated Factor
VII (see below).

Sepsis in pregnancy
Worldwide, infection is still a significant cause of maternal
death, and there was a small increase in deaths due to genital
tract sepsis in the 2003e2005 Confidential Enquiry. Pregnant
women are more susceptible to certain infections due to
reduced cell-mediated immunity and raised corticosteroid
levels. The onset of life-threatening sepsis in pregnant women
can be insidious, with rapid clinical deterioration, and pyrexia
is not always present. One reason that the prognosis is still
more favorable than the non-obstetric population, is that the

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Pre-eclampsia
Possible crises of pre-eclampsia include the HELLP syndrome
(haemolysis, elevated liver enzymes and low platelets), pulmonary oedema, and eclampsia. The commonest causes of death are
intracranial haemorrhage and ARDS, and other maternal
complications include AKI, haemorrhage, DIC, and liver
dysfunction. Fetal complications include fetal growth restriction
(FGR), placental abruption, preterm delivery, and intrauterine
death. The key management points are control of hypertension
(methyldopa, nifedipine, labetalol, and/or hydralazine), treatment or prophylaxis of seizures (magnesium sulphate), careful
fluid administration to avoid pulmonary oedema, and decision
regarding delivery. Postnatal complications and postnatal onset
of pre-eclampsia may occur even following hospital discharge.

mortality rate of between 6% and 15%. Initial management

involves treatment of heart failure and anti-coagulation. Immunosuppression may also be considered, and ultimately, cardiac
transplantation, with intra-arterial balloon pumps or left
ventricular assist devices as bridging therapies.
Amniotic fluid embolus
This is a rare, but serious complication of pregnancy, affecting 1
in 80000 pregnancies. Diagnosis relies on the finding of fetal
squames in the pulmonary vasculature at post-mortem. Mortality
exceeds 80%, especially within the first hour. Amniotic fluid or
fetal matter enters the maternal circulation causing an anaphylactic-like reaction, with development of sudden onset of
breathlessness, cyanosis, hypoxia, confusion, and hypotension,
often followed by cardiac arrest. Complications include seizures,
DIC and pulmonary oedema. There is no specific treatment, and
management is supportive and symptomatic, involving adequate
oxygenation and ventilation, maintaining circulation, and
correction of coagulopathy.

Acute fatty liver of pregnancy

Acute fatty liver is rare, affecting 1 in 10e20,000 pregnancies,
with 60% of cases requiring ICU admission due to hepatic failure.
Maternal and fetal mortality rates are high. Management
involves maternal resuscitation with correction of coagulopathy,
fluid imbalance and hypoglycaemia, and treatment of liver and
renal failure, intensive fetal monitoring, and urgent delivery. Nacetylcysteine is often administered. Careful attention should be
paid to haemostasis in view of the coagulopathy, as these women
often require re-laparotomy because of post-partum haemorrhage or wound haematoma. They may require intracerebral
pressure monitoring.

Ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is a syndrome occurring in women undergoing cycles of in vitro fertilization. Excessive
hormonal stimulation results in increased vascular permeability,
which may lead to ascites, pleural/pericardial effusions, or oedema.
It is usually self-limiting, but may be fatal if severe and not managed
appropriately. In the latest confidential enquiry into maternal
deaths, four OHSS deaths were reported. Management principles
are mostly supportive and also include thromboprophylaxis and
strict attention to fluid balance, as women have intravascular fluid
depletion despite increased total body water.

Cardiac disease
Around 1% of pregnant women have serious cardiac disease,
which may be congenital or acquired, and it remains the most
common cause of maternal mortality in the UK. Rheumatic mitral
stenosis is an increasing problem in the immigrant population.
Patients with pulmonary hypertension are at particularly high risk,
with maternal mortality of 25e40%, related to an inability to
tolerate the cardiovascular demands of late pregnancy and especially at delivery. Myocardial infarction secondary to ischaemic
heart disease is now the commonest cause of death, especially in
obese older women, and aortic dissection the next commonest.
Maternal complications include arrhythmias, cardiac failure,
thromboembolism and death. Risks to the fetus/neonate include
FGR, preterm delivery, respiratory distress syndrome, intraventricular haemorrhage, and death. It is crucial that women with
mechanical prosthetic valves remain adequately anti-coagulated.
Invasive procedures (such as valvuloplasty) and surgery are
usually avoided unless there is acute severe deterioration in status.
Cardiopulmonary bypass carries up to 30% fetal mortality, and
outcome is best if surgery is delayed until fetal viability, then the
fetus delivered by CS immediately before carrying out the surgery.

Maternal collapse/cardiopulmonary arrest

Fortunately, cardiopulmonary arrest is a rare complication of
pregnancy. In contrast to the non-pregnant individual, where
a primary cardiac cause is more likely, this is not usually the case
in the pregnant woman, where causes include haemorrhage,
placental abruption, pulmonary or amniotic fluid embolism,
eclampsia and drug toxicity. The principles of basic and
advanced life support are similar to non-pregnant individuals,
importantly remembering to keep the women in the left lateral
tilt position to avoid vena caval compression. If resuscitation is
not successful within five minutes, CS should be performed as an
aid to maternal resuscitation.

Recent developments in critical care management

Early identification of critical illness
Outreach and early warning systems have been developed for
adult patients on general wards to detect deteriorating patients
before late signs, such as hypotension, result. Generally, they utilise
five simple physiological variables: conscious level, pulse rate,
systolic blood pressure, respiratory rate (the most sensitive indicator) and temperature. Urine output is sometimes added for postoperative patients or those who are catheterized. The most recent
confidential enquiry into maternal deaths has underlined the urgent
need for setting up obstetric early warning systems, to use in all
areas where the onset of critical illness in pregnancy might be
identified early including the emergency department or the gynecology ward as well as delivery suites and maternity wards.

Peripartum cardiomyopathy
This is a cardiomyopathy specific to pregnancy, and defined as
the development of cardiac failure in the last month of pregnancy
or within 5 months of delivery, in the absence of both an identifiable cause and recognizable heart disease before this. The
aetiology is unknown, but risk factors include multiple pregnancy, multiparity, hypertension, pre-eclampsia, and prolonged
tocolysis. Outcomes differ between studies: 25e50% of women
recover, 7e14% require transplantation, with a maternal

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REVIEW

Sepsis care bundles

Sepsis resuscitation bundle-within first 6 hours

Sepsis management bundle-within 24 hours

Measure serum lactate

Obtain blood cultures prior to antibiotic administration
Administer broad-spectrum antibiotics within three hours of admission to ICU
In the event of hypotension and/or lactate >4 mmol/l:
e Deliver an initial minimum of 20 ml/kg of crystalloid (or colloid equivalent)
e Apply vasopressors for hypotension not responding to initial fluid
resuscitation to maintain mean
arterial pressure (MAP) >65 mm Hg

In accordance with local ICU policy:

- Consider low-dose steroids for septic shock
- Administer activated protein C (drotrecogin alpha)
- Maintain adequate glycaemic control - <8 mmol/l
- Prevent excessive inspiratory plateau pressures

Table 6

Surviving Sepsis Campaign: care bundles

The Surviving Sepsis Campaign Guidelines were initially
written in 2004, and then revised in 2008 up to improve the
outcome in severe sepsis and septic shock. Management in
the first 6 hours is targeted towards a number of specific
resuscitation goals, including targets for central venous filling
pressure, ScvO2, haemoglobin, and the use of vasopressors
and inotropes. These evidence-based concepts have been
described as care bundles or groups of interventions that,
when executed together, result in better outcome. They
should be delivered as a continuum in the emergency room,
ward or ICU setting (Table 6). If the patient is then admitted
to an ICU, there are further management goals for the
subsequent 24 hours.

Insulin therapy, to avoid hyperglycaemia and aim for appoximately 8 mmol/l, is probably optimal. Avoiding hyperglycaemia may reduce mortality, as well as decreasing
a number of other complications including prolonged
mechanical ventilation, neuropathy and need for renal
replacement therapy.
Recombinant Factor VII
Recombinant activated Factor VIIa (NovoSevenTM) although
unlicensed is used occasionally for intractable blood loss. It
induces short-term local haemostasis, and may buy time to
enable further correction of clotting times with standard blood
product support. It has been used for the treatment of obstetric
haemorrhage, with lifesaving results in some cases, but its use
remains controversial.
A

Corticosteroids in sepsis
Patients in septic shock often have relative adrenocortical
insufficiency (about 50%), and low-dose corticosteroid
replacement (<300 mg hydrocortisone/day) is frequently
used. Most trials have shown improved reversal of shock,
especially in those patients unresponsive to initial fluid
challenges and vasopressors, but large multicentre trials have
not shown a consistent clear reduction in mortality. Glucocorticoids are usually given in the form of intravenous
hydrocortisone (by infusion at 8 mg/hour or 6 hourly boluses
of 50 mg), and are quickly weaned when vasopressors are no
longer required.

FURTHER READING
Brace V, Kernaghan D, Penney G. Learning from adverse clinical outcomes:
major obstetric haemorrhage in Scotland, 2003e2005. BJOG 2007;
114(11): 1388e9.
Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign:
international guidelines for management of severe sepsis and septic
shock: 2008. Intensive Care Med 2008; 34: 17e60.
Farmer JC, Guntupalli KK, Baldisseri M, Gilstrap L. Critical illness of
pregnancy. Crit Care Med 2005; 33(Suppl.): S247e397.
James DK, Steer PJ, Weiner CP, Gonik B, eds. High-risk pregnancy. 3rd edn.
London: WB Saunders, 2005.
Leach R. Critical care medicine at a glance. Oxford: Blackwell Publishing
Ltd, 2004.
Lefkou E, Hunt B. Haematological management of obstetric haemorrhage.
Obstet Gynaecol Reprod Med 2008; 18(10): 265e27.
Lewis, G (ed) 2007. The Confidential Enquiry into Maternal and Child
Health (CEMACH). Saving Mothers Lives: reviewing maternal deaths to
make motherhood safer - 2003e2005. The Seventh Report on
Confidential Enquiries into Maternal Deaths in the United Kingdom.
London: CEMACH.
Nelson-Piercy C. Handbook of obstetric medicine. 3rd edn. London: Taylor
Francis, 2006.

Activated protein C
Recombinant human activated protein C, or drotrecogin alpha
(activated), has been shown to significantly reduce mortality in
severe sepsis and multiple organ failure, and is indicated in
those considered to be at high-risk of death. It has anti-inflammatory, antithrombotic, and profibrinolytic properties, and
a small increased risk of bleeding. There are a few published
case reports of its use in pregnancy in severe sepsis and acute
fatty liver.
Intensive insulin therapy
Insulin resistance and hyperglycaemia are common in critically
ill patients, even in those not previously known to be diabetic.

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2009 Published by Elsevier Ltd.

REVIEW

Royal College of Obstetricians and Gynaecologists, Royal College of

Midwives, Royal College of Anaesthetists, Royal College of Paediatrics
and Child Health. Safer childbirth. Minimum standards for the organisation and delivery of labour, 2007.
RCOG Green top guideline no 37. Available at: http://www.rcog.org.uk/
files/rcog-corp/uploaded-files/PeerReviewDraftGTGNo37.pdf.

Practice points
C

Research directions
C

Implementation of pregnancy-specific critical illness scoring

systems.
Search for cause and possible treatments for pregnancyspecific conditions such as pre-eclampsia and acute fatty liver
of pregnancy.
Evaluation in the pregnant population of best-practice guidelines from the non-pregnant population, for example Surviving
Sepsis Campaign guidelines.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:12

Up to 1% of pregnant women require ICU admission,

accounting for up to 3% of overall ICU admissions, with the
leading causes being obstetric haemorrhage and preeclampsia.
Maternal management involves necessitates knowledge of the
normal physiological changes of pregnancy, consideration of
pregnancy-specific causes, and appropriate organ support to
maintain oxygen delivery.
Fetal management primarily involves maternal resuscitation,
but also maintaining adequate placental oxygenation and
perfusion, and consideration of effect of drugs and timing of
delivery.
Suggestions for improvement of care include training of staff
regarding presentation of the critically ill pregnant woman,
early senior involvement, and prompt initiation of intensive
care management even before ICU admission.

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