Maternal critical care

Pregnancy is a normal event affecting most women, with an outcome usually happy and exciting. This journal deals with the many medical complications which may affect women during pregnancy, but at the extreme end is critical illness during pregnancy. Although a relatively rare event (0.3% of pregnancies), critical illness may have a catastrophic outcome. Obstetricians usually have very little exposure to these lifethreatening events, and intensive care physicians have little experience with pregnant patients. Regulatory and epidemiological organizations have very successfully taken on the challenge of surveillance of maternal near-misses and maternal death, with the objective of identifying preventable errors (e.g. MBRRACE in the UK). Nevertheless, the field of maternal critical care is one not fully recognized in many areas. Who should be responsible for the management of critically ill pregnant women? Often the first specialist involved will be the obstetrician, who is well versed in the management of normal pregnancy and obstetric complications, but less so in the areas of mechanical ventilation and other forms of life-support. Most intensivists experience some anxiety when confronted with a pregnant patient, the concerns being the unusual pregnancy-specific conditions, altered maternal physiology, and concerns about drug therapy and radiological imaging. These issues can be overcome by a comprehensive multidisciplinary management approach, including obstetricians, maternal–fetal medicine, critical care, obstetric medicine as well as relevant subspecialty consultants (e.g. nephrology, pulmonology, rheumatology). However, all of these specialties may not be available in one hospital. Obstetric critical care units were not uncommon in tertiary care hospitals in the 1980s, less common now with the evolution of specialty medicine. These units, run by maternal–fetal specialists, have advantages and disadvantages but can produce very good outcomes. These units tend to have a relatively lower threshold for admitting pregnant women and this early aggressive therapy may have advantages. Overall management may be better coordinated when the person responsible for patient care is the same person who will perform the delivery. In terms of critical care knowledge base, a mortality benefit can be derived from applying a few basic ICU strategies, such as pressure/volume limited ventilation, ventilation-associated pneumonia prevention, limiting sedation, restrictive transfusion practices, and prophylactic interventions (venous thromboembolism and ulcer prophylaxis). However, the patient with complex multiorgan failure may be better served in a conventional ICU setting. In terms of training, both obstetricians and intensivists receive only a cursory exposure to this high-risk patient group. Anesthesia training includes more significant exposure to the obstetric patient and increasingly in Canada general internal medicine programs require rotation through obstetric medicine, hopefully producing a coming generation of more pregnancy-friendly intensivists. We are not aided by the dearth of literature in the field, which consists largely of case reports, small case series and the occasional case–control study or systematic review. Furthermore, pregnant women have been (deliberately) excluded from almost all major studies of critical care interventions. One of the first books in this field, ‘‘Critical Care Obstetrics,’’ was published in 1987 edited by a prominent group of obstetricians and provided valuable insight into the basics of critical care for the obstetrician, but little about obstetrics for the intensivist. A more recent publication, ‘‘Maternal Critical Care’’ took the interesting approach of having chapters co-authored by an expert in critical care and an expert in obstetrics/obstetric medicine, to potentially cater to a broader spectrum of readers. There are also some very positive developments. The United Kingdom, which initiated and has lead the review of maternal deaths and the dissemination of recommendations, is now generating valuable clinical information. This is generated from a maternity unit perspective through the United Kingdom Obstetric Surveillance System (UKOSS) and from Intensive Care Unit data via the Intensive Care National Audit and Research Centre (ICNARC). In 2011, a multidisciplinary Maternal Critical Care Working Group in the UK generated a comprehensive review of standards and recommendations relevant to the care of the pregnant or recently pregnant critically ill woman. The underlying theme was equity of care, i.e.