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Care of the critically ill obstetric patient

Etienne GAYAT, MD, PhD (etienne.gayat@aphp.fr) Département d’Anesthésie – Réanimation – SMUR

Hôpitaux Universitaires Saint Louis – Lariboisière UMR-S 942, INSERM

Paris, France

No conflict of interest

What are the issues?

1. What is the epidemiology of critical illness in obstetric patients?

2. What are the recent novelties in the critical care of obstetric patients?

3. What is the impact on mid- to long-term outcome of critical illness in obstetric patients?

4. How could we globally improve the care of critically ill obstetric patients?

What are the issues?

1. What is the epidemiology of critical illness in obstetric patients?

2. What are the recent novelties in the critical care of obstetric patients?

3. What is the impact on mid- to long-term outcome of critical illness in obstetric patients?

4. How could we globally improve the care of critically ill obstetric patients?

• Improving maternal health

5th Millennium Development Goal • 303,000 maternal

deaths in 2015 ↘ 44% compared to 1990

Evolution during the last 25 years

Regional heterogeneity !

• 99% of maternal deaths occurred in the developing countries in 2015

Incidence of obstetric ICU admission

• In USA, 0.1 to 0.8% of obstetric patients are admitted to intensive care unit

American College of Obstetricians and Gynecologists. Critical care in pregnancy. Practice Bulletin No. 158. Obstet Gynecol 2016;127:e21-8.

• In Europe, 1 to 3 obstetric ICU admission for

1000 deliveries Obstetric intensive care unit admission: a 2-year nationwide population-based

cohort study. Intensive Care Med 2010. 36:256-264

• Lack of consistent data for developping regions

Causes of ICU obstetric admission

• More frequently post-natal admission

• Most frequent causes: – Obstetric haemorrahge (PPH++) – Pre-eclampsia / Eclampsia / HTN – Sepsis – Cardiac diseases

• 1st cause of death is the post-partum

haemorrhage

What are the issues?

1. What is the epidemiology of critical illness in obstetric patients?

2. What are the recent novelties in the critical care of obstetric patients?

3. What is the impact on mid- to long-term outcome of critical illness in obstetric patients?

4. How could we globally improve the care of critically ill obstetric patients?

Why focusing on postpartum haemorrhage ?

• 1st cause of maternal death in the world in both developed and developing countries (>120,000 death per year)

• Key issues – Avoidable cause of death +++ – Implies a team work (obstetrician-midwife-

anaesthesiologist-intensivist-radiologist) – Often unpredictable

• Tranexamic acid (TXA) reduces blood loss in major surgery

• TXA also significantly reduces uterine blood loss in women with menorrhagia

• 3 RCTs with poor quality already published showing significant reduction of blood loss

• Inclusion criteria: PPH defined by blood loss of over 500 mL after vaginal delivery or 1000 mL after caesarean section

• Main outcome measure: death or hysterectomy

N=10 000

N=10 000

4 g IV in 10 min then 1 g/h for the next 6 hours

• PPH with > 800 mL of blood loss after vaginal delivery

Low ratio RBC/FFP <0.5

Increased risk of advanced interventional procedure associated with a low ratio OR [95% CI] = 1.25 [1.07 to 1.47]

• Prospective cohorte of 869 severe PPH, including 44 post-partum hysterectomies

• Among those, PP hysterectomy failed to control the bleeding and additional interventions were needed in 50% of the patients

Intra-uterine balloon

1992: first attempt in 1992 using multiple Foley tubes inflated in the uterine cavity for the treatment of PPH following a Caesarean section (placenta praevia)

2001: patent for a new balloon (Cook medical, Bloomington, USA)

(Bakri, Int J Gynaecol Obstet 2001)

Literature review

• Very effective (similar to uterine arterial embolization)

• But:

– Limited sample size

– Potential Publication bias

What are the issues?

1. What is the epidemiology of critical illness in obstetric patients?

2. What are the recent novelties in the critical care of obstetric patients?

3. What is the impact on mid- to long-term outcome of critical illness in obstetric patients?

4. How could we globally improve the care of critically ill obstetric patients?

“We have failed to appreciate the journey of our patients and their loved ones after surviving critical illness” • While we are treating their acute problems, we have to consider and plan for their post-ICU recovery.

Possible mid- to long-term impact for the critical illness in obstetric patient

• Specific – Impact on fertility – Pre-eclampsia and cardiac remodelling – Partial recovery in PPCM patients – Severe PPH and myocardial injury

• Non specific

– Aggravation of pre-existing conditions (cardiac disease ++) – Social impact – Emotional impact (stress, anxiety and depression) on the

patient and on the relatives – Poor quality of life

• 1 ICU survivors on 5 develops PTSD at one-year after discharge

• ICU diaries decrease the incidence of PTSD

Significant reduction of PTSD new onset

n=30 PPH patients, matched with n=30 controls Questionnaires administrated at 1 and 3 months in both woman and her partner - IES-R: Impact of Event Scale – revised - EPDS: Edinburgh Post Natal Depression scale

• Prospective cohorte of 869 severe PPH, including 44 post-partum hysterectomies

• IES-R measured after a median follow-up time of 3 years

Emotional and Cardiac Impact of Postpartum Haemorrhage (HELP-MOM)

ClinicalTrials.gov: NCT02118038

N=800 severe PPH IES-S, EPDS and HADS measured at 1, 3 and 6

months

What are the issues?

1. What is the epidemiology of critical illness in obstetric patients?

2. What are the recent novelties in the critical care of obstetric patients?

3. What is the impact on mid- to long-term outcome of critical illness in obstetric patients?

4. How could we globally improve the care of critically ill obstetric patients?

• Many critical situations in obstetric patients are managed outside the ICU

• Running a devoted obstetric critical unit is an expensive endeavor that needs the support of a high volume of critically ill obstetric patients.

• What is a “virtual obstetrical ICU” – No fixed physical location on labor and delivery. – Instead, a mobile, multispecialty team capable of providing

individualized, patient-centered care, regardless of setting

Multi-disciplinary and training +++

It’s time to simulate to better manage critically ill patients !

• In the United States, about 98,000 patients die each year in hospitals because of substandard care.

• High-fidelity simulators commonly used educational tools, mainly by anesthesiologists

• Obstetric emergencies are subject to mismanagement.

PartoPants™

• 24 hospitals • More than 400 health care professionals

involved • Several training sessions using low level tech • Measure of indicators before and after the

intervention

“Take Home Messages”

• Critically ill obstetric patients are a particular ICU population • Post-partum haemorrhage is one the most frequent critical

condition in this population and is the leading cause of maternal death in the world – Translation of concept developed for general ICU patients to

obstetrical population

• Require a multidisciplinary team work +++ – Should be consider in any training program – Use of simulation

• While maternal mortality is decreasing, we should consider to

deal with post-ICU impact in survivors

Care of the critically ill obstetric patient

Etienne GAYAT, MD, PhD (etienne.gayat@aphp.fr) Département d’Anesthésie – Réanimation – SMUR

Hôpitaux Universitaires Saint Louis – Lariboisière UMR-S 942, INSERM

Paris, France