Critical care in pregnancy

Childbirth is a major event in the lives of mothers and their families. Critical illness in pregnancy is uncommon but may arise from conditions unique to pregnancy, conditions exacerbated by pregnancy and coincidental conditions. According to the latest Confidential Enquiry into Maternal Deaths in the UK, haemorrhage remains a leading direct cause of mortality; however, there has been an increase in mortality due to indirect causes. The obstetric population has changed over the past decade and we are caring for much older mothers with pre-existing disorders and advanced chronic medical conditions. It is therefore essential to adopt an early multidisciplinary approach for the care of these women. With birth rates increasing, complex caseloads and changes in training of both medical and midwifery staff, the challenge of caring for critically ill obstetric patients requires urgent attention.

embolism. Such conditions are responsible for what are termed direct deaths in the Confi dential Enquiry into Maternal Deaths in the UK. In the most recent report, covering the triennium 2006 to 2008, for the fi rst time the number of deaths due to direct causes has declinednotably those due to haemorrhage [3]. Th is is encouraging and probably refl ects better early multidisciplinary management as described in the article.
Although some women with severe hypertensive disorders of pregnancy will require admission to adult critical care units, the majority receive care within the maternity unit. A recent report from the Joint Standing Committee of the Royal College of Anaesthetists and the Royal College of Obstetricians & Gynaecologists emphasises the need for the same standards of critical care for the obstetric patient, wherever it is delivered [4].
If mortality is the tip of the iceberg, the intensivist should be aware that deaths due to conditions exacerbated by preg nancy (indirect causes) are on the increase. Th e authors discuss sepsis, now the leading direct cause of mater nal death [1]. A local review of obstetric ICU admis sions identi fi ed an increasing number due to sepsis pre sent ing at all stages of pregnancy but most commonly postpartum. Th e cases included H 1 N 1 infl uenza, wound infections and biliary sepsis. It also important to note that sepsis in the mother may be associated with neonatal sepsis.
Other indirect causes are on the increase. Th e reason for this is that the obstetric population has changed over the decades. Th e obstetric population is much older, with co-morbidities including essential hyper tension, type 2 diabetes and even coronary heart disease. Obesity is a major concern and in pregnancy provides numerous challenges. Indeed, the Royal College of Anaesthetists and the Royal College of Obstetricians & Gynaecologists have recently produced guidelines on management in preg nancy [5,6]. We are encountering women with chronic medical conditions that previously precluded them from pregnancy. Improved medical care and assisted repro ductive techniques now enable them to become pregnant. Women from socially deprived areas and recent immigrants may present late with advanced medical problems. All of these factors add up to a more complex, high-risk caseload with an increasing need for

Abstract
Childbirth is a major event in the lives of mothers and their families. Critical illness in pregnancy is uncommon but may arise from conditions unique to pregnancy, conditions exacerbated by pregnancy and coincidental conditions. According to the latest Confi dential Enquiry into Maternal Deaths in the UK, haemorrhage remains a leading direct cause of mortality; however, there has been an increase in mortality due to indirect causes. The obstetric population has changed over the past decade and we are caring for much older mothers with pre-existing disorders and advanced chronic medical conditions. It is therefore essential to adopt an early multidisciplinary approach for the care of these women. With birth rates increasing, complex caseloads and changes in training of both medical and midwifery staff , the challenge of caring for critically ill obstetric patients requires urgent attention. specialist input by obstetric physicians [7], intensive care and above all early multidisciplinary teamwork.
Although the majority of obstetric admissions to the intensive therapy unit are postnatal, antenatal cases (the majority of whom are not suff ering from conditions directly related to pregnancy) present particular challenges. As the authors point out, physiological parameters are changed by preg nancy. For the sake of both mother and foetus, such changes must not be ignored. Th e importance of minimising aortocaval compression cannot be over empha sised. Once a pregnant mother is admitted to intensive care, it is vital to involve midwifery and obstetric teams early. Th e increased risk of hypoxia and potential for diffi cult intubation and aspiration should be borne in mind.
With birth rates increasing, complex caseloads and changes in training for both medical and midwifery staff , the challenge of caring for critically ill obstetric patients will become greater. Unfortunately one of the fi ndings of the latest Confi dential Enquiry into Maternal Deaths report was an unacceptable level of suboptimal care. One of the steps to addressing this is the proposed Back to Basics project involving packages of education and training emphasising the fundamentals of history and examination, recognition and initial management of the unwell individual and the use of early warning systems such as early warning score charts modifi ed for preg nancy [3]. Simulation, skills and drills training, and reinforcement of medical guidelines have been shown to improve aspects of crisis resource management such as communication, teamwork and leadership. Sharing medical and nursing expertise with experience from other highdependency and intensive care areas is essential to optimise the care of the critically ill pregnant patient.