The indications for ICU admission in the obstetric population due topregnancy related causes could be widely categorised as cardiovasculardisorders of pregnancy, obstetric haemorrhage, respiratory disorders duringpregnancy, infections and hepatic disorders of pregnancy4,5,6,21.
Otherthan these, Surgical or medicalconditions which are not related to pregnancy such as trauma, diabetes,autoimmune diseases, asthma etc6 could necessitate the admission tothe ICU. There are also some medical diseases that may worsen during pregnancythat are, anaemia, congenital heart diseases, rheumatic and non-rheumaticvalvular diseases, renal failure, and autoimmune diseases etc.5,21Intensive care admission of the obstetric patient is infrequent; datafrom the UK and USA show that admission rates are about 0.9% of all mothersduring their pregnancy or puerperium. But maternal mortality of the obstetricpatients admitted to an ICU varies from 5-20%.5 The obstetric patient may have any surgical or medical conditionnecessitating intensive care unit (ICU) admission. There are alsopregnancy-specific conditions that could lead to the critical care admission.
7,21There are no well-definedcriteria that decide theadmission of an obstetric patient to an ICU. Most of the ICU admissions are based on local polices.5,21Conditions leading to critical care admission Thefetus’ wellbeing should also be considered while managing the mother’s bleedingor other emergencies1. Haemolytic disease of the fetus and theneonate, infections, premature delivery or an intra uterine death could resultfrom the maternal complications.1 Therecan be other comorbidities including eclampsia, and the HELLP syndrome whichwould further lead to severe bleeding. Hypercoagulable state in pregnancy whichusually assists in controlling the blood loss may also complicate the conditionleading to disseminated intravascular coagulopathy and pulmonary embolism.Assessingthe blood loss with the help of vital signs is not reliable in pregnancy.
1,4,18Changes in the vital signs such as hypotension or laboratory findings includingthe drop in haemoglobin or haematocrit do not occur until a larger amount ofblood lost due to the haemodilution and increased cardiac output. There couldbe concealed haemorrhage in the myometrium and/or broad ligament which would lead the clinician to underestimate the bloodloss. Blood mixed with amniotic fluid willalso complicate the calculation of blood loss. During a normalpregnancy, the mother undergoes significant anatomical and physiologicalchanges.1 The haematological changes are physiological dilutionalanaemia, neutrophilia, mild thrombocytopenia, increased procoagulant factors,and decreased fibrinolysis activity.1 These changes help the mother to stay haemodynamicallystable with the normal blood loss during delivery.
Red cell mass increases around 20-30% and there is a greater gradual increasein plasma volume around 50% which attribute to the dilutional anaemia ofpregnancy. Increased fibrinogen and factors VII, VIII, and IX, Protein A,Protein C, and Antithrombin III with reduced activity of fibrinolytic systemlead to the hypercoagulable state of pregnancy.1Transfusion in obstetricpatients is considered to be a unique challenge5, 6 due to variousreasons, including physiological changes of pregnancy, difficulty in assessingthe blood loss in obstetric patients, risk of alloimmunisation whichcomplicates the further transfusion and future pregnancies and posing a threatto the fetus1, 4, 5 Concerns specific to the obstetric patients Blood andblood components transfusion therapy isidentified as one of the essential components1,2 in emergency managementof obstetric patients who are critically ill and admitted to the intensive careunit. In the developing countries, the transfusion management could vary fromthat of the developed world due to the availability of the components, economy,infrastructure, religious belief and social taboos.
3 Literature review 1.4 To analyze the final outcome of the obstetric patientsin the intensive care unit who underwent transfusion.1.3 To analyze the transfusion triggers applied whilemaking the decision of transfusion1.2 To analyze the type of blood components and theamount of components transfused in these patients.1.1 To analyze the conditions leading to blood and blood components transfusion in the obstetric patients admitted to the intensive careunit.
Objectives and Aims Point of care testing methodsare available in the tertiary obstetric centres, and international guidelinesare followed with a few adaptations according the resources available in SriLanka. A timely analysis on the transfusion management, the triggers consideredwhile making the decision of transfusion, patient blood management as well asthe outcome of the patients admitted to the intensive care unit who have undergonea transfusion, will guide us to improve the quality of transfusion practice andpatient blood management in obstetric patients. Sri Lanka is identified asone of the countries with a low maternal mortality rate when compared to theother South Asian countries (Sri Lanka- 30 deaths/100,000 live births; India- 200 deaths/100,000live births; Pakistan- 240 deaths/100,000 live births and Bangladesh 260 deaths/100,000live births- 2015).De Soysa Maternity Hospitalremains one of the major tertiary obstetric centres in Sri Lanka.
Apart fromthe patients around Colombo, there are patients who get transferred from theperipheries of the island for further specialist management. Most literature available inSri Lanka focus on major obstetric haemorrhage and the transfusion management andthere is only limited information available on all the obstetric patientsadmitted to the intensive care unit and their transfusion management. Managementof critically ill obstetric patients admitted to the intensive care unitrequires a multi-disciplinary team’s input. Blood and blood component therapyplays a vital role in managing such patients in Sri Lanka where the bloodproducts such as activated Recombinant factor VII or fibrinogen concentrate arenot freely available.
Although obstetric patients are young and healthy, maternal mortality ratefor the patients admitted to an intensive care unit (ICU) ranges from 5–20% indeveloped countries and 15–30% in developing nations. Study on the blood and blood components transfusion therapy and the patientoutcome on obstetric patients admitted to the intensive care unit of De SoysaMaternity Hospital(DMH), Colombo, Sri Lanka.Study Title