Background and Objectives. Critically ill obstetric patients are a particularly unique cohort for the intensivist. The objective of this study was to review the indications for admission, demographics, clinical characteristics, and outcomes of obstetric patients admitted to intensive care unit of a medical college hospital in southern India and to identify conditions associated with maternal mortality. Design. Retrospective analysis of pregnant/postpartum (up to 6 weeks) admissions over a 1-year result. We studied 55 patients constituting 11.6% of mixed ICU admissions during the study period. Results. The mean APACHE (acute physiology and chronic health evaluation) II score of patients at admission was 11.8. Most of the patients (76%) were admitted in the antepartum period. The commonest indications for ICU admission were obstetric haemorrhage (51%) and hypertensive disorders of pregnancy (18%). 85% of patients required mechanical ventilation and 78% required inotropic support. Conclusions. Maternal mortality was 13%, and the majority of the deaths were due to disseminated intravascular coagulation and multiorgan failure, following an obstetric haemorrhage. A dedicated obstetric ICU in tertiary hospitals can ensure that there is no delay in patient management and intensive care can be instituted at the earliest.

SummaryNinety ASA 1 and 2 pregnant women with term singleton pregnancies and no maternal and fetal complications, scheduled for elective or emergency Caesarean section, were randomly allocated to group LT (15°left lateral table tilt, n = 45) and group MD (leftward manual displacement, n = 45). Subarachnoid block was established with a 25-gauge spinal needle at the L3-L4 interspace using 1.5 ml of 0.5% hyperbaric bupivacaine. A median sensory level of T6 was observed in both groups but the incidence of hypotension was markedly lower in group MD when compared to group LT (4.4% vs 40%; p < 0.001) with a significant reduction in mean (SD) ephedrine requirement (6 (0) vs 11.3 (4.9) mg; p < 0.001). The mean (SD) fall in systolic blood pressure was 28.8 (7.3) mmHg in group LT and 20 (12.7) mmHg in group MD. The time to maximum fall in systolic blood pressure was similar in both groups (4.5 min). We conclude that manual displacement of the uterus effectively reduces the incidence of hypotension and ephedrine requirements when compared to 15°left lateral table tilt in parturients undergoing Caesarean section. Supine hypotension that develops in pregnant women near term has been attributed to aortocaval compression by the enlarged gravid uterus, which decreases venous return to the heart. Use of subarachnoid block compounds the problem of hypotension in the supine parturient by causing vasodilation and venous pooling of blood in the lower limbs. The relative hypovolaemia caused by the combination of aortocaval compression and subarachnoid block may lead to placental insufficiency. The incidence of hypotension seems to be unexpectedly high despite preloading with crystalloids (47.4-83%) [1,2] or colloids (17-38%) [3,4] and the use of prophylactic vasoconstrictors (35-80%) [5].The universal practice of employing a 15°left lateral tilt using an obstetric wedge under the right hip [6] or tilting the table leftwards [7] might help to decrease the degree of aortocaval compression but does not guarantee its absence [8]. Maximum displacement of the uterus is best achieved by mechanical displacers. Hypotension was witnessed in only one out of the 300 patients by Colon-Morales [9] in his series. A similar magnitude of uterine displacement can be accomplished by the anaesthetist placing their right hand beneath the right costal margin to attain a maximum fundal push towards the left until the baby is delivered. Mechanical displacement of the gravid uterus seems to be a more logical and effective approach to managing hypotension as it helps in directly relieving the aortocaval compression by dislodging the gravid uterus. This study was therefore designed to evaluate the role of manual leftward uterine displacement in preventing hypotension for parturients undergoing lower segment Caesarean section (LSCS) under subarachnoid block. MethodsNinety pregnant women, ASA physical status 1 or 2, with full term singleton pregnancies and scheduled to undergo elective or emergency LSCS under subarachnoid block were included in the study followin...

Surface colonizing bacteria and not maternal genital bacteria are important in early onset neonatal sepsis.

We conclude that PCOS patients have altered autonomic modulation in the form of increased sympathetic and decreased parasympathetic reactivity and HRV. The sympathovagal imbalance exposes them to cardiovascular morbidities.

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Aim. To revisit the role of first trimester homocysteine levels with the maternal and fetal outcome. Methods. This was a cohort study comprising 100 antenatal women between 8 and 12 weeks of gestation. Serum homocysteine levels were checked after overnight fasting. Results. There were significantly elevated homocysteine levels among women with prior history of hypertensive disorders of pregnancy and prior second or third trimester pregnancy losses. There was no significant difference in homocysteine levels among women with previous gestational diabetes mellitus, preterm deliveries, or fetal malformations. Homocysteine levels were significantly elevated in those who developed hypertensive disorder of pregnancy, oligohydramnios, and meconium stained amniotic fluid, had a pregnancy loss, or delivered a low birth weight baby. There was no significant difference in homocysteine levels for those who developed gestational diabetes mellitus. Conclusions. Increased first trimester serum homocysteine is associated with history of pregnancy losses, hypertensive disorders of pregnancy, and preterm birth. This is also associated with hypertensive disorders of pregnancy, pregnancy loss, oligohydramnios, meconium stained amniotic fluid, and low birth weight in the current pregnancy. This trial is registered with ClinicalTrials.gov CTRI/2013/02/003441.

The early prediction of pregnancy-induced hypertension (PIH), a common morbid disorder of pregnancy is unsatisfactory. Therefore, in the present study we have investigated the role of spectral analysis of heart rate variability (HRV) in the early prediction of PIH. Spectral analysis of HRV was performed in three groups of subjects (Group I: normal pregnant women; Group II: pregnant women with risk factors, but did not develop PIH; Group III: pregnant women with risk factors and developed PIH). It was observed that the LF-HF ratio, the most sensitive indicator of sympathovagal balance, was significantly high (p < 0.01) since early pregnancy in group III compared to other groups, which was significantly correlated with heart rate and blood pressure. It was suggested that the predictive knowledge of sympathovagal imbalance should be utilized in designing the prevention and management of PIH.

The effect of postural changes on inferior vena cava (IVC) dimensions and its influence on intra-operative haemodynamics in term parturients can be studied using abdominal ultrasound by a subcostal approach. Thirty-two term parturients scheduled to undergo elective caesarean section under spinal anaesthesia were recruited in this observational study. End expiratory diameter and collapsibility index of IVC was measured preoperatively in 3 different positions - supine, recumbent with wedge and left lateral positions. End expiratory diameter was significantly high in recumbent (10.79) and left lateral (12.27) compared with supine (9.96) position (P < 0.0001). A greater fall in systolic blood pressure (>20%) was noted in patients with collapsibility index of more than 11.5 in recumbent with wedge position with a positive predictive value of 86%. IVC dimensions change significantly with change in position and collapsibility index in recumbent position can be a useful parameter for predicting hypotension during caesarean section under spinal anaesthesia.