In the United States each year, 1 to 3 percent of pregnant women require critical care services, and the risk of death during such admissions ranges from 2 to 11 percent (American College of Obstetricians and Gynecologists, 2017b). hose with pregnancy-associated complications-especiall) hemorrhage and hypertension-have the greatest need for intensive care (Chantry, 2015; Gafney, 2014; Guntupalli, 2015a,b). That said, many antepartum admissions are for nonobstetrical reasons, and these include diabetes, pneumonia or asthma, heart disease, chronic hypertension, pyelonephritis, and thyrotoxicosis (Guntupalli, 2015b; Zeeman, 2006). Additionally, intrapartum and postpartum critical care for hypertensive disorders, hemorrhage, sepsis, or cardiopulmonary complications is often required. In instances of life-threatening hemorrhage, surgical procedures may be necessary, and close proximity to a delivery-operating room is paramount. For women who are undelivered, fetal well-being is also better served by this close proximity, especially because many are delivered preterm (Kilpatrick,r2016).
• Organization of Critical Care he concept and development of critical care for all aspects of medicine and surgery began in the 1960s. The National Institutes of Health held a Consensus Conference (1983) and the Society of Critical Care Medicine (1988, 1999) subsequently established guidelines for ICUs. Especially pertinent to obstetrics, these costly units prompted the evolution of a step-down intermediate care unit. hese latter units were designed for patients who did not require intensive care, but who needed a higher level of care than that provided on a general ward. The American College of Critical Care Medicine and the Society of Critical Care Medicine (1998) have published guidelines for these units (Table
TABLE 47-1 . Guidelines for Conditions That Could Qualify for Intermediate Care
Cardiac: for possible infarction, stable infarction, stable arrhythmias, mild-to-moderate congestive heart failure, hypertensive urgency without end-organ damage Pulmonary: stable patients for weaning and chronic ventilation, patients potential for respiratory failure who are otherwise stable Neurological: stable central nervous system, neuromuscular, or neurosurgical conditions that close monitoring Drug overdose: hemodynamically stable Gastrointestinal: stable bleeding, liver failure with stable vital signs Endocrine: diabetic ketoacidosis, thyrotoxicosis that requires frequent monitoring Surgical: postoperative from major procedures or complications that require close monitoring Miscellaneous: early sepsis, patients who require closely titrated intravenous fluids, pregnant women with severe
Data from Nasraway, 1998 .
Although the evolution of critical care for obstetrical patients has generally followed developments just described, there are no speciic guidelines. Most hospitals employ a blend of these concepts, and in general, units can be divided into three types.
First, in most hospitals, severely ill women are transferred to medical or surgical ICUs that are operated by specialists oten certified in critical care medicine. Admissions or transfers to these units are situation-speciic and based on the acuity of care needed and on the ability of the facility to provide it. For example, pregnant women who require ventilatory support, invasive monitoring, or pharmacological support of circulation are typically transferred to an ICU (Chantry, 2015). Another example is the neurological ICU (Sheth, 2012). In an earlier review of more than 25 tertiarycare referral institutions, approximately 0.5 percent of obstetrical patients were transferred to these types ofICUs (Zeeman, 2006).