Critical Care Management in Obstetrics and Gynecology: A Comprehensive Review

Dr. Apurba Kumar Borah, Consultant & HOD, Critical Care Medicine, India

Abstract

The intersection of obstetrics, gynecology, and critical care medicine presents unique challenges requiring a multidisciplinary approach.¹ Maternal mortality and morbidity often stem from acute physiological decompensation due to hemorrhage, sepsis, or hypertensive disorders.² Similarly, complex gynecological surgeries and oncology cases increasingly require postoperative intensive care. This article reviews the pathophysiology, recognition, and management of life-threatening conditions in obstetric and gynecological patients, emphasizing the need for early intervention and specialized knowledge of female physiology.

1. Introduction

Critical illness in obstetric and gynecological patients is relatively rare but carries disproportionately high risks of morbidity and mortality. Admission to the Intensive Care Unit (ICU) occurs in approximately 0.2% to 0.9% of deliveries. The management of these patients is complicated by the physiological alterations of pregnancy and the specific surgical risks associated with gynecological procedures.³ This review aims to bridge the gap between reproductive health and critical care.

2. Physiological Adaptations in Pregnancy

Successful critical care management requires an understanding of how pregnancy alters baseline physiology.⁴ Failure to recognize these “new normals” can lead to mismanagement.

• Cardiovascular: Blood volume increases by 40–50%, while cardiac output rises by 30–50%.⁵ Systemic vascular resistance decreases.
• Respiratory: Functional residual capacity (FRC) decreases by 10–25% due to diaphragmatic elevation, making pregnant patients prone to rapid desaturation during apnea.
• Hematological: Pregnancy is a hypercoagulable state with increased levels of fibrinogen and factors VII, VIII, IX, and X, increasing the risk of venous thromboembolism (VTE).

3. Obstetric Critical Care Emergencies

A. Obstetric Hemorrhage

Postpartum hemorrhage (PPH) remains a leading cause of maternal mortality globally. Massive hemorrhage requires immediate activation of a Massive Transfusion Protocol (MTP).

• Definition: Blood loss >1000 mL irrespective of the mode of delivery, or loss accompanied by signs of hypovolemia.
• Critical Care Management:
  • Resuscitation: Permissive hypotension is generally contraindicated in pregnancy due to the need for placental perfusion (if the fetus is in utero).
  • Blood Products: Early administration of Fresh Frozen Plasma (FFP) and Platelets in a 1:1:1 ratio with Packed Red Blood Cells (PRBCs) is recommended.
  • Tranexamic Acid (TXA): Administer 1g IV within 3 hours of birth.

B. Sepsis in Obstetrics

Sepsis is the third leading cause of maternal death. The diagnosis is often delayed because tachycardia and leukocytosis are normal physiological variants in labor.

• Red Flags: Respiratory rate >25/min, altered mental status, and systolic BP <90 mmHg (qSOFA criteria).
• Management:
  • Adhere to the “Hour-1 Bundle”: Obtain lactate, blood cultures, start broad-spectrum antibiotics, and administer 30 mL/kg crystalloid for hypotension.
  • Source Control: Prompt delivery of the fetus may be required if chorioamnionitis is the source.

C. Hypertensive Disorders (Preeclampsia/Eclampsia)

Preeclampsia with severe features can lead to intracerebral hemorrhage, pulmonary edema, and hepatic rupture.

• Blood Pressure Control: Immediate treatment of severe hypertension (160/110 mmHg) using Labetalol, Hydralazine, or Nifedipine.
• Seizure Prophylaxis: Magnesium Sulfate (MgSO4) is the gold standard.
  • Loading dose: 4–6 g IV over 15–20 mins.
  • Maintenance: 1–2 g/hour.

4. Gynecological Critical Care

While less frequent than obstetric admissions, gynecological conditions necessitating ICU care are rising due to aggressive cytoreductive surgeries for ovarian cancer and increasing comorbidities in the aging population.

A. Ovarian Hyperstimulation Syndrome (OHSS)

A rare but potentially fatal complication of assisted reproductive technology (ART).

• Pathophysiology: Increased capillary permeability leading to “third-spacing” of fluids.
• Critical Complications: Ascites, pleural effusion, acute kidney injury (AKI), and thromboembolism.
• Management: Fluid balance is delicate; aggressive hydration must be balanced against the risk of pulmonary edema. Paracentesis may be required for symptomatic relief of tense ascites.

B. Pelvic Inflammatory Disease (PID) & Tubo-ovarian Abscess (TOA)

Severe sepsis can result from ruptured TOA.

• Management: Broad-spectrum antibiotics and urgent surgical source control (laparotomy or percutaneous drainage) if the patient is hemodynamically unstable or unresponsive to medical therapy.

C. Post-Radical Surgery Complications

Patients undergoing radical hysterectomy or pelvic exenteration are at high risk for:

• Hemorrhage: Due to proximity to major pelvic vessels.
• Pulmonary Embolism (PE): High risk in oncology patients.
• Urological Injury: Ureteral or bladder injuries leading to metabolic disturbances.

5. Specialized Critical Care Interventions

Airway Management

The “difficult airway” is more common in obstetric patients due to airway edema, weight gain, and breast enlargement.¹⁶

• Strategy: Use a smaller endotracheal tube (6.0–7.0 mm).
• Positioning: Ramping position (head and upper body elevated) to improve FRC and facilitate laryngoscopy.¹⁷
• Rapid Sequence Induction (RSI): Recommended due to increased risk of aspiration (delayed gastric emptying).

Hemodynamic Monitoring

Invasive monitoring (arterial lines, CVP) should be utilized early in shock states.¹⁸ However, interpretation must account for the hyperdynamic state of pregnancy (high output, low resistance).

Clinical Practice Supplement: Protocols for Obstetric Critical Care

1. Management of Acute Severe Hypertension (Preeclampsia/Eclampsia)

Goal: Prevent stroke and placental abruption. Target BP: Systolic 140–150 mmHg and Diastolic 90–100 mmHg. Lowering BP too precipitously can compromise fetal perfusion.

The following first-line agents should be administered if BP is sustained ≥160/110 mmHg for 15 minutes.

A. First-Line Antihypertensive Agents

B. Seizure Prophylaxis: Magnesium Sulfate (MgSO4​)

Note: Magnesium is for seizure prevention, not blood pressure control.

• Loading Dose: 4–6 grams IV over 15–20 minutes.
• Maintenance: 1–2 grams/hour IV continuous infusion.
• Monitoring: Check deep tendon reflexes (DTRs), respiratory rate, and urine output every hour.
• Toxicity: Loss of DTRs (level >9 mg/dL) → Respiratory depression (level >12 mg/dL) → Cardiac arrest.
• Antidote: Calcium Gluconate 1g IV (10 mL of 10% solution) over 3 minutes.

2. Management of Massive Obstetric Hemorrhage

Definition: Blood loss >1500 mL, or unstable vitals, or >4 units of PRBC transfused.

Step 1: Recognition & Activation (The “4 T’s” Assessment)

Identify the etiology immediately:

1. Tone: Atonic uterus (70% of cases).
2. Trauma: Lacerations, rupture, inversion.
3. Tissue: Retained placenta, placenta accreta.
4. Thrombin: Coagulopathy (DIC, pre-existing).

Step 2: Medical & Mechanical Management (Tone)

Simultaneously activate the Massive Transfusion Protocol (MTP).

• Bimanual Uterine Compression: Immediate first step.
• Pharmacotherapy:
  • Oxytocin: 10–40 units in 1000 mL crystalloid (rapid infusion).
  • Tranexamic Acid (TXA): 1g IV over 10 mins (within 3 hrs of birth).
  • Methylergonovine (Methergine): 0.2 mg IM (Contraindicated in Hypertension).
  • Carboprost (Hemabate): 250 mcg IM (Contraindicated in Asthma).
  • Misoprostol: 800–1000 mcg Rectally.
• Mechanical: Intrauterine Balloon Tamponade (e.g., Bakri Balloon).

Step 3: Resuscitation (MTP)

Resuscitation in obstetrics differs from trauma; coagulopathy develops early.

• Ratio: 1:1:1 (PRBCs : FFP : Platelets).
• Fibrinogen: Keep fibrinogen >200 mg/dL (higher than standard trauma guidelines). Administer Cryoprecipitate (10 units raises fibrinogen by ~70 mg/dL) or Fibrinogen concentrate.
• Temperature: Prevent hypothermia (worsens coagulopathy); use fluid warmers.

Step 4: Surgical Intervention (If medical management fails)

If hemorrhage persists despite the above:

1. Conservative: Uterine compression sutures (B-Lynch suture), Uterine artery ligation.
2. Interventional Radiology: Uterine artery embolization (if stable enough for transport).
3. Definitive: Hysterectomy (lifesaving last resort).

Summary Table: Hemorrhage Goals

6. The “Golden Hour” of Maternal Sepsis

Challenge: Pregnancy physiology mimics sepsis (tachycardia, tachypnea, leukocytosis), often delaying diagnosis. Screening Tool: Use MEOWS (Modified Early Obstetric Warning Score) rather than standard SIRS criteria.

A. Recognition (The “Sepsis Six” Modification)

Trigger a “Sepsis Alert” if infection is suspected AND any one high-risk criterion is met:

• Respiratory Rate: ≥25 bpm (Most sensitive early indicator).
• Systolic BP: ≤90 mmHg (or >40 mmHg drop from baseline).
• Lactate: ≥2 mmol/L.
• Fetal Status: Non-reassuring fetal heart rate (often the first sign of maternal hemodynamic instability).

B. The Hour-1 Bundle (Obstetric Modifications)

Must be initiated within 60 minutes of recognition.

1. Measure Lactate: Remeasure if initial is >2 mmol/L.
2. Obtain Cultures: Blood cultures ×2 (prior to antibiotics), plus urine and wound/placental swabs if applicable.
3. Broad-Spectrum Antibiotics:
   1. Do not delay for cultures if access is difficult.
   1. Common Regimen (Chorioamnionitis/Endometritis): Ampicillin + Gentamicin + Clindamycin OR Piperacillin-Tazobactam.
   1. Unknown Source: Vancomycin + Piperacillin-Tazobactam (cover MRSA and Pseudomonas).
4. Fluid Resuscitation:
   1. Dose: 30 mL/kg of crystalloid for hypotension or Lactate ≥4 mmol/L.
   1. Caution: Pregnant women are prone to pulmonary edema (low colloid oncotic pressure). Assess fluid responsiveness (e.g., Passive Leg Raise) frequently rather than blind loading.
5. Vasopressors:
   1. Start if hypotensive during/after fluid resuscitation to maintain MAP ≥65 mmHg.
   1. First Line: Norepinephrine (Levophed).
   1. Note: Ephedrine/Phenylephrine are for transient anesthesia-related hypotension, not septic shock.

7. Post-Operative Critical Care in Radical Gyn-Oncology

Patients undergoing cytoreductive surgery (e.g., for Ovarian Cancer) or pelvic exenteration behave similarly to major trauma or transplant patients due to extensive fluid shifts and organ resection.

A. Enhanced Recovery After Surgery (ERAS) in ICU

The goal is to reduce the stress response and maintain physiologic homeostasis.

• Fluid Management (Goal-Directed Therapy):
  • Intra-op: These surgeries often involve massive ascites removal (>3 L).
  • Post-op: Avoid “salt water drowning.” Use balanced salt solutions (Ringers/Plasmalyte) over Normal Saline to prevent hyperchloremic metabolic acidosis.
  • Target: Urine Output >0.5 mL/kg/hr. Use stroke volume variation (SVV) monitoring if ventilated.
• Pain Control (Multimodal):
  • Minimize opioids to prevent ileus.
  • Preferred: Thoracic Epidural Analgesia (TEA) or TAP blocks + IV Acetaminophen + Gabapentin.

B. Specific Complication Management

8. Quick Reference Drug Table for ICU

9. Case Study: The “Code White” – Placenta Percreta with Hemorrhagic Shock

Patient: Maria, 34-year-old G3P2 at 34 weeks gestation.

History: Two prior C-sections. Diagnosed with anterior placenta previa and suspected placenta accreta spectrum (PAS).

Presentation: Brought to ER with massive vaginal bleeding.

Vitals: BP 75/40 mmHg, HR 125 bpm, O2 Sat 92% on room air. Mental status: Confused/Lethargic.

Clinical Course & Critical Management

1. Immediate Recognition & Activation (T = 0 mins)

• Assessment: Signs of shock (hypotension + tachycardia + altered mental status) indicate Class III/IV Hemorrhage.
• Action: “Code White” (Massive Obstetric Hemorrhage) activated. Massive Transfusion Protocol (MTP) triggered immediately.
• Airway: Due to aspiration risk (pregnancy) and altered mental status, Anesthesia performs Rapid Sequence Induction (RSI) using a smaller ETT (6.5 mm).

2. Resuscitation (T = 0 to 15 mins)

• Access: Two 14G peripheral IVs established.
• Fluids/Blood: 1L warmed crystalloid bolus started. Uncrossmatched O-negative blood (2 units) initiated while waiting for MTP cooler.
• Tranexamic Acid (TXA): 1g IV administered over 10 minutes.

3. Surgical Intervention (T = 20 mins)

• Patient transferred to OR.
• Procedure: Emergency Cesarean Hysterectomy.
• Findings: Placenta percreta invading the bladder posterior wall.
• Hemostasis:
  • Infant delivered (APGARs 4/8).
  • Supracervical hysterectomy performed to expedite control.
  • Bladder repair by Urologist.

4. ICU Management (Post-Op)

• Coagulopathy Check: Post-op labs show Fibrinogen 150 mg/dL (Low for pregnancy).
• Correction: 10 units Cryoprecipitate administered to target Fibrinogen >200 mg/dL.
• Thermoregulation: Patient warmed to 37 C to optimize clotting enzyme function.
• Outcome: Extubated on POD 1. Discharged on POD 5.

10. Conclusion

The management of critically ill obstetric and gynecological patients requires a synthesis of critical care principles with an understanding of reproductive physiology. Early recognition of decompensation, particularly in sepsis and hemorrhage, is paramount. A multidisciplinary team comprising obstetricians, intensivists, anesthesiologists, and neonatologists is essential to optimize outcomes for both the patient and, in obstetric cases, the fetus.

References

1. American College of Obstetricians and Gynecologists (ACOG). (2019). Practice Bulletin No. 211: Critical Care in Pregnancy. Obstetrics & Gynecology, 133(5), e303-e319.
2. Society of Critical Care Medicine (SCCM). (2021). Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock. Critical Care Medicine, 49(11), e1063-e1143.²¹
3. Royal College of Obstetricians and Gynaecologists (RCOG). (2016). Postpartum Haemorrhage, Prevention and Management (Green-top Guideline No. 52).
4. Pollock, W., et al. (2018). The critically ill obstetric patient: recent concepts. Continuing Education in Anaesthesia Critical Care & Pain, 18(4), 114-120.
5. Pacheco, L. D., et al. (2020). Ovarian Hyperstimulation Syndrome: Diagnosis and Management. Gestational Critical Care, 3rd Edition.