ORIGINAL ARTICLE

Clinical Characteristics and Outcomes

of an Intensive Maternal Care Unit
in a Tertiary Hospital in the Philippines
Viktoria Ines P. Matibag, MD and Ana Marie Madamba-Burgos, MD

Department of Obstetrics and Gynecology, Philippine General Hospital, University of the Philippines Manila

ABSTRACT

Objectives. This is the first study that provides an overview of the characteristics of a specialized Intensive Maternal
Care Unit (IMU) that caters to obstetric-related conditions in the Philippines. This study aims to describe the
different kinds of cases admitted into this facility, the different medical and surgical interventions employed, length
of hospital stay, and maternal and fetal outcomes of these patients.

Methods. This is a cross-sectional descriptive study based on a chart review of medical records and admission
charts of patients admitted to the Intensive Maternal Unit of a tertiary hospital in Manila from January 2017 to
December 2019.

Results. There were a total of 17,185 obstetric admissions from 2017-2019. There were a total of 841 admissions
(4%) into the Intensive Maternal Unit, with an average of 280 admissions per year. The average length of Intensive
Maternal Unit stay was 10.46 days and the average length of hospital stay was 12.98 days. Maternal outcomes
were the following: 56.89% were discharged undelivered while 38.92% delivered on their initial admission. The
maternal mortality rate was 2.39% among those admitted to the IMU. Among those discharged undelivered,
43% were re-admitted, 6% were admitted twice, and 4% were admitted three times. The most common reason
for admission was pregnancy-related hypertensive diseases (34%). Blood transfusion (2.4%), the use of ventilator
support (0.6%), and the use of inotropic drugs (0.6%) were the major medical interventions. Cesarean section was the
most common surgical intervention, seen in 54.49% of patients. Most neonates were admitted to the neonatal ICU
(23.95%), at an average pediatric age of 33 weeks, with an average length of stay in the Neonatal ICU of 12.33 days.

Conclusion. Pregnant women are a special group of patients with different needs compared to the general patient
population. Pregnancy-associated hypertensive disease is the most common cause of admission to the IMU and
hospitals should be able to cater to these patients who will present in their institutions, as this may lead to poor
maternal and neonatal outcomes. An Intensive Care Unit dedicated to complicated obstetric care in institutions is
recommended to cater to high-risk pregnancies.

Keywords: pregnancy, intensive care unit, maternal morbidity, critical care

INTRODUCTION

The effort to lower maternal mortality rates is always in

the top health agenda of each country. The United Nations
have set the 17 Sustainable Development Goals, where goals
related to Health ranked on the top three. Under Health, the
first target aims to reduce the global maternal mortality ratio
Corresponding author: Viktoria Ines P. Matibag, MD to less than 70 per 100,000 live births by 2030. Maternal
Department of Obstetrics and Gynecology mortality is widely acknowledged as a general indicator of
Philippine General Hospital
University of the Philippines Manila
the overall health of a population, of the status of women in
Taft Avenue, Ermita, Manila 1000, Philippines society, and of the functioning of the health system.1 The latest
Email: [email protected] statistics show that as of 2015, the maternal mortality rate

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Clinical Characteristics and Outcomes of an Intensive Maternal Care Unit

in the Philippines is 114 per 100,000 live births.1 Providing The institution in this study has an intensive maternal
women with accessible health care during pregnancy should care unit, called the “Intensive Maternal Unit” or IMU, which
be a top priority in the health care system in each region of is a specialized area under the Department of Obstetrics
the country. and Gynecology dedicated to the intensive surveillance of
There is still a huge gap between the maternal care high-risk pregnancies; patients with a pregnancy at risk for
provided across public and private hospitals. Not all hospitals perinatal and neonatal complications, as well as patients
have a dedicated Intensive Maternal Care Unit that can who need highly specialized post-partum care. It is an extra
cater to obstetric cases that need close monitoring and function under a CEmONC-capable facility, however, not all
special or advanced care. A systematic literature review on institutions have a dedicated IMU, rather, some have a High-
Maternal Intensive Care was done by Van Parys et al. in 2010, Risk Unit bed which may function similarly. There is a need
where they reviewed fourteen papers, and two conclusions for this particular institution to have more beds catering to
were drawn: 1) there is no standard definition of maternal more patients as it is the primary referral center for such cases.
intensive care and 2) that admission criteria to a maternal This unit has a capacity for eight beds, where six beds are
intensive care unit differ widely.2 Each country has its own dedicated for undelivered patients and two are for critically-
healthcare system and have adapted terminologies to refer ill patients. Patients who are deemed less priority but may
to what each one understands as maternal intensive care.2 still need close monitoring by the IMU staff are assigned to
One such admission criteria was presented in a study done special detail beds labeled as IMU beds in the regular obstetric
by Panda et al. in 2017, where they delineated intensive care ward. In the IMU, there is a resident physician on duty who
unit (ICU) admissions from their high-dependency unit monitors patients admitted in the facility. They are joined by
(HDU) admissions by using a criteria based on derangements a trained nurse in intensive care. Monitoring of vital signs is
in different organ systems: respiratory arrest, cardiac arrest, done every four hours, and may be more frequent depending
CNS derangement, signs suggestive of diminished tissue on the case of the patient. Fetal heart tones are monitored
perfusion, renal derangement, and liver derangement. In this hourly, and a tococardiogram is available to perform a non-
study, women with single-organ system involvement were stress test once or twice a day. Intrapartum monitoring is
managed in the HDU3, which resulted in lower rates of ICU done every four hours or continuously if a patient is in labor.
admissions. In other studies, the criteria for admission into The admission criteria to the IMU are as follows:
the ICU were not distinctly mentioned. In the Philippines, A. Intensive maternal care patients are patients, pregnant
some hospitals and rural health units are only capable of or post-partum, who need to be admitted into the
Basic Emergency Obstetric and Newborn Care (BEmONC), Intensive Maternal Unit for closer monitoring, may be
where the following obstetric functions are being done: (1) co-managed by a perinatologist during her pregnancy, or
parenteral administration of oxytocin in the third stage need specialized care post-partum.
of labor; (2) parenteral administration of loading dose of B. High-risk patients refer to patients who have co-
anti-convulsants; (3) parenteral administration of initial morbidities such as hypertensive diseases, diabetic
dose of antibiotics; (4) performance of assisted deliveries; conditions, cardiac diseases, thyroid diseases, epilepsy,
(5) removal of retained products of conception; and (6) malignancies, recurrent pregnancy loss, previous fetal
manual removal of retained placenta; as well as the following death, previous pre-term deliveries, and other conditions
emergency newborn interventions, including: (1) newborn that will need co-management with perinatology service
resuscitation; (2) treatment of neonatal sepsis/infection; and and other specializations.
(3) oxygen support; as well as being capable of providing
blood transfusion services. A tertiary center may be classified Criteria for direct admission to the Perinatology service
as a Comprehensive Emergency Obstetric and Newborn • Conditions that may require invasive procedures
Care (CEmONC)-capable facility if it is able to perform the for fetal diagnosis and therapy (e.g., cordocentesis,
functions mentioned prior, with the addition of being able chorionic villous sampling)
to perform cesarean section deliveries, blood banking and • Disorders of amniotic fluid volume that may require
transfusion services, and other highly specialized obstetric invasive procedures for therapy and or intensive fetal
interventions and contraceptive services such as IUD monitoring (e.g., amnioreduction, amnioinfusion)
insertion, vasectomies, and tubal ligations; plus providing an • Severe fetal growth restriction documented by serial
itinerant team composed of one physician/surgeon, one nurse, ultrasound examinations with abnormal Doppler
and one midwife who will conduct out-reach services to findings
remote communities. Smaller institutions with no attending • Multiple gestations (with three or more fetuses)
obstetricians who receive such high-risk patients will not be • Twin pregnancy complicated by:
able to provide the necessary interventions, and will eventually ○○ Discordant growth (>30% instead of the
refer these cases to the few tertiary hospitals who also have original >20%)
very limited beds for such cases. ○○ Selective intrauterine growth restriction
○○ Twin to twin transfusion syndrome

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 Clinical Characteristics and Outcomes of an Intensive Maternal Care Unit

○○ Death or impending death of one twin prevalent, and help determine which hospital equipment
○○ Conjoined twins are needed, properly allocate health care workers, improve
○○ Acardiac twins existing facilities, and identify which sub-specialties are
○○ PPROM of one twin available and what other specialties are needed to co-manage
• Pregnancies with congenital anomaly EXCEPT: these patients.
○○ Anencephaly
○○ Unregistered patients for delivery on admission Objectives
and no further monitoring is required (example:
Unregistered term patient in labor with fetal General Objective
hydrocephalus) To determine the different patient characteristics in the
• Patients with antiphospholipid antibody syndrome Intensive Maternal Care Unit in a tertiary hospital and its
or other acquired or congenital thrombophilias who: outcomes
○○ require additional therapy other than aspirin
and heparin Specific Objectives
○○ had a history of thrombo-embolic disease prior 1. To determine the primary obstetric causes of admission
to or during current pregnancy of obstetric patients to the Intensive Maternal Care Unit.
• Medical conditions in pregnancy that would need 2. To determine the average hospital stay in the Intensive
intensive care of the mother and the fetus, like: Maternal Care Unit.
○○ Diabetic ketoacidosis 3. To determine the medical and surgical interventions per-
○○ Hyperosmotic nonketotic coma formed on patients at the Intensive Maternal Care Unit
○○ SLE in activity as they relate to their medical/surgical co-morbidities
○○ Hemolytic uremic syndrome 4. To determine the maternal outcomes in terms of
• Gynecologic and non-gynecologic neoplastic condi- morbidities, mortalities, and condition on discharge.
tions requiring oncologic intervention in the form of 5. To determine the fetal outcomes in terms of age of
chemotherapy and/or surgery during the pregnancy gestation at delivery, APGAR scores, NICU admissions,
and/or those with complications related to the morbidities, and mortalities.
malignancy
MATERIALS AND METHODS
C. Priority admissions to the IMU include:
• Placenta previa with minimal bleeding Research Design
• Complicated multiple gestation This is a cross-sectional descriptive study based on a
• Pre-eclampsia with severe features review of existing medical records and admission charts of
• Worsening or poor control of any of the following patients who were admitted into the Intensive Maternal
medical conditions: Unit of the selected tertiary hospital from January 2017 to
• Chronic hypertensive vascular disease December 2019.
• Heart disease
• Bronchial asthma Study Population
• Diabetes mellitus The following criteria were used to determine eligibility
• Chronic renal disease for the study:
• Hematologic disorder • Patient with high-risk pregnancies, patients with a
• Neurologic disorder pregnancy at high risk for neonatal intensive care,
• Maternal infections and patients who will need highly specialized post-
• Preterm pre-labor rupture of membranes / uncon- partum care
trolled preterm labor • Undelivered pregnant patients who are admitted in
the service ward deemed to need specialized care
There are currently no in-depth studies on specialized • Post-partum patients needing close monitoring
intensive maternal care units that cater to obstetric-related under the Intensive Maternal Unit
conditions in the Philippines. This study will help inform • The patients described above were admitted under
obstetricians about the kind of cases that should be admitted the Intensive Maternal Unit for at least 24 hours
into an Intensive Maternal Unit. Assessing their demo-
graphics will also enable the healthcare staff to anticipate Exclusion criteria included those:
these cases and avoid untoward outcomes for patients who • Who delivered within 24 hours and did not need
will be admitted to intensive maternal care units. Data from admission into the IMU post-partum
this study may help health institutions plan for and build • Who were re-admitted into a non-IMU bed
intensive maternal care units by knowing which cases are • Undelivered patients in a non-IMU bed

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Clinical Characteristics and Outcomes of an Intensive Maternal Care Unit

Sample Size Calculation the participants will be provided with additional pertinent
All patients admitted into the Intensive Maternal information after their participation (whenever appropriate)
Care who satisfied the inclusion and exclusion criteria in accordance to the National Ethical Guidelines of Health
provided were included in the study. Data from January and Health-related Research 2017. Patient confidentiality
2017 - December 2019 was collected. The computed sample was kept by assigning a control number for each patient
size is 167 patients. A 95% confidence interval was used in included in the study. The participants of the study did not
computing the sample size. A design effect of 1, 50% antici- receive any form of financial compensation and they did not
pated frequency to achieve highest minimum sample size, directly benefit from the research.
95% absolute precision, and 95% confidence interval.
RESULTS
Description of Study Procedure
A sample of 167 pregnant Filipino women who were There were a total of 17,185 obstetric admissions from
admitted in the tertiary hospital’s Intensive Maternal Unit 2017-2019, where 841 patients (4%) were admitted into the
from January 2017 to December 2019 were included in the Intensive Maternal Unit, with an average of 280 admissions
study. Data was collected from patient charts and were placed per year.
in the Data Collection form and organized in an Excel file for Table 1 shows the patient characteristics of this sample.
analysis. Admissions were categorized in order to determine The average age of the patients was 30.37 years old. The
the causes of admissions and mean number of days admitted median obstetric score for gravidity was 3 and parity 1. The
in the hospital was obtained per category. Patients who were average number of pre-natal consultations is five consultations
re-admitted were counted as one subject. Interventions per patient. The average height, weight, BMI were 153.32 cm,
done were summarized per category. Categorical data were 64.57 kg, 27.25 kg/m2, respectively.
expressed as percentages and was compared using the chi- The average length of Intensive Maternal Unit stay
square test. Continuous data were expressed as the mean was 10.46 days and the average length of hospital stay was
and standard deviation (SD) and was compared using the 12.98 days as shown in Table 2. Among those discharged
T-test. A univariate analysis was performed to examine the undelivered, a total of 72 patients (43%) were re-admitted
association with IMU mortality. The statistical significance once, 11 patients (6%) were re-admitted a second time,
was defined as a P value of less than .05. and eight patients (4%) were re-admitted for a third time.
The research protocol was approved by the University of The average stay is 2.48 days in the IMU and 7.49 days in
the Philippines-Manila Research Ethics Board (UPMREB) the hospital.
PGH Review Panel prior to data collection. A waiver of Reasons for admission are shown in Table 3; 56 patients
informed consent was requested from the UPMREB panel (33.53%) were admitted for elevated blood pressure, 44
since: the research presents no more than minimal risk, patients (26.35%) for pre-term labor, 9 patients (5.39%)
the waiver or alteration will not adversely affect the rights for dyspnea, 8 patients (4.79%) for complications of cardiac
and welfare of the participants, the research cannot be disease, 7 patients (4.19%) required intensive blood sugar
practicably carried out without the waiver or alteration; and control, and 6 patients (3.59%) for vaginal bleeding.
The following referrals were made to sub-specialties as
Table 1. Patient Characteristics (n=167) shown in Table 4: 94.61% were referred to the perinatology
service and 50.9% were referred to the Internal Medicine
Continuous
Median service. Referrals were also made to Ophthalmology (12.5%),
Mean SD
Endocrinology (7.1%), Pulmonology (4%), OBGYN-
Age 30.37 6.44
Infectious Diseases (2%), Hematology (1.7%), Cardiology
OB Score (Gravidity) 2.92 1.73 3 (1.1%), General Surgery (1.1%), and Neurology (1.1%).
OB Score (Parity) 1.68 1.67 1 Medical interventions are depicted in Table 5. For anti-
Number of pre-natal consults 5.26 2.75 5 hypertensive medications, 32.34% were given methyldopa,
Height 153.32 5.46 20.96% were given magnesium sulfate, and 17.37% were
Weight 64.57 16.70 given hydralazine. Nifedipine and nicardipine drip were also
BMI 27.25 6.32 used as antihypertensives. For tocolysis, 41.32% were given

Table 2. Length of IMU and Hospital Stay (n=167)

Initial admission Readmission 1 Readmission 2 Readmission 3
Mean SD Mean SD Mean SD Mean SD
Length of IMU stay 10.46 8.21 2.48 4.98 2.38 2.97 1.40 2.19
Length of hospital stay 12.98 9.51 7.49 5.41 7.00 3.50 7.17 4.62

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 Clinical Characteristics and Outcomes of an Intensive Maternal Care Unit

Table 3. Reasons for Admission (n=167) Table 5. Medical Interventions (n=167) Table 6. Major Medical Inter-
Frequency % n % ventions (n=167)
Elevated blood pressure 56 33.53 Anti-hypertensive medications n %
Preterm labor 44 26.35 Methyldopa 54 32.34 Blood transfusion 4 2.4
Hydralazine 29 17.37 Ventilator support 1 0.6
Dyspnea 9 5.39
Terbutaline 1 0.6 Inotropic support 1 0.6
Cardiac disease 8 4.79
Nicardipine 1 0.6
Elevated blood sugar 7 4.19 Nifedipine 7 4.19
Vaginal bleeding 6 3.59 MgSO4 35 20.96 Table 7. Surgical Interventions
Abdominal pain 5 2.99 Tocolysis (n=167)
Thyroid disease 4 2.40 Nifedipine 69 41.32 n %
Ruptured membranes 4 2.40 MgSO4 5 2.99 Cesarean section 91 54.49
Terbutaline 2 1.2
Hypokalemia 4 2.40 Vaginal delivery 43 25.74
Dydrogesterone - -
Isoxuprine 5 2.99 Exploratory 3 1.8
laparotomy
Table 4. Referrals to Other Services (n=167) Proluton 1 0.6
Micronized progesterone 32 19.16 Biopsy 1 0.6
n %
Glycemic Control Others 6 3.59
Perinatology 158 94.61
Insulin 30 17.96
Internal Medicine 85 50.9
Metformin 2 1.2
Ophthalmology 21 12.5
Antibiotics
Endocrinology 12 7.1 No antibiotics 86 51.5
Pulmonology 7 4 With antibiotics 81 48.5
OBGYN-Infectious Diseases 4 2 Cefuroxime 23 13.77
Hematology 3 1.7 Ampicillin 6 3.59
Ceftriaxone 6 3.59
Cardiology 2 1.1
Ceftriaxone, Azithromycin 6 3.59
General Surgery 2 1.1 Erythromycin, Ampicillin, 4 2.4
Neurology 2 1.1 Amoxicillin

nifedipine, 19.16% were given micronized progesterone, with similar APGAR scores. The average length of stay in
2.99% were given MgSO4, 2.99% were given isoxuprine, the Neonatal ICU was 12.33 days.
1.2% were given terbutaline, 0.6% were given 17-hydroxy-
progesterone caproate. For glycemic control, 17.96% were DISCUSSION
given insulin and only 1.2% were given metformin. Antibiotics
were given to 81 patients (48%), with cefuroxime being the The need for an Intensive Maternal Unit for specialized
most common antibiotic used. obstetric care in hospitals has been emphasized in previous
Blood transfusion (2.4%), the use of ventilator support literature, because pregnant women are a special population
(0.6%), and the use of inotropic drugs (0.6%) were the major with different needs from that of the general population.
medical interventions as shown in Table 6. Table 7 shows Some institutions do not even have the capacity to admit
the surgical interventions done, where a total of 91 patients women with high-risk pregnancies. Co-morbidities such as
(54.49%) underwent cesarean section, 43 (25.74%) underwent hypertension and cardiac diseases are unmasked and may
vaginal delivery, 6 (3.59%) other surgical interventions such worsen during pregnancy. These conditions will require
as exploratory laparotomy and biopsy were done. advanced care from several specialties, as well as require a
Table 8 shows the Maternal outcomes: 56.89% (95 variety of diagnostic tests and medications for these patients.
patients) were discharged undelivered while 38.92% (65 The average length of Intensive Maternal Unit stay
patients) delivered while admitted. There was 1.8% maternal was 10.46 days and the average length of hospital stay were
mortality rate among those admitted in this institution’s 12.98 days, which may mean that turnover of beds to newer
IMU. Fetal outcomes are shown in Table 9; neonates were patients may take more than two weeks for some cases.
either admitted to the neonatal ICU (32.93%), directly As mentioned, IMU beds in this institution are limited to
roomed-in (10.18%), mortality (1.79%), or fetal death in eight beds, with special detail beds labeled as IMU beds in
utero (1.19%). Moreover, the average pediatric aging was the regular obstetric ward depending on their availability.
33.06 weeks during the initial admission, with an average More resources may be needed for these patients in the
APGAR score of 8.27 at 1 min, and 8.70 at 5 mins. In IMU, including medications and healthcare workers. It was
subsequent re-admissions, the pediatric aging was 36 weeks, also noted that more than half of the patients included in

5
Clinical Characteristics and Outcomes of an Intensive Maternal Care Unit

Table 8. Maternal Outcomes (n=167)

Initial admission Readmission 1 Readmission 2 Readmission 3
n % n % n % n %
Discharged undelivered 95 56.89 17 10.18 4 2.4 2 1.2
Discharged delivered 65 38.92 55 32.93 8 4.79 8 4.79
Mode of Delivery
Cesarean section 44 26.35 35 20.96 7 4.19 5 2.99
Vaginal delivery 21 12.5 18 12.5 1 0.6 3 1.8
Mortality 3 1.8 1 0.6 - - - -

Table 9. Fetal Outcomes

Initial admission Readmission 1 Readmission 2 Readmission 3
Fetal Outcome
n % n % n % n %
Room-in 20 10.18 47 28.14 5 2.99 5 2.99
Neonatal ICU 40 32.93 9 5.39 3 1.8 3 1.8
Mortality 3 1.79 1 0.6 - - - -
Fetal death in utero 2 1.19 1 0.6 - - - -

Mean SD Mean SD Mean SD Mean SD

Pediatric aging 33.06 3.52 36.91 3.13 36.00 2.14 36.125 2.03
APGAR Score
1st minute 8.27 1.70 8.86 0.90 8.88 0.35 8.37 1.41
5th minute 8.70 0.98 8.91 0.75 9.00 0.00 8.87 0.35
Length of stay in NICU 12.33 19.66 8.50 7.78 - - - -

the study (56.89%) were initially discharged undelivered as mentioned non-obstetric causes of admission to the ICU,
their initial concern for being admitted (severe hypertension, where sepsis was the most common non-obstetric indication
uncontrolled diabetes, infection) were resolved and did not among pregnant patients, with community-acquired
need immediate termination of pregnancy. 75% of these pneumonia and urinary tract infection as the most common
patients were re-admitted, however, data on the outcomes underlying diseases causing the cases of sepsis.8 Consistent
of the other patients were not gathered as these patients with the data from the literature reviewed,5,6 our data showed
delivered in other institutions. The sample that was taken for that pregnancy-associated hypertensive disease is still the
this study were all antenatal admissions. most common cause of admission to the IMU. Other studies
Several studies found that hypertensive disorders and showed that obstetric hemorrhage was the most common
hemorrhagic complications were the top reasons for admission cause of admission in their countries9, however, among
into an intensive maternal care unit. In a study done by our study population, this was not observed. Pregnancy-
Jain et al., hypertensive disorders were found to be the associated hypertensive disease account for 30.3% of all
most frequent clinical diagnosis leading to ICU admission maternal deaths in the Philippines, which is higher than
(37.7%), followed by hemorrhage (28.8%).4 This is similar to the worldwide rate. Guidelines for screening hypertensive-
another study done in Mexico, where 67.9% were admitted related diseases in the Philippines is still underway, but
for hypertensive disorders, 28.3% were admitted due to may help curb the number of patients developing compli-
obstetric hemorrhage, 3.9% patients were admitted with a cations if we are able to effectively screen these patients
diagnosis of sepsis, and another 3.8% patients were admitted in the outpatient clinic. In this institution, preterm labor,
for HELLP syndrome.5 Some data may also show diffe- dyspnea, complicated cardiac disease, were common causes
rences in geographic locations, as a study done in Southern of admission in the IMU, which were not reported in the
India showed that hypertensive disorders of pregnancy was literature review from other countries. Preterm labor, in
the most common condition which necessitated HDU particular, comes second as an indication of admission to the
admission (52.2%), followed by obstetric hemorrhage (23.4%)6 IMU in this institution. Preterm labor may be caused by prior
while in another city in India, it was reported that obstetric preterm birth, smoking, malnutrition, infections, multifetal
hemorrhage (44.05 %) was the most common condition pregnancies, and low socio-economic status, to name a few.
requiring ICU admission followed by hypertensive disorders However, the particular causes of preterm labor were not
of pregnancy (28.88 %)7. A study done in Saudi Arabia also specifically mentioned in the data collected and may be a

6
 Clinical Characteristics and Outcomes of an Intensive Maternal Care Unit

point of improvement in subsequent studies as it can improve was significantly lower than the percentage reported in the
antenatal care and decrease admissions. For institutions literature reviewed. This may be attributable to the status
who are planning to create an Intensive Maternal Unit in of the patients when they were admitted into the facility, as
their own obstetric wards, taking note of the most common majority were not critical with life-threatening conditions,
causes of admission may help prepare their own institutions however, due to the nature of the disease in these high-risk
to cater to such specialized cases. pregnancies where maternal or fetal condition can deteriorate
Referral to other sub-specialties were also very frequent, at any time, admission to the Intensive Maternal Unit for
with almost all cases being referred to the Perinatology service. closer monitoring was indicated. Baseline intensive care
The diverse sub-specialties of this tertiary training institution and monitoring, with additional monitoring of patients by
benefited these patients since referrals for specialized care resident physicians, nurses, and medical interns were also
are readily available and easily accessible. strictly implemented, which resulted into timely referrals and
Data regarding the medications used for the various interventions which may have resulted in good outcomes.
interventions that were commonly used for the most frequent Fetal outcomes showed that the average pediatric age
reasons for admission were also presented. Availability of these was 33.06 weeks at delivery and the average length of stay in
medications in other institutions must be ensured if they are the neonatal ICU was 12.33 days. Further review of the data
going to cater to patients with such co-morbidities. Blood showed that most babies with poor APGAR scores were born
transfusion and mechanical ventilation were also common to mothers with complications of uncontrolled hypertensive
medical interventions, which was also similar to that reported diseases. These are important findings as neonatal ICUs in
from other countries. different institutions have different capacities in handling
The most common interventions being performed in preterm neonates.
the ICU were reported by Rathod and Malini: blood and This is the first local study that provides an overview
blood component transfusion, followed by inotropic support, of the characteristics of specialized intensive maternal
and ventilator support.7 Another study reported that cesarean care units that cater to obstetric-related conditions in the
section was the most common surgical intervention, which Philippines. Being able to characterize the patients being
was attributed to the higher number of complicated cases admitted to the IMU has given us knowledge regarding the
referred during the later stages of gestation.8 Meanwhile, in a demographics of the patients being admitted into the facility,
study done in the Netherlands by Zwart et al., the following identify the different medications and interventions that
interventions were done: assisted ventilation, inotropic are most commonly performed on these patients, and more
support, and renal dialysis, while surgical interventions importantly, determine the maternal and fetal outcomes of
included hysterectomy and arterial embolization because these group of patients resulting from this specialized set
of obstetric hemorrhage.10 In this study, it was seen that up. In this time of the COVID-19 pandemic, it has been
cesarean section was the most common surgical intervention reported that pregnancy increases the risk for acquiring
done among the patients admitted in the IMU. This was severe COVID-19 infection and admission to the intensive
consistent with the literature reviewed. Emergency cesarean care unit13, which may even be associated with several co-
section while admitted in the IMU was indicated when morbidities such as pre-eclampsia, gestational diabetes
deterioration of the maternal status or a non-reassuring fetal mellitus, and preterm birth14. Hospitals should be prepared
condition was noted, however, specific indications for the to at least stabilize these patients in the emergency room for
cesarean section were not included in this study and may be a such conditions prior to transfer to tertiary hospitals if they do
point for review in subsequent studies. not have the capacity to admit them into intensive maternal
Most studies reported the outcomes as they relate to the units. Coordination of the obstetricians with their respective
morbidity and mortality of the patients, however, most did pediatricians and neonatal ICUs will also help them prepare
not include neonatal outcomes. One study showed an 8% for the deliveries and management of the babies of such
mortality rate for critically ill obstetric patients, consistent high-risk pregnancies.
with the reports of maternal mortality in the area studied
(9.4% in Eastern Saudi Arabia), which was comparable to CONCLUSIONS
the mortality rates in North America and Europe. Such low
rates were attributed to better hospital facilities since the ICU Pregnancy-associated hypertensive disease is the most
was manned by board-certified critical care physicians and common cause of admission to the IMU and hospitals
an obstetric team was available 24 hours a day, seven days a should be able to cater to these patients who will present
week.11 In developed countries where a more complex ICU in their institutions, as this may lead to poor maternal and
system exists, it was found that obstetric ICU admissions neonatal outcomes. Maternal complications like eclampsia,
represented 0.24% of all deliveries, and the mortality rate nephropathy, and retinopathy may be avoided if timely
of 3.4% was significantly lower than the rates presented in interventions are performed. Neonatal complications such
other studies done in developing countries.12 The maternal as stillbirth and poor delivery outcomes leading to NICU
mortality of patients admitted in the IMU was 2.39%, which admission may also be prevented. Prenatal care for these

7
Clinical Characteristics and Outcomes of an Intensive Maternal Care Unit

patients should also be strengthened to avoid further REFERENCES

complications that may lead to their admission. Cesarean
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catering to such cases should be ready to perform this 2. Van Parys AS, Verstraelen H, Roelens K, Temmerman M. Maternal
intervention when indicated. intensive care: a systematic literature review. Facts Views Vis Obgyn.
Data was gathered only from a single tertiary hospital 2010;2(3):161-7.
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research paper, under the Research Grant 2021. 10.1007/s00134-009-1707-x.
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