Review
HJOG 2026, 25 (1), 65-71 | doi: 10.33574/hjog.0616
Amr Ahmed Mahmoud Riad, Ahmed Ramy Mohamed Ramy, Norhan Emad ElGerby ELGebaly, Ahmed Gamal Abdelnasser
Obstetrics & Gynecology Department, Faculty of Medicine – Ain Shams University, Cairo, Egypt.
Correspondence: Norhan Emad ElGerby ELGebaly, E-mail: norhan02@outlook.com, Tel: 010009878987
Abstract
Background: Admitting obstetric patients to the Intensive Care Unit (ICU) necessitates specialized care and coordination by a multidisciplinary team. These patients present unique challenges to ICU specialists, primarily due to the physiological changes and disease progression that occur during pregnancy and the postpartum period (puerperium). Furthermore, the complexity of these cases is heightened by the dual responsibility of ensuring the health of the mother and the survival of the fetus.
Aim of the work: The objective of the study is to assess the mortality rate of pregnant and postpartum patients necessitating intensive care unit (ICU) admission at Ain Shams University Maternity Hospital.
Methods: this retrospective analytic study was conducted at tertiary care hospital at Ain Shams University hospitals from Mars 2023 till October 2023 and performed on total 534 pregnant women who had admitted to the ICU during pregnancy or during the postpartum period (42 days after delivery) in a period from January 2018 till December 2022 with inclusion and exclusion criteria.
Results: SPET was the most frequent clinical presentation; was in more than one third of the studied cases, followed by Placenta previa, PGDM and IUFD. Anemia was the most frequent morbidity; found in less than half of the studied cases. Maternal mortality was 2.4% among the studied cases. NICU needed in more than quarter of the studied cases. Fetal mortality occurred in more than one tenth of the studied cases. IUFD, Eclampsia, Jaundice and Shock were significantly more frequent in maternal mortality cases. Anemia, Blood transfusion, Plasmapheresis and Hemodialysis were significantly more frequent in maternal mortality cases.
Conclusion: Our study strongly suggests that early admission to the ICU and effective treatment for obstetrical patients, identifying and modifying risk factors, evaluations of comorbidities and providing guidance on how pregnancy can affect the condition, offering preconception counseling, adequate perinatal services, and ensuring the availability of multidisciplinary expert consultations can help to reduce both maternal and fetal morbidity and mortality.
Keywords: Obstetrics admission to ICU, maternal mortality
Introduction
Pregnant women, typically in their reproductive years, frequently experience uneventful pregnancies and labor. However, sudden complications during this period can result in maternal mortality. Although obstetric admissions to the intensive care unit (ICU) are relatively rare, the mortality rate among these cases is high. Adequate antenatal care remains the primary means of preventing complications in pregnant women. (1).
Admissions of pregnant women to the ICU necessitate specialized care and attention from a team of experts from many fields. Intensivists face challenges while dealing with obstetric patients who are brought to the ICU because of the physiological changes and progression of diseases that occur during pregnancy and the postpartum period. The challenge is further compounded by the imperative to ensure the well-being of the mother and the viability of the fetus. There is a notable correlation between the incidence of maternal mortality and the availability of ICU facilities, as the nations with the greatest maternal mortality rates also have the lowest ICU bed per capita (2).
The injury severity scores upon admission to the ICU in developing countries exhibit a notable increase in comparison to those observed in developed countries. This indicates that the delay in accessing ICU treatment is the primary contributing factor to the rise in maternal mortality. The incidence of intensive care unit (ICU) admissions among obstetric patients ranges from 1 to 9 per 1,000 pregnancies, accounting for less than 1% of all ICU admissions (3).
In a retrospective analysis of 1,023 gravid subjects exhibiting severe morbidity, the investigators denoted advanced age, ethnic background, inferior economic status, and substandard antenatal oversight as probable predisposing factors for intensive monitoring requirement. Documented rationales necessitating this degree of care incorporated gestational comorbidities like PET, obstetric hemorrhage, maternal cardiac dysfunction, and postpartum infections. Moreover, concession instances arose due to pathologies unrelated to gravidity, encompassing congenital and valvular cardiac defects, elevated pulmonary arterial pressures, and nephric insufficiency. Additionally, the gravid condition potentiated the severity of select preexisting disease states. (4). Obstetric patients admitted to the ICU exhibit a lower average age and a decreased prevalence of comorbidities compared to the general female population. Obstetric ICU patients exhibit a comparatively reduced mortality rate in comparison to the overall female population in the ICU (2-3% versus 20%) (5).
Maternal obstetric morbidity refers to morbidity that arises from any cause directly related to or exacerbated by the pregnancy or its medical care, excluding morbidity resulting from accidental or coincidental factors. The regions with elevated rates of maternal mortality are those that have insufficient research data available. It is crucial to address these gaps. Obstetric patients necessitate prompt provision of high-quality medical attention during the perinatal period, encompassing the time of childbirth and the postpartum phase, given that obstetric hemorrhage stands as the primary contributor to maternal morbidity (6).
Presently, there is a heightened awareness of the critical importance of intensive care unit (ICU) management in mitigating obstetrical-associated mortality and morbidity. Due to the extreme difficulty of conducting prospective studies, knowledge, experience, and treatment methods regarding the subject are derived from retrospective studies (7) . The objectives of this study are to examine the causes for the admission of obstetric patients to the intensive care unit and their clinical outcomes, to assess the effectiveness of the current gathered data in predicting the mortality of these patients, and to identify unfavorable prognostic factors in critically ill obstetric patients.
Aim of the work
The aim of the study is to evaluate the incidence, characteristics, and mortality of pregnant and postpartum patients requiring ICU admission in Ain Shams University Maternity Hospital.
Material and methods
After ethical committee approval, this retrospective analytic study was conducted at tertiary care hospital at Ain Shams University hospitals from Mars 2023 till October 2023 and performed on total 534 pregnant women who had admitted to the ICU during pregnancy or during the postpartum period (42 days after delivery) in a period from January 2018 till December 2022.
Inclusion criteria: All obstetric patients (up till 42 days of delivery), Age between 18- 45 years and Obstetric patients who admitted to the ICU between 1st January 2018 and 31st December 2022.
Study Procedures: All participants were submitted to the following:
1. At first, medical records of the study population during the planned time frame which involved all obstetric patients (up till 42 days of delivery).
2. And then the collected data was coded, tabulated, and statistically analyzed.
The following data was gathered (whenever available), tabulated and subjected to the proper statistical analysis:
Administrative data: including Hospital number, Name (for the record identification list only), Date and time of admission, Indications for ICU admission and Date of discharge
History including Age, BMI, Obstetric history (parity and mode of delivery), History of previous ICU admission, Time of ICU admission., Gestational age at admission and delivery and Mode of delivery and Pre-existing Medical disorders (Hypertension, DM, SLE), Surgical or Obstetric problems (HELLPS, GDM, Pre-eclampsia and Eclampsia).
General examination: revision of the medical records for; Abdominal examination: to exclude abruptio placentae, Vital data (Pulse, Blood Pressure, Temperature and urine output) and Albumin in urine (dipstick test).
Investigations performed: Basic obstetric Ultrasound, Fetal Viability at time of admission, CBC with platelets count for thrombocytopenia, AST, ALT, S. Creatinine (normal: up to 0.9 mg/dl) and Total and direct bilirubin, LDH (normal: up to 400), Schistocytes in blood film in case of Suspected Microangiopathic hemolytic anemia and MRI, CT (if done).
Outcome measures: 1ry outcome including reasons for admission to intensive care unit (Preeclampsia/eclampsia/HELLP/Ablatio placentae/placenta previa) (8), Incidence of Maternal Mortality (acute kidney injury, respiratory failure, DIC, sepsis, cardiomyopathy and postpartum hemorrhage) (4) and Maternal Morbidities (Renal failure, anemia, ARDS and Cerebral hemorrhage) (4).
2ry outcome: Maternal outcome including recovery, Haemodialysis, Plasmapheresis and Plasma Exchange transfusion and Fetal outcome including NICU Admission, APGAR score and Neonatal Mortality.
Sample Size: As a descriptive study on archival data, the study will include cases registered in Ain Shams Maternity hospital in the period from January 2018 till December 2022.
Ethical Considerations: Patient identities were anonymized within the dataset. Case presentations referred solely to medical diagnoses, upholding anonymity protections. Confidentiality was ensured by assigning numerical codes to individuals’ initials – the cross-reference was exclusive to the study researcher.
Conflict of interest: the candidate declared that there is no conflict of interest and the candidate paid the cost of the study.
Statistical analysis: The analysis is to be conducted using SPSS for Windows version 20.0, which is a statistical software commonly used in medical research. The data was presented in terms of range, mean, and standard deviation for numeric parametric variables. For numeric non-parametric variables, the data was presented in terms of range, median, and inter-quartile range. Lastly, for categorical variables, the data was presented in terms of number and percentage. The analysis involved comparing the differences between two separate groups using the independent student’s t-test for numeric parametric variables. This will also include calculating the mean difference and its 95% confidence interval. For categorical variables, the chi-squared test was used, along with calculating the risk ratio and its 95% confidence interval. A binary logistic regression analysis was conducted to assess the correlation between good/poor response and the measured variables in a medical context. Receiver Operating Characteristic (ROC) curves were utilized in the medical field to construct a graphical representation for evaluating the accuracy and effectiveness of measured variables as indicators for predicting favorable or unfavorable response outcomes. The validity of the data was assessed using medical parameters such as sensitivity, specificity, positive and negative predictive values. The corresponding 95% confidence intervals was evaluated, with a significance level set at 0.05.
Results
Among the admitted 55287 cases, 534 (0.96%) needed ICU admission.
Table (1) shows that majority of the studied cases was within 20-39 years. Parity of 1-2 was in near half of the studied cases. About one third of cases had preterm pregnancy. Multiple pregnancy was uncommon.
Table (3) shows that that Anemia was the most frequent mobiditiy; found in less than half of the studied cases.
Table (4) shows that Maternal mortality was infrequent among the studied cases. Mean±SD of ICU stay was 4.2±1.0 days.
Table (5) shows that NICU needed in more than quarter of the studied cases. Fetal mortality occurred in more than one tenth of the studied cases. The most frequent cause of fetal mortality was Respiratory distress, followed by abortion.
Table (6) shows Anemia, Blood transfusion in ICU, Plasmapheresis in ICU, Hemodialysis in ICU and Permanent disability (renal failure) were significantly more frequent in maternal mortality cases.
Table (7) shows Fetal mortality was significantly more frequent in maternal mortality cases. No significant difference according to maternal mortality regarding NICU admission and causes of fetal mortality.
Discussion
Maternal mortality is widely utilized on a global scale as a means to evaluate the standard of healthcare services. As per the World Health Organization, maternal mortality refers to the unfortunate demise of a woman during pregnancy or within 42 days after the termination of pregnancy. With enhanced healthcare resources, there has been a substantial reduction in maternal mortality rates during the previous few decades. Nevertheless, the incidence of severe maternal morbidity continues to be a subject of debate within the medical community, primarily due to the inconsistent application of criteria and limited availability of comprehensive data. Assessing the incidence, morbidity, and mortality of pregnant and postpartum women who necessitated admission to the ICU was identified as a primary focus due to the fact that obstetric ICU admissions represent significant conflict and may be associated with maternal mortality and morbidity (6-9).
Therefore, this study was conducted with the objective of assessing the incidence, features, and mortality rate of pregnant and postpartum individuals necessitating intensive care unit (ICU) admission at Ain Shams University Maternity Hospital.
This retrospective analytic study was conducted at tertiary care hospital at Ain Shams University hospitals from Mars 2023 till October 2023 and performed on total 534 pregnant women who had admitted to the ICU during pregnancy or during the postpartum period (42 days after delivery) in a period from January 2018 till December 2022.
The current study revealed that Majority of the studied cases (90%) was within 20-39 years. Parity of 1-2 was 41.2% of the studied cases. About one third of cases (37.5%) had preterm pregnancy (<37 weeks). Multiple pregnancy was uncommon (1.7%). Among the total obstetric admission in the studied period 55287 cases, 534 cases needed ICU admission. Consequently, the incidence of hospital admission was 0.96%.
To the best of our knowledge, this is the first study to evaluate the incidence, characteristics, and mortality of pregnant and postpartum patients requiring ICU admission in Ain Shams University Maternity Hospital in Egypt, and that represents a strength point of our study.
These findings align with preceding investigations. Ghike, S et al., (10) executed a retrospective hospital-centered analysis at Nagpur across 24 months assessing obstetric intensive care unit (ICU) admissions and determinant factors influencing maternal prognosis. The mean age of conceded women was 26.05 ± (range, 18-32 years) with mean parity of 1.2 (range, 1-3). The majority were between 36-42 gestational weeks 20/47 (42-55%) or 28-36 weeks 12/47 (25-53%). Total ICU-requiring obstetric cases constituted 1.04% of all births and 0.77% of obstetric hospitalizations at the facility.
Krawczyk, P. et al., (4) performed a retrospective analysis on a sample of 266 pregnant and postpartum patients who were admitted to the ICU of an obstetric tertiary care center. The objective was to determine the prevalence of maternal morbidity and mortality among this population. The results indicated that the average age of the patients was 30.2 ± 5.6 years, and the average gestational age was 30.8 ± 7.6 weeks. Fourteen patients (6.4%) were carrying twins, while two hundred forty (90.23%) were primiparous.
Furthermore, as reported in a retrospective analysis by Oliveira, S et al., (9) pertaining to 93 obstetric patients admitted to the ICU, the mean gestational age was 33.6 weeks, the mean age of the patients was 30.3 years, 51 (54.8%) were primiparous, nine (9.7%) were carrying twins, and five (5.4%) had not been monitored throughout their pregnancies.
As regards the causes of ICU admission, the current research study revealed that SPET was the most common obstetric causes of ICU admission (35.2%); followed by Placenta previa (13.9%), IUFD (11.4%) and HEG (8.8%) while the most common non-obstetric causes were PGDM (12.2%), cardiac valvular diseases (6.4%) and Epilepsy (2.4%). Conservative management was needed in 23.2% of the studied cases. LSCS was the most frequent surgical intervention (56.2%); while Hysterectomy was performed in (10.5%) of the studied cases.(Table 2)
As regards maternal morbidity and mortality, our study results revealed that Anemia was the most frequent morbidity (46.8%), followed by blood transfusion (27.9%) and plasmapheresis (24.2%). Of the 534 obstetrical patients admitted to the ICU, 521 of the 534 were discharged while 13 patients died, the Maternal mortality rate was 2.4%.
Ghike, S et al., (10) reveled that severe anemia and heart disease were the primary non-obstetric preexisting medical conditions that necessitated intensive care unit admissions (19.25% (9/47) of patients), followed by sickle cell disease (4.25%), hepatitis, renal disease, and essential HTN (2.1%).
As regards the fetal outcome, our study results revealed that NICU needed is more than quarter of the studied cases (27.9%). Fetal mortality occurred in more than one tenth of the studied cases (16.7%).
Previous studies have shown a mortality rate between 0% and 36% in obstetrical patients admitted to the ICU, depending on the country (1).
According to a study by Oliveira, S et al., (9) hypertensive disorders of pregnancy were the leading causes of admission. Prolonged preeclampsia accounted for 35.5% of the admissions and was linked to HELLP syndrome in seventeen cases, while eclampsia was identified in nine. A total of 23 obstetric hemorrhages occurred, of which 22 were attributed to uterine atony and one to uterine rupture. The most prevalent cause outside of obstetrics was infections (20.4%), with pneumonia being reported in seven women. In 23 cases, transfusion of blood products was required (57.0%). The incidence of maternal mortality was 4.3%, with uterine perforation during childbirth leading to hemorrhagic shock and septic shock (clostridium sordellii infection) resulting from legal medical abortions, which are prohibited in Egypt, being the leading causes of maternal death. Furthermore, the fetal mortality rate was recorded at 4.2%.
Krawczyk, P. et al., (4) discovered that that hypertensive disorders of pregnancy (n = 99, 37.22%), hemorrhage (n = 46, 17.29%), sepsis/infection (n = 46, 17.29%), and maternal mortality (1.5%) were the leading causes of admission.
In a retrospective study by Joseph, C. M et al., (5) examined 109 cases admitted to the intensive care unit (ICU) of a tertiary hospital to characterize the prevalence, clinical features, and outcomes of obstetric ICU patients. Pre-eclampsia with eclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) constituted the most prevalent admitting diagnoses, followed by anemia and antepartum bleeding. Non-obstetric causes included acute renal failure, coagulation abnormalities, and infections like miliary tuberculosis, dengue shock syndrome, and typhoid fever. The maternal mortality rate in this cohort was 17.76%.
Pollack et al, (11), found that obstetric hemorrhage constituted 5%–53% of intensive care unit admissions, while sepsis/infection constituted 0%–24%, other obstetric complications comprised 0%–55%, and non-obstetric diagnoses comprised 0%–47%. According to a study by Wanderer et al, (2013), approximately 30% and 19% of intensive care unit admissions are attributed to hypertensive disorders of pregnancy and hemorrhage, respectively. In addition, Ghike, S et al., (10) revealed that obstetric conditions that required intensive care unit (ICU) admission, the leading causes were hypertensive disorders of pregnancy (preeclampsia and eclampsia) (15/47, or 31.9%), dengue malarial fever (11/47, or 23.40%), poisoning (4/47, or 8.51%), acute gastroenteritis, meningitis, malignancy, seizure disorder, each accounting for one.
Moreover, the maternal mortality rate among ICU-admitted women in the Ghike et al. study was 31.91% (15/47), exceeding the present analysis. The predominant causes of mortality were dengue and malarial fever 5/15 (33.33%), followed by severe anemia and septicemia 3/15 (20%). The heightened mortality could be attributable to hemodynamic instability and respiratory failure necessitating mechanical ventilation.
This discrepancy may rely on the high incidence of malaria in the country of study (India) according to the World Health Organization (WHO) which reported that 93% of the population in India are at risk of malaria (12).
In addition, Zwart JJ et al., (13) and Munench MV et al., (14) reported hemorrhage and sepsis was the leading cause of ICU admission, while in other study by Mirghani HM et al., (15), it was hemorrhage (28.4%), preeclampsia and eclampsia (25%). Fapronle AF et al., (16), Battacharje P et al., (17) and Pallock W et al., (11) reported that eclampsia was commonest indication for admission, as eclampsia is still common in developing countries, especially in women with poor antenatal care. Hemorrhage was another indication for admission and was direct cause of mortality in many cases (10).
As regards maternal outcome, our study results revealed that IUFD, Eclampsia, Jaundice and Shock were significantly more frequent in maternal mortality cases than survival cases (p values= 0.049, 0.021, 0.003. 0.018) while there were no statistically significant differences between them regarding maternal, fetal demographic characteristics, other clinical presentations and surgical interventions.
As regards maternal and fetal mortality, our study results revealed that Anemia, Blood transfusion, Plasmapheresis and Hemodialysis were significantly more frequent in maternal mortality cases (p values= 0.045, 0.011, 0.019, <0.001) and fetal mortality was significantly more frequent in maternal mortality cases (p= 0.012). APH and Impending rupture uterus were significantly more frequent in cases of fetal mortality (p values= <0.001, 0.008).
Moreover, Conservative and LSCS were significantly less frequent in fetal mortality cases (p values= 0.017, <0.001) while SVD, D&C, Laparotomy and Surgical evacuation were significantly more frequent in fetal mortality cases (p values= <0.001, <0.001, 0.030, 0.002). Maternal anemia, Plasmapheresis and mortality were significantly more frequent in fetal mortality cases (p values= 0.030, 0.042, 0.012).
In a retrospective study, ŞİMŞEK, T et al., (8) examined the factors influencing the admission of obstetrical patients to the ICU and their clinical outcomes. The findings of the research indicated that maternal or gestational age, parity, and gravidity did not differ significantly between groups. The most prevalent reasons for admission (65.1%) were preeclampsia, eclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Disseminated intravascular coagulation (DIC) and hemorrhage (9.5%) subsequently develop.
As their exacerbation during pregnancy affects comorbidities, Panchal et al., (17) found that morbidity and mortality rates increase. A higher prevalence of comorbidities was observed among patients in the mortality group in comparison to those in the survival group (8).
The results of this investigation support the World Health Organization’s assertion “There is a story behind every maternal death or life-threatening complication. Understanding the lessons to be learnt can help to avoid such outcomes” (18). Gaining a more comprehensive understanding of the range, attributes, and consequences of the illnesses that affect this subset of individuals is the initial stride in order to prevent and, consequently, decrease morbidity and mortality among both mothers and newborns (4).
The strength points of this study:
The relatively larger sample size in comparison to previous research and the study’s location at a singular tertiary care center are both strengths of this investigation. This study represents the initial assessment of the characteristics and mortality rates of expectant and postpartum individuals who necessitate admission to theICU at Ain Shams University Maternity Hospital in Egypt. Additionally, the research was conducted exclusively at a solitary institution, employing an identical surgical team and anesthetic protocol, factors that most likely contributed to the robustness of our findings.
The limitations of the study:
Notable among the study’s limitations is its retrospective, single-center design, which may have resulted in the omission of clinically relevant patient information. Tertiary care center admissions to regional hospitals are associated with pregnancy complications, which have the potential to impact the rates of collected maternal morbidity and mortality.
Conclusion
The present study examined the attributes of critically ill obstetric patients who were admitted to our intensive care unit over a span of five years, specifically from 2018 to 2023.Hypertensive disorders of pregnancy (specifically severe preeclampsia) and hemorrhagic complications resulting from anemia were the primary etiologies. Potentially, increasing antenatal care could decrease the incidence of obstetric ICU admissions. Comparable to findings reported in other intensive care unit studies, the maternal mortality rate was 2.4%, while the fetal mortality rate was 16.7%.
Urgent obstetrical patients should be admitted to the ICU as soon as possible and managed appropriately in order to reduce maternal and fetal morbidity and mortality.
References
1. Vargas M, Marra A, Buonanno P, Iacovazzo C, Schiavone V, Servillo G. (2019). Obstetric Admissions in ICU in a Tertiary Care Center. A 5-years Retrospective Study. Indian J Crit Care Med ; 23(5):213–219.
2. Gama, S., De Vasconcellos, K., & Sebitloane, M. (2019). Outcomes of patients admitted to the intensive care unit for complications of hypertensive disorders of pregnancy at a South African tertiary hospital–a 4-year retrospective review. Southern African Journal of Critical Care, 35(2), 62-69.
3. Taghavi, S. A., Heidari, S., Jahanfar, S., Amirjani, S., Aji-Ramkani, A., Azizi-Kutenaee, M., & Bazarganipour, F. (2021). Obstetric, maternal, and neonatal outcomes in COVID-19 compared to healthy pregnant women in Iran: a retrospective, case-control study. Middle East Fertility Society Journal, 26(1), 1-8.
4. Krawczyk, P., Jastrzebska, A., Lipka, D., & Huras, H. (2021). Pregnancy related and postpartum admissions to intensive care unit in the obstetric tertiary care center-An 8-year retrospective study. Ginekologia Polska, 92(8), 575-578.
5. Joseph CM, Bhatia G, Abraham V, Dhar T. (2018). Obstetric admissions to tertiary level intensive care unit –Prevalence, clinical characteristics and outcomes. Indian J Anaesth ; 62:940-4.
6. Romano, D. N., Hyman, J., Katz, D., Knibbs, N., Einav, S., Resnick, O., & Beilin, Y. (2020). Retrospective analysis of obstetric intensive care unit admissions reveals differences in etiology for admission based on mode of conception. Anesthesia & Analgesia, 130(2), 436-444.
7. He, F., Li, R. R., Liu, P. S., Yang, Y. L., Huang, C. J., & Chen, D. J. (2021). Maternal cardiac arrest: a retrospective analysis. BJOG: An International Journal of Obstetrics & Gynaecology, 128(7), 1200-1205.
8. Şİmşek, T., Eyİgör, C., Uyar, M., Karaman, S., & Moral, A. R. (2011). Retrospective review of critically ill obstetrical patients: a decade’s experience. Turkish Journal of Medical Sciences, 41(6), 1059-1064.
9. Oliveira, S., Filipe, C., Husson, N., Vilhena, I. R., Anastácio, M., Miranda, M., & Devesa, N. (2019). Obstetric admissions to the intensive care unit: a 18-year review in a Portuguese tertiary care Centre. Acta Médica Portuguesa, 32(11), 693-696.
10. Ghike, S., & Asegaonkar, P. (2012). Why obstetric patients are admitted to intensive care unit? A retrospective study. J South Asian Feder Obstr Gynae, 4(2), 90-92.
11. Pallock W, Rose L, Dennis CL. Pregnanat and postpartum admissions to the ICU: A systemic review. Intensive Care Med 2010 Sep;36(9):1465-74
12. Mohan, I., Kodali, N.K., Chellappan, S. et al. Socio-economic and household determinants of malaria in adults aged 45 and above: analysis of longitudinal ageing survey in India, 2017–2018. Malar J 20, 306 (2021).
13. Zwart JJ, Dupvis JR, Richters A, et al. Obstetric ICU admissions, a 2 years nationwide population based cohort study. Intensive Care Med 2010 Feb;36(2):256-63.
14. Munench MV, Baschat AA, Malinow AM, Mighty HE. Analysis of disease in the obstetric ICU at university Referrel center: A 24 months review of prospective data. J Reprod Med 2008 Dec;53(12): 914-20.
15. Mirghani HM, Hameed M, et al. Pregnancy related admissions to the ICU. Int J Obstet Anaesth 2004 Apr;12(2):82-85.
16. Fapronle AF, Adenekan AT. Obstetric admission into the ICU in a suburban university teaching hospital NJOG 2011 Nov- Dec;6(2):33-36.
17. Panchal S, Arria AM, Harris AP. Intensive care utilization during hospital admission for delivery: prevalence, risk factors, and outcomes in a statewide population. Anesthesiology 2000; 92: 1537-44.
18. Leung, N. Y., Lau, A. C., Chan, K. K., & Yan, W. W. (2010). Clinical characteristics and outcomes of obstetric patients admitted to the Intensive Care Unit: a 10-year retrospective review. Hong Kong Medical Journal, 16(1), 18.