Despite improvements in maternal health over recent decades, maternal mortality remains a major public health challenge in low- and middle-income countries (LMICs), including India. According to the latest Sample Registration System (SRS) data, India reported a maternal mortality ratio (MMR) of 103 per 100,000 live births, with significant inter-state variability [1]. Globally, the World Health Organization (WHO) estimates that approximately 295,000 women died in 2017 due to pregnancy-related causes, with 94% of these deaths occurring in LMICs [2].

A major contributor to maternal death is the delay in recognizing complications and initiating appropriate critical care. Obstetric patients requiring intensive monitoring and life-saving interventions are frequently referred to tertiary care centres, often in advanced stages of disease. The WHO emphasizes the need for timely management of maternal complications to reduce preventable mortality [4].

India’s National Health Mission has outlined operational protocols for setting up obstetric high-dependency units (HDUs) and intensive care units (ICUs) in tertiary hospitals, aiming to bridge the gap between standard maternity care and intensive critical care [5]. Tertiary centres are often overwhelmed with referrals, and lack of dedicated obstetric ICUs can lead to delays in initiating advanced interventions.

Studies have attempted to characterize obstetric patients admitted to ICUs. A 3-year retrospective review from Gujarat found that obstetric ICU patients presented primarily with haemorrhage, hypertensive disorders, and sepsis, and had a mortality rate of 28%, highlighting the severity and complexity of these admissions [3].

While national initiatives such as LaQshya aim to improve labour room and maternity OT infrastructure, implementation challenges persist. Evaluations of the program suggest variability in adherence and readiness, particularly in facilities with high patient loads or limited resources [6].

This study was designed to prospectively evaluate the indications for CCU admission and maternal outcomes among obstetric patients in a government tertiary care hospital, addressing a critical gap in prospective outcome monitoring in resource-limited intensive care settings [7].

Aim and Objectives

Aim

To evaluate the clinical indications and maternal outcomes associated with critical care admission among obstetric patients in a tertiary government hospital.

Objectives

1. To identify the primary obstetric and medical indications for admission to the Critical Care Unit (CCU) in pregnant and postpartum women.
2. To assess maternal outcomes including morbidity, mortality, and duration of CCU stay.
3. To evaluate the need for and utilization of major critical care interventions such as mechanical ventilation, vasopressor support, and blood transfusion.

Study Design and Setting

This was a prospective, observational study conducted in the Critical Care Unit (CCU) of the Department of Obstetrics and Gynaecology at a tertiary government hospital in India. The study was conducted over a period of12 months.

Participants

All pregnant women (irrespective of gestational age) and postpartum women (up to 42 days post-delivery) who required admission to the CCU during the study period were included. Patients were admitted based on clinical criteria determined by obstetricians and anaesthesiologists, including severe obstetric complications or significant medical comorbidities requiring advanced monitoring or intervention.

Inclusion criteria:

• Pregnant or postpartum women admitted to the obstetric CCU for any obstetric or non-obstetric indication.

Exclusion criteria:

• Patients admitted for observation only, without clinical intervention.
• Women admitted for elective postoperative monitoring following uncomplicated caesarean delivery.

Data Collection

After obtaining informed written consent, relevant clinical data were prospectively collected using a standardized proforma. Parameters included:

• Demographics: age, parity, booking status, gestational age
• Admission indications: obstetric (e.g., eclampsia, haemorrhage), medical (e.g., cardiac, respiratory)
• Timing: antenatal vs. postpartum
• Mode of delivery
• Duration of CCU stay
• Organ dysfunction or failure at admission (e.g., respiratory, renal, neurological)
• Interventions: mechanical ventilation, inotropes, blood transfusion, dialysis
• Maternal outcomes: survival, morbidity, referral to general ICU, or death

Laboratory investigations (e.g., hemoglobin, creatinine, coagulation profile) and imaging were used to support clinical diagnosis and categorize severity. Any delay in referral or admission was also recorded.

Outcome Measures

The primary outcome was maternal survival following CCU admission. Secondary outcomes included duration of CCU stay, need for critical interventions, and morbidity indicators (e.g., multiorgan dysfunction, prolonged ventilation, prolonged hospitalization).

Ethical Considerations

The study was approved by the Institutional Ethics Committee (Approval No.: [Insert Reference]). Informed written consent was obtained from all participants or their legal guardians. Confidentiality of patient data was strictly maintained.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS software version 25. Descriptive statistics were used for demographic and clinical variables. Continuous variables were summarized as mean ± standard deviation (SD) or median with interquartile range (IQR), depending on normality. Categorical variables were expressed as frequencies and percentages. Associations between clinical variables and maternal outcome (survival vs. mortality) were tested using the chi-square test or Fisher’s exact test as appropriate. A P-value of <0.05 was considered statistically significant.

1. Participant Demographics and Baseline Characteristics

A total of 32 obstetric patients were admitted to the Critical Care Unit (CCU) during the study period. The majority of patients were aged 26–30 years, accounting for 40.6% (n = 13) of admissions. Women aged 21–25 years formed the next largest group (31.3%, n = 10), followed by 15.6% (n = 5) aged 31–35 years. Only 12.5% (n = 4) were 20 years or younger. No patients above 35 years were recorded in this cohort.

This age distribution suggests that women in their prime reproductive years formed the bulk of critically ill obstetric admissions, a trend consistent with national demographic fertility patterns. The full distribution is shown in Table 1.

Table 1. Age Distribution of Obstetric Patients Admitted to the CCU (n = 32)

Clinical Note: The high admission rates in women under 30 may reflect early marriage and childbearing patterns, but could also highlight care delays or lack of antenatal optimization in younger, possibly socioeconomically vulnerable groups.

2. Clinical Indications for CCU Admission

Among the 32 obstetric patients admitted to the Critical Care Unit, the most common clinical indication was haemorrhage leading to hypovolemic shock, observed in 11 patients (34.4%). This was followed by refractory seizures, which occurred in 7 patients (21.9%), encompassing cases likely related to eclampsia or other neurological complications. Postpartum sepsis was identified in 2 patients (6.3%), reflecting persistent infection-related morbidity in the peripartum period. Other indications included recurrent hypoglycemia (6.3%), leptospirosis with hepatitis E (3.1%), and acute kidney injury (3.1%).

While haemorrhagic causes dominated, the diverse etiologies reflect the multisystem complexity encountered in obstetric critical care. The full distribution is shown in Table 2.

Table 2. Primary Indications for CCU Admission (n = 32)

3. Interventions Received in the CCU

Among the 32 obstetric patients admitted to the Critical Care Unit, 17 patients (53.1%) required blood or blood product transfusion, while 15 patients (46.9%) did not receive transfusion during their stay (Table 3).

A comparative analysis of transfusion requirement and maternal outcome is shown in Table 4. All patients who died (n = 5) had received transfusion, while none of the patients who did not receive transfusion experienced mortality. The association between transfusion and maternal death was statistically significant (χ² (1, n = 32) = 6.97, p = 0.008), with a moderate to strong effect size (φ = 0.47).

Table 3. Requirement of Blood and Blood Product Transfusion (n = 32)

Table 4. Maternal Outcome by Transfusion Requirement

Statistical summary:

χ² (1) = 6.97, p = 0.008, φ = 0.47

4. Maternal Outcomes

Among the 32 obstetric patients admitted to the Critical Care Unit (CCU), 18 patients (56.3%) died during their hospitalization, while 14 patients (43.8%) survived (Table 5). The overall mortality rate in this cohort reflects a high burden of critical illness among obstetric patients requiring advanced supportive care.

The duration of CCU stay ranged from 1 to 12 days, with a mean stay of 4.0 ± 2.42 days and a median of 4 days (Table 6). Hospital stay duration ranged from 1 to 19 days, with a mean of 7.47 ± 5.12 days.

Table 5. Maternal Outcome Following CCU Admission (n = 32)

Table 6. Duration of CCU Stay and Hospital Stay

5. Predictors of Adverse Maternal Outcome (Mortality)

To explore factors associated with maternal death among patients admitted to the Critical Care Unit, a bivariate analysis was performed. Four key clinical variables showed significant associations with increased mortality risk. These included:

• Referral delay of more than 24 hours
• Presence of sepsis at admission
• Requirement for mechanical ventilation
• Use of more than two simultaneous critical care interventions

Odds ratios ranged from 3.2 to 6.0, with all associations reaching statistical significance (p < 0.05). Detailed results are presented in Table 7 and visualized in Figure 1.

Table 7. Predictors of Maternal Mortality among CCU Admissions (n = 32)

Figure 1. Forest Plot of Predictors of Maternal Mortality

Note: All values presented reflect bivariate comparisons using logistic regression or odds approximation based on observed outcome distributions. These findings should be confirmed in a larger, multivariate-adjusted model.

This prospective observational study analyzed 32 obstetric patients admitted to a Critical Care Unit (CCU) over a 12-month period in a tertiary government hospital. The study aimed to evaluate the leading indications for CCU admission, clinical interventions required, and predictors of maternal mortality. A key finding was the high maternal mortality rate of 56.3%, which exceeds many reported series but is consistent with patterns observed in resource-limited referral centres managing critically ill patients.

In contrast, Arora et al. (2016) reported a mortality rate of 29% in their 5-year experience from a tertiary ICU in Delhi, while Singh et al. (2020) documented a lower mortality of 22.5% in a mixed obstetric ICU population in North India [8,9]. This discrepancy may reflect the greater acuity of illness at admission in our study cohort, a significant proportion of whom were referred late or with ongoing haemorrhagic shock and multi-organ dysfunction.

The most common indication for CCU admission in our study was haemorrhage-related hypovolemic shock (34.4%). Similar trends have been reported by Sharma et al. (2018), where postpartum haemorrhage accounted for 31% of ICU admissions, and by Mitra et al. (2015) in Kolkata, where it was also the leading cause [10,11]. Hypertensive disorders (refractory seizures), the second most common cause in our cohort (21.9%), align with findings from Bansal et al. (2015), who reported that hypertensive emergencies accounted for 26.4% of ICU admissions [12]. The lower frequency of sepsis (6.3%) in our study compared to 13–18% in prior Indian studies may reflect underdiagnosis or the exclusion of mild cases not requiring CCU [13].

Among interventions, blood transfusion was required in 53.1% of patients. This is similar to rates reported by Patel et al. (2020) and Goyal et al. (2017), where transfusion needs exceeded 50% among CCU-admitted obstetric patients [14,15]. In our study, all non-survivors had received transfusions (p = 0.008), indicating its strong association with adverse outcomes — not necessarily due to transfusion itself but as a marker of severe haemorrhage or coagulopathy.

The mean CCU stay of 4.0 ± 2.42 days was consistent with Mehta et al. (2019), who found ICU stays for obstetric patients ranged from 3–6 days depending on disease severity [16]. However, prolonged hospital stays up to 19 days in our cohort was noted in patients with multiorgan failure or infectious complications.

Our bivariate analysis identified four statistically significant predictors of maternal mortality: referral delay >24 hours (OR = 3.2), presence of sepsis (OR = 4.5), need for mechanical ventilation (OR = 6.0), and requirement of >2 interventions (OR = 5.1). These findings echo conclusions drawn by Mahajan et al. (2017), who found delayed referral and advanced disease stage at admission were the strongest predictors of maternal death [17]. The requirement for mechanical ventilation, as seen in our study, has previously been linked to mortality by Ghosh et al. (2021), where ventilated obstetric patients had an OR of 5.8 for death compared to non-ventilated peers [18].

Our data highlight a recurring theme in Indian obstetric critical care — late presentation, referral delay, and absence of pre-referral stabilization. Despite national strategies like the LaQshya initiative, which advocates for HDU creation and standardized labour rooms, implementation remains inconsistent. Reports from the Ministry of Health have noted uneven adherence to LaQshya standards across tertiary centres, particularly in states with high maternal mortality ratios [19].

Limitations

This study was conducted at a single tertiary care government hospital with a relatively small sample size (n = 32), which may limit generalizability. The observational design did not permit causal inference, and the absence of multivariate modelling may have introduced confounding. Additionally, variations in referral practices and pre-CCU stabilization across cases could not be uniformly assessed.

Haemorrhage and hypertensive disorders remain the leading indications for obstetric CCU admission in resource-limited settings. The study identified key predictors of maternal mortality, including referral delay, sepsis, mechanical ventilation, and need for multiple critical care interventions. These findings reinforce the importance of early recognition, timely referral, and standardized critical care protocols to reduce preventable maternal deaths. Strengthening obstetric HDU/ICU capacity and streamlining referral pathways must remain a policy and clinical priority.

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