DOI: 10.1097/CCM.0b013e31819bb7de

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Issn Print: 0090-3493

Publication Date: 2009/03/01


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The authors reply:

Rodrigo Cartin-Ceba; Ognjen Gajic; Vivek N. Iyer; Nicholas E. Vlahakis

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Excerpt

We thank Grisaru-Granovsky et al for their interest in our article (1) and for their insightful comments. Before addressing the specific comments that were raised, we want to emphasize that the main objective of our article was to describe the risk factors associated with poor fetal outcomes in maternal admissions to the intensive care unit (ICU) for primary nonobstetrical causes.
The study cited by Grisaru-Granovsky et al (2) does indeed describe antepartum ICU cases; however, outcome data were focused on prediction of maternal mortality and not on fetal complications. In addition, the authors did not include any patients admitted for primary nonobstetrical causes. In fact, they excluded 14 patients (29% of the sample) with pre-existing medical/surgical conditions who presumably had preplanned ICU admissions without acute decompensation. The fetal mortality was not specifically stated in the published article, but we appreciate that this important finding has now been reported by them. This notwithstanding, the majority of publications related to obstetrical admissions to the ICU has focused on the postpartum period, and both ours and the cited article are some of the few that have reported the opposite.
Regarding the second comment, we would like to clarify our data. The reference to abortion refers to the fetal outcome in pregnant women with a viable fetus at ICU admission. Also, we have acknowledged the race disparity in the limitations of the study, and we do not believe either this or socioeconomic status can be inferred from the diagnosis of “trauma” and “drug overdose.” We cannot address the socioeconomic bias of the study because this was not assessed in this retrospective study. Furthermore, although there were more fetal deaths in the incidental pregnancy group, there were no statistical differences in the fetal deaths between the two groups. In addition, the statistical difference between the two groups in the presence of antenatal care decreased after adjustment for severity of illness in a multivariable analysis.
Finally, we consider that incidental pregnancies in the ICU are a real concern and see no reason to exclude them from the study. In fact, they represent the same physiologic stress to the mother as a known pregnancy. Also, we do agree that information regarding preadmission obstetrical care is an important influence on fetal outcome in a critically ill mother. Furthermore, we clarify that all patients admitted were evaluated and comanaged by “around the clock” multidisciplinary specialists including obstetric and perinatal care and intensivists. However, we respectfully disagree that our identified indicators of maternal state only secondarily indicate fetal outcome. In contrast, we believe, as stated by Grisaru-Granovsky et al, that there is a strong interdependent “mother–fetus dyad,” in which the maternal state has profound direct effects on fetal well-being. This is one of the important messages that our article intends for the reader to appreciate.
Grisaru-Granovsky et al (3) state that compared to the findings of our study superior fetal outcome has been previously reported. However, the aim of this cited study to support their claims was focused specifically to “describe the effect of prolonged antepartum mechanical ventilatory support on the mother and neonate” and reported on only three patients. As such, these data cannot be generalized to a larger population as we have reported.
The authors have not disclosed any potential conflicts of interest.
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