Obstetric conditions requiring intensive care at the Analankiriny University Hospital Centre, Toamasina, Madagascar

¹Faculty of Medicine, University of Toamasina, Toamasina, Madagascar, ²Multidisciplinary Intensive Care Unit, Analankininina University Hospital Centre (CHU Analankininina), Toamasina, Madagascar, ³Faculty of Medicine, University of Fianarantsoa, Fianarantsoa, Madagascar, ⁴Department of Obstetrics and Gynaecology, Analankininina University Hospital Centre (CHU Analankininina), Toamasina, Madagascar, ⁵Faculty of Medicine, University of Antsiranana, Antsiranana, Madagascar

^&Corresponding author
Rafanomezantsoa Toky Andriamahefa, Faculty of Medicine, University of Toamasina, Toamasina, Madagascar

Introduction    

The obstetric intensive care unit provides specialised management for women requiring close monitoring or critical care interventions. At the Analankininina University Hospital Centre, Toamasina (CHUAT), the multidisciplinary intensive care unit also manages major obstetric emergencies such as eclampsia and postpartum haemorrhage [1]. In high-income countries, obstetric patients represent about 1% of intensive care admissions, most commonly for cardiac disease, severe haemorrhage, infection, or shock [2]. Approximately 0.5% of pregnant women require intensive care, and 30-50% need mechanical ventilation [3]. However, maternal morbidity and mortality remain disproportionately high in low-resource settings, reflecting socioeconomic and organisational disparities rather than medical incompetence [4-6]. In Madagascar, limited data are available on obstetric admissions to intensive care. At CHUAT, no detailed statistics had previously been reported [7,8]. This study therefore aimed to describe the epidemiological and clinical profiles, as well as outcomes, of obstetric patients admitted to the multidisciplinary intensive care unit during 2023-2024.

Methods     

We conducted a retrospective, descriptive, cross-sectional study including women admitted to the multidisciplinary intensive care unit of the Analankininina University Hospital Centre (CHUAT) over an 18-month period, from January 2023 to June 2024. The study population consisted of all female patients admitted to the intensive care unit during the study period. All complete medical records of patients aged over 15 years were included, while incomplete files were excluded. The variables analysed included epidemiological characteristics, obstetric history, reasons for emergency admission, type of surgical intervention, indication for intensive care admission, length of hospital stay, and patient outcomes. Data were collected from medical records. Data entry was performed using Microsoft Word 2021®, and tables were created with Microsoft Excel 2021® and Epi-Info version 3.5.3. Ethical principles, including confidentiality, anonymity, and professional secrecy, were strictly observed. No patient names were recorded, and a coding system was used to ensure data protection. The retrospective and single-centre design represents the main limitation of this study.

Results     

During the study period, 537 patients were admitted to the multidisciplinary intensive care unit, including 58 cases (10.8%) of obstetric pathologies. The mean age of the women admitted was 25.3 ± 6.7 years, with a predominance of young women aged 15-25 years (42.6%). Most of the admitted women (81.5%) were employed in the primary sector. The mean gravidity was 2.7. Primigravidae accounted for 51.7%, multigravidae for 46.4%, and nulligravidae for 1.9%. The mean parity was 1.8, with primiparous women representing 42.6% and nulliparous women 26.8% of admissions. Hypertension was the most common medical history (18.5%), including 6.4% with a prior history during pregnancy. Regarding the mode of admission, 86.8% (50/58) of patients presented directly to the emergency department, 12.8% were referred from other facilities, and 0.4% were interdepartmental transfers. At admission, 17.7% of patients had a Glasgow Coma Scale (GCS) alteration, including nine cases in coma (Table 1). The categories of ICU admissions were diverse (Table 2). Most patients were postoperative cases (48%), followed by postpartum complications (19%) requiring transfer to intensive care. Among surgical indications, eclampsia was the most common reason for caesarean section (n = 12; 60%). Pelviperitonitis was the leading indication for laparotomy (n = 3; 37.5%), followed by hysterectomy, ruptured ectopic pregnancy, and infectious adhesions. Postpartum complications requiring intensive care were mainly postpartum haemorrhage (n = 3) and severe infections (n = 3), including sepsis (n = 2) and post-abortion meningitis (following induced abortion). Medical conditions accounted for some ICU admissions, primarily asthma exacerbations (25%) and vaso-occlusive crises (75%) among pregnant women with sickle-cell disease. Among hypertensive disorders of pregnancy, eclampsia (40%) was the leading cause of ICU admission, followed by placental abruption (13.3%), acute pulmonary oedema (26.7%), and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome (20%).The mean length of stay in intensive care was 4 ± 3.5 days (range: 1-10 days). Regarding outcomes, 81.0% of patients had a favourable recovery, 6.8% died, 8.6% developed complications, and 3.4% required transfer to another specialty. Among the four deaths, two were due to hypovolaemic shock secondary to postpartum haemorrhage, one to disseminated intravascular coagulation (DIC), and one to septic shock.

Discussion     

The mean age of patients admitted was 28.4 years, with a predominance of young women aged 15-25 years (42.6%). This result is comparable to those reported by Bonnet et al. in France (25 years) [2] and Owono in Cameroon (25.7 ± 7.3 years) [9]. The most represented age group in previous studies was 20-39 years [2]. Similarly, Daddy et al. in 2014 in Niger found a predominance of women aged 30-36 years [10]. According to Owono´s 2017 study in Cameroon, the mean age was 25.7 ± 7.3 years [9]. Our results differ from those of Mbouta in Bamako (2009), where the 14-19-year age group predominated [11]. The majority of women (81.5%) were employed in the primary sector, of whom 67.2% were housewives. These findings partially align with those of Owono [9], but differ from Tchaou in Benin [12] and Mbouta in Bamako [11], who reported a more diversified occupational distribution. The low socioeconomic and educational level remains a major risk factor for obstetric complications.

Primigravidae (51.7%) and primiparous women (42.6%) were predominant, rates similar to those observed by Tchaou [12] and Owono [9], but higher than those reported by Andrianirina in Antananarivo [8]. Regarding medical history, 82.6% of patients had no history of abortion, and 71.3% had no prior medical condition. Hypertension was the most common antecedent (18.5%), similar to findings by Tchaou [12] and Andrianirina [8]. In our study, 82.6% of women had never had an abortion. Harioly et al. (2009) at Befelatanana Maternity, Antananarivo, found that 17.2% of women with a previous abortion experienced pregnancy complications [13]. The main reasons for admission were genital bleeding (28.3%), abdominal pain (20.8%), and seizures (14.7%). In the intensive care unit, eclampsia was the leading cause (15.5%), followed by operated ectopic pregnancies (12.8%) and complicated post-caesarean cases (9.4%). These results differ from those of Owono [9] and Tchaou [12], who reported predominance of hypertensive and haemorrhagic emergencies. At admission, 17.8% of patients presented with an altered Glasgow Coma Scale, including 15.5% in coma-lower than the 23% reported by Samaké at the Gabriel Touré University Hospital [14]. The mean length of stay was 4 days, comparable to results from Tchaou [12] and Ngagoue [15]. Complications occurred in 12.1% of cases, mainly haemorrhagic (6.7%), and were most frequent among women under 35 years, multiparous, or multigravidae, consistent with Ngagoue´s findings [15]. The overall mortality rate was 6.8%, lower than that reported in other African series. Hypovolaemic shock and eclampsia-related complications each accounted for 33.3% of deaths, followed by septic shock (11%). These results are consistent with those of Owono [9], highlighting the persistence of avoidable causes of maternal death. These findings are consistent with previous studies on obstetric critical care, highlighting the need for specialised management and early intervention to improve maternal outcomes [11]. Economic hardship, delayed referral, inadequate technical facilities, and poor antenatal follow-up remain major determinants of maternal morbidity and mortality in low-resource settings.

Conclusion     

Admission of a patient to intensive care for pregnancy-related complications requires coordination, multidisciplinary collaboration, and clinical experience. Maternal pathologies managed in obstetric and general intensive care units are highly diverse, and the management of critically ill obstetric patients demands both technical competence and organisational efficiency. Developing structured protocols for quality and safety of care within maternity services, supported by multidisciplinary high-risk medical teams, is essential for achieving hospital accreditation and improving outcomes. The maternal condition at admission and the associated complications remain the main determinants of maternal outcome.

Competing interests     

The authors declare no competing of interests.

Authors' contributions     

Rafanomezantsoa Toky Andriamahefa: conceptualization, methodology, writing-original draft, formal analysis, investigation. Razafindraibe Felanarivo: formal analysis, writing, review and editing. Razafindrabekoto Lova Dany Ella: formal analysis, writing review and editing. Harioly Nirina Marie Osé Judicaël, Andriatahina Todisoa: validation. All the authors have read and agreed the final version of this manuscript.

Tables     

Table 1: distribution of women according to the Glasgow score at admission

Table 2: distribution according to the reasons for admission to the intensive care unit

References