Though global maternal mortality has declined by 1.3 percent a year since 1990, the rate continues to remain stubbornly high in certain regions. At present, fewer than one of 50 pregnant women require critical care. However, both maternal and fetal mortality can be high when it is required.
In industrialized countries, the rate of obstetric ICU admissions varies from 50 to over 400 per 100,000 deliveries with an overall case-fatality rate of 2%. In developing countries, fatality in obstetric ICU patients can be 3-5 times higher.

Obstetric disorders in the ICU
Obstetric ICU patients include those with obstetric disorders as well as pregnant patients with medical/surgical disorders. The bulk of patients are admitted to the ICU for obstetric disorders. In general, obstetricians are aware of all obstetric patients in hospital, whether they have a medical or obstetric problem.
There are several obstetric conditions which can require ICU admission. The most common are hemorrhage and hypertensive disorders, above all pre-eclampsia toxemia (PET) and eclampsia. In industrialiZed Western countries, these typically account for 30-35% and 20% of admissions to the ICU.

Hemorrhage leading cause of mortality, ICU admission
Obstetric hemorrhage is either antepartum or postpartum, and remains the leading cause of maternal mortality. Antepartum hemorrhage occurs in 5 percent of pregnant women, and in the bulk of cases carries no risk to the mother or fetus. Major causes involve the placenta and uterine rupture.
Postpartum hemorrhage (PPH) is the single most frequent indication for ICU admission, and involves major blood loss, regardless of the mode of birth. Though there is no universally accepted definition, it typically means more than a half litre of blood loss within 24 hours. In about two out of three cases, PPH is due to failure of uterine contraction after delivery, with most of the rest caused by placental retention. Genital trauma, due to laceration of the vagina or cervix because of instrument delivery, is also increasingly implicated in PPH.

Patient management of obstetric hemorrhage depends on identifying the cause and whether or not delivery has occurred. In PPH, management is aggressive, beginning with administration of oxytocin, emptying of the bladder and massage of the uterus. The care team also begins intravenous prostaglandin therapy, coupled with uterine tamponade via balloon compression or packing. If bleeding persists, surgical intervention is indicated: arterial ligation, suture, Cesarean hysterectomy or uterine artery embolization. Should bleeding continue, recombinant factor VIIa is administered and repeated, if there is no response.

Hypertensive disorders
Pre-eclampsia toxemia (PET) occurs in 2 to 3 percent of all pregnancies after 20 weeks of gestation, and is classified as mild, moderate or severe. Its pathogenesis results from abnormal placenta formation, and it is characterized by impaired organ perfusion due to impaired vasodilation and placental ischemia. As pregnancy progresses, the ischemia worsens. This makes the mother hypertensive, with a risk of renal dysfunction.
Severe PET is associated with significant morbidity and mortality, both for the mother and fetus. It requires one or more of the following indicators: hypertension (BP over 160 systolic or 110 diastolic), proteinuria higher than 5 grams per 24 hours or oliguria below 400 ml per 24 hours, along with cerebral irritability, epigastric pain, and pulmonary edema.
PET usually resolves following delivery of the fetus but may manifest postpartum. A variety of antihypertensive agents, including hydralazine, labetalol, sodium nitroprusside, alpha blockers, calcium channel blockers and methyl dopa, have been advocated in PET.  Hydralazine and labetalol are the most widely used in the critical care setting. Magnesium is usually co-administered to provide vasodilatation and prevent seizures. Care should be taken with fluid resuscitation because of the risk of pulmonary edema.
Eclampsia is an extreme complication of PET, and is marked by the occurrence of convulsions and seizures, 40% of which occur following delivery. The seizures tend to be self-limiting, with a very rare incidence of status epilepticus. Though the mortality from eclampsia has been high in the past, death is now uncommon. Common causes of mortality are hepatic complications, including hepatic failure, hemorrhage, or infarction.

Other challenges of pregnancy
Peripartum cardiomyopathy is another challenging condition during pregnancy, albeit of unknown cause. It is one of the leading causes of maternal death, with mortality as high as 25-50%. It can occur from the final month of pregnancy up to 5 months after delivery.
Other conditions unique to pregnancy include HELPP syndrome (hemolysis, elevated liver enzymes and low platelets), placental disorders (abruption, previa or retention), amniotic fluid embolism and chorioamnionitis, and acute fatty liver. 

Changing epidemiology
The epidemiology of obstetrics in the ICU has changed dramatically since the past decade. Obstetric conditions such as thrombocytopenic purpura of pregnancy, which were rare in the past, are now being diagnosed more frequently. Massive hemorrhage from adherent placenta is increasing due to the growing number of pregnant women bearing scars from previous cesarean sections (CS). Uterine rupture during labour is also sometimes associated with previous CS. Another condition is ovarian hyper-stimulation syndrome, which is not uncommon any more due to the sharp growth in the availability of assisted reproduction techniques.
There are now many older mothers with pre-existing disorders and chronic medical conditions, some of which can be in an advanced stage. Typical co-morbidities today including essential hypertension, Type 2 diabetes and coronary heart disease. Obesity is also a major concern, which poses numerous challenges for managing pregnant patients in the ICU.

Impact on multiple physiological systems
Pregnancy affects several physiological systems – among them, the cardiovascular, respiratory, renal, hematologic and endocrine. These tax a patient’s reserves and often compromise responses needed to combat a disease state during pregnancy and the peripartum period.
Pregnancy’s impact on physiological systems is twofold: first, by worsening pre-existing conditions, and second, by heightening susceptibility.
For example, cardiovascular conditions which can deteriorate significantly in pregnancy include aortal coarctation, primary pulmonary hypertension and valvular disease; congenital heart disease is another such condition. Cardiovascular issues are also important since that shortness of breath is a very common symptom in pregnancy. When this occurs, clinicians must distinguish the dyspnea resulting from underlying medical disorders versus that caused by normal physiologic changes in pregnancy. The latter include anemia, upward displacement of the diaphragm, and respiratory alkalosis.
One of the most confounding cardiovascular challenges is associated with PET. Aside from hypertension, patients also show increased systemic vascular resistance and reduced intravascular volume, which cause a reduction in cardiac output as disease severity progresses. In such cases, left ventricular function can deteriorate leading to a risk of pulmonary edema after fluid resuscitation.
On the other side, pregnant women also face an increase in risk for a gamut of infections ranging from varicella pneumonia and urinary tract infections to malaria and hepatitis.
In the respiratory system, the impact of pregnancy on cystic fibrosis is well known. However, pregnant women also face a concurrent increase in susceptibility to venous embolisms and pulmonary thromboembolism.

This kind of dual impact is also faced by the renal, endocrinal and neurological systems. Pregnancy worsens renal insufficiency and glomerulonephritis and enhances susceptibility to acute renal failure.
In the endocrinal system, it worsens diabetes and prolactinoma and increases susceptibility to gestational diabetes.
The list of neurological conditions which deteriorate during pregnancy is especially large, and includes epilepsy, myasthena gravis and multiple sclerosis, while an increase in susceptibility is seen with intracranial hemorrhage. Another complicating factor is that up to half of obstetric critical care patients have some form  of neurological compromise. In most circumstances, this is the result of their admission diagnosis   (that is, pre-eclampsia or obstetric   hemorrhage),  rather than as the precipitant of their ICU admission.

Two patients in one
As a result of the above factors, obstetric critical care represents a major challenge for medical professionals. Obstetricians need to master both maternal and fetal physiology, and avoid any potentially adverse effects on a fetus of diagnostic and therapeutic interventions given as part of care for the mother. Indeed, it is a common statement that obstetricians treat two patients, the mother and the fetus. They must also assess two separate risks – maternal and fetal – from continuing with a pregnancy and decide if termination of the pregnancy improves the outcome for the mother. This is a very charged challenge since a fetus is generally robust despite maternal illness, and it has been demonstrated that pregnancy-induced critical illnesses are resolved by delivery of the fetus.

Mastering general principles
Obstetric ICU practice consists of firstly mastering general principles such as drug safety, ventilation and management of patient airways, monitoring of the fetus, muscle relaxation and sedation, cardiovascular support, thromboprophylaxis, as well as radiology and ethical issues. This is followed by the acquisition of expertise in the management of obstetric and medical conditions.
Critical care interventions for an obstetric patient are similar to those for the non-pregnant patient. However, it is often necessary to adjust physiologic targets for metabolic, pulmonary, and hemodynamic control.

The need for teamwork
Given the complexity and time-sensitiveness of critical care medicine, teamwork skills are essential. Typically, the care team for an obstetric patient at an ICU is multidisciplinary, consisting of the intensivist, obstetrician, anesthesiologist, maternal-fetal medicine specialist, the neonatologist and the ICU nurses. This team needs to operate effectively alongside regular staff.
Although clinicians working in critical care environments are generally highly trained and competent, they have traditionally not learned how to work well as part of a team. Remedying this has become a priority on both sides of the Atlantic.

As part of a paper on standards of care, the European Board and College of Obstetrics and Gynaecology (EBCOG) explicitly recommends “multidisciplinary, high-quality teamwork” as being “essential” in obstetric medical care and urges healthcare providers to ensure that maternity services have adequate facilities, expertise, capacity and back-up for “timely transfer to intensive care.” EBCOG also seeks to give substance to such a mission. It urges a system of “clear referral paths” to enable pregnant women requiring additional care to be managed and treated by the appropriate specialist teams when problems are identified. One of its most interesting recommendations is for development and routine use of an obstetric ‘early warning chart’  to help in the timely recognition, treatment and referral of women developing a critical illness.

Teamwork is also seen as being a priority in the US, where the Joint Commission pointed to failures in teamwork and communication as among the leading causes of adverse obstetric events. Although obstetric clinicians seem aware of deficiencies in teamwork, their perceptions of teamwork differ based upon their role. In a survey by Johns Hopkins University of 44 hospitals across the US, the majority had fewer than half of respondents reporting ‘good teamwork’ in their labour and delivery units.

Point-of-care testing (POCT) is typically described as a clinical test which is done at, or close to, the physical location of a patient. This could be at a patient’s home, in a pharmacy, a GP’s office or an in-hospital bed site. POCT typically consists of portable devices and instruments, which return results quickly. As a result, POCT permits immediate intervention or treatment.
POCT can also be defined usefully by specifying what it is not. In this case, a POCT is simply a test that is not analysed in a laboratory. POCT short circuits many steps involved in the latter. It eliminates the need to collect a specimen, transfer it to the lab, perform the test, and transmit results back to the provider.
POCT is increasingly used to diagnose and manage a range of diseases, from chronic conditions such as diabetes to acute coronary syndrome (ACS). Recent additions include genetic tests.

Driven by miniaturisation
The POCT era is considered to have begun in the 1970s, with a test to measure blood glucose levels during cardiovascular surgery. In 1977, a rapid pregnancy test called ‘epf’ became the first POCT for use wholly outside a hospital.
Since the late 1980s, one of the key drivers of POCT has been product miniaturization, with increasingly sophisticated and ever-smaller mechanical and electrical components integrated onto chips that can analyse biological objects at the microscale. The pace of miniaturization has accelerated at a breakneck speed in recent years, to mobile handheld and wearable POCT devices. These can be inte-
grated with other applications within a healthcare facility, or aid patients in monitoring and self-management of chronic conditions.

Wide product range, but handful of tests dominate
The most widely-used POCTs include “blood glucose testing, blood gas and electro-
lytes analysis, rapid coagulation testing, rapid cardiac markers diagnostics, drugs of abuse screening, urine strips testing, pregnancy testing, faecal occult blood analysis, food pathogens screening, haemoglobin diagnostics, infectious disease testing and cholesterol screening.” Nevertheless, just three tests – urinalysis by dipstick, blood glucose and urine pregnancy – are believed to account for the majority of POCT.

Comparisons with the lab
Beyond definition, the relationship of POCT to a laboratory is close for a very good reason. Most clinical cases for POCT use lab testing as a comparator. In other words, the first question that comes to many people when using POCT is whether its results match those of a laboratory. Although evidently quicker to obtain, is POCT as reliable? Another topic for comparison consists of the cost of POCT versus lab tests.

Costs: a vexed question
Even in the heady early days of POCT, there was awareness about potential cost downsides. One of the first efforts to address this question was a US study, published in 1994 in ‘Clinical Therapeutics’. [1] The study, by the Office of Health Policy and Clinical Outcomes at the Thomas Jefferson University Hospital in Philadelphia, sought to determine time and labour costs for POCT versus central laboratory testing on a cohort of 210 patients presenting to the emergency department.
The patients had blood drawn for a Chem-7 profile (sodium, potassium, chloride, carbon dioxide, blood urea nitrogen, glucose, and creatinine), or for cell blood count (CBC). Largely due to much quicker turnaround time (TAT), physicians reported that POCT would have resulted in earlier therapeutic action for 40 of 210, or 19 percent of patients. Costs for POCT were, however, over 50 percent higher, and also showed significant variability, depending on test volume. The authors speculated that increasing volumes of POCT would reduce costs “substantially.”

Volumes lower cost
The perception that POCT is much more expensive than a centralized laboratory persists. There are several reasons for this. Consumables generally cost more than tests done with automated laboratory instruments. On its part, POCT simply cannot achieve the scale economy associated with the latter. It also requires more staff downtime.
However, right from the early stages of POCT use, it seemed likely that unit costs could be reduced by increasing test volumes, as anticipated in the 1994 study by Jefferson University Hospital.
POCT was also to quickly demonstrate enhanced utility for certain kinds of tests. In 1997, a study at an Indiana hospital reported a near-halving in unit costs of panels, from USD 15.33 to USD 8.03, following POCT implementation for blood gases and electrolytes [2].

Levelling the field of play
One of the biggest hurdles in making cost comparisons of POCT with lab tests is the difficulty of levelling the playing field. It is also difficult to use such an exercise to draw generalised conclusions, since key conditions often vary significantly from one care facility to another. POCT is also complex to manage, and it is especially challenging to maintain regulatory compliance, especially in large institutions.
Though the cost of consumables is straightforward to determine, this is hardly so for labour.
Labour costs for a lab test are not limited to staff in the laboratory. They also include costs of staff in the pre-analysis phase, for phlebotomy, nursing and other services. Many of the latter entail administrative overheads. Typically, these would consist of formalities in the collection of phlebotomy supplies, the completion and submission of a test request, the labelling of tubes, specimen packaging and despatch.
In contrast, POCT eliminates most pre-analytic steps, along with associated staff costs and overheads. POCT can be undertaken by personnel who are not trained in clinical laboratory sciences.

Cost versus value
Although it seems to be common sense that POCT labour costs are significantly less than for a laboratory test, calculating this precisely requires a complex time-and-motion study which takes account of differences in wages and other costs for phlebotomists, nurses, administrative staff and medical technologists.
Unit product cost therefore reflects only a part of the overall equation, as far as justifying the case for a test is concerned. Indeed, many experts now urge for making assessments based on unit value rather than unit cost.
The role of TAT
With POCT, faster TAT promises better treatment, reduced patient stay, superior workflow and improved clinical outcomes. POCT is however less about reducing TAT than making results available in an optimal and clinically relevant time frame. This, in turn, is frequently dictated by conditions for which care is targeted as well as the setting in which it is delivered.
Delayed test results also impact upon cost in indirect ways. For instance, radiology departments use creatinine POCT before administering contrast agents, since patients with impaired renal function can develop contrast-induced kidney injury. This allows for quick decisions about patients and efficient use of costly CT scanners. If physicians had to wait for test results from a laboratory, the scanner would risk having to idle in a stand by status.

POCT can sometimes be only choice
Some tests have to be performed at point of care since there is no choice, in terms of time for transport to a lab.
One good example is an activated clotting-time test. This is used to monitor cardiac patients undergoing high-dose heparin therapy, whose blood immediately starts to clot after collection of a sample. Another is a POCT glucose test, where a quick result is crucial in determining insulin dosage for diabetic patients.
Elsewhere, whole blood cardiac-marker POCT tests in an A&E facility allow physicians to make rapid decisions on patients with acute coronary syndromes in terms of triage and disposition for observation, catheterization or transfer to a cardiac ICU.
Yet another example is a rapid flu test, used to identify patients who could benefit from antiviral therapy requiring administration as soon as possible after infection, in order to reduce symptomatic intervals. None of the above permit the wait times required for a lab test.

The grey zones
Still, there are grey zones where lab tests have advantages, which are non-negotiable under certain conditions.
One example is routine monitoring of international normalized ratios (INR) for patients on warfarin. The latter is used for prophylaxis against stroke and systemic embolism in patients with atrial fibrillation or mechanical heart valves. The goal of testing is to ensure that anticoagulant levels are appropriate. Over a certain threshold, there is a risk of bleeding, while below it, there is the danger of clotting.
While warfarin toxicity can result in life-threatening risk of bleeding, inappropriate warfarin dose reduction can lead to inadequate protection from a stroke or systemic embolism.
Lab-based testing entails the patient travelling to a GP, or having a caregiver come to take blood at the patient’s home, and doing this regularly. However, even a one-day TAT for the lab test can be a major problem in terms of warfarin dosage. The utility of POCT here seems clear. The GP can know the results and adjust the medication dosage immediately. In addition, POCTs can enable certain categories of patient to self-test and manage warfarin therapy.

Lab tests as gold standard
However, POCT tests can vary significantly from laboratory analysers. In the case of warfarin monitoring, this happens as INR values rise. Correction factors are also typically device- and institution-specific. They cannot be uniformly applied across institutions. Many clinicians therefore require POCT INRs which are greater than 5.0 to be confirmed with a venipuncture sample and a lab test.
Lab tests therefore remain a gold standard. Instrumentation in a laboratory provides robust analytics during a test, and includes a host of quality controls, from test strengths and timings to testing accuracy. These are incorporated into a laboratory information system (LIS) and stored in a patient case file. POCT simply cannot provide such a depth of information.

Gaps being closed
In brief, both POCT and laboratory testing have pluses and minuses. POCT provides definite advantages and reduce risk in some situations.
However, laboratory testing is more advanced, more closely follows scientific process and is fully integrated with the kinds of technical redundancies necessary to ensure greater accuracy and validation of records.
Nevertheless, gaps between the two are being closed, especially through software technology.
Some hospitals now have dedicated satellite labs in emergency rooms and outpatient facilities equipped with POCT.

[1]  https://www.ncbi.nlm.nih.gov/pubmed/7859247
[2] Bailey TM, Topham TM, Wantz S, et al. Laboratory process improvement through point-of-care testing. Jt Comm J Qual Improv 1997;23(7):362–80