Most recent estimates suggest that 1–3% of pregnant women in the United States require critical care services each year. Whereas approximately 0.1–0.8% of obstetric patients are admitted to a traditional intensive care unit, it is estimated that an additional 1–2% of pregnant women receive critical care services outside such units but within a specialized obstetric care setting. Given the low incidence of pregnancies complicated in this fashion, there is limited research to guide recommendations regarding the optimal setting for delivery of care to the critically ill pregnant woman.

Pregnancy constitutes a complex physiological state characterized by alterations of various hematological, cardiopulmonary, renal, gastrointestinal, and endocrine processes. Special consideration by experienced providers must be had for these changes and their impact on vital signs, laboratory values, imaging, and physical examination findings.

Provision of critical care services may be indicated in the management of both obstetric complications and those related to the aggravation of comorbid conditions by the physiological changes of pregnancy. Most commonly, these complications include hypertensive disorders, respiratory failure, hemodynamic instability with or without precedent hemorrhage, thromboembolic events, and infection. These morbid conditions, coupled with a higher incidence of underlying and undiagnosed chronic disease in this population, have resulted in an increasing rate of pregnancy-related mortality in the United States, now estimated at 14.5 deaths per 100,000 live births.

In 1976, the March of Dimes published a report titled Toward Improving the Outcome of Pregnancy in which the concept of regionalized perinatal care was first introduced. As a result, coordinated regional systems for perinatal care were developed based on the stratification of maternal and neonatal complexity of care. In support of this network of regionalized levels of care, the American College of Obstetrics and Gynecology and the American Academy of Pediatrics first called for health care delivery systems to be organized into an integrated, regionalized framework in their publication, Guidelines for Perinatal Care. A generalized framework that addressed availability of critical care services was proposed; however, no recommendations were made for the setting in which critical care should be provided to pregnant women.

Management of the critically ill pregnant woman may take place in a variety of settings, most often in an intensive care unit. Traditionally an intensive care unit may be further demarcated as medical, surgical, cardiac, or neurological to denote the subspecialized care that it provides. Such units may be additionally classified as open or closed. In an open intensive care unit, any physician may admit and manage patients with or without the involvement of a qualified intensive care physician. Alternatively, a closed intensive care unit requires that a critical care physician accept patients for admission and actively manage their care.

Whereas these broad definitions are in place, many hybrid models exist with varying degrees of intensivist involvement in care, the importance of which was demonstrated in a 2002 systematic review in which reductions in both intensive care unit and hospital mortality, as well as both intensive care unit and hospital length of stay, were noted when critical care intensivists were involved in patient care.

Administration of care in the intensive care unit, although comprehensive and well equipped, comes with a significant cost. Intensive care unit health care costs are currently estimated to account for approximately 1% of the US gross domestic product. Naturally, avoiding the overutilization of critical care services has thus been identified as a means of reducing unnecessary health care spending. To reduce health care costs, the Society of Critical Care Medicine has published guidelines to promote the development of intermediate care or step-down units in which higher-level care can be provided for ill patients not meeting traditional requirements for standard intensive care unit admission.

An example of an intermediate care unit can be found at Parkland Hospital (Dallas, TX). Within their system, several labor and delivery suites are dedicated to high-acuity care and staffed by maternal-fetal medicine specialists and nursing staff experienced in critical care obstetrics. Should the clinical scenario dictate, the unit may be expanded to accommodate care from other medical/surgical subspecialists in accordance with guidelines proposed for traditional intensive care units.

Running a devoted obstetric critical unit is an expensive endeavor that needs the support of a high volume of critically ill obstetric patients. Volume of this capacity is rare, even in most tertiary facilities, and therefore an exceptional model rather than a uniformly implementable goal.

When determining the optimal setting of care for the critically ill pregnant woman, multiple variables must be considered. These include proximity to neonatal intensive care, patient stability, staff experience, and the probability of and accommodations for delivery. A multidisciplinary, patient-centered approach should be used, and team members may include intensivists, maternal-fetal medicine specialists, anesthesiologists, neonatologists, cardiologists, pulmonologists, critical care nurses, obstetric nurses, pharmacists, respiratory therapists, providers of spiritual care, social work/case management, and the appropriate subspecialty physicians, depending on the clinical picture.

Improved patient outcomes have been demonstrated with the utilization of this approach, use of protocol-driven care, and physical centralization of patients into the same area of the hospital in which technically skilled subspecialists and nurses can provide high-level care with the appropriate equipment and technology.

With this in mind, we propose the concept of a virtual obstetric intensive care unit. In this model, the term unit no longer refers to a fixed physical location on labor and delivery. Instead, it reflects a mobile, multispecialty team capable of providing individualized, patient-centered care, regardless of setting.

In many hospital systems, a separate obstetric intensive care unit with the necessary equipment and resources is neither practical nor possible. The virtual obstetric intensive care unit delivers care by a core group of providers, which may include maternal-fetal medicine specialists, intensivists, cardiologists, pulmonologists, anesthesiologists, obstetric and critical care nurses, respiratory therapists, and clinical pharmacologists identified to have an interest in this patient population. When a critically ill pregnant patient is admitted, these team members are mobilized to the hospital unit most appropriate, given the nature of the patient’s critical illness. An example of this may include provision of care in a cardiac care unit for the obstetric patient with cardiac disease.

The benefits of this approach cannot be understated. Development of a virtual obstetric intensive care unit team comes with many advantages. For example, an environment of both trust and consistent clinical practice are fostered through the identification and utilization of subspecialists on whose involvement and participation can be unquestionably depended. Having these key members in place allows for participation in preadmission patient care conferences, or prebrief, in which multidisciplinary preparation and coordination of care can occur. This practice facilitates the early identification of the optimal setting of care, identifies additional resources and specialists that may be required, anticipates complications, and coordinates a mutually agreed on plan of care. In a similar fashion, debriefings routinely occur to foster learning and improvement in system practices.

In critical care illnesses in which timing is often of utmost importance, an additional benefit of this approach includes response time. Traditionally, critical care of the obstetric patient has required an intricate, interdisciplinary care model with the potential for delay in care, pending the responsiveness and availability of subspecialist involvement. Within our proposed system, maternal-fetal medicine specialists, intensivists, designated obstetric anesthesiologists, and neonatologists are on site and available to respond to emergencies at any given time. Although this availability may not be practical for the other subspecialists on the team (cardiologists, pulmonologists, etc), constant communication and familiarity with the participating team members allows for rapid involvement should the clinical picture necessitate.

Our model is exemplified by the case of a 39 year old patient with severe pulmonary hypertension and a pregnancy further complicated by Class B diabetes mellitus, class III obesity, advanced maternal age, and asthma. She has a history of requiring a tracheostomy for prolonged mechanical ventilation because of respiratory failure and right-sided heart failure as a complication of her pulmonary disease a couple years before this incident. She was continued on her subcutaneous remodulin pump and oral adcira antenatally and admitted directly to the intensive care unit at 34 weeks 3 days for a multiday induction of labor. Coordination of care was developed as an outpatient between the patient’s perinatologist, pulmonologist, and cardiologist in addition to the anticipated inpatient intensivist, neonatologist, and anesthesiologist.

Once admitted, the transition to intravenous remodulin and advanced monitoring techniques of pulmonary pressures was managed by the pulmonologist and intensivist, whereas her fetal monitoring was overseen by a labor and delivery nurse in the intensive care unit and labor managed by the perinatologist and obstetric residents. Appropriate pain management was managed by the obstetric anesthesiologist, and, based on the agreed plan between the perinatologist and pulmonologist, the patient delivered vaginally in the intensive care unit 2 days after she was admitted with minimal maternal pushing efforts and discharged in stable condition on postpartum day 2.

In its current state, the literature has yet to identify the optimal setting for the provision of critical care to the obstetric patient. Hence, we are left to ponder the risks and benefits of the various units that are available. Although unnerving at times, it is of utmost importance to consider that management of the critically ill pregnant patient may be best suited on a unit other than labor and delivery. With our proposal described in the previous text, we ask for a reconsideration of the obstetric intensive care unit beyond its traditional brick-and-mortar definition.

Whereas our model brings several challenges, including the necessity for transportation of delivery equipment and staff to various hospital units, the concept of a virtual obstetric intensive care unit prioritizes optimization of stabilization of the critically ill pregnant woman while simultaneously adapting, based on location, for the performance of common obstetric procedures (fetal monitoring, delivery, etc). Provision of care in alternative settings, in which care most appropriate for the patient’s illness may be best delivered, eliminates the need to maintain a separate unit for such patients and optimizes resource allocation.