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Severe maternal morbidity requires regionalistion of obstetric critical care

Severe pre-eclampsia represents, even in the developed world, one of the main causes of maternal mortality and morbidity. Its clinical management is focused on preventing lifelong sequelae for mother and child. How hospital care should be optimally organised to achieve this is still unknown. High hospital volumes of combined low-, mediumand high-risk obstetric populations may not by definition result in better maternal and perinatal outcomes. Increased exposure to critically ill pregnant women, however, is likely to result in increased experience and expertise of individual specialists and centres resulting in better outcomes. This has been shown for many medical disciplines (Nguyen et al. Chest 2015;148:79–92). The study by Ananth et al. published in this issue of the Journal provides important clues suggesting that this is true for women suffering from severe pre-eclampsia as well. Data of women with an ICD-9 indication of severe pre-eclampsia and eclampsia, and the rates of serious maternal complications were retrospectively analysed in relation to patient, physician and hospital characteristics in the USA Perspective database covering over 28 million deliveries. They report that maternal mortality rates in relation to severe pre-eclampsia were lower in highvolume hospitals and the risk of complications was increased in the case of low compared with high, severe preeclampsia rates. This supports, in our opinion, the rationale of regionalisation of certain perinatal services as is established and acknowledged by the professional societies in the Netherlands for fetal complications like risk of imminent premature delivery (<32 weeks of gestation), severe fetal growth restriction and severe congenital birth defects. However, for severe maternal morbidity, similar to many other countries, no clear Dutch guidelines regarding centralisation of care are in place. A woman with severe preeclampsia, irrespective of gestational age, should be regarded as a critically ill obstetric patient, with a challenging complex heterogeneous multi-organ disease, requiring the best possible expertise. In our hospital, obstetric critical care, which does not by definition imply transfer to an ICU, encompasses a joint multidisciplinary approach with direct availability of a maternal-fetal medicine specialist, an anaesthesiologist and an internal medicine specialist. Along with the implementation of standardised treatment protocols, as for temporising treatment, this can optimise patient safety and contribute to a decrease of substandard hospital care (Schutte et al. BJOG 2008;115:732–6). In view of the often compromised fetal condition, a neonatologist should already be involved prenatally as a fellow treating physician of the unborn child. Although one may question the need for similar availability of senior personal inand outside office hours for the general obstetric population (Myers & Johnstone, PLOS Med 2016, April 19) we strongly feel that, at least for critically ill obstetric patients, such multidisciplinary teams in specialised regional centres should be onsite 24 hours per day, 7 days a week. Because of the risks of interhospital transfer, early consultation and referral is warranted. Obstetric critical care increasingly asks for an anticipating instead of a ‘reacting to emergency’ management style.