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\begin{document}

\title{``A STUDY OF CLINICAL PROFILE AND FETOMATERNAL OUTCOME OF OBSTETRIC
PATIENTS ADMITTED TO INTENSIVE CARE UNIT'': A Prospective hospital-based
study}



\author[1]{URVASHI MIGLANI}%
\author[1]{ANJALI PATHAK}%
\author[1]{POONAM LAUL}%
\author[1]{SUSHMITA SARANGI}%
\author[2]{SHALINI GANDHI}%
\author[3]{SANJEEV MIGLANI}%
\author[1]{VIJAY KADAM}%
\author[4]{ANISH LAUL}%
\affil[1]{Deen Dayal Upadhyay Hospital}%
\affil[2]{KD Medical College Hospital and Research Centre}%
\affil[3]{Sir Ganga Ram Hospital}%
\affil[4]{Maulana Azad Medical College}%


\vspace{-1em}



  
  \date{May 22, 2024}


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\selectlanguage{english}
\begin{abstract}
Objectives: To study clinical profile of obstetric patients admitted to
intensive care unit and to analyze the relation of demographic factors
like age, parity, literacy level, socio economic status, APACHE 2 score
and level of delay with fetomaternal outcome. Design: Prospective Cross
sectional Observational Setting and Population: Obstetric Admissions to
ICU of tertiary hospital in North India Methods: After admission to ICU
a detailed history, analysis of basic demographic variables along with
level of delay was done. APACHE II score was calculated. These
parameters were correlated with fetomaternal outcome. The Chi-square
test was used to compare categorical variables. The one-way analysis of
variance was used to compare the continuous variables among the strata
with Tukey's post hoc test. Outcome: Prolonged ICU stay, maternal
mortality, perinatal morbidity, perinatal mortality and long hospital
stay. Results: Incidence of obstetric ICU admission was 0.77\%. Mean age
was 26.03years. Most common indication of ICU admission was obstetrical
hemorrhage (37.1\%) followed by hypertensive disorders of pregnancy
(25.8\%). Type 1 delay was the most common followed by type 2 delay.
Mean APACHE II score was 14.77\selectlanguage{ngerman}±6.85. Observed mortality rate (30.6\%)
was found to be higher than predicted mortality rate (25\%). APACHE II
score was significantly high in the presence of level 1 (p=0.003) and
level 2 delay (p=0.0001). Also, it was significantly increased with the
duration of delays. Conclusion: Unbooked and referred cases had high
incidence of ICU admission. Presence of delay was associated with poor
outcome%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


\textbf{INTRODUCTION}

Maternal mortality is a grave injury to a family, community and the
entire nation. It remains unacceptably high with about 830 women dying
from pregnancy or childbirth related complications around the world
every day (WHO). Majority (99\%) of all maternal deaths occur in
developing countries. Between 1990 and 2015, maternal mortality
worldwide dropped by about 44\%from 385 to 216 maternal deaths per
100,000 live births. Despite this progress, the world still fell far
short of the Millennium Development Goals target of a 75\% reduction in
the global MMR by 2015. Between 2016 and 2030, as part of the
sustainable development goals, the target is to reduce the global
maternal mortality ratio to less than 70 per 100000 live
births.\textsuperscript{1}

It is of utmost importance that women at risk must be identified and
managed appropriately. ``Near miss maternal mortality'' or ``Severe
Acute Maternal Morbidity'' (SAMM) is more common than maternal mortality
and is defined as ``a woman who nearly died but survived a complication
that occurred during pregnancy, childbirth or within 42 days after
termination of pregnancy''.\textsuperscript{2} As SAMM cases share many
characteristics with cases of maternal mortality\textsuperscript{3,4},
therefore understanding and managing SAMM (organ dysfunction/failure)
will help to decrease and/or prevent maternal mortality.

To achieve optimal management of women with SAMM, principles of critical
care management need to be applied.\textsuperscript{5} Critically ill
obstetric patients represent an interesting group with unique
characteristics whose management is challenged by the presence of a
fetus, an altered maternal physiology and disease specific to
pregnancy.\textsuperscript{5,6}

The characteristics of these patients admitted to ICU (Intensive care
unit) including the sociodemographic factors are a useful tool to guide
us in better management of these patients in future. Also, the admission
of the obstetric patient to intensive care unit and their outcome is an
indirect indicator of health care status of a country. There are three
main factors that affect the outcome of emergency presentation during
pregnancy. These factors were defined, chronologically, as the lengths
of the delays in: (i) the decision to seek care, (ii) reaching an
appropriate medical facility, and (iii) the receipt of adequate and
appropriate treatment. Socioeconomic and cultural factors, accessibility
of facilities and quality of care may independently affect the lengths
of these three delays\textsuperscript{.6}

Recently the report on ``Strategies toward ending preventable maternal
mortality (EPMM Strategies), a direction-setting report outlining global
targets and strategies for reducing maternal mortality in the
Sustainable Development Goal (SDG) period published by WHO in 2015 also
reiterates the need to address the social, political, and economic
determinants of maternal health and mortality.\textsuperscript{7}

In this regard, the present study was designed to evaluate the factors
responsible for ICU admission of obstetric patients, to analyze their
clinical characteristics, the associated levels of delay \& correlate
these with the fetomaternal outcome.

MATERIAL AND METHODS

This was a prospective observational hospital-based study which was
conducted in 10 Bedded Intensive care unit at Deen Dayal Upadhyay
Hospital, Hari Nagar, Delhi. 124 obstetric patients admitted to
intensive care unit during pregnancy, delivery or within 42 days
postpartum, from July 2017 to December 2018 were included in the study.

After admission to ICU, a detailed history was taken from relatives of
the patient and also extracted from available medical records.

Basic demographic variables (age, parity, literacy level, socio economic
status) of the patient were recorded. Acute Physiology and Chronic
Health Evaluation (APACHE II), of each patient was calculated with in 24
hour of intensive care unit admission.

Clinical data regarding diagnosis at the time of hospital admission,
indication for intensive care unit admission, mode of delivery, length
of ICU stay and hospital stay, interventions if any, treatment
administered and maternal and perinatal outcome was collected.

OUTCOME MEASURE\textbf{:}

\begin{enumerate}
\tightlist
\item
  Maternal survival.
\item
  Length of intensive care unit stay.
\item
  Total length of hospital stays.
\item
  Perinatal morbidity (NICU Admission, Low APGAR Score)
\item
  Perinatal mortality.
\end{enumerate}

The patients were followed up till discharge or death.

\textbf{Statistical analysis:} The results are presented in frequencies,
percentages and mean\selectlanguage{ngerman}±SD. The Chi-square test was used to compare
categorical variables. The one-way analysis of variance was used to
compare the continuous variables among the strata with Tukey's post hoc
test. The p-value\textless{}0.05 was considered significant. All the
analysis was carried out on SPSS 16.0 version (Chicago, Inc., USA).

RESULTS

\begin{itemize}
\tightlist
\item
  The incidence of ICU admission was 0.77\% (124 ICU admission/15982
  total obstetric admission).
\item
  Majority of patients were between 20-30 years (80.6\%). Age was not
  associated with outcome (p\textgreater{}0.05)
\end{itemize}

\begin{itemize}
\tightlist
\item
  53.2\% cases were unbooked and 55.6\% patients were referred from
  peripheral hospitals. All the outcomes were significantly worse in
  referred patients except perinatal morbidity.
\item
  More than one third of the patients were uneducated (39.5\%) followed
  by below high school (30.6\%), high school-intermediate (21.8\%) and
  graduate (8.1\%).The maternal mortality ,perinatal mortality and
  prolonged ICU stay was higher in the uneducated patients .However a
  significant association could be established only with prolonged ICU
  stay (p=0.001) .
\end{itemize}

More than half of the patient belonged to lower class (66.9\%) followed
by upper lower (29\%) and lower middle class (4\%). All the outcomes
were worst in patients of lower socioeconomic strata. However, no
significant (p\textgreater{}0.05) association could be established.

\begin{itemize}
\tightlist
\item
  67.7\% of patients were multiparous. There was no significant
  association found between parity and the outcomes.
\item
  Admission to ICU was more common in postpartum period (88.7\%) as
  compared to antenatal period (11.3\%).
\end{itemize}

\begin{itemize}
\tightlist
\item
  There was no delay present at any level in 25\% cases. 75\% of
  patients had delay at single or multiple levels. Presence of delay was
  significantly associated with prolonged ICU stay(p=0.001), maternal
  mortality(p=0.003) and perinatal mortality (p=0.01). The association
  of outcomes with presence or absence of delay and duration of delays
  is depicted in Table 1and 2 and Figure 1.
\item
  First level delay was present in 34.7\% cases. Second level delay was
  present in 50\% cases and it was more than 4 hours in 16.9\% patients.
  Third level delay was present in 9.7\% patients.
\item
  Presence of 1\textsuperscript{st} and 2\textsuperscript{nd} level
  delay and their increasing duration was significantly associated with
  prolonged ICU stay (p=0.002) (p=0.01), maternal mortality
  (p=0.001,0.004) and perinatal mortality (p=0.002.0.005).
\item
  APACHE II score of 5-9 was most common (28.2\%) and APACHE II score of
  \textless{}4 was present only in 0.8\% cases. Mean APACHE II score was
  14.77±6.85. Table 3-4 depicts the comparison of APACHE II score with
  delays and its association with outcomes.
\item
  The post hoc test revealed that APACHE II score was significantly
  (p\textless{}0.05) high in patients having delay of \selectlanguage{english}[?]24 hrs. APACHE II
  score was significantly higher in the presence of
  2\textsuperscript{nd} level delay and it significantly increased as
  the duration of delay increased (p=0.0001).
\item
  High APACHE II score was significantly associated with length of ICU
  stay(p=0.001), maternal mortality(p=0.001), perinatal
  mortality(p=0.001) and length of hospital stay(p=0.008).
\end{itemize}

Most common indication for ICU admission was obstetrical hemorrhage
(37.1 \%) followed by hypertensive disorders of pregnancy (25.8\%).

\begin{itemize}
\tightlist
\item
  Blood and blood product transfusion (83.87\%), mechanical ventilation
  (66.12\%) and the use of inotropic support (47.58\%) were the major
  interventions done. Surgical intervention was done in 25\% cases in
  association with other major interventions. Maternal mortality was
  decreased in patients who had timely surgical intervention though no
  significant association was found.
\item
  About half of patients had ICU stay of \textgreater{}48 hours
  (51.6\%). Mean length of ICU stay was 3.18+-2.40.
\item
  Most common mode of delivery was cesarean section (58.1\%).
\item
  38(30.6\%) patients could not be saved. .
\end{itemize}

\begin{itemize}
\tightlist
\item
  30(29.12\%) neonates had low Apgar score and needed NICU admission.
  13(12.62\%) patients had intrauterine death of the fetus and another
  eight (7.76\%) had early neonatal death in NICU. Five (4.85\%)
  patients had stillbirth. Perinatal morbidity was seen in 29.12\%
  subjects and perinatal mortality rate was 31.06\%.
\item
  The length of hospital stay was \selectlanguage{english}[?]7 days in 58.9\% patients. Mean
  length was 7.09+-3.49 days.
\end{itemize}

DISCUSSION

In the present study, which was done over a period of 18 months,
incidence of ICU admission was 0.77\% which is comparable to the results
of Begum and Padmavat\textsuperscript{8.} However, Ozumba et
al\textsuperscript{9} in 2018 in their study found a higher incidence of
1.7\% probably due to different admission criteria or due to a large
catchment area.

It is obvious that booked status of the patients is associated with
better outcome as is also reflected in the present study. In contrast to
the present study, Joseph et al\textsuperscript{10} found increased ICU
admission among booked cases. Probably this was due to the referral of
these booked cases in complicated stages.\textsuperscript{10}

In the present study, referred cases comprised the major part (55.6\%)
of the ICU admissions and their outcomes were significantly worse than
the direct admissions.

This may be attributed to the fact that the patients who are referred
are generally high risk or in critical condition as they could not be
managed at the periphery hospital. If this factor is also associated
with delay in the transport then the outcome of the referred patients
further deteriorates.

Maternal health behavior varies with socioeconomic status and it is also
affected by education level. Low socioeconomic status is usually
associated with low education status, poor health seeking behavior,
unintended and unplanned pregnancy, inadequate antenatal visits, lack of
knowledge regarding available health facility benefits and their
cultural stigma. These issues are clubbed with logistic problems like
inaccessibility to health care and form a vicious circle in this strata.
The same is clearly reflected in the present study where patients of
lower socioeconomic strata had worse outcomes. Concordant results were
found by Panda et al, 64.13\% of the patients admitted to ICU in their
study belonged to lower socioeconomic status.\textsuperscript{11}

To improve the medical care in obstetric emergency, time is a crucial
factor in life threatening conditions. Delay at any level worsens the
prognosis of patients because life-threatening conditions may develop
without any warning and require prompt treatment.

In the present study, first level delay was present in 65.4\% cases
admitted in ICU.

Similar to present study, Ghumare et al found that 27\% delays were at
the first level. In 19\% cases mixed delay was
present.\textsuperscript{12} Kumari K et al also observed that first
delay was present in 81.8\% of cases and level 1 delay was the most
common delay found.\textsuperscript{13}

In the present study most, common delay found was the delay at level 1,
which is the delay in deciding to seek care. It was mainly due to
socioeconomic and cultural characteristics. They were also not educated
about the warning sign of any complication by the front-line provider
(ASHA) in some cases. An accredited social health activist
(\textbf{ASHA} ) is a community health worker instituted by the
government of India's Ministry of Health and Family Welfare (MOHFW) as a
part of the National Rural Health Mission (NRHM). Their antenatal visits
were limited to nutritional supplements and a general check up at the
ground level, which might have missed preexisting medical and also
obstetrical complications like malpresentation and cephalopelvic
disproportion.

The hesitation to seek health care was compounded by cultural taboos and
gender bias which further increased the duration of delay. The outcomes
worsened significantly with increasing duration of level 1 delay. This
again emphasizes the importance of intervention in the first few golden
hours.

Second level delay is the delay in reaching the appropriate health care
facility and in the present study, it was present in 50\% cases.

Similar to our study Kumari K, et al also found that contribution of
second level delay was present in 54.5\% cases.\textsuperscript{13}

Second level delay of \textless{}4hr is present in 33.1\% which was
mainly due to geographic distribution of referral center, cost of
transportation and unavailability of transport. Second level delay of
\textgreater{}4hr was found in 16.9\% and was associated with delayed
decision of referral by peripheral hospital. Main reasons of referral
were non availability of NICU, blood bank, ICU facility and facility of
cesarean section (lack of functional operation theatre or trained
personnel). This results in lack of active intervention in the first few
golden hours thus worsening the condition of the patients. Increased
duration of level 2 delay was significantly associated with worse
outcome.

Third level delay was present in 9.7\% cases in the present study.
Presence of third level delay in our tertiary care hospital could
probably be explained by disproportionate infrastructural facility in
comparison to the patient load. (only single functional emergency
operation theatre, no availability of dedicated obstetric ICU facility,
a smaller number of beds available in general ICU).

In contrast to present study, Ghumare et al found that third level delay
was present in 21\% cases\textsuperscript{12} and Kumari K et al also
found third level delay in 45.5\% cases.\textsuperscript{13} It was
higher than the present study which may have been contributed by
superadded effect of inadequate specialist services and inadequate blood
component transfusion facility.\textsuperscript{12,13}

Presence of any delay was significantly associated with worse outcomes.
In a multicentric cross sectional study done by Pacagnella et al, any
type of delay was observed in 53.8\% of subjects and there was positive
association between the presence of any delay and severity of maternal
outcome.\textsuperscript{14}Kumari K et al observed that most of the
deaths were associated with multiple levels of
delay.\textsuperscript{13}

It was observed that the most common indication for ICU admission was
obstetrical hemorrhage (37.1\%), followed by hypertensive disorder of
pregnancy (25.8\%). In concordance with the present study, Sodhi et
al\textsuperscript{15} and Joseph et al\textsuperscript{10} had similar
results but Ozumba et al \textsuperscript{9} found that rupture uterus
was the most common indication of ICU admission. Uterine rupture has
been remarkably eliminated in most parts of the world but probably low
socioeconomic status and poor health-seeking behavior of the subjects in
the study (South Ease Nigeria) contributed to this
finding.\textsuperscript{9}

Mean APACHE II score was 14.77+-6.85, According to this predicted
mortality was 25\% but observed mortality was found to be higher i.e.
30.6\%. \%. This was probably due to the infrastructure and logistic
constraints of our study area, which is a government organization. There
was significant (p\textless{}0.01) difference in APACHE II score in the
presence of 1\textsuperscript{st} and 2\textsuperscript{nd} level delay.
APACHE II score was significantly (p\textless{}0.05) high in patients
having delay of \selectlanguage{english}[?]24 hrs. Also, APACHE II score was significantly higher
in the presence of 2\textsuperscript{nd} level delay and it was
significantly increased as the duration of delay increased (p=0.0001).

In contrast to the present study, Sodhi et al found observed mortality
rate (OMR) to be too low as compared to the predicted mortality of
24\%.\textsuperscript{15} This variability can probably be explained as
this study was conducted in a private hospital having most of the modern
equipment. Our study was conducted in a government setup having limited
and conventional resources.

\textbf{Strengths:} It is one of the few studies conducted in a tertiary
center of northern India correlating all three levels of delay to
fetomaternal outcome thus allowing a genuine root cause analysis at the
ground level.

\textbf{Limitations:}

Level of delay was estimated from the available referral documents or by
patients recall method which may have led to inaccurate estimation of
level of delay.

\textbf{Recommendation and Conclusion}

\begin{itemize}
\tightlist
\item
  The results clearly reflect that presence of delay and its increasing
  duration play a vital role in increasing maternal and perinatal
  mortality. So concrete steps should be taken to address these issues
  in a way that they are socially acceptable also. This implies that
  social and health initiatives taken to decrease duration of level 1
  delay will go a long way in decreasing maternal morbidity and
  mortality.
\item
  It was also evident by results that patients who had timely surgical
  intervention had less maternal and perinatal mortality. So, at
  tertiary care level, improvements should be done to bridge the gap
  between infrastructural facilities and the growing demands by building
  dedicated obstetric ICU, recruiting more trained staff and developing
  obstetric corridor in every tertiary care hospital to reduce the
  delay. Facilitating triage and fast tracking of the patients should be
  done for better outcome.
\end{itemize}

\textbf{Acknowledgements:} Dr Gargi Chowdhary DNB student Deen Dayal
Upadhyay Hospital, Hari Nagar, New Delhi, India

\textbf{Disclosure of interests} : None

\textbf{Contribution of Authors}

\textbf{Dr Urvashi Miglani} conceptualized the study and planned its
execution. Supervised the clinical management and the formation and
editing of the manuscript.

\textbf{Dr Anjali} Collected and compiled data of eligible subjects

\textbf{Dr Poonam Laul} Supervised the clinical management and the
formation and editing of the manuscript.

\textbf{Dr Sushmita Sarangi} Supervised the clinical management and the
formation and editing of the manuscript.

\textbf{Dr Shalini Gandhi} Supervised the clinical management and the
formation and editing of the manuscript.

\textbf{Dr Sanjeev Miglani} Supervised the clinical management and the
formation and editing of the manuscript.

\textbf{Dr Vijay Kadam} Supervised the clinical management and the
formation and editing of the manuscript.

\textbf{Dr Anish Laul} Compiled, edited and formatted the data

Ethics Approval : The procedures of the study received ethics approval
from the relevant institutional ethics committee of Deen Dayal Upadhyay
Hospital.Date of approval is 14/08/2017. There are no associated
reference numbers however for communication we use 14082017.

\textbf{Funding} : None

\emph{REFERENCES}

\begin{enumerate}
\tightlist
\item
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\item
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\item
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\item
  Begum PR, Padmavati P. Critical Care in Obstetrics: A One Year
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\item
  Ozumba BC, Ajah LO, Obi VO, Umeh UA, Enebe JT, Obioha KC. Pattern and
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\end{enumerate}

\textbf{Table /Figure Caption List}

\begin{itemize}
\tightlist
\item
  \textbf{Table-1: Association of outcomes with presence or absence of
  delay and single or multiple delay}
\item
  \textbf{Table-2: Association of outcomes with different level of delay
  and their duration}
\item
  \textbf{Table-3: Comparison of APACHE II score with delay}
\item
  \textbf{Table-4: Association of outcomes with APACHE II score}
\item
  \textbf{Fig-1: Association of outcomes with presence or absence of
  delay and single or multiple delay.Table-1: Association of outcomes
  with presence or absence of delay and single or multiple delay}
\end{itemize}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
\textbf{Delay} & \textbf{No. women} & \textbf{Length of ICU
stay\textgreater{}48 hrs.} & \textbf{Length of ICU stay\textgreater{}48
hrs.} & \textbf{Maternal mortality} & \textbf{Maternal mortality} &
\textbf{Perinatal morbidity} & \textbf{Perinatal morbidity} &
\textbf{Perinatal mortality} & \textbf{Perinatal mortality} &
\textbf{Hospital stay \textgreater{}7 days} & \textbf{Hospital stay
\textgreater{}7 days}\tabularnewline
\midrule
\endhead
& & \textbf{No.} & \textbf{\%} & \textbf{No.} & \textbf{\%} &
\textbf{No.} & \textbf{\%} & \textbf{No.} & \textbf{\%} & \textbf{No.} &
\textbf{\%}\tabularnewline
\textbf{Any of 3 delay} & & & & & & & & & & &\tabularnewline
Yes & 93 & 56 & 60.2 & 35 & 37.6 & 20 & 21.5 & 29 & 31.2 & 39 &
41.9\tabularnewline
No & 31 & 8 & 25.8 & 3 & 9.7 & 10 & 32.3 & 3 & 9.7 & 12 &
38.7\tabularnewline
p-value\textsuperscript{1} & & 0.001* & 0.001* & 0.003* & 0.003* & 0.22
& 0.22 & 0.01* & 0.01* & 0.75 & 0.75\tabularnewline
\textbf{Type of delay} & & & & & & & & & & &\tabularnewline
Single & 36 & 20 & 55.6 & 11 & 30.6 & 7 & 19.4 & 7 & 19.4 & 13 &
36.1\tabularnewline
Multiple & 57 & 36 & 63.2 & 24 & 42.1 & 13 & 22.8 & 22 & 38.6 & 26 &
45.6\tabularnewline
p-value\textsuperscript{1} & & 0.46 & 0.46 & 0.26 & 0.26 & 0.70 & 0.70 &
0.05 & 0.05 & 0.36 & 0.36\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{1}Chi-square test, *Significant

\textbf{Table-2: Association of outcomes with different level of delay
and their duration}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
\textbf{Delay} & \textbf{No. women} & \textbf{Length of ICU
stay\textgreater{}48 hrs.} & \textbf{Length of ICU stay\textgreater{}48
hrs.} & \textbf{Maternal mortality} & \textbf{Maternal mortality} &
\textbf{Perinatal morbidity} & \textbf{Perinatal morbidity} &
\textbf{Perinatal mortality} & \textbf{Perinatal mortality} &
\textbf{Hospital stay \textgreater{}7 days} & \textbf{Hospital stay
\textgreater{}7 days}\tabularnewline
\midrule
\endhead
& & \textbf{No.} & \textbf{\%} & \textbf{No.} & \textbf{\%} &
\textbf{No.} & \textbf{\%} & \textbf{No.} & \textbf{\%} & \textbf{No.} &
\textbf{\%}\tabularnewline
\textbf{1\textsuperscript{st} level} & & & & & & & & & &
&\tabularnewline
No delay & 43 & 14 & 32.6 & 6 & 14.0 & 12 & 27.9 & 6 & 14.0 & 18 &
41.9\tabularnewline
\textless{}24 hrs. delay & 39 & 20 & 51.3 & 10 & 25.6 & 7 & 17.9 & 7 &
17.9 & 14 & 35.9\tabularnewline
[?]24 hrs. delay & 42 & 30 & 71.4 & 22 & 52.4 & 11 & 26.2 & 19 & 45.2 & 19
& 45.2\tabularnewline
p-value\textsuperscript{1} & & 0.002* & 0.002* & 0.001* & 0.001* & 0.53
& 0.53 & 0.002* & 0.002* & 0.69 & 0.69\tabularnewline
\textbf{2\textsuperscript{nd} level} & & & & & & & & & &
&\tabularnewline
No delay & 62 & 24 & 38.7 & 11 & 17.7 & 16 & 25.8 & 8 & 12.9 & 21 &
33.9\tabularnewline
[?]4 hrs. delay & 41 & 25 & 61.0 & 16 & 39.0 & 10 & 24.4 & 16 & 39.0 & 19
& 46.3\tabularnewline
\textgreater{}4 hrs. delay & 21 & 15 & 71.4 & 11 & 52.4 & 4 & 19.0 & 8 &
38.1 & 11 & 52.4\tabularnewline
p-value\textsuperscript{1} & & 0.01* & 0.01* & 0.004* & 0.004* & 0.82 &
0.82 & 0.005* & 0.005* & 0.23 & 0.23\tabularnewline
\textbf{3\textsuperscript{rd} level delay} & & & & & & & & & &
&\tabularnewline
No delay & 112 & 59 & 52.7 & 36 & 32.1 & 28 & 25.0 & 28 & 25.0 & 45 &
40.2\tabularnewline
\textless{}6hrs delay & 12 & 5 & 41.7 & 2 & 16.7 & 2 & 16.7 & 4 & 33.3 &
6 & 50.0\tabularnewline
\textgreater{}6hrs delay & 0 & 0 & 0 & 0 & 0 & 0 & 0 & 0 & 0 & 0 &
0\tabularnewline
p-value\textsuperscript{1} & & 0.46 & 0.46 & 0.26 & 0.26 & 0.52 & 0.52 &
0.53 & 0.53 & 0.51 & 0.51\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{1}Chi-square test, *Significant

\textbf{Table-3: Comparison of APACHE II score with delay}\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Delay} & \textbf{APACHE II score} &
\textbf{p-value\textsuperscript{1}}\tabularnewline
\midrule
\endhead
\textbf{1\textsuperscript{st} level} & &\tabularnewline
No delay & 11.95\selectlanguage{ngerman}±5.66\textsuperscript{a, b} & 0.003*\tabularnewline
\textless{}24 hrs. delay & 15.77\selectlanguage{ngerman}±7.36 \textsuperscript{a}
&\tabularnewline
[?]24 hrs. delay & 16.74\selectlanguage{ngerman}±6.67\textsuperscript{b} &\tabularnewline
\textbf{2\textsuperscript{nd} level} & &\tabularnewline
No delay & 12.60\selectlanguage{ngerman}±6.33 \textsuperscript{a,b} & 0.0001*\tabularnewline
[?]4 hrs. delay & 15.85\selectlanguage{ngerman}±6.21 \textsuperscript{a} &\tabularnewline
\textgreater{}4 hrs. delay & 19.10\selectlanguage{ngerman}±7.25 \textsuperscript{b}
&\tabularnewline
\textbf{3\textsuperscript{rd} level delay} & &\tabularnewline
No delay & 14.86\selectlanguage{ngerman}±7.00 & 0.68\tabularnewline
\textless{}6hrs delay & 14.00\selectlanguage{ngerman}±5.47 &\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{1}ANOVA test,
*Significant,\textsuperscript{a,b}p\textless{}0.05 (Post hoc tests)

\textbf{Table-4: Association of outcomes with APACHE II score}\selectlanguage{english}
\begin{longtable}[]{@{}llllllllllll@{}}
\toprule
\textbf{Interventions} & \textbf{No. women} & \textbf{Length of ICU
stay\textgreater{}48 hrs.} & \textbf{Length of ICU stay\textgreater{}48
hrs.} & \textbf{Maternal mortality} & \textbf{Maternal mortality} &
\textbf{Perinatal morbidity} & \textbf{Perinatal morbidity} &
\textbf{Perinatal mortality} & \textbf{Perinatal mortality} &
\textbf{Hospital stay \textgreater{}7 days} & \textbf{Hospital stay
\textgreater{}7 days}\tabularnewline
\midrule
\endhead
& & \textbf{No.} & \textbf{\%} & \textbf{No.} & \textbf{\%} &
\textbf{No.} & \textbf{\%} & \textbf{No.} & \textbf{\%} & \textbf{No.} &
\textbf{\%}\tabularnewline
\textless{}4 & 1 & 0 & 0.0 & 0 & 0.0 & 0 & 0.0 & 0 & 0.0 & 0 &
0.0\tabularnewline
5-9 & 35 & 5 & 14.3 & 3 & 8.6 & 5 & 14.3 & 5 & 14.3 & 9 &
25.7\tabularnewline
10-14 & 34 & 22 & 64.7 & 2 & 5.9 & 15 & 44.1 & 3 & 8.8 & 22 &
64.7\tabularnewline
15-19 & 25 & 19 & 76.0 & 7 & 28.0 & 4 & 16.0 & 8 & 32.0 & 12 &
48.0\tabularnewline
20-24 & 18 & 11 & 61.1 & 16 & 88.9 & 4 & 22.2 & 12 & 66.7 & 4 &
22.2\tabularnewline
25-29 & 5 & 4 & 80.0 & 4 & 80.0 & 1 & 20.0 & 1 & 20.0 & 3 &
60.0\tabularnewline
30-34 & 6 & 3 & 50.0 & 6 & 100.0 & 1 & 16.7 & 3 & 50.0 & 1 &
16.7\tabularnewline
p-value\textsuperscript{1} & & 0.001* & 0.001* & 0.001* & 0.001* & 0.09
& 0.09 & 0.001* & 0.001* & 0.008* & 0.008*\tabularnewline
\bottomrule
\end{longtable}

\textsuperscript{1}Chi-square test, *Significant

\textbf{Hosted file}

\verb`Figures.doc`  available at \url{https://authorea.com/users/324795/articles/452899--a-study-of-clinical-profile-and-fetomaternal-outcome-of-obstetric-patients-admitted-to-intensive-care-unit-a-prospective-hospital-based-study}

\selectlanguage{english}
\FloatBarrier
\end{document}

