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  1. Home
  2. Books
  3. Maternal Critical Care
  • Cited by 3
Publisher:
Cambridge University Press
Online publication date:
July 2013
Print publication year:
2013
Online ISBN:
9781139088084
DOI:
https://doi.org/10.1017/CBO9781139088084
Subjects:
Anesthesia, Intensive Care, Pain Management, Obstetrics and Gynecology, Reproductive Medicine, Medicine
Information

Book description

If you are an obstetrician whose patient has been admitted to ICU, you need to know how she is managed there. If you are an intensivist, you need to adapt to changes in physiology, alter techniques for the pregnant patient and keep the fetus from harm. This book addresses the challenges of managing critically ill obstetric patients by providing a truly multidisciplinary perspective. Almost every chapter is co-authored by both an intensivist/anesthesiologist and an obstetrician/maternal-fetal medicine expert to ensure that the clinical guidance reflects best practice in both specialties. Topics range from the purely medical to the organizational and the sociocultural, and each chapter is enhanced with color images, tables and algorithms. Written and edited by leading experts in anesthesiology, critical care medicine, maternal-fetal medicine, and obstetrics and gynecology, this is an important resource for anyone who deals with critically ill pregnant or postpartum patients.

Reviews

“…Provides a wide-ranging approach to factors complicating pregnancy. A focused book such as this is uncommon and I recommend it be housed in units that manage complications of pregnancy.”

- Doody's Review Service

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Contents

Page 2 of 2

Contents
  • Chapter 21 - Monitoring the critically ill gravida
    pp 217-229
  • View abstract

    Summary

    Maternal collapse includes a variety of acute life threatening events involving maternal cardiorespiratory or central nervous systems. Maternal resuscitation follows standard Advanced Cardiac Life Support (ACLS) guidelines with a limited number of pregnancy-specific alterations. The primary variation from non-pregnancy guidelines is the requirement to displace the gravid uterus laterally to increase cardiac output. Cardiac output during closed chest massage in cardiopulmonary resuscitation (CPR) is approximately 30% of normal. Traditionally, displacement of the gravid uterus has been done by maternal tilt from 15° to 30° to facilitate increased venous return and cardiac output. Immediate awareness of the need to perform perimortem cesarean delivery 4 minutes after persistent cardiopulmonary arrest and the availability of an emergency kit for surgery can result in faster delivery of the baby, faster return of the maternal circulation, and better clinical outcomes for both mother and child.
  • Chapter 22 - Imaging issues in maternal critical care
    pp 230-246
  • View abstract

    Summary

    The well-being of the fetus is strongly influenced by the status of the critically ill mother. Understanding basic principles of placental gas exchange is important when caring a pregnant patient in the intensive care unit (ICU). Aside from the few cases in which delivery is the preferred therapy, managing a pregnant patient in ICU should focus primarily on maternal well-being and only secondarily on the effects of interventions on the fetus. If preterm delivery is anticipated, administration of antenatal corticosteroids to the mother will decrease rates of common complications of prematurity of the newborn. The usual rule is to optimize the maternal medical condition and allow the fetus and placenta to take care of themselves. Certain fetal conditions such as severe intrauterine growth restriction may also provide a reason to separate the fetus from the mother.
  • Section 4 - The pregnant patient with coexisting disease
    pp 247-402
  • View abstract

    Summary

    Pregnancy is a state of flux with the placental-fetal unit undergoing constant changes that affect both pharmacodynamics and pharmacokinetics of many drugs. Pregnancy affects hepatic biotransformation in an enzyme-specific manner. Increased cardiac output, tissue flow, and vasodilatation during pregnancy may enhance absorption of drugs administered subcutaneously, intramuscularly, epidurally, transvaginally, and via mucous membranes. The treatment of drug overdose in pregnancy presents a unique challenge because of changes in the pharmacodynamics and pharmacokinetics of drugs during gravid state. The most frequently used agents for self-inflicted poisoning during pregnancy are analgesics, antipyretics, and antirheumatics. The treatment of acetaminophen overdose is aimed at decreasing the absorption of acetaminophen and protecting the hepatocytes from the toxic effects of the highly reactive metabolites. The therapeutic approach in carbon monoxide poisoning is to deliver high-dose oxygen to displace carbon monoxide from the hemoglobin molecule.
  • Chapter 24 - Respiratory disease
    pp 267-276
  • View abstract

    Summary

    Obstetricians most commonly encounter shock in the form of hemorrhage, but it is important to realize that shock can be classified in several types, and correction of the physiological derangement can correct the dysoxia at the tissue level before shock becomes irreversible. Etiologically shock is classified into the following types: hypovolemic shock (i.e. hemorrhage in coagulopathy), cardiogenic shock (myocardial dysfunction in the systemic inflammatory response syndrome and with toxins associated with septicemia), distributive shock (through activation of the systemic inflammatory response system), and obstructive shock (septic embolism). Therapy for cardiogenic shock requires restoration of adequate coronary perfusion in order to minimize further myocardial depression and necrosis. Anaphylactic and anaphylactoid reactions are clinically indistinguishable. The goals of management of anaphylaxis are interrupting contact with the responsible drug, modulating the effects of the released mediators, and preventing further mediator production and release.
  • Chapter 25 - Thromboembolism
    pp 277-284
  • View abstract

    Summary

    Brainstem death in the pregnant patient is a tragic but fortunately rare event that involves complex medical, ethical, and legal issues. Prolongation of maternal somatic function constitutes experimental care where the physician must consult case reports and reviews and extrapolate from experiences in sustaining organ function after brain death to facilitate organ donation. Nutritional support should be initiated early and preferably via the enteral route. Special attention should be paid to the management of gastroesophageal reflux in the context of pregnancy and of the reduced motility of the gastrointestinal tract in brain-dead patients. Three main sources of sepsis may complicate prolonged somatic support, including ventilator associated pneumonia, urinary tract infections from dwelling catheters, and infection of intravascular catheters. The goal of extended maternal somatic support is to attempt to facilitate fetal maturation in order to deliver a healthy, viable infant.
  • Chapter 26 - Neurological disease and neurological catastrophes
    pp 285-300
  • View abstract

    Summary

    The problems in the pregnant woman are universal: physiological changes during pregnancy lead to a reduction in time from onset of apnea to oxygen desaturation and to an increased likelihood of regurgitation from a full stomach. An antenatal visit allows the airway to be evaluated and discussion to be held with the parturient about the use of invasive monitors, such as invasive arterial blood pressure monitoring and the use of continuous positive airway pressure devices during and after labor and delivery. A recent development in the management of the airway in the obese patient is the use of the so-called ramped position. Perhaps the main factor responsible for a higher incidence of difficulties in airway management is that general anesthesia is generally reserved for extreme obstetric emergencies. The use of supraglottic airways in the management of the obstetric airway is undergoing evaluation.
  • Chapter 28 - Cancer
    pp 313-321
  • View abstract

    Summary

    This chapter deals with issues related to mechanical ventilation in general and considers those relevant to the obstetric patient in particular. The most common modes of mechanical ventilation are: volume-controlled continuous mandatory ventilation (VC-CMV), pressure-controlled continuous mandatory ventilation (PC-CMV), intermittent mandatory ventilation (IMV), continuous mandatory ventilation (CMV), airway pressure release ventilation (APRV) and positive end-expiratory pressure (PEEP). All patients receiving mechanical ventilation should be monitored by pulse oximetry. Non-invasive ventilation can be delivered nasally or by face mask, using either a conventional mechanical ventilator or a machine designed specifically for this purpose. The 2009 H1N1 influenza pandemic and the particular susceptibility of pregnancy in such circumstances reinforce the need to appraise the rationale for mechanical ventilation in such patients. Finally, APRV as a ventilatory paradigm, in particular, may be particularly useful in the pregnant patient with pneumonits, acute lung injury, or acute respiratory distress syndrome (ARDS).
  • Chapter 29 - Endocrine disorders
    pp 322-334
  • View abstract

    Summary

    Analgesia and sedation are frequently used in intensive care unit (ICU) patients. Appropriate analgesia is of great importance in ICU patients. Fentanyl is the most frequently used drug for this purpose but can lead to a substantial overhang after prolonged administration. Remifentanil is a promising alternative with a stable context-sensitive half-life. Agitation is the most frequent reason to sedate the patient, and the drug of choice is usually midazolam. There is a growing trend to use propofol in ICU sedation. Propofol has the advantage of less accumulation and, therefore, has a more stable context-sensitive half-life. Although propofol seems to be an almost ideal sedative, there is concern about the propofol infusion syndrome. Volatile anesthetics are frequently used for anesthesia in pregnant patients. More recently, volatile anesthetics have also been used for sedation in the ICU.
  • Chapter 30 - Acute abdomen
    pp 335-345
  • View abstract

    Summary

    This chapter outlines the typical nutritional needs for a pregnant woman, reviews some of the unique issues of administering adequate nutrition for the benefit of the maternal-fetal dyad, and provides an overview of some of the more common clinical situations. Inadequate maternal nutrition may be associated with a low infant birth weight and is significantly correlated with later development of adult diseases such as cardiovascular disease, stroke, obesity and type 2 diabetes mellitus, even when adjusting for lifestyle factors. The initial focus for nutritional supplementation should be to optimize the micronutrients, avoid hypo- or hyperglycemia, and maintain an appropriate fluid balance. As the situation stabilizes, then efforts towards adequate macronutrients and calories can be undertaken, while avoiding refeeding syndrome, avoiding overfeeding, and balancing the iatrogenic complications of aggressive enteral nutrition (EN) or parenteral nutrition (PN) against the risks of underfeeding.
  • Chapter 31 - Sepsis
    pp 346-355
  • View abstract

    Summary

    Intensivists, physicians specially trained in critical care medicine, and other members of the ICU care team may have in-depth knowledge of monitors not available to the practitioner, who does not use them on a daily basis. The most commonly encountered non-invasive monitors are electrocardiography (ECG), pulse oximetry, blood pressure measurement by manometry, urine output, pulse oximetry and end-tidal carbon dioxide monitoring. Central venous pressure (CVP) is measured by placing a catheter into or near the right atrium or vena cava. Central venous pressure can be measured via a small microcatheter inserted into the frontal white matter. The physiological basis for intracranial pressure (ICP) monitoring is based on two separate but related mechanisms that contribute to cerebral ischemia. Fetal monitoring, in practice, is generally limited to the generation and interpretation of fetal heart rate patterns obtained through Doppler ultrasound.
  • Chapter 32 - Trauma
    pp 356-366
  • View abstract

    Summary

    This chapter describes various imaging modalities and safety concerns associated with a person when used during pregnancy or in the immediate postpartum period. The radiation effects to the fetus are categorized into deterministic and stochastic effects. Plain radiography and fluoroscopy, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine scan are the most commonly used imaging modalities during pregnancy. Following intravenous administration, very low level of iodinated or gadolinium-based contrast agents is excreted in breast milk and ingested by the infant. The advantages of the nuclear medicine scan are lower radiation dose to the maternal breast and the avoidance of intravenous iodinated contrast. Trauma is a major cause of maternal and fetal mortality, and imaging choices in this setting should be prioritized for fast and accurate diagnosis. CT evaluation is strongly recommended in patients with an acute abdomen who suffered abdominal trauma.
  • Chapter 33 - Malaria, bites, and stings during pregnancy
    pp 367-378
  • View abstract

    Summary

    The spectrum of cardiovascular disease presenting during pregnancy is evolving and differs according to geographical conditions. Several risk scoring systems have been developed and represent easily identifiable hemodynamic predictors for maternal and/or fetal risk. If heart failure occurs, management should be as for non-pregnant patients, with prescription of diuretics to relieve congestion, and beta-blockers for afterload reduction and modulation of sympathomimetic tone. Mitral stenosis accounts for most of the morbidity and mortality of rheumatic disease during pregnancy and is mostly encountered in the developing world. There is a broad spectrum of congenital abnormalities and therefore a wide range of risk associated with pregnancy, from a risk similar to the normal population (e.g. mild pulmonary stenosis) up to very high-risk conditions such as the Eisenmenger syndrome. Acute coronary syndromes during pregnancy are rare events with an estimated prevalence of 3-6 per 100,000 deliveries.
  • Chapter 35 - Autoimmune disease in pregnancy
    pp 391-402
  • View abstract

    Summary

    Various physiological changes occur as a result of the pregnant state, affecting patients with pre-existing lung disease and affecting the assessment and management of the patient with respiratory failure. Asthma, pulmonary infections, tuberculosis are some of the conditions not specific to pregnancy. Acute severe asthma in pregnancy may be treated as in the non-pregnant patient with intravenous beta- 2-adrenergic agonists, intravenous theophylline, intravenous magnesium sulfate and steroids. Standard drug therapy, namely with isoniazid, rifampin, and ethambutol has an acceptable safety profile in pregnancy and is recommended for pregnant women by the US Centers for Disease Control and Prevention and the American Thoracic Society. Acute respiratory distress syndrome (ARDS) occurs fairly frequently in pregnancy and is a leading cause of maternal death. Several approaches to respiratory support, including conventional mechanical ventilation, airway pressure release ventilation, high-frequency oscillation, and extracorporeal membrane oxygenation, have been used successfully in pregnancy.
  • Section 5 - Serious problems related to pregnancy
    pp 403-471
  • View abstract

    Summary

    The most important risk factor for thrombosis in pregnancy is a history of thrombosis. Although both heparin and warfarin are satisfactory for use postpartum, including in women who are breastfeeding, many women prefer to use low-molecular-weight heparin (LMWH) (with once-daily dosing postpartum) because they have become accustomed to its administration and because they can avoid the monitoring associated with coumarin therapy. With massive life-threatening pulmonary thromboembolism (PE), the pregnant woman needs emergency assessment by a multidisciplinary team of obstetricians, surgeons, and radiologists, who should decide rapidly on appropriate treatment ranging from intravenous unfractionated heparin (UFH) to systemic thrombolysis, catheter thrombolysis or embolectomy, or surgical embolectomy. Women are at an increased risk of venous thromboembolism (VTE), during pregnancy. In anticipation of delivery, surgery, or other invasive procedures, anticoagulation should be manipulated to reduce the risk of bleeding complications while minimizing the risk of thrombosis.
  • Chapter 37 - Acute fatty liver of pregnancy
    pp 418-427
  • View abstract

    Summary

    Pregnant women may have chronic neurological disease or may develop neurological disease during pregnancy and the postpartum period. Status epilepticus, stroke, cerebral vein thrombosis, posterior spinal encephalopathy syndrome (PRES), are some neurological conditions that are more likely to occur during pregnancy. Clinical trials of PRES treatment are lacking. Intensive care is usually indicated, with continuous blood pressure monitoring, treatment of hypertension, and if possible, removal of the underlying cause. Both neuraxial (including both spinal and epidural anesthesia/analgesia) and general anesthesia have been described for delivery of patients with Guillain-Barre syndrome. High thoracic or cervical spinal cord lesions are associated with neurogenic shock because of blockade of autonomic function at the level of the spinal cord injury (SCI). Spinal/epidural hematoma is a rare complication of neuraxial procedures in the obstetric population. Pregnant patients are hypercoagulable and this may confer some degree of protection.
  • Chapter 38 - Peripartum cardiomyopathy
    pp 428-437
  • View abstract

    Summary

    Renal anatomy and physiology are significantly affected by pregnancy, with changes to kidney size as well as glomerular and tubular function. Any potential interstitial, vascular, or glomerular cause of renal insufficiency and/or proteinuria can present or worsen during pregnancy. Due to the pregnancy-associated dilatation of the urinary tract, asymptomatic bacteriuria can progress to cystitis and/or pyelonephritis, along with more severe maternal complications such as septicemia and renal insufficiency, if not promptly treated. Pre-eclampsia, the most common cause of the constellation of renal insufficiency, hypertension and proteinuria, is essentially a disease of the placenta. Acute kindney injury, if severe enough, may require renal replacement therapy irrespective of the etiology. Indications for dialysis are no different in pregnancy and include imbalances in electrolytes and volume status that cannot be managed medically. Drugs typically given to dialysis patients, including erythropoietin stimulating agents and heparin, are safe.
  • Chapter 39 - Obstetric hemorrhage
    pp 438-453
  • View abstract

    Summary

    The diagnosis and treatment of cancer in pregnant women is a clinical and ethical challenge for medical care workers. The complex medical, ethical, psychological, and religious issues arising in pregnant women with cancer demand care from a multidisciplinary team with obstetricians, oncologists, radiation oncologists, surgeons, pediatricians, geneticists, and psychologists. Surgery can be performed safely during pregnancy. The placenta seems to fulfill its barrier role for most of the chemotherapeutic drugs and reduces fetal exposure to chemotherapy. Radiation doses used in cancer therapy are in the range 30-70 Gy. Biological agents have the potential to affect the fetus and should be used with caution during pregnancy. Supportive treatment for pregnant women is possible, similar to non-pregnant women. Considering the gestational period, surgery, chemotherapy (not in the first trimester), and radiotherapy (not in the third trimester) can safely be applied in pregnancy. Hormonal therapy and trastuzumab should be deferred until after birth.
  • Chapter 40 - Anaphylactoid syndrome of pregnancy (amniotic fluid embolus)
    pp 454-461
  • View abstract

    Summary

    There is little evidence base for pregnancy-specific management of endocrine crises, and in the majority of cases the underlying condition should be treated as it would be outside of pregnancy, with no need for immediate delivery. Thyroid storm is associated with an increased risk of preterm labor, and staff in the critical care setting should be aware of this, along with the signs and symptoms of labor. Myxedema coma is a challenge to diagnose because of its insidious onset and lack of classic signs and symptoms. Acute adrenal crisis in the pregnant patient, if left untreated, is associated with high risk of maternal and fetal mortality. If labor coincides with pituitary apoplexy, steroid administration and correction of electrolyte imbalances are essential. In pregnancy, diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) typically occur in the second and third trimesters, affecting an estimated 1-2 percentage of pregnancies.
  • Chapter 41 - Maternal complications of fetal surgery
    pp 462-471
  • View abstract

    Summary

    Management of the pregnant woman with an acute abdomen is a typical multidisciplinary challenge. Regardless of the type of surgery and anesthesia, close cooperation and communication between surgeons, anesthesiologists, obstetricians, radiologists, the intensivist, as well as nurses and midwives, is essential. Non-obstetric causes of acute abdomen in pregnancy include appendicitis, bowel obstruction, inflammatory bowel disease, spontaneous esophageal rupture, peptic ulcer disease and perforated gastric ulcer, cholecystitis and pancreatitis. Obstetric causes of acute abdomen involving liver are spontaneous hepatic rupture, ruptured splenic artery aneurysm and aortic aneurysm. Nephrolithiasis, or kidney stones, is uncommon in pregnancy. Careful preoperative assessment of the woman should be made and all preparative measures taken in order to minimize the risk and possible harm of the anesthetic procedure. For major abdominal surgery, the use of epidural analgesia is safe and beneficial provided there is a stable hemodynamic situation.

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