Critical Care in Pregnancy

Trauma In Pregnancy• Treatment priorities are the same as those for

nonpregnant.• Be aware neurologic symptoms of eclampsia may

mimic head injury.• Aortocaval compression contribute hypotension.• Pregnant px can lose up to 35% of blood volume

before significant sign of hypovolemia are seen. • Evaluate uterine irritability (fetal heart rate, fetal

movement).• Pelvic examination should be performed if necessary.

Definitive care:• Adequate hemodynamic and respiratory

resuscitation, stabilization of the mother, continued fetal monitoring and radiographic studies as necessary.

Postpartum Hemorrhage

General treatment:• Aggressive and early fluid resuscitation• Attempt to locate the source of bleeding

(ultrasound)• Surgical therapy may be required

Amniotic Fluid Embolism

• Occurs during pregnancy or in the intermediate postpartum period.

• Presentation: hypoxia, shock, altered mental status, DIC, seizure, agitation, fetal distress, fever, chills, nausea, and vomiting.

• Diagnosis is clinical and a diagnosis of exclusion.

• In pregnant or postpartum women who abruptly and dramatically present with profound shock and cardiovascular collapse with severe respiratory distress always consider AMNIOTIC FLUID EMBOLISM !!

• Occasionally, DIC is the first presenting sign.

• Radiologic: pulmonary edema with bilateral interstitial and alveolar infiltrates.

• Management: supportive, rapid maternal cardiopulmonary stabilization and preventing subsequent end-organ damage.

Severe Asthma

• Asthma the most common pulmonary condition in pregnancy.

• Pharmacologic treatment of asthma usually does not require modification during pregnancy.

• Supplemental oxygen.• Non-invasive positive-pressure ventilation

should be used cautiously increased risk of aspiration.

Management:• Inhaled beta agonists and systemic steroids is

preferred• Antibiotics, if with respiratory infection• Intubation and mechanical ventilation

adjusted to avoid hyperventilation and respiratory alkalosis

• Consider termination of pregnancy via CS, if with refractory asthma

Peripartum Cardiomyopathy

• Definition:–CHF that occurs during the last month of

pregnancy or in the first 5 months postpartum.

• Symptoms: – severe progressive dyspnea, progressive

orthopnea, paroxysmal nocturnal dyspnea, or syncope with exertion.

• Signs:– Right and left heart failure, generalized or

chamber- specific cardiomegaly, pulmonary hypertension, murmurs, prominent JVD, cyanosis, clubbing, or dysrhythmias.

• Associated with:– Maternal age >30 years, first pregnancy, twins,

gestational hypertension, pregnant women with tocolytic agents.

Management• Initially: bed rest, sodium restriction, diuretics,

possibly vasodilators. • Invasive hemodynamic monitoring often

required.• Drugs: digoxin, dobutamine, milrinone, ACE

inhibitors (contraindicated prior to delivery), loop diuretics.

• Urgent delivery may be considered if with advanced heart failure or hemodynamic instability.

• Anticoagulation should be considered.• Subsequent pregnancies are discouraged if no

resolution of signs and symptoms of heart failure 6 months after delivery.