Chapter 45 INTENSIVE CARE MONITORING OF THE CRITICALLY ILL PREGNANT PATIENT Bernard Gonik, MD, and Michael Raymond Foley, MD As the field of obstetrics and gynecology continues to develop, physicians have become more aware of the need for a better understanding of critical care medicine as it applies to obstetrics (Mabie and Sibai, 1990). This isue is not based on the fact that ‘maternal mortality is increasing in the United States or Europe, hecause demographic statistics demonstrate dramatic decreases in maternal mottality over the past 50 years. Neither does this approach advocare the exclusion of other traditional health cate providets in the area of critical care medicine. However, it does point out that the gravid patient who becomes critically ill is best served by individuals who appreciate both maternal and fetal physiology, in addition to those needs associated with the acute medical ot surgical pathologic condition at hand. This chapter addresses basic critical care monitoring in obstetrics and specifically discusses conditions in which more intensive care management of the pregnant patient may be indicated. @ MATERNAL MORTALITY Maternal mortality is defined as the number of maternal deaths (direct and indirect) per 100,000 live births. Direct obstetric deaths resule primarily from hypertensive disorders of pregnancy, hemorrhage, sepsis, and thromboembolic phenom enon. Indirect obstetric deaths arise from preexisting medical conditions including, but not limited to, diabetes, systemic lupus erythematosus, asthma, and heart disease aggravated by the physiologic changes of pregnancy. This vital statistic is periodically surveyed by various local, state, and national agen- ties. Because these maternal mortality committees frequently axe death certificates as their only database, some have sug od that these numbers underestimate this mortality rate by uch as 20% to 50% (Kaunitz et al., 1985; Atrash et al, 1995). Variations in the definition of death, medicolegal concems, and physicians untrained in the proper completion of death certificates further confuse these inves- tigations. To address these concerns, the Division of Reproductive Health at the Centers for Disease Control and Prevention, in collaboration with the American College of Obstetricians and Gynecologists (ACOG) and state health departments, began in 1987 to systematically collect these data in the Pregnancy-Related Mortality Surveillance System. Mortality rates have declined in the United States over the ‘maternal” last two decades (Fig. 45-1) (Atrash et al., 1990), Although this is true for all races, wide discrepancies still exist between white and nonwhite populations. These differences have been attributed mainly to socioeconomic factors limiting adequacy of health care for minority groups (Centers for Disease Control and Prevention, 1995). Geographic differences also appear to exist in maternal mortality: Rates are highest in the South and lowest in the Western states. Here again, racial differences within each tegion of the United States appear to be the factor influencing these discrepancies. More recently, Berg and col leagues (1996) reported a modest rise in maternal mortality from 1987 to 1990. They attributed some of this increase to hetter ascertainment of data collected prospectively and to the use of multiple source documents. The currently reported overall maternal mortality rate for the United States is 7.7 per 100,000 (5.3 per 100,000 for whites, 19.6 per 100,000 for African Americans) (Centers for Disease Control and Prevention, 1999). ‘Advanced maternal age is a recognized risk factor for death. This phenomenon appears to be a result of the increased age associated incidence of chronic illnesses, such as hypertension, dliabetes, and obesity, rather than age alone, In addition, advancing age is usually accompanied by increasing, parity, which is associated with an increased incidence of abruptio placentae, placenta previa, and uterine rupture. Variables relared to health care delivery systems, such as hospital size, have also been correlated with maternal mortal- ity. Both very large delivery services and very small obstetric Units are associated with higher maternal death rates compared with medium-sized institutions. The underlying reasons for these discrepancies in mortality rates are distinctly different. For larger hospitals, patients tend to come from higher risk groups (ie., African Americans, tertiary care referrals, and so on). As for smaller hospitals, less sophisticated blood banking facilities and limited intensive care technology make them less able to handle acute life-threatening conditions. Figure 45-2 demonstrates cause-specific pregnancy-related mortality ratios for two time periods (Berg et al, 1996). As can be seen, the most commonly identified causes of death were obstetri¢ hemorthage, embolism, hypertensive disease, and infection. Although most causes declined between the wo study periods, ratios for deaths because of infection and car diomyopathy’ increased by approximately 36% and 70%, respectively 925926 AB jlncensive Care Monitoring of the Critically II! Pregnant Patient BR 8 Deaths pr 100000 Wve baths an eT) Yeu FIGURE 45-1. m Maternal mortality rates in the United States, 1979-1986, rom Atrash HK, Koonin LM, Lawson HW, etal Maternal mortality in the United States, 1979-1986, Obstet Gy 76:1055, 1990,) CRITICAL CARE FACILITIES ON AN OBSTETRIC UNIT Recent advances in critical care medical knowledge and instrumentation have influenced many directors of obstetric services to develop full cardiovascular hemodynamic monitor- ing capabilities within their labor and delivery suites or in nearby special care units. Because these special facilities are located on the obstetric ward, one is able to provide feral surveillance in addition to maternal care equivalent t0 that of most medical of surgical intensive care units. Precise information regarding which patients would most benefit from admission to these units has yet to be established (Mabie and Sibai, 1990), Cause of Death FIGURE 45-2 m Cause-spociic pregnancy-related mortality ratios (pe 100,000 lve births). (From Berg CJ, Aviash HK, Koonin LM, et a: ancy related mortality in the United States, 1987-1990. Obstet Gynecol 88:181, 1996) The overall dimensions of a room designated for this purpose need to be large to accommodate large pieces of monitoring equipment, along with the expectation that many members of the management team may be ln addition, itis necessary that capabilities be available within the room or nearby for emergency cesarean section. Ifa vaginal delivery is anticipated, this should he performed within the intensive care room itself to minimize the need for switching monitors or transporting the critically ill patient The basic monitoring equipment should preferably include a hemodynamics unit, oscilloscope, pressure transducers, electto- cardiograph module, a caniac output (CO) computer, and a puke oximeter, Although direct ascilloscopic or digital display readings ate usually adequate, a hard-copy chart recorder may be desirable for evaluating complex pressure tracings ot for times when a patient's respiratory efforts add too much variation 10 the displayed values. The fetal surveillance equipment should include capabilities for both extemal and intemal heart rate monitoring along with pressure transducer tracings. A hand- held or desktop computer can be programmed to calculate extrapolated hemodynamic variables. A pH/blood gas analy co-oximeter, and oncometer are also preferred to complete the hemodynamic requirements of the unit. Most often, these latter picces of equipment do not need to he individually purchased if the institution has an established emergency laboratory facility The most important component to the successful operation of acritical care unit is adequate health care provider training. Nuning supervisory staff should designate individuals from each work shift interested in working in these units. Training should include critical care patient management, Swan-Gat data interpretation, and equipment maintenance. Frequently, this requites periodic assignments to the surgical or medical intensive care units of the hospital. Refresher courses to main- se skills should also be planned at regular intervals, depending on the amount of utilization of the facility the room at any given time, © INVASIVE HEMODYNAMIC MONITORING Indications for Pulmonary Artery Catheterization Current indications for the use of invasive pulmonary artery catheterization in obstetrics ate based on individual experi- ences and empirical thinking. Controlled trials evaluating this new technology in the management of the critically ill preg- nant woman have yet to be carried out. These comparisons may never be made because of the limited clinical exposure to these types of patients in obstetrics and because too many confounding variables exist to make meaningful comparisons possible, Robin (1985) pointed out that invasive monitoring should be used in the clinical setting only when the data obtained will specifically influence acute management; too often this tenet is not followed. ‘The lack of clearly supportive literature mandates caution and selective application; however, the following include sug gested indications for invasive monitoring of the obstetric patient (ACOG, 1992): 1, Hypovolemic shock that is unresponsive to initial velume resuscitation attempts 2. Septic shock when vasopressor therapy is needed45/Incensive Care Monitoring of th 3. Pregnancy-induced hypertension complicated by unrespon- sive oliguria 4. Ineffective intravenous antihypertensive therapy 5. Adult respiratory distress syndrome requiring ventilatory support 6, Catdliae disease, class 3 oF 4, in labor or requiring surgery 7. Anaphylactoid syndrome of pregnancy (amniotic. fluid embolism) Isolated primary or secondary pulmonary hypertension in labor or during surgery (selective application) 9. Pulmonary edema, from any etiology, that is unresponsive to initial therapy Central venous pressure (CVP) monitoring should not be considered equivalent to pulmonary artery catheter monitor ing. Data evaluating the relationship between serial CVP measurements and pulmonary capillary wedge pressure (PCWP) readings in severe pregnancy-induced hypertension ate shown in Figure 45-3 (Cotton et al., 1985a). Although statistically a linear relationship was noted, there was large variation in PCWP between patients for a given CVP meas urement. For instance, a CVP reading of 8 mm Hy might be associated with a PCWP of between 8 and 21 mm Hg. Thus, from a clinical perspective, CVP measurement would not appear to be as satisfactory a measure of left atrial filling pres- sure as PCWP, Whether this holds true for pregnant women with critically ill disease states other than pregnancy-induced hypertension remains unknown, Pulmonary Artery Catheterization Description and Insertion Technique In 1970, Swan and associates first described the use of a balloon-tipped pulmonary artery catheter that allowed inva- sive serial hemodynamic measurements. The original instru- POW (mm Ha) 202 4 6 8 0 2 4 16 18 CVP (mm Hg) tral venous pressure (CVP) to sure (PCWP) in severe prognancy- ion DB, Gonik B, Dorman K, etal ascular alterations in severe prognancy-nduced hypertension ‘ship of contral venous pressure to pulmonary capilary wedge pressure. Am J Obstet Gynecol 159:762, 1985 ) pilary wedge pi 'ypertension. [From C Critically II] Pregnant Patient 927 40 FIGURE 45-4 m Pressure wave ors in laton to mena artery Pale WP. pulmonary capilary wedge pressur RA. right artery: BY, right ventricle. (Fram Hankins GDC: Principles of invasive hemodynamic monitoring. Io Cotton OB, Clark SL feds} Clinics in Perinatology. Philadelphia, Saunders, 1986.) ‘ment has undergone numerous modifications and improve- ‘ments. It is now commercially available through several sup: pliers in the United States and abroad. The Swan-Ganz catheter, a no, 7 French polyvinyl chloride multilumen device, is capable of directly measuring right aatial pressure (CVP), pulmonary artery pressure, and PCWP. CO and mixed venous oxygen saturation can he measured in the conventional manner by thermodilution and direct distil port aspiration, respectively, or by newer fiberoptic technology that allows continuous “monitoring of CO and mixed venous oxygen saturation, By percutaneous insertion, the catheter is directed into place via the internal or external jugular, subclavian, basilic, or femoral vein. Some of the more peripheral access sites make catheter positioning more difficult but may be prefered when a coagulopathy is present. Characteristic oscilloscopic pressure waveforms (Fig. 45-4) are used to establish the catheter’ loca- tion when it is advanced. Simultaneous continuous electrocardiographic monitoring is needed to identify catheter-related arrhythmias. These acthythmias tend to be transient and generally do not require intervention except for withdrawal of the catheter. Inflation of the balloon assists in positioning of the catheter because the device is carried through the heart’s chambers by established venous and cardiac flow patterns. Once the inflated balloon teaches the pulmonary artery, a dampened tracing (PCWP) usually indicates that the balloon is situated in the proper wedged” position. When it is deflated, return of an iden tifiable pulmonary artery systolic and diastolic pressure tracing should occur. Periodic manipulation of the catheter may be needed to maintain accurate readings and to avoid permanent wedging of the catheter. A portable chest x-ray can be used t¢ verify appropriate catheter positioning. Complications of Pulmonary Artery Catheters Recognized complications associated with insertion and maintenance of a pulmonary artery catheter are listed Table 45-1. The initial complications seem to be most closely correlated with the technical skills and experience of the cli- nician. Many of the later complications can be minimized by