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.