Anders – Critical Care for Two: When Pregnancy Meets the ICU

We were fortunate to have Dr. Megan Graybill Anders, anesthesiologist extraordinaire and all around critical care expert. For today’s lecture, Dr. Anders will walk the audience through those tense several days when a pregnant patient finds herself in the ICU. Even the simplest septic work-up can hit a snag when dealing with the physiological changes associated with a normal pregnancy, add on any additional morbidity and tensions will rise! Over the next 60 minutes, we hope to explore the difficult decisions common to such scenarios and, in the process, try to alleviate any fears the intensivist might experience.

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-Pearls-

Physiology 101: 

• #1 cause of death for pregnant patients: cardiovascular disease (up to 14% mortality)
• Cardiovascular changes:
  • ↑ cardiac output (↑ 40% at term) with an increase to both SV and HR
  • ↓ SVR- placenta is very low resistance
  • ScVO₂ is not reliable
  • Aorto-caval compression when laying supine
  • No autoregilation in placenta; ie: disruption of fetal circulation → fetal distress → early warning for mother
• Respiratory changes:
  • ↑ alveolar ventilation (20-40%)
  • ↑ TV
  • ↑ RR
  • Compensated hypocarbia
  • Faster desaturation: ↑ O₂ consumption + ↓ function residual capacity + ↑ small airway collapse with exhalation
  • Increased risk of difficult airways
    • Upper airway edema
    • Friable mucosa
    • Aspiration risk (weak lower esophageal sphincter tone)
• Hematological changes:
  • ↑ RBC mass (20%)
  • ↑ Plasma volume (40-50%)

Critical Care

• Mechanical ventilation– need to adjust for PaCO₂ 30-32 (compensated hypercarbia); no studies show harm with permissive hypercarbia
• Sedation– avoid benzos and NSAIDS; limited data exists for Propofol or Precedex
• Vasopressors– #1 is NE!
• Fetal monitoring–
  • Look for uterine contractility- eval for abruption or premature labor >20 weeks
  • Start fetal HR monitoring EARLY, is an early warning for maternal distress
• Sepsis– UTI/Pyelo are common; post-partum: Endometritis
• Maternal trauma– even minor trauma can cause fetal harm, recommend:
  • 4 hrs min of Fetal HR monitoring, longer with: 1) contraction, bleeding, abdominal pain
  • Steroids early for surfactant formation
  • Image mom as NEEDED (don’t hold back if its is important)
  • Put in chest tubes HIGHER than expected
• Fetomaternal hemmorhage: 30% of trauma patients
  1. Quant: Kleinhauer-Betke testing (fetal cells in circulation
  2. Give Rho-Gam early

Pregnancy Specific Problems: 

• Pre-eclampsia/Eclampsia:
  • Features: HTN, Hypovolemia, Renal dysfunction
  • 40% of Eclampsia is post-partum
  • Tx: HTN meds, MgSO4 (watch for AKI)
• HELLP:
  • 15% w/o HTN or proteinuria
  • Features: plts<100, hemolytic anemia, LFT dysfunction, and RUQ pain
  • Tx all SBP>160 or DBP>110 = ↓ CVA risk
• Acute fatty liver of pregnancy:
  • Features: similar to HELLP but with more significant liver failure
  • Tx: delivery (though some need transplant)
• Amniotic fluid embolism:
  • Normally immediately following labor (w/in 8 mins)
  • SIRS + anaphylaxis → severe hypoxemia
  • 20-40% mortality (with severe neurological morbidity)
  • DIC is a staple of the disease
• Cardiomyopathy:
  • Peripartum (up to 5 months)
  • LVEF <30%
  • ↑ to trop/BNP = worse outcome

Peri-Mortem C-section

• Maternal CPR
  • #1: Manual uterine displacement > L lateral positioning
    • Improve compressions =  improved outcome
• Give Calcium for Mg toxicity (wide QTc)
• C-section = increased venous return to mother, ↓ O₂ demand
• Who: fetus at umbilicus (20-24 weeks) on “obviously” pregnant
• When: w/in 4 mins of ACLS (have 1 minute to get baby out)