"This book contains a collection of the most recent insights regarding maternal morbidity and mortality and optimization of the care processes during acute critical illness.
The volume represents a practical resource to be used in real-time by medical practitioners faced with a woman who is critically ill during pregnancy and the peripartum period. By providing concise tools for disease identifiers and management flow-charts, the Editors aimed to increase awareness and improve processes of care for this population. Many care paradigms for obstetric patients are currently unstandardized, unfocused and often do not follow a pre-determined path.
Each chapter will provide the practitioner with updated information on how to identify specific critical conditions and how to manage them once they have been identified, to enhance recognition and readiness. This book should be used as a resource to improve the quality of care administered to obstetric patients, to reduce fragmented care processes and to improve interdisciplinary co-ordination and communication, with the overall aim of decreasing maternal morbidity and mortality. Therefore, this book represents an invaluable guide to specialists in critical care, anesthesia and obstetrics as well as to intensive care nurses and midwives."
Author(s): Sharon Einav, Carolyn F. Weiniger, Ruth Landau
Publisher: Springer
Year: 2020
Language: English
Pages: 582
City: Cham
Foreword
Foreword
Preface
Preface
Preface
Contents
Contributors
Part I: Epidemiology
1: Maternal Deaths in Developed Countries: Epidemiology and Preventable Causes
1.1 Introduction
1.2 Epidemiology of Maternal Mortality
1.2.1 Incidence and Trends of Maternal Mortality
1.2.2 Risk Factors for Maternal Deaths
1.3 Leading Causes of Preventable Maternal Deaths
1.3.1 Cardiovascular Disease and Cardiomyopathy
1.3.2 Other Medical Non-cardiovascular Disease
1.3.3 Infection and Sepsis
1.3.4 Obstetrical Hemorrhage
1.3.5 Thrombotic Pulmonary Embolism
1.3.6 Hypertensive Disorders of Pregnancy and Cerebrovascular Accidents
1.3.7 Amniotic Fluid Embolism
1.3.8 Anesthesia
1.4 Conclusions
References
2: Identifying the Critically Ill Parturient
2.1 The Modern Parturient: A Changing Demographic
2.2 Maternal Hemodynamic Screening Tools: Balancing Sensitivity and Specificity
2.3 Predicting Adverse Outcomes in Infection
2.4 Beyond Infection
2.5 The Identification and Management of High-Risk Pregnant and Postpartum Women
2.6 Accounting for Comorbidities in Screening for the High-Risk Parturient
2.7 Antenatal and Early Pregnancy Screening
2.8 Maternal Screening Tools: A Valuable Tool Looking Forward
References
3: Maternal Near Miss
3.1 Maternal Mortality and Maternal Morbidity
3.2 The Advantages of Studying Maternal Near Miss Events
3.3 Definition and Terminology
3.4 Identification of Maternal Near Miss
3.5 Development of the Near Miss Concept: The WHO Approach
3.6 Causes and Incidence of Near Miss Events
3.7 Risk Factors
3.8 Healthcare Organizational Factors Contributing to Maternal Mortality
3.9 Conclusions
References
4: The Epidemiology of Maternal Intensive Care Unit Admissions
4.1 Maternal Mortality
4.2 Severe Maternal Morbidity and Maternal Near Miss Definitions
4.3 Prevalence of Critical Maternal Events
4.4 Maternal Intensive Care Admission
4.4.1 General Considerations
4.5 Levels, Patterns, and Trends
4.6 Key Characteristics of Women Admitted to ICUs During Pregnancy and/or Peripartum
4.7 Causes of ICU Admission
4.8 Severity of Cases Admitted to ICU
4.9 Surveillance and Future Research Considerations
References
Part II: The Coagulation System
5: Physiology and Pathology of Coagulation in Pregnancy
5.1 Normal Physiology of Coagulation in Pregnancy
5.2 Hypercoagulable Conditions and Pregnancy
5.2.1 Antiphospholipid Syndrome
5.2.2 Protein C Deficiency
5.2.3 Protein S Deficiency
5.2.4 Factor V Leiden Mutation
5.2.5 Antithrombin III Deficiency
5.3 Acquired Hypocoagulable Conditions and Pregnancy
5.3.1 Disseminated Intravascular Coagulation
5.3.2 Therapeutic Anticoagulation
5.3.3 Drug-Related Coagulopathy
5.4 Non-acquired Hypocoagulable Conditions and Pregnancy
5.4.1 von Willebrand’s Disease (vWD)
5.4.2 Thrombotic Thrombocytopenic Purpura
5.4.3 Autoimmune Thrombocytopenic Purpura (ATP)
5.5 Blood Management Strategies in Pregnant Women
5.6 Conclusion
References
6: Peripartum Hemorrhage
6.1 Introduction
6.2 Diagnostic Considerations for Obstetric Hemorrhage
6.3 Management Considerations for Obstetric Hemorrhage
6.3.1 Antepartum Hemorrhage (APH)
6.3.2 Postpartum Hemorrhage (PPH)
6.4 Definitions
6.5 Prevention
6.6 Identification
6.7 Management of PPH
6.8 Pharmacological Management
6.8.1 Uterotonics
6.9 Tranexamic Acid (TXA)
6.10 Recombinant Factor VIIa (rFVIIa)
6.11 Blood Component Therapy
6.12 Pitfalls
6.13 Transfusion-Related Lung Injury and Transfusion-Associated Circulatory Overload
6.14 Further Hemorrhage and Venous Thromboembolism
6.15 Other Complications of Global Hypoperfusion/Post-circulatory Arrest
References
7: Fluid Management
7.1 Normal Maternal Physiology
7.1.1 Gain in Weight, Total Water and Plasma Volume During Pregnancy
7.1.2 The Urogenital and Renin-Angiotensin System and Plasma Osmolality During Pregnancy
7.1.3 Maternal Haemodynamic and Uteroplacental Blood Flow During Pregnancy
7.2 Fluid Management
7.2.1 State-of-the- Art Care Regarding Fluid Therapy in Critically Ill Adult Patients in General
7.2.2 Fluid Management During Massive Transfusion
7.2.3 Fluid Management During Pre-Eclampsia/Eclampsia
7.2.4 Fluid Management During Severe Sepsis
7.2.5 Fluid Management and Potential Impact on the Foetus
7.3 Summary
References
8: Management and Prevention of Thrombotic and Embolic Phenomena During Pregnancy: Deep Vein Thrombosis, Pulmonary Embolism, and Amniotic Fluid Embolism
8.1 Introduction
8.2 Venous Thromboembolism
8.2.1 Physiologic Changes Associated with Pregnancy: Hypercoagulable State
8.2.2 Prevention
8.3 Thromboembolic Events
8.3.1 Clinical Presentation
8.3.2 Diagnosis
8.4 Pulmonary Embolism
8.4.1 Clinical Presentation
8.4.2 Anticoagulation Management of Thromboembolic Events
8.4.3 Management of Massive Pulmonary Embolism
8.5 Amniotic Fluid Embolism
8.5.1 Clinical Presentation and Diagnosis
8.5.2 Management of Amniotic Fluid Embolism
8.5.3 Prevention
8.6 Conclusion
References
Part III: The Cardiovascular System
9: Cardiovascular Changes in Pregnancy
9.1 Introduction
9.2 Physiologic Changes During Pregnancy
9.2.1 Blood Volume
9.2.2 Blood Pressure
9.2.3 Heart Rate
9.2.4 Stroke Volume
9.2.5 Cardiac Output
9.2.6 Systematic Vascular Resistance
9.2.7 Cardiac Structural Changes
9.2.8 Aortocaval Compression
9.3 Physiologic Changes During Labor and Delivery
9.4 Physiologic Changes Postpartum
9.5 Brain Natriuretic Peptide
9.6 Conclusion
References
10: Preexisting Heart Disease in Pregnancy
10.1 Epidemiology of Preexisting Heart Disease
10.2 Infertility and Complicated Valvular Lesions
10.3 Risk Assessment for Heart Disease
10.4 Management Strategies in Specific Lesions
10.4.1 WHO III Congenital Heart Diseases
10.4.2 Management of Pregnancy with Systemic Right Ventricle
10.4.3 Cyanotic Heart Disease Without Pulmonary Hypertension
10.4.4 Management of Pregnancy with Cyanotic Heart Disease Without Pulmonary Hypertension
10.4.5 Single-Ventricle Physiology/Fontan Palliation
10.4.6 Management of Pregnancy with Single-Ventricle Physiology/Fontan Palliation
10.4.7 Valvular Heart Disease in Pregnancy
10.4.7.1 Rheumatic Heart Disease
10.4.7.2 Simple Valvular Lesions
10.4.7.3 Mitral Stenosis
10.4.7.4 Aortic Stenosis
10.4.8 Mitral and Aortic Regurgitation
10.5 Marfan Syndrome
10.6 Antiarrhythmic Treatment in Pregnancy
10.7 Management of Heart Failure in Pregnant Women with Preexisting Heart Disease
10.8 Prosthetic Valves
10.8.1 Anticoagulation
10.8.2 Anticoagulation Protocols
10.8.3 Valve Thrombosis (“Stuck Valve”)
10.9 Conclusion
References
11: Maternal Cardiomyopathy and Critical Care Medicine
11.1 Introduction
11.2 Cardiomyopathy
11.2.1 Definition
11.2.2 Subtypes
11.3 Diagnosis
11.3.1 Signs and Symptoms
11.3.2 Imaging and Procedural Diagnostic Modalities
11.3.3 Laboratory Investigations
11.4 Pharmacologic Considerations
11.4.1 Intravascular Volume Reduction
11.4.2 Afterload-Reducing Medications
11.4.3 Vasopressors and Inotropes
11.4.4 Anti-arrhythmic Agents
11.4.5 Targeted Therapy for Cardiomyopathy
11.4.6 Medications for Prevention of Thromboembolism
11.5 Management of Decompensated Heart Failure
11.6 Management of Delivery
11.7 Conclusion
References
12: Pulmonary Hypertension
12.1 Overview of the Disease
12.2 Pulmonary Arterial Hypertension (WHO Classification Group 1)
12.3 Pulmonary Hypertension (WHO Classification Groups 2–5)
12.4 Failure of the Physiologic Adaptation to Pregnancy in Women with Pulmonary Hypertension
12.5 Clinical Presentation of PH During Pregnancy
12.6 Diagnosis and Assessment
12.6.1 Transthoracic Echocardiography
12.6.2 Right Heart Catheterization
12.7 Management of PH During Pregnancy
12.8 Pharmacological Therapies for Pulmonary Vasodilation
12.9 Management of Right Ventricular Failure in Women with PH
12.10 Extracorporeal Membrane Oxygenator
12.11 Mode of Delivery
12.12 Management of Delivery
12.12.1 Hemodynamic Monitoring
12.12.2 Hematologic Monitoring
12.12.3 Anesthesia Considerations
12.13 Termination of Pregnancy
12.14 Postpartum Considerations
12.14.1 Uterotonic Medications
12.14.1.1 Oxytocin
12.14.1.2 Second-Line Uterotonics (Prostaglandins, Ergot Alkaloid Derivatives)
12.14.2 Postpartum Monitoring
12.15 Long-Term Considerations
12.15.1 Maternal Outcomes
12.15.2 Fetal and Neonatal Outcomes
12.16 Conclusion
12.17 Addendum
References
13: Point-of-Care Ultrasound in the Critically Ill Pregnant Woman
13.1 Definition and Applications
13.2 Point-of-Care Transthoracic Echocardiography During Pregnancy
13.3 Cardiovascular POCUS During Pregnancy
13.4 Maternal Cardiac Arrest
13.5 Point-of-Care Abdominal Ultrasonography During Pregnancy
13.5.1 POCUS Assessment of Pregnant Women with Non-pregnancy-Related Conditions
13.6 POCUS to Identify Obstetrical Complications
13.6.1 Emergency Screening of Women of Childbearing Age (Possible or Confirmed Pregnancies) for Severe Acute Causes of Hemodynamic Compromise
13.6.2 Use of POCUS to Screen Pregnant Woman for Obstetric Diseases that Cause Gradual Maternal Deterioration
13.7 Pregnant Women: The HELLP Syndrome
13.8 Conclusion
References
14: Extracorporeal Membrane Oxygenation During Pregnancy and the Peripartum Period
14.1 Introduction
14.2 Literature Review
14.3 Technical Aspects of ECMO Management
14.3.1 ECMO Circuit
14.3.2 Pump
14.3.3 Oxygenator or Membrane Lung
14.3.4 Cannulation
14.4 Which Configuration for Which Patients?
14.5 ECMO Indications and Contraindications
14.5.1 Contraindications
14.5.2 Indications
14.5.2.1 VV ECMO for ARDS
14.5.2.2 VA ECMO for Cardiogenic Failure
14.5.2.3 VA ECMO for Refractory Cardiac Arrest
14.6 Referral ECMO Centers and Mobile ECMO Teams
14.7 ECMO Management
14.7.1 Anticoagulation
14.7.2 ECMO Settings
14.7.2.1 VV ECMO
14.7.2.2 VA ECMO
14.8 Respiratory Management
14.8.1 Ventilator Setting for ARDS
14.8.2 Hypoxemia During VV ECMO
14.8.3 Hypoxemia During VA ECMO
14.9 Weaning from ECMO
14.10 Delivery and Bleeding Complications
14.10.1 Bleeding Complications
14.10.2 Delivery
References
Part IV: The Immune System
15: Physiological Changes of the Immune System During Pregnancy
15.1 Physiological Changes in the Immune System in Pregnancy
15.2 Clinical Implications of the Altered Immune Response in Pregnancy
15.2.1 Response to Infection
15.2.2 Autoimmune Disease
15.2.2.1 SLE and Pregnancy
15.3 Antibodies and the Placental Barrier
15.3.1 Neonatal “Passive” Immunity to Infection
15.3.2 Direct Effects of Autoantibodies on the Fetus/Neonate
15.3.3 Implications for Use of “Biologic” Drugs
15.4 Conclusion
References
16: Hypertension, Preeclampsia, and Eclampsia
16.1 Introduction
16.2 Epidemiology
16.3 Maternal Mortality
16.4 Maternal Morbidity
16.5 Definitions of Hypertensive Disorders in Pregnancy
16.6 Risk Factors
16.7 Pathogenesis
16.8 Clinical Features
16.9 Clinical Management
16.10 Monitoring
16.11 Eclampsia Prophylaxis
16.12 Blood Pressure Management
16.13 Oxygenation
16.14 Fluid Administration
16.15 Delivery of the Fetus
16.16 Conclusion
References
17: Viral Infections in Obstetric Critical Care
17.1 Introduction
17.2 Influenza and Other Respiratory Viruses
17.3 Neurotropic Viruses
17.4 Hepatitis and Herpes Viruses
17.5 Arboviral Infections
17.6 Conclusion
References
18: Infection during Early Pregnancy and Septic Abortions
18.1 Introduction
18.2 Immune Response in Pregnancy
18.3 The Use of Modified Scoring Systems for Sepsis and Septic Shock in Pregnancy
18.4 Sexually Transmitted Diseases (STD)
18.4.1 Gonorrhoea
18.4.2 Chlamydia
18.4.3 Syphilis
18.5 Genital Tract Infections
18.6 Vaginitis
18.7 Septic Abortions
18.8 Investigation of Pregnant Women with Suspected Sepsis
18.9 Summary
Flow Diagram
References
19: Infections in Late Pregnancy and Puerperium
19.1 Introduction
19.2 The Complexity of Defining Maternal Sepsis
19.3 Maternal Sepsis
19.3.1 Risk Factors
19.3.1.1 Categories of Infection Occurring during Pregnancy and the Peripartum Period
19.3.2 Pregnancy-Specific Infections
19.3.2.1 Chorioamnionitis (CA)
19.3.2.2 Toxic Shock Syndrome
19.3.2.3 Surgical Site Infection and Necrotizing Soft Tissue Infections
19.3.3 Infections Exacerbated during Pregnancy
19.3.3.1 Urinary Tract Infections
19.3.3.2 Listeria Monocytogenes
19.3.3.3 Toxoplasmosis
19.3.4 Malaria
19.3.5 Fetal Considerations in Maternal Infections
19.4 Conclusions
References
Part V: The Respiratory System
20: Physiologic Changes in the Airway and the Respiratory System Affecting Management in Pregnancy
20.1 Introduction
20.2 Upper Airway Anatomy during Pregnancy
20.2.1 The Nasal Cavities
20.2.2 The Larynx
20.2.3 The Pharynx
20.3 The Mallampati Score in the Peripartum Period
20.3.1 The Mallampati Score in Normal Labor and Delivery
20.3.2 The Mallampati Score with Hypertensive Disease of Pregnancy
20.3.3 Correlating Mallampati Score and Actual Intubation Difficulty during Cesarean Delivery
20.4 Respiratory Anatomical and Physiological Changes during Pregnancy
20.4.1 Chest Wall Configuration
20.4.2 Static Lung Function during Pregnancy
20.4.3 Dynamic Respiratory Parameters during Pregnancy
20.4.4 Peak Expiratory Flow, Forced Expiratory Volume, and Forced Vital Capacity
20.4.5 Pulmonary Function Tests in Women with Asthma
20.4.6 Pulmonary Function Tests in Women with Preeclampsia
20.4.7 Pulmonary Function Tests in Women with Multiple Gestation (Twins)
20.5 Diffusing Capacity
20.6 Ventilation and Gas Exchange
20.6.1 Oxygen Consumption and Carbon Dioxide Production
20.6.2 The Partial Pressure of Oxygen in Arterial Blood (PaO2)
20.6.3 Partial Pressure of Arterial Carbon Dioxide (PaCO2)
20.7 Conclusions
References
21: Airway Management during Pregnancy and the Peripartum Period
21.1 Incidence of Difficult Airway and Failed Intubation in Obstetrics
21.2 Maternal Airway Challenges
21.2.1 Maternal Anatomic and Physiologic Factors
21.2.1.1 Airway Edema
21.2.1.2 Respiratory, Metabolic Changes, and Denitrogenation
21.2.1.3 Obesity and Weight Gain
21.2.1.4 Breast Enlargement
21.2.1.5 Gastroesophageal Changes and Aspiration Risk
21.2.2 Environmental/Situational and Anesthetic Factors
21.3 Safe General Anesthesia for Healthy Pregnant Patients
21.3.1 Algorithms for Management of Difficult Intubation
21.4 Airway Management of the Critically ill Pregnant Patient
21.4.1 Hazards of ICU Airway Management
21.4.2 Equipment and Readiness
21.4.2.1 Drugs
21.4.3 Airway Assessment
21.4.4 Rapid Sequence Induction and Intubation (RSI)
21.4.5 Optimizing Oxygenation Preintubation
21.4.6 Videolaryngoscopy
21.4.7 Confirmation of Tracheal Intubation
21.4.8 Awake Intubation
21.4.9 Failed Intubation
21.4.10 Emergency Invasive Airway Access
21.5 Conclusion
References
22: Introduction to Lung Ultrasound Techniques and Diagnosis in the Seriously Ill Pregnant Woman
22.1 Introduction
22.2 Physiological Changes to Respiratory System during Pregnancy
22.3 Role of Lung Ultrasound in Pregnancy
22.4 Concepts and Techniques Used in Lung Ultrasound
22.4.1 How Lung Ultrasound Works
22.4.2 Basic Principles of Lung Ultrasound
22.4.3 Type of Probe for Lung Ultrasound
22.4.4 Positioning for Lung Ultrasound
22.4.5 Methods to Study Lung Ultrasound
22.5 Selective List of Signs and Artifacts Used in Lung Ultrasonography
22.6 Critical Respiratory Illness during Pregnancy
22.7 Common Protocols Used in Lung Ultrasonography
22.7.1 BLUE (Bedside Lung Ultrasound in Emergency) Protocol
22.7.2 FALLS Protocol
References
23: Management of Ventilation
23.1 Introduction
23.2 Causes of Acute Maternal Respiratory Failure
23.2.1 Cardiogenic Pulmonary Edema
23.2.2 Acute Respiratory Distress Syndrome (ARDS)
23.2.3 Other Conditions
23.3 Ventilatory Targets (Table 23.2)
23.3.1 Oxygen
23.3.2 Carbon Dioxide (PaCO2)
23.4 Ventilation Management
23.4.1 Noninvasive Ventilation
23.4.2 Invasive Mechanical Ventilation
23.5 Other Aspects of Management
23.5.1 Role of Delivery
23.5.2 Imaging
23.5.3 Drug Therapy
23.6 Outcome after Mechanical Ventilation during Pregnancy
References
Part VI: The Neuromuscular System
24: Brain Function Monitoring of Critically Ill Pregnant Patients
24.1 Physiologic Changes in Brain Function during Pregnancy
24.1.1 Cerebral Blood Flow (CBF)
24.2 The Neuroprotective Role of Estrogen and Progesterone
24.3 Brain Function Monitoring in the Intensive Care Unit (ICU)
24.4 Brain Function Monitoring in Critically Ill Pregnant Patients
24.5 Brain Monitoring in Specific Pathologic States during Pregnancy (Table 24.1)
24.5.1 Preeclampsia/Eclampsia
24.5.2 Intracranial Hemorrhage
24.5.3 Intracranial Tumors
24.5.4 Other Cerebral Disorders in Pregnancy
24.6 Summary
References
25: Maternal Stroke
25.1 Introduction
25.2 Definitions, Epidemiology, and Risk Factors
25.2.1 Epidemiology
25.2.2 Risk Factors
25.3 Anatomy, Signs, and Symptoms of Stroke
25.4 Management of Acute Stroke
25.4.1 Acute Ischemic Stroke
25.4.2 Intracerebral Hemorrhage (ICH)
25.4.3 Subarachnoid Hemorrhage
25.4.4 Cerebral Venous Sinus Thrombosis
25.4.5 Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome
25.4.6 Blood Pressure Management after Acute Stroke
25.4.6.1 Early Poststroke Risks and Care
25.4.7 Delivery after Antepartum Stroke
25.5 Long-Term Effects of Pregnancy-Associated Stroke
25.5.1 Recovering from Stroke
25.5.2 Long-Term Prognosis
References
26: Neurological Crises
26.1 Maternal Seizures
26.2 Maternal Weakness
26.2.1 Myasthenia Gravis Crisis
26.3 Summary
References
Part VII: Maternal Cardiac Arrest
27: Maternal Resuscitation
27.1 Introduction
27.2 Physiological Changes in Pregnancy
27.3 Resuscitation
27.4 Cardiac Compressions and Defibrillation
27.5 Airway, Oxygenation and Ventilation
27.6 Circulation
27.7 Relieving Aortocaval Compression
27.8 Monitoring
27.9 Drugs
27.10 Reversible Causes
27.11 Perimortem Caesarean Delivery
27.12 Vaginal Delivery
27.13 When to Stop
27.14 Aftermath
27.15 Human Factors and Teamwork
27.16 Conclusion
References
28: Intensive Care Management of the Pregnant Patient after Cardiac Arrest
28.1 Introduction and Epidemiology
28.2 Pathophysiology of the Post-Cardiac Arrest Syndrome
28.3 Stage of Pregnancy and Change in Physiology Relevant to the ICU Physician
28.4 Immediate Management after Return of Spontaneous Circulation
28.4.1 Circulation
28.5 Logistics of ICU Care
28.6 Determining the Cause of the Arrest
28.7 Mechanical Ventilation
28.8 Targeted Temperature Management
28.9 Sedation
28.10 Blood Pressure Management
28.11 Fluid and Glucose Management
28.12 Management of Seizures
28.13 General Intensive Care Management
28.14 Extracorporeal Membrane Oxygenation (ECMO) and Mechanical Assist Devices
28.15 Prognostication
28.16 Further Care and Rehabilitation
28.17 Conclusions
References
29: The Brain-Dead Mother in Intensive Care Unit: Ethics, Physiology and Management
29.1 Introduction: Concepts and Controversies in Defining Death
29.2 Epidemiology of Maternal Brain Death
29.3 Brain Death Testing
29.4 Ethical and Legal Considerations
29.4.1 Beneficence
29.4.2 Non-Maleficence
29.4.3 Autonomy
29.4.4 Justice
29.5 Physiological Changes in Brain Death and Organ Support
29.5.1 Cardiovascular Changes and Management
29.5.2 Respiratory Changes and Management
29.5.3 Endocrine Changes and Management
29.5.4 Temperature Regulation
29.5.5 Nutrition
29.5.6 The Coagulation System
29.5.7 Infections
29.5.8 Fetal Monitoring, Tocolytics and Timing of Delivery
29.6 Potential Future Developments
29.7 Conclusion
References
Part VIII: The Renal System
30: Renal Physiology during Normal Pregnancy
30.1 Introduction
30.1.1 Anatomical Changes
30.1.2 Renal Haemodynamics
30.2 Changes in Glomerular Filtration Rate (GFR)
30.3 Calculating the GFR in Pregnancy
30.4 Tubular Function
30.5 Acid-Base and Electrolyte Balance
30.6 Conclusion
References
31: Renal Failure and Renal Replacement Therapy During Pregnancy and the Peripartum Period
31.1 Introduction
31.2 Acute Kidney Injury
31.2.1 Definition
31.2.1.1 Role of AKI Biomarkers
31.2.2 Epidemiology
31.2.3 Etiology of AKI
31.2.3.1 Common Pregnancy-Specific Causes of AKI
Hypertensive Disorders of Pregnancy
Volume Depletion
Infection
Obstruction
Cardiovascular Collapse
31.2.3.2 Other Causes of AKI that May be Co-incident but Not Specific to Pregnancy
Thrombotic Thrombocytopenic Purpura/Hemolytic-Uremic Syndrome
Primary Renal Diseases, Including Autoimmune Disease and Vasculitis
Drug Nephrotoxicity
31.2.4 Diagnostic Work-Up
31.2.5 Treatment
31.2.5.1 General Measures
31.2.5.2 Treatment of Specific Causes of AKI
Control of Hypertensive Disorders of Pregnancy
Relief of Obstruction
Management of Amniotic Fluid Embolism
31.2.5.3 Renal Replacement Therapy
Timing of RRT
Modality of RRT
Dose of RRT
Anticoagulation
31.2.5.4 Perioperative Management of AKI
31.2.6 Long-Term Prognosis
31.2.7 End-Stage Renal Disease
31.2.8 Renal Transplant Recipients
31.2.8.1 Immune Suppression and Rejection
References
Part IX: The Endocrine and Metabolic Systems
32: Nutrition in Critical Illness During Pregnancy
32.1 Introduction
32.2 Metabolic Changes During Pregnancy
32.3 Nutritional Assessment During Normal Pregnancy
32.4 Nutritional Assessment in the Intensive Care Unit
32.5 Nutritional Concerns During Critical Illness and Pregnancy
32.6 Carbohydrate and Insulin Metabolism
32.7 Fat Metabolism
32.8 Proteins
32.9 Micronutrients
32.10 Feeding the Critically Ill Mother
32.11 Conclusions
References
33: Acute Fatty Liver of Pregnancy, Liver Failure, and Liver Transplantation
33.1 Introduction
33.2 Epidemiology
33.3 Pathogenesis
33.3.1 The Hibernating Bear: A Good Analogy for AFLP Pathogenesis
33.4 Acquired Predisposition
33.5 Placental Pathogenesis
33.6 Timing of AFLP Manifestation: Why Does AFLP Manifest in Late Pregnancy?
33.7 Manifestations
33.8 Diagnosis
33.9 Management of AFLP (Fig. 33.2)
33.10 Delivery Considerations
33.10.1 Intensive Care Treatment
33.11 Outcomes: Maternal and Fetal
33.12 Conclusion
References
Part X: Surgical Dilemmas in Critically Ill Women
34: Trauma During Pregnancy
34.1 Introduction
34.2 The Unique Physiology of Pregnancy
34.2.1 Additional Anatomical Considerations
34.3 The Epidemiology of Trauma in Pregnancy
34.4 Initial Management of Maternal Trauma
34.4.1 The Primary and Secondary Survey
34.4.2 Fetal Assessment
34.4.3 Extracorporeal Membrane Oxygenation for Maternal Salvage
34.4.4 Perimortem Cesarean Delivery
34.5 Management in the Intensive Care Unit
34.5.1 Complications Specific to the Injuries of Pregnant Women
34.5.2 Massive Transfusion
34.5.3 Delivery Considerations
34.5.4 Special Considerations in Treatment of Conventional Trauma
34.6 Repetitive Imaging
34.6.1 Predicting Maternal and Pregnancy Outcomes Following Trauma
34.7 Summary
References
35: Non-obstetric Intra-Abdominal Surgery During Pregnancy
35.1 Introduction
35.2 Pre-surgery Diagnostic Imaging
35.2.1 Ionizing Radiation Techniques
35.3 Maternal Considerations and Outcomes
35.3.1 Maternal Morbidity
35.3.2 Maternal Mortality
35.4 Fetal and Neonatal Outcomes
35.4.1 Miscarriage
35.4.2 Preterm Delivery
35.5 Anesthesia Considerations
35.6 Specific Intra-abdominal Surgical Conditions
35.6.1 Appendicitis
35.6.2 Recommended Surgical Approach to Appendectomy
35.7 Biliary Tract Disease
35.7.1 Recommended Surgical Approach to Cholecystectomy
35.8 Hernias
35.9 Obesity and Bariatric Surgery
35.10 Robotic Surgery
35.11 Conclusions
References
36: Neurosurgical Crises and Brain Surgery
36.1 Introduction
36.2 Initial Workup
36.3 Intensive Care Considerations
36.3.1 Management of Increased Intracranial Pressure (ICP)
36.3.2 Glucose Control
36.3.3 Timing of Neurosurgery Versus Delivery
36.4 Approach to Anesthesia for Surgery
36.4.1 Awake Craniotomy
36.4.2 General Anesthesia
36.5 Brain Tumors
36.5.1 Management of Intracranial Tumors in Pregnant Women
36.5.1.1 Gliomas
36.5.1.2 Meningioma
36.5.1.3 Pituitary Adenomas
36.6 Cerebrovascular Disease
36.6.1 Arterio-venous Malformation (AVM)
36.6.2 Aneurysm
36.6.2.1 Management of a Pregnant Women with an Aneurysm
36.6.3 Cavernous Malformation
36.7 Spinal Surgery
36.8 Conclusion
References
37: Maternal Critical Care in a Disaster
37.1 Introduction
37.1.1 Historical Disaster Preparedness
37.1.2 Why Disaster Preparedness for Pregnant and Peripartum Women Is Unique
37.2 Organization and Resources
37.2.1 Organizational Support of Disaster Readiness
37.2.2 Framework of an Obstetric Disaster Plan
37.3 Terminology
37.4 Tools
37.4.1 Hospital Stratification
37.4.2 Availability of a Disaster Plan
37.4.3 Specifics for Evacuation
37.4.4 Specifics for Surge
37.5 Disaster Training
References
Part XI: Medications and Complications
38: Medication Use During Pregnancy in the Intensive Care Unit
38.1 Introduction
38.2 Drugs That Control Cardiac Rhythm (Anti-arrhythmic Drugs)
38.3 Adrenergic Blockers
38.3.1 Alpha adrenergic blockers
38.3.2 Beta adrenergic blockers
38.3.3 Combined Alpha and Beta Adrenergic Blockers
38.4 Digoxin
38.5 Vasopressors and Inotropes
38.6 Antibiotics
38.6.1 Aminoglycoside Antibiotics
38.6.2 Cephalosporins
38.6.3 Fluoroquinolones
38.6.4 Metronidazole (Flagyl)
38.7 Antifungal Drugs
38.8 Antiviral Drugs
38.8.1 Antiretroviral Drugs
38.8.2 Other Antiviral Drugs
38.9 Drugs for Decreasing Intracerebral Pressure (ICP)
38.10 Anticonvulsant Therapy
38.11 Nitric Oxide
38.12 Peptic Ulcer Prophylaxis
38.13 Anti-histamines and Anti-emetics
38.14 Analgesics
38.14.1 Paracetamol
38.14.2 Dipyrone
38.14.3 Opioids
38.14.4 Non-steroidal Anti-inflammatory Drugs (NSAIDs) Including Aspirin
38.15 Anesthetic Agents
38.16 Conclusions
38.17 Appendix
38.17.1 Pregnancy and Breastfeeding Drug Classifications
References
39: Management of Pain During Maternal Critical Illness
39.1 Introduction
39.1.1 Pain in the Context of Pregnancy
39.1.2 Physiologic Changes During Pregnancy and Their Impact on Pain Tolerance and Analgesia
39.1.2.1 Pulmonary Physiology and Physiopathology
39.1.2.2 Cardiovascular Physiology and Physiopathology
39.1.2.3 Gastrointestinal Physiology and Physiopathology
39.1.2.4 Hematological and Immune Physiology and Physiopathology
39.1.3 Pain Management in the Obstetric Population
39.2 Neuraxial Analgesia
39.2.1 Continuous Epidural Analgesia
39.2.1.1 Indications
39.2.1.2 Procedure and Medications
39.2.1.3 Side Effects and Complications
39.2.2 Intrathecal Morphine
39.2.2.1 Indication
39.2.2.2 Procedure and Medication
39.2.2.3 Side Effects and Complications
39.2.2.4 Absolute and Relative Contraindications for Neuraxial Procedures
39.3 Trunk Blocks
39.3.1 Indications
39.3.2 Procedures and Medications
39.3.2.1 Transversus Abdominis Plane (TAP) Block
39.3.2.2 Quadratus Lumborum Block (QLB)
39.3.2.3 Serratus Anterior Plane Block
39.3.2.4 Additional Trunk Blocks
39.3.3 Side Effects and Complications
39.4 Limb Plexus Blocks
39.4.1 Indications
39.4.2 Procedures and Medications
39.4.3 Contraindications
39.5 Systemic Analgesia
39.5.1 Stepwise Systemic Multimodal Analgesia for the Obstetric Patient
39.5.2 Nonsteroidal Anti-inflammatory Drugs (NSAIDs) and Acetaminophen
39.5.2.1 Indication
39.5.2.2 Contraindications
39.5.3 Opioids
39.5.3.1 Indication
39.5.3.2 Medication and Mode of Administration
39.5.3.3 Contraindication
39.5.3.4 Side Effects and Complications
Maternal
Fetal/Neonatal
39.5.4 Ketamine
39.5.5 Dexmedetomidine
39.5.6 Gabapentinoids
39.6 Systemic Sedation
39.7 Clinical Scenarios Specific to the Obstetric Patient
39.7.1 The Opioid-Tolerant Obstetric Patient
39.7.2 Sickle Cell Crisis During Pregnancy
39.7.3 Blunt Thoracic Trauma in the Obstetric Patient
39.7.4 Acute Pancreatitis
39.7.5 Preeclampsia and Complications Associated with Hypertensive Disorders of Pregnancy
39.7.6 Fatty Liver of Pregnancy
39.7.7 Specific Postpartum Considerations in the Breastfeeding Patient
39.8 Conclusion
References
40: Anaphylaxis in Pregnancy
40.1 Introduction
40.2 Risk Factors
40.3 Causes
40.4 Symptoms
40.5 Differential Diagnosis
40.6 Diagnosis
40.7 Management
40.7.1 Caveats to Application of Anaphylaxis Treatment Protocols During Late Pregnancy and in Labor
40.8 Summary
References
Appendix
