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This chapter provides an overview of hospital and departmental service delivery issues, which hospitals may use in formulating a service for the critically ill parturient. In general, critically ill parturients are cared for in the delivery unit or in an obstetric high dependency unit (HDU); alternatively they may be admitted or transferred to a medical or surgical intensive care unit (ICU). Generally, the HDU may be appropriate for pregnant or puerperal women who are conscious and who have single-organ dysfunction. Ideally, the HDU should be located in or in close proximity to the labor and delivery ward. The HDU physician director and nurse/midwife director can give clinical, administrative and educational direction through guidelines and education of the HDU nursing, medical, and other ancillary staff. Simulation can encompass a large range of activities ranging from basic skills and drills to more sophisticated multidisciplinary training in purpose-built simulation centers.
Renal anatomy and physiology are significantly affected by pregnancy, with changes to kidney size as well as glomerular and tubular function. Any potential interstitial, vascular, or glomerular cause of renal insufficiency and/or proteinuria can present or worsen during pregnancy. Due to the pregnancy-associated dilatation of the urinary tract, asymptomatic bacteriuria can progress to cystitis and/or pyelonephritis, along with more severe maternal complications such as septicemia and renal insufficiency, if not promptly treated. Pre-eclampsia, the most common cause of the constellation of renal insufficiency, hypertension and proteinuria, is essentially a disease of the placenta. Acute kindney injury, if severe enough, may require renal replacement therapy irrespective of the etiology. Indications for dialysis are no different in pregnancy and include imbalances in electrolytes and volume status that cannot be managed medically. Drugs typically given to dialysis patients, including erythropoietin stimulating agents and heparin, are safe.
This chapter summarizes standards and recommendations relevant to the care of the pregnant or recently pregnant critically ill woman for maternity and critical care. The acute care competencies required focus primarily on the clinical and technical aspects of care and the delivery of effective patient management. They assume the possession and application at every level of complementary generic competencies such as recordkeeping, team working, interpersonal skills, and clinical decision making. Maternity services should define which of their staff take on each one of the acute care responder roles and ensure that they have suitable training and assessment of the competencies they require. Lead professionals in maternity services have a responsibility to ensure that staff are deemed competent in the early recognition of acutely ill and deteriorating patients and are able to perform the initial resuscitation and management.
The most important risk factor for thrombosis in pregnancy is a history of thrombosis. Although both heparin and warfarin are satisfactory for use postpartum, including in women who are breastfeeding, many women prefer to use low-molecular-weight heparin (LMWH) (with once-daily dosing postpartum) because they have become accustomed to its administration and because they can avoid the monitoring associated with coumarin therapy. With massive life-threatening pulmonary thromboembolism (PE), the pregnant woman needs emergency assessment by a multidisciplinary team of obstetricians, surgeons, and radiologists, who should decide rapidly on appropriate treatment ranging from intravenous unfractionated heparin (UFH) to systemic thrombolysis, catheter thrombolysis or embolectomy, or surgical embolectomy. Women are at an increased risk of venous thromboembolism (VTE), during pregnancy. In anticipation of delivery, surgery, or other invasive procedures, anticoagulation should be manipulated to reduce the risk of bleeding complications while minimizing the risk of thrombosis.
Complete and comprehensive surveillance of maternal mortality and maternal near miss should increase the consistency and accuracy of the data. Extremes of age, pre-existing medical conditions, language barriers, ethnicity, and socioeconomic status are recognized risk factors for maternal and obstetric complications. An important challenge to the identification of maternal near miss outcomes has historically been varying definitions between local, national, and international institutions. The majority of definitions may be classified as clinically based, organ system based, or management/intervention based. Organ-system dysfunction criteria are based on abnormalities detected by laboratory tests, such as platelet levels, and basic critical care monitoring. Complications from pre-existing medical conditions such as chronic heart disease are emerging as an important cause of maternal near miss, as improvements in medical care allow more women to live to reproductive age. Effective prevention policies are necessary to influence the long-term outcomes associated with maternal near miss.
Maternal critical care is not a formalized discipline and, as such, access to this scarce resource constitutes a major concern. The situation in South Africa is illustrative of the issues elsewhere. Critical care provision is not considered to be a major priority as the focus is instead on primary healthcare provision. Providing regular supply of oxygen cylinders to any hospital in rural Africa is both expensive and difficult. Early identification of the critically ill woman in developing regions is equally important as focusing, for critically ill obstetric patients, on basic infrastructure (facilities, transport, and electricity), accessibility, and basic equipment, essential drugs for advanced life support, blood, human resources, and quality of care. The challenge in the management of the critically ill antenatal or peripartum patient in poorly resourced settings is the need to tailor treatment around the significant cardiorespiratory, immunological, hematological, and metabolic alterations that accompany the gravid state.
Pregnancy is a state of flux with the placental-fetal unit undergoing constant changes that affect both pharmacodynamics and pharmacokinetics of many drugs. Pregnancy affects hepatic biotransformation in an enzyme-specific manner. Increased cardiac output, tissue flow, and vasodilatation during pregnancy may enhance absorption of drugs administered subcutaneously, intramuscularly, epidurally, transvaginally, and via mucous membranes. The treatment of drug overdose in pregnancy presents a unique challenge because of changes in the pharmacodynamics and pharmacokinetics of drugs during gravid state. The most frequently used agents for self-inflicted poisoning during pregnancy are analgesics, antipyretics, and antirheumatics. The treatment of acetaminophen overdose is aimed at decreasing the absorption of acetaminophen and protecting the hepatocytes from the toxic effects of the highly reactive metabolites. The therapeutic approach in carbon monoxide poisoning is to deliver high-dose oxygen to displace carbon monoxide from the hemoglobin molecule.
If you are an obstetrician whose patient has been admitted to ICU, you need to know how she is managed there. If you are an intensivist, you need to adapt to changes in physiology, alter techniques for the pregnant patient and keep the fetus from harm. This book addresses the challenges of managing critically ill obstetric patients by providing a truly multidisciplinary perspective. Almost every chapter is co-authored by both an intensivist/anesthesiologist and an obstetrician/maternal-fetal medicine expert to ensure that the clinical guidance reflects best practice in both specialties. Topics range from the purely medical to the organizational and the sociocultural, and each chapter is enhanced with color images, tables and algorithms. Written and edited by leading experts in anesthesiology, critical care medicine, maternal-fetal medicine, and obstetrics and gynecology, this is an important resource for anyone who deals with critically ill pregnant or postpartum patients.
Managing risk in antenatal care is dependent upon the identification of risk factors through clinical risk assessment during pregnancy to identify the care that is appropriate to individual women's needs. All guidelines need to be reviewed at regular intervals to incorporate new evidence and issues identified through audit and adverse event reporting. National Institute for Health and Clinical Excellence (NICE) guidelines and interventional procedures guidance provide evidence-based information for use by clinicians and pregnant women to make decisions about appropriate treatment in specific circumstances. The aim of pregnancy care pathways is to ensure that there are clear pathways in place to address the needs of pregnant women with various health problems during pregnancy, intrapartum and postnatally in accordance with national guidelines. Service providers should ensure that the staff mix provides multidisciplinary teams with agreed shared objectives.