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Respiratory diseases affect a large proportion of the population and can cause complications when associated with pregnancy. Pregnancy induces profound anatomical and functional physiological changes in the mother, and subjects the mother to pregnancy-specific respiratory conditions. Reviewing respiratory conditions both specific and non-specific to pregnancy, the book also addresses related issues such as smoking and mechanical ventilation. Basic concepts for the obstetrician are covered, including patient history, physiology and initial examinations. Topics such as physiological changes during pregnancy and placental gas exchange are discussed for the non-obstetrician. Guidance is practical, covering antenatal and post-partum care, as well as management in the delivery suite. An essential guide to respiratory diseases in pregnancy, this book is indispensable to both obstetricians and non-obstetric physicians managing pregnant patients.
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.
This chapter discusses the various clinical settings in which critically ill parturients may be cared for, along with the common nursing and midwifery staffing arrangements. Routine antenatal care consists of confirming the pregnancy and gestation, preventing rhesus isoimmunization, multidisciplinary planning for labor/delivery as appropriate, and surveillance of the common complications of pregnancy that may arise during an intensive care unit (ICU) admission. Notable pregnancy complications include gestational diabetes, pre-eclampsia, preterm prelabor rupture of the membranes, and preterm labor. Importantly, the 7Bs of postpartum care include consideration of the mother-infant bond and the partner/broader family in recognition of the need to provide holistic care to critically ill patients. The 7Bs of postpartum care are blues, breasts, belly, bottom, body, baby, and beloved. Finally, effective communication and coordination of the health care team are important elements for the best outcomes to be achieved for the woman, her baby, and family.
Maternal collapse includes a variety of acute life threatening events involving maternal cardiorespiratory or central nervous systems. Maternal resuscitation follows standard Advanced Cardiac Life Support (ACLS) guidelines with a limited number of pregnancy-specific alterations. The primary variation from non-pregnancy guidelines is the requirement to displace the gravid uterus laterally to increase cardiac output. Cardiac output during closed chest massage in cardiopulmonary resuscitation (CPR) is approximately 30% of normal. Traditionally, displacement of the gravid uterus has been done by maternal tilt from 15° to 30° to facilitate increased venous return and cardiac output. Immediate awareness of the need to perform perimortem cesarean delivery 4 minutes after persistent cardiopulmonary arrest and the availability of an emergency kit for surgery can result in faster delivery of the baby, faster return of the maternal circulation, and better clinical outcomes for both mother and child.
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.
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.