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.
“…Provides a wide-ranging approach to factors complicating pregnancy. A focused book such as this is uncommon and I recommend it be housed in units that manage complications of pregnancy.”
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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.
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 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.
This chapter presents an overview on the current recommendations and guidelines that may be implemented to improve the management of planned and unplanned urgent high-risk obstetric patients and prevent fatal outcomes for both mothers and their babies. Reviewing morbidity and mortality data over the 10 years from 2000 reveals an increase in the proportion of indirect causes of maternal deaths and demonstrates that many of the case-fatalities were women who did not receive pre-pregnancy counseling or any specific medical management. The chapter discusses two examples of multidisciplinary care planning: for women who have placenta previa with acreta and have had a previous cesarean section and for women with a serious comorbidity. The goal of rapid response teams (RRTs) is to bring critical expertise and equipment to the patient without delay, in a timely manner, and to provide a solution to the problem in a standardized manner.
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.
Ethics is an essential dimension of maternal critical care. This chapter commences with a definition of ethics, medical ethics, and the fundamental ethical principles of medical ethics: beneficence and respect for autonomy. The ethical concept of the fetus as a patient is essential to maternal critical care in all cultural and national settings. Maternal critical care is ethically more complex when the fetus is a patient. After viability, discontinuation of critical care management should include delivery of the fetal patient. Preventive ethics uses the informed consent process to anticipate and prevent ethical conflict between patients and their physicians. The physician's role is to explain to the pregnant patient before critical care is initiated its nature as a trial of management. The advantage of the durable power of attorney for healthcare is that it applies only when the patient has lost decision-making capacity, as judged by his or her physician.
Critical care staff caring for the patient and her fetus or newborn also benefit from systematic supports, as they are repeatedly exposed to patient trauma, family crisis, and loss. This chapter reviews the supports that can be provided to both families and staff in these scenarios. When a pregnant woman becomes critically ill, the threats to her health and that of her fetus may necessitate multiple decisions about medical management. Pregnant patients in the ICU who are conscious require the emotional and psychological support needed by any adult with a critical illness. While maternal, fetal, and neonatal mortality rates continue to fall worldwide, there will still be situations where clinicians are unable to save the life of the mother and/or infant. Supporting staff members and enabling them to continue their important work requires a culture which permits expression of emotion, confusion, and conflict.
The long-term outcome of intensive care unit (ICU)-acquired weakness has far-reaching consequences for the patient. Healthy postpartum women are at increased risk of postpartum depression. The treatment of postpartum depression has a biopsychosocial basis. It is important to recognize women at risk for the development of post-traumatic stress disorder (PTSD), and certain measures can be taken to reduce the risk of developing it. In order to help the obstetric patient to recover fully from ICU and enable her to have a good quality of life, measures must be taken to prevent cognitive impairment and delirium. Fertility and pregnancy after recovery from critical illness presents a challenge because of the limited data on which to base counseling. Counseling should address any risks to the pregnancy that might result from the inciting event or condition as well as any new risks resulting from sequelae.
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.
This chapter reviews the major physiological adaptations during pregnancy and also highlights changes in the reference ranges of common laboratory values encountered in pregnancy. Pregnancy induces a myriad of changes involving the cardiovascular system, respiratory system, gastrointestinal and hepatobiliary systems and genitourinary system. Pregnancy is associated with an overall increase in the serum concentrations of total cortisol, free cortisol, aldosterone, deoxycorticosterone, corticosteroid binding globulin, and adrenocorticotropic hormone. Pituitary enlargement occurs in pregnancy by estrogen mediated proliferation of prolactin-producing cells. During the first trimester of pregnancy, total thyroxine and total tri iodothyronine concentrations begin to increase and peak at mid-gestation, primarily as a result of increased production of thyroid-binding globulin. The immunological adaptations of pregnancy, particularly at the maternal-fetal interface, comprise complex mechanisms that enable the fetus to grow while preventing the mother from rejecting the fetus.
This chapter focuses on three entities namely disseminated intravascular coagulation (DIC), HELLP syndrome, and thrombotic thrombocytopenic purpura (TTP), which represents unique and critical threats to the well-being of mother and fetus during peripartum period. It is concerned with the etiology, clinical features, diagnostic methods and management of these entities. In non-bleeding patients with DIC, platelets and factor replacement should not be administered prophylactically or based on laboratory tests alone. The treatment of HELLP involves monitoring and responding to maternal signs and symptoms, particularly when pre-eclampsia is present, and includes fluid management and the use of antihypertensive agents and magnesium sulfate for seizure prophylaxis. Plasma exchange is the treatment of choice for TTP. The optimal treatment regimen for obstetric coagulation disorders continues to evolve, given the frequently dynamic clinical situation, the presence and health of the fetus, and a growing interest in conducting investigations during the peripartum period.