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April MD, Long B. Trauma in pregnancy: A narrative review of the current literature. Am J Emerg Med 2024; 81:53-61. [PMID: 38663304 DOI: 10.1016/j.ajem.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/10/2024] [Accepted: 04/12/2024] [Indexed: 06/07/2024] Open
Abstract
INTRODUCTION Trauma accounts for nearly half of all deaths of pregnant women. Pregnant women have distinct physiologic and anatomic characteristics which complicate their management following major trauma. OBJECTIVE This paper comprises a narrative review of the most recent literature informing the management of pregnant trauma patients. DISCUSSION The incidence of trauma during pregnancy is 6-8%. The focus of clinical assessment must be on the mother, starting with the primary survey. During airway management, clinicians should consider early intubation if necessary and utilize gastric tubes to minimize the risk of aspiration. Pregnant women experience progesterone-mediated hyperventilation, and normal PaCO2 levels may portend imminent respiratory failure. Clinicians should utilize left lateral tilt in hypotensive pregnant women to displace the uterus off the inferior vena cava. Ultrasonography is an attractive imaging modality for pregnant women which is specific for ruling in intraabdominal hemorrhage but not sufficiently sensitive to exclude this diagnosis. Clinicians should not hesitate to order computed tomography imaging in unstable patients if there is diagnostic ambiguity. Cardiotocographic monitoring simultaneously assesses uterine contractions and fetal heart rate and should last at least 4 h for pregnant women following even minor abdominal trauma if their fetus has achieved viable gestational age (approximately 24 weeks). In the event of cardiac arrest, peri-mortem cesarean section may improve outcomes for the mother and fetus alike. Unique specific complications include uterine rupture and placental abruption, which require emergent resuscitation and obstetrics consultation for definitive management. Emergency clinicians should maintain a low threshold for transfer to a tertiary care center given correlations between even isolated and relatively minor traumatic injuries with adverse fetal and maternal outcomes. CONCLUSIONS Trauma is a common cause of morbidity and mortality in pregnant women. Emergency clinicians must understand the evaluation and management of pregnant trauma patients.
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Affiliation(s)
- Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA; 14th Field Hospital, Fort Stewart, GA, USA.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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2
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Lapinsky SE, Vasquez DN. Acute Respiratory Failure in Pregnancy. Crit Care Clin 2024; 40:353-366. [PMID: 38432700 DOI: 10.1016/j.ccc.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Respiratory failure may affect up to 1 in 500 pregnancies, due to pregnancy-specific conditions, conditions aggravated by the pregnant state, or other causes. Management during pregnancy is influenced by altered maternal physiology, and the presence of a fetus influencing imaging, and drug therapy choices. Few studies have addressed the approach to invasive mechanical ventilatory management in pregnancy. Hypoxemia is likely harmful to the fetus, but precise targets are unknown. Hypocapnia reduces uteroplacental circulation, and some degree of hypercapnia may be tolerated in pregnancy. Delivery of the fetus may be considered to improve maternal respiratory status but improvement does not always occur.
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Affiliation(s)
- Stephen E Lapinsky
- Mount Sinai Hospital, Toronto, Interdepartmental Division of Critical Care Medicine, University of Toronto, 600 University Avenue, Toronto M5G1X5, Canada.
| | - Daniela N Vasquez
- ICU Head of Department, Sanatorio Anchorena, Tomás M. de Anchorena 1872, City of Buenos Aires, Argentina
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3
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Fajardo A, Rodríguez A, Chica C, Dueñas C, Carrillo R, Olaya X, Vera F. [Prone position in the third trimester of pregnancy during the COVID-19 era: a transdisciplinary approach.]. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2023; 50:100906. [PMID: 38620219 PMCID: PMC10308227 DOI: 10.1016/j.gine.2023.100906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 06/22/2023] [Indexed: 04/17/2024]
Abstract
There is very limited evidence regarding the use of prone position as part of the treatment of severe ARDS in pregnant patients. Currently, recommendations for invasive ventilatory management in this population are very scarce and are based on the extrapolation of conclusions obtained in studies of non-pregnant patients. The available literature asserts that the anatomy and physiology of the pregnant woman undergoes complex adaptive changes that must be considered during invasive ventilatory support and prone position. With prone ventilation, the benefits obtained for the couple far outweigh the eventual risks. Adequate programming of the mechanical ventilator correlates with a clear and simple concept: individualization of support. In any case, the decision on the timing of termination of pregnancy should be based on adequate multidisciplinary clinical judgment and should be supported by strict monitoring of the product.
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Affiliation(s)
- Aurio Fajardo
- Servicio de Medicina Interna - Unidad de Paciente Crítico. Head of WeVent (International Mechanical Ventilation Group), Viña del Mar, Chile
| | - Asariel Rodríguez
- Unidad de Cuidados Intensivos Obstétricos. Hospital Materno Infantil RPG, TGZ. México
| | - Carmen Chica
- Asociación Colombiana de Medicina Crítica y Cuidado Intensivo (AMCI), Bogotá, Colombia
| | - Carmelo Dueñas
- Neumología y Medicina Crítica. Jefe UCI Gestión Salud, Cartagena, Colombia
| | - Raúl Carrillo
- Academia Nacional de Medicina. Subdirección de Áreas Críticas, Instituto Nacional de Rehabilitación, México
| | - Ximena Olaya
- Universidad de Manizales, COINT Grupo de Investigación, Colombia
| | - Fabricio Vera
- Medicina Crítica. Hospital General Manta del IESS, Manabí, Ecuador
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4
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Barbosa RN, Braga MA, Costa BB, Peret FJA. Treatment of pregnant and early postpartum women with severe and critical COVID-19: experience at a tertiary center. Eur J Med Res 2022; 27:269. [PMID: 36461042 PMCID: PMC9716514 DOI: 10.1186/s40001-022-00907-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 11/20/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The management of acute respiratory failure during pregnancy is a poorly defined issue in the literature, especially regarding the use of the prone position and the appropriate time for delivery. This study describes our experience in treating pregnant and postpartum women with severe or critical coronavirus disease 2019 (COVID-19). MATERIALS AND METHODS This descriptive retrospective study included 25 pregnant and 4 postpartum women admitted to an ICU due to respiratory complications from COVID-19 from June 2020 to August 2021. RESULTS The mean maternal age was 33.6 years, and the median gestational age (GA) at admission was 33 weeks. Obesity was the most common comorbidity. The median time between symptom onset and ICU admission was 10 days, while the median length of ICU stay was 14 days. Invasive mechanical ventilation (IMV) was required in 16 (55.2%) patients for a median time of 16.5 days. Prone positioning (PP) was performed in 68.7% of the patients on IMV, and resulted in an expressive increase in arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2 ratio). Eleven (44%) pregnant women delivered during their ICU stay for obstetric or fetal reasons: of these, 2 (18%) developed postpartum hemorrhagic shock and 1 (9%) developed abdominal wall infection. None of the 25 pregnant women underwent delivery due to acute respiratory failure or in an attempt to avoid intubation. There were 2 fetal deaths, but no maternal or neonatal deaths. CONCLUSION We observed favorable outcomes in pregnant and postpartum women with severe and critical COVID-19 admitted to our institution. This finding reinforces the effectiveness of PP in the treatment of hypoxemic respiratory failure secondary to COVID-19 in pregnant women undergoing IMV, and suggests that gestation should only be interrupted in cases of obstetric and fetal complications, provided the patient is stable, or when hypoxemia is refractory to PP.
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Affiliation(s)
- Rodrigo Nacif Barbosa
- Unidade de Tratamento Intensivo, Maternidade Unimed-Unidade Grajaú, Belo Horizonte, Brazil ,Rua Viamão, 1171, UTI adulto. Bairro Grajaú, Belo Horizonte, Minas Gerais CEP 30431-253 Brazil
| | - Maria Aparecida Braga
- Unidade de Tratamento Intensivo, Maternidade Unimed-Unidade Grajaú, Belo Horizonte, Brazil
| | - Bárbara Braga Costa
- Unidade de Tratamento Intensivo, Maternidade Unimed-Unidade Grajaú, Belo Horizonte, Brazil
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5
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Wong MJ, Bharadwaj S, Galey JL, Lankford AS, Galvagno S, Kodali BS. Extracorporeal Membrane Oxygenation for Pregnant and Postpartum Patients. Anesth Analg 2022; 135:277-289. [PMID: 35122684 DOI: 10.1213/ane.0000000000005861] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has seen increasing use for critically ill pregnant and postpartum patients over the past decade. Growing experience continues to demonstrate the feasibility of ECMO in obstetric patients and attest to its favorable outcomes. However, the interaction of pregnancy physiology with ECMO life support requires careful planning and adaptation for success. Additionally, the maintenance of fetal oxygenation and perfusion is essential for safely continuing pregnancy during ECMO support. This review summarizes the considerations for use of ECMO in obstetric patients and how to address these concerns.
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Affiliation(s)
- Michael J Wong
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shobana Bharadwaj
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jessica L Galey
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Allison S Lankford
- Department of Obstetrics and Gynecology, University of Maryland School of Medicine and Program in Trauma and Anesthesia Critical Care, Shock Trauma Center, Baltimore, Maryland
| | - Samuel Galvagno
- Department of Anesthesiology, Multi Trauma Critical Care Unit, Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Bhavani Shankar Kodali
- From the Division of Obstetric Anesthesiology, Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland
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7
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Cojocaru L, Turan OM, Levine A, Sollecito L, Williams S, Elsamadicy E, Crimmins S, Turan S. Proning modus operandi in pregnancies complicated by acute respiratory distress syndrome secondary to COVID-19. J Matern Fetal Neonatal Med 2021; 35:9043-9052. [PMID: 34915799 DOI: 10.1080/14767058.2021.2013464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Prone positioning has been widely utilized in ARDS management before and during the COVID-19 pandemic due to its demonstrated mortality benefits. In pregnancy, proning requires careful attention to often overlooked physiologic changes in pregnancy and additional technical challenges accompanying a gravid abdomen. The purpose of this manuscript is to demonstrate a proning technique that was successfully used at our institution to avoid premature delivery of the fetus while improving maternal outcomes. All technical challenges are addressed in the instructional videos using a pregnant model with twin gestation at 32 weeks. METHODS We reviewed all the patients' charts with positive SARS-CoV-2 from March 2020 until July 2020 and identified those who developed ARDS. Subsequently, we identified four patients that were proned during the antepartum period. We described their clinical course, including the change in ventilatory parameters in relationship with proning timing. Stepwise instructions for self-proning and proning in mechanically ventilated patients are illustrated in video format. RESULTS During the study period, we identified 100 pregnant patients with SARS-CoV-2 infection. Mechanical ventilation was required in 8 of these patients. In four cases, proning was performed during the antepartum period. We were able to improve the P/F ratio while decreasing FiO2 and avoiding iatrogenic preterm delivery. Except for one case, where the patient self-extubated and required emergent delivery, all patients were successfully extubated, followed for prenatal care, and delivered for usual obstetric indications. CONCLUSION Proning remains a well-proven intervention in ARDS and should be considered in pregnant women when indicated. We recognize that proning might not be effective in all cases. However, proning positioning is an option to improve oxygenation in patients with severe hypoxemia when the next consideration is delivery of a premature infant or maternal cannulation for extracorporeal membrane oxygenation.
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Affiliation(s)
- Liviu Cojocaru
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ozhan M Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrea Levine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Linda Sollecito
- Medical Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD, USA
| | - Susan Williams
- Medical Intensive Care Unit, University of Maryland Medical Center, Baltimore, MD, USA
| | - Emad Elsamadicy
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah Crimmins
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sifa Turan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Science, University of Maryland School of Medicine, Baltimore, MD, USA
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8
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Cavalcante FML, Fernandes CDS, Rocha LDS, Galindo-Neto NM, Caetano JÁ, Barros LM. Use of the prone position in pregnant women with COVID-19 or other health conditions. Rev Lat Am Enfermagem 2021; 29:e3494. [PMID: 34755775 PMCID: PMC8584876 DOI: 10.1590/1518-8345.5181.3494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 07/14/2021] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE to analyze, in the scientific literature, the knowledge available on the use of the prone position in pregnant women diagnosed with COVID-19 or other health conditions. METHOD an integrative literature review developed through the following guiding question: What is the scientific knowledge available on the use of the prone position in pregnant women with COVID-19 or other health conditions? The search for studies was carried out in eight databases. RESULTS using the prone position in pregnant women with Acute Respiratory Distress syndrome allowed for improvements in lung compliance and oxygenation. It also allowed reducing uterine compression on the maternal large vessels, and a reduction in blood pressure was observed in pregnant women with pre-eclampsia. The prone position was also safe in the surgical management of pregnant patients. In addition, the following conditions stood out as disadvantages related to the prone position in pregnant women: possibility of aortocaval compression, causing severe hypotension, and inability to easily monitor fetal status or to perform emergency Cesarean sections. CONCLUSION the prone position was considered safe, reliable and comfortable for its use in the clinical management of pregnant women, where specific care measures must be taken to avoid compression of gravid abdomen, as well as fetal monitoring is important to detect placental circulation impairment.
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Affiliation(s)
- Francisco Marcelo Leandro Cavalcante
- Universidade Estadual Vale do Acaraú, Centro de Ciências da Saúde, Sobral, CE, Brazil.,Scholarship holder at the Fundação Cearense de Apoio ao Desenvolvimento Científico e Tecnológico (FUNCAP), Brazil
| | - Cristina da Silva Fernandes
- Universidade Federal do Ceará, Departamento de Enfermagem, Fortaleza, CE, Brazil.,Scholarship holder at the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil
| | - Luanna Dos Santos Rocha
- Instituto Federal de Educação, Ciência e Tecnologia de Pernambuco, Campus Pesqueira, Pesqueira, PE, Brazil
| | - Nelson Miguel Galindo-Neto
- Instituto Federal de Educação, Ciência e Tecnologia de Pernambuco, Campus Pesqueira, Pesqueira, PE, Brazil
| | - Joselany Áfio Caetano
- Universidade Federal do Ceará, Departamento de Enfermagem, Fortaleza, CE, Brazil.,Scholarship holder at the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil
| | - Lívia Moreira Barros
- Universidade da Integração Internacional da Lusofonia Afro-Brasileira, Curso de Enfermagem, Redenção, CE, Brazil
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9
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Brady A, Aglan A. Critical COVID-19 in a pregnant patient who presented in starvation ketoacidosis with a background history of acrorenal syndrome. BMJ Case Rep 2021; 14:14/11/e244117. [PMID: 34728503 PMCID: PMC8565554 DOI: 10.1136/bcr-2021-244117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A primiparous woman in her late 30s at 28+1 weeks’ gestation presented with a 3-day history of abdominal pain, loss of appetite, nausea and vomiting and was diagnosed with starvation ketoacidosis. A routine admission swab returned positive for COVID-19. She had been diagnosed with acrorenal syndrome from birth. Three days post admission, she deteriorated rapidly into respiratory failure requiring intubation and ventilation. She was treated with dexamethasone, prophylactic enoxaparin, a course of piperacillin/tazobactam followed by meropenem and fluconazole and 8 cycles of proning. An emergency caesarean section was performed on day 12 of hospital admission at 29+5 weeks’ gestation to improve maternal oxygenation and ventilation. The baby had deformities consistent with acrorenal syndrome but no evidence of COVID-19. She spent 23 days in the intensive care unit. Our case describes an unusual presentation of COVID-19, the challenges in managing critically ill pregnant patients along with a rare background history of acrorenal syndrome.
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Affiliation(s)
- Aoife Brady
- Department of Anaesthesiology, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - Ahmed Aglan
- Department of Anaesthesiology, Our Lady of Lourdes Hospital, Drogheda, Ireland
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10
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Neuhaus S, Neuhaus C, Weigand MA, Bremerich D. [Principles of intensive medical care in pregnant patients]. Anaesthesist 2021; 70:621-630. [PMID: 33851229 DOI: 10.1007/s00101-021-00947-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/27/2022]
Abstract
As the incidence of diseases during pregnancy or in the puerperium necessitating intensive medical care is very low, intensive care physicians are faced with a multitude of unfamiliar challenges in the treatment of this patient collective. The physiological and pathophysiological alterations during pregnancy induce some specific features with respect to the intensive medical treatment of pregnant or postpartum patients. Therefore, the first article in this CME series summarizes the most important principles and current recommendations on the care of pregnant or postpartum patients who need intensive medical treatment, always under consideration of the well-being of mother and child. The second article describes the diagnostics and treatment of special selected pathologies.
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Affiliation(s)
- Sophie Neuhaus
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - Christopher Neuhaus
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - Dorothee Bremerich
- Klinik für Anästhesiologie, Universitätsmedizin Mainz, Mainz, Deutschland
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11
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Arasu M, Swaminathan N, Cherian A, Parthiban M. Prone ventilation in a pregnant patient with scrub typhus-induced acute respiratory distress syndrome. BMJ Case Rep 2021; 14:e242870. [PMID: 33827889 PMCID: PMC8031017 DOI: 10.1136/bcr-2021-242870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2021] [Indexed: 11/03/2022] Open
Abstract
A 23-year-old primigravida at 20 weeks of gestation presented to our hospital with undifferentiated febrile illness and severe acute respiratory distress syndrome. She was intubated in the emergency department and transferred to the intensive care unit. Initial treatment included ventilatory care, vasopressor support and broad-spectrum antibiotics. Based on a positive PCR assay for scrub typhus, she was treated with intravenous doxycycline and azithromycin. Despite reduction in fever, her oxygenation further declined. Following a risk-benefits assessment, we decided to ventilate her in prone position for 8 hours a day for three consecutive days using a checklist-based protocol. Her oxygenation indices and lung compliance markedly improved over this period, and she was extubated a day later. She was eventually discharged home after 1 week.
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Affiliation(s)
- Meenupriya Arasu
- Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, India
| | - Nagalakshmi Swaminathan
- Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, India
| | - Anusha Cherian
- Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, India
| | - Magesh Parthiban
- Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education, Puducherry, India
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12
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Donzelli M, Ippolito M, Catalisano G, Renda B, Tarantino F, Diquattro O, Cortegiani A. Prone positioning and convalescent plasma therapy in a critically ill pregnant woman with COVID-19. Clin Case Rep 2020; 8:3352-3358. [PMID: 33363933 PMCID: PMC7752326 DOI: 10.1002/ccr3.3426] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 12/15/2022] Open
Abstract
Prone positioning is feasible in pregnancy and may have contributed to the positive outcome in this case. Doctors should not be reluctant to move a patient to a prone position just because they are pregnant.
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Affiliation(s)
- Massimo Donzelli
- Unità Operativa di Anestesiae RianimazioneAzienda Ospedaliera Ospedali Riuniti (AOOR) P.O. CervelloPalermoItaly
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.)University of PalermoPalermoItaly
| | - Giulia Catalisano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.)University of PalermoPalermoItaly
| | - Baldassare Renda
- Unità Operativa di Anestesiae RianimazioneAzienda Ospedaliera Ospedali Riuniti (AOOR) P.O. CervelloPalermoItaly
| | - Francesco Tarantino
- Unità Operativa di Anestesiae RianimazioneAzienda Ospedaliera Ospedali Riuniti (AOOR) P.O. CervelloPalermoItaly
| | - Orazia Diquattro
- Unità Operativa di MicrobiologiaAzienda Ospedaliera Ospedali Riuniti (AOOR)PalermoItaly
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.)University of PalermoPalermoItaly
- Department of Anesthesia, Intensive Care and EmergencyPoliclinico Paolo GiacconeUniversity of PalermoPalermoItaly
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Abstract
Pregnant patients can suffer from the same respiratory diseases as the general population in addition to unique syndromes of pregnancy (such as pre-eclampsia and tocolytic induced pulmonary edema, and pregnancy induced cardiomyopathy). Pregnancy by itself may add certain challenges such as difficult intubation. The critically ill pregnant patient requires a multidisciplinary approach and early inclusion of obstetrical expertise is paramount in managing these patients especially in the third trimester.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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14
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Abstract
Background: Maternal sepsis accounts for 11% of all maternal deaths worldwide. It is the third most common direct cause of maternal death and is a major contributor to other common causes of maternal death, such as haemorrhage and thromboembolism.
Methods: This review addresses important topics, including the epidemiology, risk factors, prevention, diagnosis, care bundles and management of maternal sepsis, including antibiotic treatment, and critical care interventions such as extracorporeal membrane oxygenation. Preventative measures that have had an impact on maternal sepsis as well as future research directions are also covered in this review. Case studies of maternal sepsis which highlight key learning points relevant to all clinicians involved in the management of obstetric patients will also be presented.
Results: Although, historically, maternal death from sepsis was considered to be a problem for low-income countries, severe obstetric morbidity and maternal death from sepsis are increasing in high-income countries. The global burden of maternal sepsis and the obstetric-related and patient-related risk factors and the likely sources are presented. Recent changes in definition and nomenclature are outlined, and challenges in diagnosis and identification are discussed.
Conclusions: Following maternal sepsis, early diagnosis and early intervention are critical to save lives and prevent long-term adverse sequelae. Dogma surrounding critical care interventions in pregnancy is being challenged, and future research is warranted to maximise therapeutic options available for maternal septic shock.
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Affiliation(s)
- Amaan Ali
- St Bartholomew's and The London School of Medicine and Dentistry, 4 Newark St, Whitechapel, London, E1 2AT, UK
| | - Ronnie F Lamont
- Department of Gynecology and Obstetrics, University of Southern Denmark, Institute of Clinical Research, Research Unit of Gynaecology and Obstetrics, Kløvervænget 10, 5000 Odense C, Denmark.,Division of Surgery, University College London, Northwick Park Institute for Medical Research Campus, Watford Road, London, HA1 3UJ, UK
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15
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Sahoo AK, Tripathy S, Singh SK. Prone ventilation in a patient with severe ARDS having a floating sternum. BMJ Case Rep 2019; 12:12/3/e227892. [PMID: 30862672 DOI: 10.1136/bcr-2018-227892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Prone ventilation is used to manage patients with refractory hypoxia in the critical care unit. Complex chest trauma and chest drains have been a considered relative contraindication to prone ventilation. To the best of our knowledge, it is hitherto unreported in patients having traumatic floating sternum and acute respiratory distress. We present a brief case report of a patient with floating sternum (complete disruption of sternum) managed successfully by prone position ventilation.
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Affiliation(s)
- Alok Kumar Sahoo
- Anaesthesiology & Critical Care medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Swagata Tripathy
- Anaesthesiology & Critical Care medicine, All India Institute of Medical Sciences Bhubaneswar, Bhubaneswar, Odisha, India
| | - Santosh Kumar Singh
- Medicine, Siksha O Anusandhan University Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
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16
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Muthu V, Agarwal R, Dhooria S, Prasad KT, Aggarwal AN, Suri V, Sehgal IS. Epidemiology, lung mechanics and outcomes of ARDS: A comparison between pregnant and non-pregnant subjects. J Crit Care 2018; 50:207-212. [PMID: 30572147 DOI: 10.1016/j.jcrc.2018.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 01/24/2023]
Abstract
PURPOSE We describe the epidemiology, lung mechanics and outcomes of acute respiratory distress syndrome (ARDS) complicating pregnancy. We also compare the outcomes of ARDS in pregnant and non-pregnant females. METHODS Retrospective observational study of all women admitted with ARDS. RESULTS 211 women with ARDS were admitted, which included 27 (12.8%) pregnant subjects. All were ventilated with a low tidal volume strategy. Most pregnant females presented during the third trimester. There was no difference in the lung compliance, the applied PEEP and the plateau pressures across trimesters. The pregnant females had a lower median age (25 [22-28] vs. 32 [22-42] years, p = 0.003), higher proportion of severe ARDS (40.8% vs. 10.3%, p < 0.0001), and higher driving pressure (18.2 vs. 15.5 cm H2O, p = 0.03) compared to non-pregnant females. The maternal (18.5%) and perinatal (37%) mortality was high. However, the mortality was not different between pregnant and non-pregnant subjects with ARDS. On a multivariate logistic regression analysis, the baseline APACHE II score, driving pressure and the delta SOFA score were independent predictors of mortality. CONCLUSIONS ARDS complicating pregnancy is severe and is associated with high perinatal mortality. However, the outcomes of ARDS in pregnant females were similar to non-pregnant females.
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Affiliation(s)
- Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
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The prone position in healthy pregnant women and in women with preeclampsia - a pilot study. BMC Pregnancy Childbirth 2018; 18:445. [PMID: 30445912 PMCID: PMC6240306 DOI: 10.1186/s12884-018-2073-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/23/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The prone position is rarely used in medical settings in pregnancy. There is no published information about the prone position in women with preeclampsia. This study examined the feasibility and acceptability of the prone position in pregnant women, and the short-term effect of the prone position on blood pressure (BP) in term healthy pregnant women and in women with preeclampsia. METHODS After ethics approval, written consent and trial registration (ACTRN:12615000160538 registered 18/02/2015, date of first participant enrolled 03/03/2015), 50 healthy term pregnant women and 15 women with preeclampsia had BP, heart rate (HR), oxygen saturation (SpO2), respiratory rate (RR), fetal heart rate (FHR) and comfort levels measured in two positions: left lateral, and prone. Measurements were after five minutes rest in each position. RESULTS Mean ± SD age, gestation and body mass index for healthy pregnant women was 33 ± 4.1 years, 38 ± 1.0 weeks and 27 ± 3.2 kg.m- 2 and for women with preeclampsia was 32 ± 4.7 years, 36 ± 3.4 weeks, 31 ± 5.6 kg.m- 2 respectively. No clinically significant changes occurred in healthy pregnant women in the prone position. Systolic BP was reduced in the prone position in women with preeclampsia (P = 0.019, mean difference - 6.6 mmHg, 95% confidence interval - 11.9 to - 1.3 mmHg). 33% of women with preeclampsia experienced a 10 mmHg or greater reduction in systolic BP in the prone position. 42% of healthy pregnant women and 47% of women with preeclampsia preferred the prone position to lateral. CONCLUSIONS This is the first study to examine the prone position in women with preeclampsia. For short periods of time the prone position is feasible and comfortable in pregnant women including those at term. The prone position may reduce systolic BP in women with preeclampsia without obvious adverse effects. Larger studies with women lying for longer periods in the prone position are required. Pregnancy should not be a contraindication to the prone position for short periods of time. TRIAL REGISTRATION ACTRN:12615000160538.
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18
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Respiratory Diseases of Pregnancy. EVIDENCE-BASED CRITICAL CARE 2017. [PMCID: PMC7121415 DOI: 10.1007/978-3-319-43341-7_89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Zieleskiewicz L, Chantry A, Duclos G, Bourgoin A, Mignon A, Deneux-Tharaux C, Leone M. Intensive care and pregnancy: Epidemiology and general principles of management of obstetrics ICU patients during pregnancy. Anaesth Crit Care Pain Med 2016; 35 Suppl 1:S51-S57. [PMID: 27386763 DOI: 10.1016/j.accpm.2016.06.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In developed countries, the rate of obstetric ICU admissions (admission during pregnancy or the postpartum period) is between 0.5 and 4 per 1000 deliveries and the overall case-fatality rate is about 2%. The most two common causes of obstetric ICU admissions concerned direct obstetric pathologies: obstetric hemorrhage and hypertensive disorders of pregnancy. This review summarized the principles of management of critically ill pregnant patient. Its imply taking care of two patients in the same time. A coordinated multidisciplinary team including intensivists, anesthesiologists, obstetricians, pediatricians and pharmacists is therefore necessary. This team must work effectively together with regular staff aiming to evaluate daily the need to maintain the patient in intensive care unit or to prompt delivery. Keeping mother and baby together and fetal well-being must be balanced with the need of specialized advanced life support for the mother. The maternal physiological changes imply various consequences on management. The uterus aorto-caval compression implies tilting left the parturient. In case of cardiac arrest, uterus displacement and urgent cesarean delivery are needed. The high risk of aspiration and difficult tracheal intubation must be anticipated. Even during acute respiratory distress syndrome, hypoxemia and permissive hypercapnia must be avoided due to their negative impact on the fetus. Careful analysis of the benefit-risk ratio is needed before all drug administration. Streptococcal toxic shock syndrome and perineal fasciitis must be feared and a high level of suspicion of sepsis must be maintained. Finally the potential benefits of an ultrasound-based management are detailed.
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Affiliation(s)
- Laurent Zieleskiewicz
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France.
| | - Anne Chantry
- Inserm UMR 1153, équipe de recherche en épidémiologie obstétricale, périnatale et pédiatrique (EPOPé), centre de recherche épidémiologie et statistique Sorbonne Paris Cité, DHU risques et grossesse, université Paris Descartes, 75014 Paris, France; École de sages-femmes Baudelocque, université Paris Descartes, DHU Risques et grossesse, Assistance publique-Hôpitaux de Paris, 75014 Paris, France
| | - Gary Duclos
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
| | - Aurelie Bourgoin
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
| | - Alexandre Mignon
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
| | - Catherine Deneux-Tharaux
- Inserm UMR 1153, équipe de recherche en épidémiologie obstétricale, périnatale et pédiatrique (EPOPé), centre de recherche épidémiologie et statistique Sorbonne Paris Cité, DHU risques et grossesse, université Paris Descartes, 75014 Paris, France
| | - Marc Leone
- Service d'anesthésie et de réanimation, Aix Marseille université, hôpital Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
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Abstract
In the first part of this review, the epidemiology of obstetric critical care is discussed. This includes the incidence of severe morbidity in pregnancy, identification of critically ill and potentially critically ill patients, the incidence of obstetric ICU admissions, the type of critical illness by stage of pregnancy, ICU admission diagnoses, the severity of illness in obstetric ICU patients compared to non-obstetric patients, ICU mortality of obstetric patients, the ICU proportion of total maternal mortality, and the causes of death for obstetric patients in ICU. In the second part, the management of obstetric patients who happen to be admitted to a general ICU is discussed. Rather than focusing on the management of particular obstetric conditions, general principles of ICU management will be discussed as applied to obstetric ICU patients. These include drug safety, monitoring the fetus, management of the airway, sedation, muscle relaxation, ventilation, cardiovascular support, thromboprophylaxis, and radiology and ethical issues.
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Affiliation(s)
- Alan Gaffney
- Department of Anesthesiology, Columbia University Medical Center, 622 W 168th St PH5-505, New York, NY 10032.
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21
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Samanta S, Samanta S, Wig J, Baronia AK. How safe is the prone position in acute respiratory distress syndrome at late pregnancy? Am J Emerg Med 2013; 32:687.e1-3. [PMID: 24412021 DOI: 10.1016/j.ajem.2013.12.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Accepted: 12/03/2013] [Indexed: 01/12/2023] Open
Abstract
We encountered a case of severe acute respiratory distress syndrome in late pregnancy due to influenza (H1N1) with refractory hypoxemia to conventional mechanical ventilation. Ventilation in prone position rescued this patient by maintaining oxygenation and sustaining improvement thereafter. Here, we discuss the mechanism of prone ventilation with special references to safety management of acute respiratory distress syndrome in the third trimester of pregnancy. It requires frequent monitoring of possible complications due to prone position and highly dedicated supporting staffs. More data are required on safety of proning in the late pregnancy.
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Affiliation(s)
- Sukhen Samanta
- Department of Anesthesia & Critical Care (Trauma Centre), JPNA Trauma Centre, AIIMS, New Delhi 110029 India.
| | - Sujay Samanta
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Luckow, 226014 India
| | - Jyotsna Wig
- Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education & Research, Chandigarh, 160012 India
| | - A K Baronia
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Luckow, 226014 India
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Ashton-Cleary DT, Duffy MR. Prone ventilation for refractory hypoxaemia in a patient with severe chest wall disruption and traumatic brain injury. Br J Anaesth 2012; 107:1009-10. [PMID: 22088877 DOI: 10.1093/bja/aer374] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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23
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Honiden S, Abdel-Razeq SS, Siegel MD. The management of the critically ill obstetric patient. J Intensive Care Med 2011; 28:93-106. [PMID: 21841145 DOI: 10.1177/0885066611411408] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.
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Affiliation(s)
- Shyoko Honiden
- Department of Medicine, Section of Pulmonary and Critical Care Medicine, Yale University School of Medicine, New Haven, CT 06520, USA.
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