Obstetric complications in pulmonary and critical care medicine

Long-term maternal and subsequent pregnancy outcomes 5 years after hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome

OBJECTIVE

To evaluate subsequent pregnancy outcome and impact of gestational age at onset of HELLP on long-term prognosis after HELLP over an average follow-up of 5 years

STUDY DESIGN

One hundred twenty-eight patients with a history of HELLP filled out questionnaires and sent their medical records. Hemolysis, elevated liver enzymes, and low platelets data were stratified according to gestational age at onset of HELLP < or =28 weeks and >28 weeks.

RESULTS

Fifty-three patients had subsequent pregnancies with 24% complicated by HELLP and 28% by preeclampsia. During follow-up, 33% of the patients had new onset hypertension develop, 32% had depression develop, 26% had anxiety develop, and 2.4% required dialysis. There was no significant difference in long-term outcome between comparison groups.

CONCLUSION

Patients with a history of HELLP are at increased risk for preeclampsia and HELLP as well as long-term morbidities as depression and chronic hypertension. Gestational age at the onset of HELLP could be a predictor for long-term outcome.

Obstetric disorders in the ICU

Obstetric disorders account for 55% to 80% of admissions to the intensive care unit in the obstetric population. Medical conditions are emerging as the leading cause of maternal mortality, partly because of marked improvement in surgical and obstetric care in the developed world. The rise in maternal mortality related to medical conditions can be explained by multiple factors: improved medical care, women with chronic illnesses reaching childbearing years, older age at time of first pregnancy, improved reproductive technologies, and severe medical conditions exacerbated by the physiologic changes of pregnancy. This article reviews obstetric disorders leading to intensive care unit admissions.

Clinical characteristics and outcomes of obstetric patients requiring ICU admission

OBJECTIVES

To review a series of critically ill obstetric patients admitted to our ICU to assess the spectrum of disease, required interventions, and fetal/maternal mortality, and to identify conditions associated with maternal death.

DESIGN

Retrospective cohort.

SETTING

Medical-surgical ICU in a university-affiliated hospital.

PATIENTS

Pregnant/postpartum admissions between January 1, 1998, and September 30, 2005.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

We studied 161 patients (age, 28 +/- 9 years; mean gestational age, 29 +/- 9 weeks) [mean +/- SD], constituting 10% of 1,571 hospital admissions. APACHE (acute physiology and chronic health evaluation) II score was 14 +/- 8, with 24% predicted mortality; sequential organ failure assessment score was 5 +/- 3; and therapeutic intervention scoring system at 24 h was 25 +/- 9. Forty-one percent of patients required mechanical ventilation (MV). ARDS, shock, and organ dysfunction were present in 19%, 25%, and 48% of patients, respectively. Most patients (63%) were admitted postpartum, and 74% of admissions were of obstetric cause. Hypertensive disease (40%), major hemorrhage (16%), septic abortion (12%), and nonobstetric sepsis (10%) were the principal diagnoses. Maternal mortality was 11%, with multiple organ dysfunction syndrome (44%) and intracranial hemorrhage (39%) as main causes. There were no differences in death rate in patients admitted for obstetric and nonobstetric causes. Fetal mortality was 32%. Only 30% of patients received antenatal care, which was more frequent in survivors (33% vs 6% nonsurvivors, p = 0.014).

CONCLUSIONS

Although ARDS, organ failures, shock, and use of MV were extremely frequent in this population, maternal mortality remains within an acceptable range. APACHE II overpredicted mortality in these patients. Septic abortion is still an important modifiable cause of mortality. Efforts should concentrate in increasing antenatal care, which was clearly underprovided in these patients.

Acute asthma in pregnancy

OBJECTIVES

To provide an overview on the interrelationship between asthma and pregnancy, focusing on management of pregnant women presenting with an acute severe exacerbation.

DESIGN

A review of the current English-language published clinical trials was performed based on MEDLINE search using the Medical Subject Headings pregnancy and asthma. Current reviews on the topic and practice guidelines were also reviewed.

RESULTS

Asthma is the most common medical condition to complicate pregnancy, and episodes of acute asthma requiring emergency department visits or hospitalization have been reported in 9-11% of pregnant women managed by asthma specialists. Pregnancy can affect the course of asthma, and the risk of asthma exacerbations requiring intervention in pregnant women is higher than in nonpregnant women. Similarly, asthma can affect pregnancy outcomes. Maternal inflammatory pathways may contribute to the poor pregnancy outcomes, especially in women with uncontrolled asthma. Although data on the effects of maternal asthma on pregnancy have been conflicting, mainly because many published studies have not corrected for asthma severity, it has generally been observed that poorly managed asthma during pregnancy is associated with a higher risk of preterm delivery, low birth weight, and complications such as preeclampsia. Optimal therapy of asthma has been shown to contribute to improved maternal and fetal outcomes.

CONCLUSIONS

Asthma can complicate the course of pregnancy, and pregnancy can worsen asthma control in some women. Optimal management of asthma during pregnancy is key in ensuring the safety of the mother and the fetus.

Critical illness in pregnancy: an overview

OBJECTIVES

To provide an overview of the critical illnesses that afflict the pregnant patient.

DESIGN

A comprehensive review of the literature was performed with Pubmed Medline using medical subject headings of pregnancy, critical care, epidemiology, prognostic score, dyspnea, fever, and jaundice.

RESULTS

Although pregnant women constitute a small number of admissions to an intensive care unit, they pose a challenge to the health care team. The physiological changes that occur in pregnancy stress and limit the compensatory response required to adapt to a superimposed acute illness. Although a number of conditions are uniquely associated with pregnancy, other medical conditions may complicate the course of pregnancy. The pregnant state also increases susceptibility to a number of illnesses. In this overview, we reviewed the epidemiology and different clinical presentations of critical illness in a pregnant patient.

CONCLUSIONS

The critically ill pregnant patient presents a challenge to the critical care physician due to unique physiology and specific medical disorders in this population.

Cardiopulmonary complications of pregnancy

OBJECTIVES

To provide an up-to-date review of the literature on the assessment and management of pulmonary and cardiac conditions that may affect women during pregnancy and the postpartum period.

DESIGN

A review of the current literature was performed.

RESULTS

Pregnancy may be complicated by a variety of pregnancy-specific and other cardiopulmonary complications. Management requires knowledge of the cardiopulmonary physiologic changes occurring in pregnancy, the pregnancy-specific conditions that may occur, and the effect of a fetus on maternal care.

CONCLUSIONS

Admission of the pregnant or postpartum woman to the intensive care unit is uncommon but may require specialized knowledge for successful management.

Critical illness and pregnancy: review of a global problem

Obstetric patients are a small but important group of patients in the intensive care unit (ICU). Their problems are unique and need specialized attention. Decision making may be confounded by physiologic changes in pregnancy. In developed countries with good antenatal care, comparatively fewer obstetric patients are admitted to ICUs, but the maternal mortality rate remains high in the developing countries. Medical disorders and organ dysfunction caused by critical illness of pregnancy differ from region to region. With improvement in antenatal care, the number of ICU admissions for obstetric disorders would decline in developing countries; however, this number may increase gradually in developed countries because of increasing maternal age and pregnancies in women with complicated chronic medical disorders.

Acute lung injury and acute respiratory distress syndrome in pregnancy

Acute respiratory failure can be the result of a variety of clinical conditions, such as congestive heart failure, pneumonia, pulmonary embolism, exacerbation of obstructive lung diseases, and acute respiratory distress syndrome (ARDS). This article focuses on developments related to acute lung injury and ARDS and reviews epidemiology, pathogenesis and therapeutic advances with an emphasis on the obstetric population. A brief discussion of tocolytic-induced pulmonary edema, preeclampsia, venous air embolism, and aspiration-related ARDS is included. Management of pregnant women with ARDS is outlined.

Extended somatic support for pregnant women after brain death

OBJECTIVE

To review case reports of pregnant women who have been supported after brain death until successful delivery of their infants. From these reports and other literature about brain death, normal physiologic changes of pregnancy, and specific needs for fetal development, recommendations were made to assist in supporting pregnant women after brain death until delivery of a mature fetus who is likely to survive.

DATA SOURCES

Personal files and experiences, MEDLINE review of case reports and publications about physiologic changes present during normal pregnancy and after brain death, and the critical needs for fetal development were included.

DATA EXTRACTION

Eleven reports of ten patients comprise the accumulated clinical experience. Hypotension, requiring fluid administration and inotropic/vasopressor therapy, occurred in all the mothers, and in six cases, was the reason for urgent delivery. The longest period of support was 107 days, from 15 to 32 wks of gestation. Two mothers also became organ donors. Recurrent infections, thermolability, and other complications common to prolonged ICU care were encountered. All infants survived. One had congenital abnormalities caused by phenytoin use by the mother. When followed, all others developed within normal growth and mental variables. These cases plus literature citations noted above were used to develop recommendations for maternal/fetal care.

CONCLUSION

Preservation of uterine/placental blood flow is the most important priority during somatic support. Imprecise autoregulation of the uterine vasculature during maternal hypoxemia or hypotension makes this goal a significant challenge. Special considerations for nutrition; medication use; cardiovascular, respiratory, or endocrine therapy; fetal monitoring; hormone replacement; and ethical concerns are discussed.

Critical care obstetrics and gynecology

The critical care aspects of obstetrics and pregnancy are varied and demand that critical care practitioners have a thorough knowledge of fetal and maternal changes in physiology as pregnancy progresses. Pregnancy can affect every organ system; and organ-specific conditions as well as syndromes that span multiple organ systems were described. Care of the critically ill, pregnant patient requires a true multidisciplinary approach for optimal outcomes. A review of the current concepts and suggestions for therapy were presented.

Cardiac disease and pregnancy

The pregnant state imposes a supraphysiologic strain on the pregnant woman's cardiac performance through complex biochemical, electric, and physiologic changes affecting the blood volume, myocardial contractility, and resistance of the vascular bed. In the presence of underlying heart disease, these changes can compromise the woman's hemodynamic balance, her life, and that of her unborn child. Cardiac pathology represents a heterogeneous group of disorders, each with its own hemodynamic, genetic, obstetric, and social implications. Physicians caring for these women should actively address the issue of reproduction. Ideally, pregnancy should be planned to occur after optimization of cardiac performance by medical or surgical means. Once pregnancy is achieved, the concerted effort of a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, nursing, social, and other services provides the best opportunity to carry the pregnancy to a successful outcome.

Non-haemorrhagic obstetric shock

The causes of non-haemorrhagic obstetric shock (pulmonary thromboembolism, amniotic fluid embolism, acute uterine inversion and sepsis) are uncommon but responsible for the majority of maternal deaths in the developed world. Clinically suspected pulmonary thromboembolism should be treated initially with heparin and objective testing should be performed. If the diagnosis is confirmed, heparin is usually continued until delivery, following which anticoagulation in the puerperium is achieved with either warfarin or heparin. Amniotic fluid embolism is a rare complication of pregnancy, occurring most commonly during labour. The management of amniotic fluid embolism involves maternal oxygenation, the maintenance of cardiac output and blood pressure, and the management of any associated coagulopathy. Acute uterine inversion arises most commonly following mismanagement of the third stage of labour. The shock in uterine inversion is neurogenic in origin, although there may also be profound haemorrhage. The management of this condition includes maternal resuscitation and replacement of the uterus either manually, surgically or by hydrostatic pressure. Genital tract sepsis remains a significant cause of maternal death, the most common predisposing factor being prolonged rupture of the fetal membranes. The management of septic shock in pregnancy includes resuscitation, identification of the source of infection and alteration of the systemic inflammatory response.