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KEY POINTS
Critical illness in obstetrics can be the result of pregnancy-specific conditions or due to commonly seen critical care diagnoses with unique-management considerations in pregnancy as a result of physiologic alterations and fetal concerns.
Any pregnant patient requiring ICU level care should be in a facility with obstetric and neonatal teams for collaborative multidisciplinary care.
A critically ill pregnant patient is at risk for labor and delivery, regardless of the initial inciting condition.
For patients who are still pregnant, in general, the rule is for maternal stabilization prior to delivery of the fetus. In most cases, appropriate treatment of the mother will improve fetal status.
The American Heart Association publishes guidelines for cardiac arrest in special situations including pregnancy. Key interventions to prevent arrest in a critically ill pregnant woman include left lateral positioning, 100% oxygen, IV access above diaphragm, and treatment of hypotension.
In maternal cardiac arrest not immediately reversed by basic life support and advanced cardiovascular life support (ACLS), prompt consideration for emptying the uterus must be undertaken (“perimortem cesarean”). For this to be feasible, resuscitation teams must activate a protocol for possible cesarean delivery as soon as a maternal cardiac arrest is identified.
Important obstetric conditions outlined within the text include preeclampsia, eclampsia, hemolysis, elevated liver enzymes, and low platelets syndrome, acute fatty liver of pregnancy, anaphylactoid syndrome of pregnancy/amniotic fluid embolism, peripartum cardiomyopathy, and obstetric hemorrhage.
Nonobstetric conditions with a focus on presentation in pregnancy outlined within the text include thromboembolic disease, severe sepsis, septic shock, and multiorgan failure, pulmonary edema, arrhythmia, diabetic ketoacidosis, and status asthmaticus.
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The mortality rate for critically ill obstetric patients ranges from 12% to 20%. A recently published retrospective study described the current leading diagnoses associated with ICU admission in obstetrics. ICU admissions related to abortions and ectopic pregnancy accounted for 10% of all ICU admissions among pregnant and postpartum women. Leading causes for antepartum admissions included obstetric-related hypertensive disease (23%), trauma (17%), and cardiac disease (13%). Delivery-related ICU admissions were overwhelmingly related to obstetric-related hypertensive disease (38%), hemorrhage (33%), and cardiac disease (18%). Postpartum admissions were most often attributed to cardiac disease (37%), obstetric-related hypertensive disease (21%), and cerebrovascular disease (20%).
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Critical illness in obstetrics can be the result of pregnancy-specific conditions or due to commonly seen critical care diagnoses which may have unique-management considerations in pregnancy as a result of physiologic alterations and fetal concerns. Herein, we will review physiologic adaptations due to pregnancy by systems, general considerations for the critically ill pregnant patient, and management strategies for both pregnancy-specific conditions and critical medical conditions seen most commonly in gravid women.
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PHYSIOLOGIC ADAPTATION TO PREGNANCY
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Gestation in singleton pregnancies lasts an average of 40 weeks spanning from the first day of the last menstrual period to the estimated date of delivery. Previously, “term pregnancy” was defined as the period between 37 ...