Patient Care Vignette
A 33-year-old patient at 28 weeks gestation presents to the emergency department with a fever, and back and flank pain as well as symptoms that suggest a urinary tract infection (UTI). This is her first pregnancy and she and her partner are quite anxious about the developing baby. She has a history of obstructive kidney stones that have required treatment multiple times over the last 5 years. Her current symptoms were similar to symptoms she had experienced about 3 weeks into her current pregnancy when she was also treated for a UTI. Because she was pregnant, she was initially evaluated in Obstetrical Triage where blood and urine cultures were obtained. Based on a high heart rate and a low blood pressure, she had two IV lines placed and she was administered 2 liters of intravenous fluid. She was also started on pregnancy-compatible antibiotics to treat her UTI as well as any urinary bacteria that were in her bloodstream.
Despite fluid resuscitation, her blood pressure remained low and her laboratory profile demonstrated an increasing amount of acid in her bloodstream (lactic acid, a lab marker of poor blood flow and oxygen delivery). To help with blood pressure of both mother and baby, a continuous infusion of a blood pressure–raising medication (vasopressor agent) was started. To assess the developing baby, fetal heart rate monitoring was initiated. It demonstrated indeterminate tracings that required ongoing surveillance as they were neither normal nor completely reassuring. The patient started to have contractions every 2 minutes, which were tracked by the monitor. Given her low blood pressure that needed fluid resuscitation and a vasopressor infusion, frequent uterine contractions, and indeterminate fetal heart rate tracings, she was admitted to the ICU for septic shock management.
Approximately 1-10 per 10,000 pregnant patients are admitted to the ICU in the United States each year, with most patients being admitted immediately following delivery. The majority of these patients require critical care due to postpartum hemorrhage or complications of preeclampsia. ICU stay is typically short (∼2 days) and patients are more likely to be Black, are older than 35 years of age, and have their child or children delivered by cesarean section. Internationally, epidemiologic risk factors are similar to that of the general intensive care population, but the United States continues to have higher rates of maternal mortality compared to other developed countries. This chapter addresses special considerations of the obstetric population in the ICU, and the importance of a collaborative approach between the intensivist, obstetric care clinicians, other consultants, and bedside staff. It will also help patients and families understand the kinds of medical or surgical conditions that impact pregnancy and how the required care influences post-ICU survivorship.
ICU CARE CONSIDERATIONS FOR THE OBSTETRIC POPULATION
Obstetrical and Postpartum Bleeding
The majority of obstetrical patients admitted to an ICU have either obstetrical (still pregnant) ...