Critical

Care in
Pregnancy

Introduction
A pregnant woman may present for critical
care support either with a disease state that
is unique to pregnancy or with a critical
illness that is not unique to pregnancy.
Preeclampsia
Eclampsia
HELLP syndrome
Amniotic fluid
syndrome

Maternal
hypertension
Thromboembolic
disease
Cardiac disease
Respiratory disease
Trauma

Hypertensive Disorders
Pregnancy Induced Hypertension
Defined as gestational hypertension without the
presence of proteinuria. Manifests as diastolic
hypertension that resolves 1-2 month after delivery.

Essential hypertension
Approximately one-third all causes high BP during
pregnancy, may present at any time during
gestation.
Differentiated from preeclampsia by the lack of
proteinuria in the last trimester.

Preeclampsia
Defined by the development of hypertension with
proteinuria, usually presenting after 20th week of
gestation but possible up to 1 week after delivery

 Preeclampsia is classified as severe with end organ

involvement if at least one of the following signs is
present:
Resting BP 160 mmHg systolic or 110mmHg diastolic
at any time, or
140mmHg systolic or 90 mmHg diastolic associated
with any of the complications listed below
Proteinuria 5g/24 h or 3+/ 4+ on urine dipstick
Oliguria (UO < 30ml/h for 3 consecutive hours)
A wide spectrum of systemic symptoms,

Acute renal failure

Pulmonary Edema
Impaired liver function
Headache
Visual changes
Thrombocytopenia

 Eclampsia
Defined as severe preeclampsia with
generalized tonic-clonic seizures
Seizures are its most dramatic manifestation,
other intracranial catastrophes, such as
hemorrhage, stroke, or intracranial
hypertension, are more likely to cause death
Usually occurs after 20 week gestation or
within 48 h after delivery
Benzodiazepines are appropriate as initial
therapy for seizures in eclampsia.

Management of hypertensive
Disorders
Hospital ICU admission
MgSO4 20% prevention seizures loading dose 4
to 6 g in 250ml saline over 10-15 min followed
by IV 1-2 g/h
Checked 2-4 h later and should in the range of
2.0-3.5 mmol/L
Maternal and fetal monitoring, ensuring
oxygenation
Discussed with OB and ICU physician
BP control
Diastolic shoud be gradually reduced to 90-100mmHg
Nitroglycerin, nicardipine, oral nifedipine

Treatment preeclampsia
Definitive treatment delivery
Seizure prophylaxis: MgSO4 4gr slow IV, 12gr/hour
Antihypertensive medication: NTG 50-100mcg
IV, Nifedipine 10mg sublingual
Fluid management, carefull pulmonary edema
Coagulation abnormalities thrombocytopenia

Treatment of eclampsia

Stop the convulsions (thiopental, 50-100mg IV)

Establish an airway, turn patient to the left side
Attempt bag and mask ventilation
Maintain ventilation and oxygenation
Apply monitor and pulse oxymeter
Maintain circulation (10ml/Kg)
Administer magnesium sulfate
Treat hypertension
Delivery the baby expenditiously

HELLP syndrome management

Hemolysis: hemolytic microangiopathic anemia
with an abnormal result on peripheral smear,
Total bilirubin level > 1.2mg/dL, or
Serum lactate > 600U/L

Elevated liver enzymes:

aspartate aminotransferase > 70U/L

Low platelet < 150.000/L

Treatment:

Supportive care
IV MgSO4
Antihypertensive therapy
Dexamethasone10mg every 12 hours

Trauma In Pregnancy
Treatment priorities are the same as those for
nonpregnant.
Be aware neurologic symptoms of eclampsia may
mimic head injury.
Aortocaval compression contribute
hypotension.
Pregnant px can lose up to 35% of blood volume
before significant sign of hypovolemia are seen.
Evaluate uterine irritability (fetal heart rate, fetal
movement).
Pelvic examination should be performed if
necessary.

Definitive care:
Adequate hemodynamic and respiratory
resuscitation, stabilization of the mother,
continued fetal monitoring and
radiographic studies as necessary.

In line Stabilization

Postpartum Hemorrhage
Frequent cause is uterine atony
General treatment:
Aggressive and early fluid resuscitation
Blood transfusion, include FFP after 4 U
PRC
Attempt to locate the source of bleeding
(ultrasound)
Surgical therapy may be required

Amniotic Fluid Embolism

Occurs during pregnancy or in the
intermediate postpartum period.
Presentation: hypoxia, shock, altered
mental status, DIC, seizure, agitation,
fetal distress, fever, chills, nausea, and
vomiting.
Diagnosis is clinical and a diagnosis of
exclusion.

 In pregnant or postpartum women who

abruptly and dramatically present with
profound shock and cardiovascular
collapse with severe respiratory distress
always consider AMNIOTIC FLUID
EMBOLISM !!
Occasionally, DIC is the first presenting
sign.

 Radiologic: pulmonary edema with

bilateral interstitial and alveolar
infiltrates.
Management: supportive, rapid maternal
cardiopulmonary stabilization and
preventing subsequent end-organ
damage.
The goals of therapy: maintenance
oxygenation, circulatory support,
correction of the coagulopathy

Severe Asthma
Asthma the most common pulmonary
condition in pregnancy.
Pharmacologic treatment of asthma
usually does not require modification
during pregnancy.
Supplemental oxygen.
Non-invasive positive-pressure
ventilation should be used cautiously
increased risk of aspiration.

Management:
Inhaled beta agonists and systemic
steroids is preferred
Antibiotics, if with respiratory infection
Intubation and mechanical ventilation
adjusted to avoid hyperventilation and
respiratory alkalosis
Consider termination of pregnancy via
CS, if with refractory asthma

Peripartum cardiomyopathy
Defined as systolic heart failure that occurs
during the last month of pregnancy or in the 1 st 5
month postpartum
Clinical symtoms include

Severe progressive dyspnea

Progressive orthopnea
Noctural dyspnea
Syncope with exertion

Signs

Right and left heart failure

Cardiomegaly
Pulmonary hypertension
Cyanosis

Peripartum Cardiomyopathy
Management

Bed rest
Sodium restriction
Diuretics
IV inotropic support: dobutamine
Afterload reduction: milrinone