Review Article (J Intensive Care Med. 2006 Sep-Oct;21(5):278-86)
Back to topVent Stuff
↑ alveolar ventilation (20-40%), ↑ TV, ↑ RR
Compensated hypocarbia (Normal 25-32 and normal bicarb 18-21)
Mechanical ventilation- need to adjust for PaCO2 30-32 (compensated hypercarbia); no studies show harm with permissive hypercarbia
Faster desaturation: ↑ O2 consumption + ↓ function residual capacity + ↑ small airway collapse with exhalation
Back to topMeds
Avoid benzos and NSAIDs
First line should be norepi for pressors
Back to topPlacenta
No auto-regulation of the blood supply, fetal distress may = mom compensated shock
Back to topFetal Monitoring
Uterine Activity
consider monitoring after 20 weeks
Fetal Heart Rate Monitoring
consider after 24 weeks
mom in full lateral tilt, IV fluids, supp. ox
Back to topHematological changes
↑ RBC mass (20%)
↑ Plasma volume (40-50%)
Back to topSepsis
pyelo more common
chorioamnionitis
endometritis
ScvO2 not accurate
Critical Care
Sedation- avoid benzos and NSAIDS; limited data exists for Propofol or Precedex
Vasopressors- #1 is NE!
Fetal monitoring-
Look for uterine contractility- eval for abruption or premature labor >20 weeks
Start fetal HR monitoring EARLY, is an early warning for maternal distress
Sepsis- UTI/Pyelo are common; post-partum: Endometritis
Maternal trauma- even minor trauma can cause fetal harm, recommend:
4 hrs min of Fetal HR monitoring, longer with: 1) contraction, bleeding, abdominal pain
Steroids early for surfactant formation
Image mom as NEEDED (don’t hold back if its is important)
Put in chest tubes HIGHER than expected
Fetomaternal hemmorhage: 30% of trauma patients
Quant: Kleinhauer-Betke testing (fetal cells in circulation
Give Rho-Gam early
Pregnancy Specific Problems:
Pre-eclampsia/Eclampsia:
Features: HTN, Hypovolemia, Renal dysfunction
40% of Eclampsia is post-partum
Tx: HTN meds, MgSO4 (watch for AKI)
HELLP:
15% w/o HTN or proteinuria
Features: plts<100, hemolytic anemia, LFT dysfunction, and RUQ pain
Tx all SBP>160 or DBP>110 = ↓ CVA risk
Acute fatty liver of pregnancy:
Features: similar to HELLP but with more significant liver failure
Tx: delivery (though some need transplant)
Amniotic fluid embolism:
Normally immediately following labor (w/in 8 mins)
SIRS + anaphylaxis → severe hypoxemia
20-40% mortality (with severe neurological morbidity)
DIC is a staple of the disease
Cardiomyopathy:
Peripartum (up to 5 months)
LVEF <30%
↑ to trop/BNP = worse outcome
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