General Care of the Pregnant Patient in the Intensive Care Unit

Timothy M.E. Crozier, MBBS (Hons), FRACP, FCICM, MPH

Disclosures

Semin Respir Crit Care Med. 2017;38(2):208-217. 

In This Article

Abstract and Introduction

Abstract

Pregnant women represent a small subset of all intensive care unit (ICU) admissions and may require intensive care for "obstetric" or "nonobstetric" reasons. Women may be admitted to the ICU at any stage of pregnancy or in the postpartum period. Pregnancy may be discovered at the time of admission to the ICU. Pregnancy impacts on ICU care in a variety of ways and requires a multidisciplinary approach to management. Pregnancy is associated with considerable physiological changes that affect most organ systems, including an expansion in blood volume, an increase in minute ventilation, and an increased risk of thrombosis. The enlarging uterus may be associated with mechanical complications due to compression and displacement of other structures. The growing fetus places considerable demands upon the mother, being reliant on maternal systems for oxygenation, nutrition and disposal of carbon dioxide, and other waste products. This "second patient" must be considered when managing the pregnant woman. Optimal management of the mother usually constitutes best treatment for the fetus. Maternal shock and physiological disturbance, medications, and ionizing radiation from diagnostic imaging may have harmful effects on the unborn child. Delivery of the fetus for either maternal or fetal indications may be necessary and should be planned for, even if considered unlikely to be required. Care of the postpartum woman has its own challenges, including managing lactation and facilitating mother/infant contact. In this article, the general care aspects of ICU treatment of the pregnant woman will be discussed, including monitoring, physiological target setting, and general supportive care.

Introduction

Maternal intensive care unit (ICU) admission is an uncommon occurrence, with an incidence of between 7 and 13.5 admissions per 1,000 live births.[1] Women may be admitted with obstetric or nonobstetric conditions, although the most common reasons for admission are hypertensive spectrum disorders and obstetric hemorrhage.[1] Obstetric conditions leading to ICU admission are discussed in another article. Nonobstetric conditions leading to ICU admission are a mixed group. Some chronic medical conditions such as systemic lupus erythematosus may flare during pregnancy,[2] or else a previously asymptomatic underlying condition such as valvular heart disease may be unmasked by the physiological demands of pregnancy. Other acute insults such as sepsis or trauma leading to ICU admission may be superimposed onto an otherwise uncomplicated pregnancy in a healthy woman.

Irrespective of the reason for admission, pregnant women require special consideration in their day-to-day ICU care. A multidisciplinary approach to care is important, including involvement of an obstetrician. Significant maternal physiological changes occur in pregnancy that may make recognition of pathophysiology more challenging. Physiological target setting needs to account for these changes to ensure maternal organ protection as well as providing an adequate uteroplacental circulation. Hormonal anatomical changes such as airway edema or breast enlargement may make airway procedures difficult. Maternal obesity and excessive weight gain may make mechanical ventilation and invasive procedures more challenging. As pregnancy continues, the presence of a viable fetus presents challenges surrounding maternal management decisions and delivery scenarios. The enlarging uterus can obstruct vena caval and aortic flow in the supine position, necessitating lateral positioning in bed. Pregnant women have altered nutritional requirements and so artificial nutrition strategies must be adapted to provide adequate and appropriate caloric intake. Pregnancy is a prothrombotic state, and deep venous thrombosis (DVT) prophylaxis and surveillance are vitally important. ICU care in the postdelivery phase and postpartum state has its own challenges, including management of lactation and promotion of mother/infant contact in a scenario where both mother and infant may be critically ill.

In addition to these and other medical considerations, a maternal ICU stay is also highly emotionally charged and stressful for patients, families, and caregivers. Issues of maternal or fetal mortality and morbidity are highly confronting and may be very difficult to manage, and adequate support must be provided to all involved.

processing....