Академический Документы
Профессиональный Документы
Культура Документы
Matthew C Frise*
Charlotte J Frise*
Catherine Nelson-Piercy
Abstract
From 2006 to 2008, 261 women in the United Kingdom died either as
a direct or indirect result of pregnancy. More than half of these received
critical care input. The support required varied from observation and
supportive management to multi-organ support. In many women death
occurred despite optimal care, but in a number substandard care was
identified when the cases were reviewed as part of the Confidential
Enquiry into Maternal Deaths. An understanding of the different types
of organ support and treatment that are available in a critical care setting
and when these are indicated is therefore crucial for medical professionals caring for these unwell obstetric patients.
Described here are the technical aspects of organ support that can be
utilized in a critical care setting and the alterations in physiology that
occur in pregnancy which influence the use of each treatment modality.
Also highlighted in more detail are conditions that are common or life
threatening in pregnancy and key points about management of these
conditions when they mandate critical care support.
Introduction
The majority of pregnant women negotiate pregnancy, delivery
and the post-partum period without any significant complication.
A small number of women, however, can become severely
unwell with pregnancy-related conditions such as eclampsia or
acute fatty liver of pregnancy, or develop complications from preexisting conditions that are worsened by the physiological
changes of pregnancy or delivery. Despite the best efforts of
241
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users September 24, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
REVIEW
Types of patient
Obstetric examples
Level 0
Level 1
Level 2
C
C
C
C
Level 3
Table 1
Cardiovascular
At the simplest level, more intensive monitoring can be utilized
involving either non-invasive (frequent measurement of blood
pressure, continuous cardiac monitoring and oxygen saturations,
meticulous fluid balance) or invasive measures (arterial lines,
central venous pressure monitoring). This allows judicious fluid and
if necessary blood product therapy and correction of electrolyte
disturbances.
Patients receiving vasoactive drugs will require invasive blood
pressure monitoring using an arterial line. Commonly used
agents include norepinephrine, a vasopressor predominantly
causing peripheral vasoconstriction, and dobutamine, an inotrope mainly increasing cardiac work. Many such drugs have to
be given into a central vein via central venous catheters, which
also allow measurement of central venous pressure (CVP) and
mixed venous oxygen saturation (a marker of oxygen extraction
by the tissues and hence adequacy of cardiac output). Various
techniques exist for measuring cardiac output including oesophageal Doppler probes (only in sedated, intubated patients) and
lithium dilution cardiac output (LiDCO). The once favoured
pulmonary artery catheter is now used infrequently, following
recognition of its significant complication rate and lack of
evidence of beneficial effect on outcome.
242
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users September 24, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
REVIEW
Renal
Glomerular filtration increases in pregnancy leading to a fall in
plasma creatinine, but tubular reabsorption is unable to match
this, so mild glycosuria and proteinuria may be normal. Acute
kidney injury (AKI) can be signalled by a fall in urine output
before any rise in plasma creatinine, and a small rise in serum
creatinine may indicate very significant renal injury. Treatment
involves identifying and treating the underlying cause. Nephrotoxic drugs should be withdrawn, hypovolaemia corrected and
renal replacement therapy instituted if needed. Oliguria and
a mild rise in creatinine may be seen in pre-eclampsia and liberal
fluid administration risks pulmonary oedema, the mortality and
morbidity from which are far greater than from AKI. A degree of
polyuria is normal after delivery.
243
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users September 24, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
REVIEW
C
C
C
Box 1
Hepatic
Close monitoring and supportive care are needed to correct the
biochemical and haematological derangement that occur with
hepatic impairment, including hypoglycaemia, coagulopathy and
acidosis, alongside optimization of fluid balance. N-acetylcysteine may be used but there is a lack of supporting evidence in
non-paracetamol related acute liver injury. If hepatic encephalopathy develops, intubation for airway protection may be
required and intracranial pressure monitoring may be instituted.
Empirical antibiotics and antifungal agents are also used. Regular
lactulose is given to reduce the absorption of ammonia which can
worsen encephalopathy.
Fulminant liver failure is suggested by hypoglycaemia,
hyperlactataemia and derangement of synthetic function (falling
albumin and increasing prothrombin time) as opposed to an
isolated increase in transaminases. This occurs in a small
number of women with pregnancy-related liver disease and may
require transfer to a tertiary liver centre for consideration of
transplantation. The criteria for transplantation referral that are
used outside pregnancy are not reliable in pregnancy and so
earlier referral of these women is advised.
Shock
Shock describes the circulatory state where cardiac output is
inadequate to meet tissue oxygen demands. There are several
different types based on the underlying pathophysiology and
characteristic clinical features are recognized (Table 2). The
causes of shock most often seen in obstetric patients are sepsis
and hypovolaemia following haemorrhage. The clinical appearance is highly variable and in this population pathologies may
coexist to complicate the picture, for example sepsis and
obstetric haemorrhage due to septic abortion.
Classifying sepsis and related syndromes
Systemic inflammatory response syndrome (SIRS) is encountered
in response to a range of pathological processes and is defined as
two or more of the following:
Temperature below 36 C or above 38 C
Heart rate above 90 beats per minute
Respiratory rate greater than 20 per minute (or hypocapnia
below 4.3 kPa)
White cell count less than 4 109/litre or greater than
12 109/litre or >10% immature forms.
When infection is proven or suspected in the setting of SIRS
a diagnosis of sepsis is made. If there is associated organ
dysfunction such as confusion or hypotension then the patient is
Gastrointestinal
Early delivery of nutrition is important to aid wound healing and
prevent the consequences of malnutrition in all critically ill
patients. Specialist dietetic input is required in obstetric patients
Classification of shock
Type
Pathophysiology
Typical appearance
Examples
Hypovolaemic
Cardiogenic
Distributive
Obstructive
Neurogenic
Volume depletion
Pump failure
Uncontrolled vasodilatation
Blood flow obstructed
Loss of sympathetic tone
Table 2
244
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users September 24, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
REVIEW
Haemorrhage
Major obstetric haemorrhage is defined as blood loss greater than
1000 ml. This occurs in approximately 3.7 per 1000 deliveries
and the commonest contributory factor is uterine atony. This was
the most common reason for critical care admission in women
described as recently pregnant in the recent ICNARC report.
Admission to critical care permits close monitoring and delivery
of large quantities of blood products as determined by local
massive haemorrhage protocols. Correction of DIC and observation for signs of ALI/ARDS are also key management
principles.
Venous thromboembolism
Maternal mortality from venous thromboembolism (VTE) is
falling. This is likely to be the result of heightened awareness of
risk factors for VTE in pregnancy and the increasing use of
antenatal and postnatal prophylactic anticoagulation. The
majority of women with acute VTE can be managed with low
molecular weight heparin either on a maternity ward or as an
outpatient. Management in a critical care setting should be
considered for women with large pulmonary emboli, especially
those causing haemodynamic compromise. Augmentation of
preload by fluid resuscitation is crucial. Thrombolysis is
a potential treatment option if there is evidence of shock despite
filling, significant right ventricular dysfunction on echocardiography or right ventricular injury (i.e. increased troponin
concentration).
245
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users September 24, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
REVIEW
The data from the most recent triennial report show that there
were no deaths in pregnant women as a result of OHSS but there
were two deaths in non-pregnant women. If this condition
develops, supportive care is needed and strict fluid balance to
maintain euvolaemia and renal perfusion.
Amniotic fluid embolism
This is a rare, unpredictable, unpreventable and often fatal event
of unclear aetiology, the diagnosis of which can be made by
demonstrating fetal squames in the maternal pulmonary circulation either at post-mortem or from blood taken from a pulmonary artery catheter. Previous data describe maternal mortality
rates of up to 86% but more recent information suggests the rate
is lower at approximately 26e30%. The symptoms are often nonspecific and overlap with those of other conditions particularly
pulmonary emboli, as the common presenting symptoms include
breathlessness and maternal cardiovascular collapse. Impaired
cardiac function, arrhythmias, DIC and seizures can also occur.
Supportive care in a critical care setting is usually necessary if the
patient survives the acute event.
246
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users September 24, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
REVIEW
General considerations
Gestational age
At gestational ages that are not compatible with ex utero survival,
continuous fetal monitoring is difficult and abnormal results
would not lead to delivery being expedited. Delivery would only
be considered if the pathology was thought to be placentally
mediated and life threatening to the mother, for example worsening severe early onset pre-eclampsia.
At gestational ages compatible with ex utero survival, regular
assessment of fetal wellbeing is needed, either by ultrasound
imaging, fetal heart rate monitoring or cardiotocography (at the
appropriate gestational age). A decision must be made as to
whether delivery will alter the natural history of the condition
and improve maternal survival and needs to take into account
the risks of delivery to the mother, in addition to the risks of
preterm delivery to the fetus. These decisions can be very difficult and often benefit from multidisciplinary team discussion
including the consultant obstetrician. They need to be reviewed
on a regular basis and when the clinical condition changes. If
preterm delivery is a possibility, intramuscular steroids to aid
fetal lung maturation should be considered.
FURTHER READING
Bersten A, Soni N, eds. Ohs intensive care manual. 6th edn. ButterworthHeinemann, 2008.
Bone R, Balk R, Cerra F, et al. Definitions for sepsis and organ failure and
guidelines for the use of innovative therapies in sepsis. The
ACCP/SCCM Consensus Conference Committee. American College of
Chest Physicians/Society of Critical Care Medicine. Chest 1992; 101:
1644e55.
Centre for Maternal and Child Enquiries (CMACE). Saving mothers lives:
reviewing maternal deaths to make motherhood safer: 2006e08. The
Eighth Report on Confidential Enquiries into Maternal Deaths in the
United Kingdom. BJOG 2011; 118(suppl 1): 1e203.
Critical care in obstetrics. In: Scholefield H, ed. Best Pract Res Clin Obstet
Gynaecol 2008; 22: 761e996.
Female admissions (aged 16e50 years) to adult, general critical care units
in England Wales and Northern Ireland, reported as currently pregnant or recently pregnant. 1 January 2007e31 December 2007
ICNARC, 2009. www.oaa-anaes.ac.uk/assets/_managed/editor/File/
Reports/ICNARC_obs_report_Oct2009.pdf.
Royal College of Obstetricians and Gynaecologists. Bacterial sepsis in
pregnancy. Green-top guideline No. 64a. London: RCOG, 2012.
West JB. Pulmonary pathophysiology: the essentials. 7th edn. Lippincott
Williams & Wilkins, 2008.
Westbrook RH, Yeoman AD, Joshi D, et al. Outcomes of severe pregnancyrelated liver disease: refining the role of transplantation. Am J
Transplant 2010; 10: 2520e6.
Logistics
When obstetric patients require critical care this often occurs in
a setting geographically remote from maternity services. Plans
must be put in place to manage obstetric emergencies in this
setting. If there is a possibility of emergency delivery, equipment
including a caesarean section pack should be located on the same
unit as the patient. Access to emergency drugs should also be
arranged, in particular those used often in the obstetric setting
but not in routine use in the general adult critical care setting
such as syntocinon and ergometrine.
A plan for fetal monitoring is essential. This should include daily
midwifery visits, fetal heart rate monitoring and cardiotocography
if appropriate. This is particularly relevant if the patient is sedated
and unable to report the presence or absence of fetal movements.
Practice points
Post-partum
If a woman requires critical care support after delivery, additional measures have to be considered. The severity of the
maternal illness may distract attention from normal postnatal
care, including anti-D for rhesus negative mothers. If the patient
is keen to breastfeed and is well enough to be shown how to
express milk, this can be explained and may often be enough to
ensure that she can breastfeed when she no longer requires
critical care. Despite the paucity of evidence concerning the
safety of most drugs in breastfeeding mothers, the benefits of
breast milk for the neonate and the drug for the mother means
that there are very few drugs that preclude breastfeeding.
The highest risk period for venous thromboembolism in
obstetric patients is in the first 6 weeks post-partum, so the
appropriate dose of low molecular weight heparin should be used
unless clearly contra-indicated.
Critical care admission during pregnancy can be traumatic for
the mother and her family and an opportunity to discuss events
247
Downloaded from ClinicalKey.com at ClinicalKey Global Guest Users September 24, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.