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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
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
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
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
Signs
Peripartum Cardiomyopathy
Management
Bed rest
Sodium restriction
Diuretics
IV inotropic support: dobutamine
Afterload reduction: milrinone