Acute pulmonary oedema in pregnant women

Abstract

SummaryAcute pulmonary oedema in pregnant women is an uncommon but life-threatening event. The aims of this review are to address why pulmonary oedema occurs in pregnant women and to discuss immediate management. We performed a systematic literature search of electronic databases including MEDLINE, EMBASE and the Cochrane Library, using the key words obstetrics, pregnancy, acute pulmonary oedema, pregnancy complications, maternal, cardiac function and haemodynamics. We present a simple clinical classification of acute pulmonary oedema in pregnancy into pulmonary oedema occurring in normotensive or hypotensive women (i.e. without hypertension), and acute pulmonary oedema occurring in hypertensive women, which allows focused management. Pre-eclampsia remains an important cause of hypertensive acute pulmonary oedema in pregnancy and preventive strategies include close clinical monitoring and restricted fluid administration. Immediate management of acute pulmonary oedema includes oxygenation, ventilation and circulation control with venodilators. Pregnancy-specific issues include consideration of the physiological changes of pregnancy, the risk of aspiration and difficult airway, reduced respiratory and metabolic reserve, avoidance of aortocaval compression and delivery of the fetus. Acute pulmonary oedema in pregnant women is a lifethreatening event. Despite improvements in the management of congestive heart failure in non-pregnant adults, it continues to cause significant morbidity and mortality in pregnancy. This is due to the superimposed issues of the physiological changes of pregnancy and the presence of the fetus, as well as the contributory effect of poorly understood pathophysiology of pregnancyrelated disease such as pre-eclampsia. The objective of this review is to present an overview of the physiology and pathophysiology underpinning acute pulmonary oedema in pregnancy and to consider the management issues specific to pregnancy, including risk reduction and preventative strategies. MethodsThe criteria for consideration of the literature that was reviewed included any systematic review, randomised controlled trial, observational study, case report or expert or consensus statement pertaining to pregnant women and their cardiovascular physiology, cardiovascular pathophysiology, acute pulmonary oedema, and management and interventions in pregnant women with acute pulmonary oedema. Electronic search strategies included searching the databases MEDLINE (until October 2011), EMBASE (until October 2011) and the Cochrane Library using the following key words: obstetrics; pregnancy; acute pulmonary oedema; pregnancy complications; maternal; cardiac function;

Cardiovascular Implications in Preeclampsia

“…[2][3][4][5][6][7]70 Pulmonary Edema Pulmonary edema is the most common cardiopulmonary complication of preeclampsia, which occurs in up to 3% of women, mainly in the peripartum or postpartum stage, and treatment is similar to that used in the nonobstetric patients. 69,70,77,78 In hypertensive pulmonary edema, urgent reduction of critically high BP with an intravenous antihypertensive agent is necessary. 69,70,77,78 The European Society of Cardiology 2011 guidance 70 recommends intravenous nitroglycerine (glyceryl trinitrate) as the first-line choice in treatment for pulmonary edema associated with preeclampsia (Level 1C).…”

“…69,70,77,78 In hypertensive pulmonary edema, urgent reduction of critically high BP with an intravenous antihypertensive agent is necessary. 69,70,77,78 The European Society of Cardiology 2011 guidance 70 recommends intravenous nitroglycerine (glyceryl trinitrate) as the first-line choice in treatment for pulmonary edema associated with preeclampsia (Level 1C). An alternative agent, sodium nitroprusside, is recommended in severe heart failure associated with pulmonary edema and critical hypertension (Level 4), but it should be used only with caution and by experienced clinicians.…”

“…69,78 Although most patients will respond to pharmacological intervention, fluid restriction and strict fluid balance should be maintained. 69,70,77,78 Afterload reduction using vasodilators may be necessary especially in the case of LV diastolic dysfunction, and inotropic support should be given in the case of LV systolic dysfunction. 77 The majority of women would be cared for in an intensive care setting with oxygen saturation monitoring and oxygen supplementation used depending on the severity of the respiratory compromise.…”

“…69,70,77,78 Afterload reduction using vasodilators may be necessary especially in the case of LV diastolic dysfunction, and inotropic support should be given in the case of LV systolic dysfunction. 77 The majority of women would be cared for in an intensive care setting with oxygen saturation monitoring and oxygen supplementation used depending on the severity of the respiratory compromise. 7,8,69,70,77 Despite the risks of aspiration, noninvasive ventilation is preferred, because it provides increased inspired oxygen concentration, displaces fluid from the alveoli into the pulmonary circulation, decreases the work of breathing, and decreases the need/risks for tracheal intubation (Level 1).…”

Pré-éclampsie sévère et hémorragie post-partum: apport de l’échographie « corps entier »

“…5 En fait, la physiopathologie de l'oedème pulmonaire en péripartum est multifactorielle et une augmentation des pressions de remplissage n'est pas systématique. 21 L'échographie pulmonaire détectant l'oedème interstitiel à un stade préclinique, tout remplissage vasculaire délétère pourrait être arrêté avant la survenue de signes cliniques et d'un oedème alvéolaire. 7,22 Nous avons rapporté son utilisation pour 12 Elle donne des compétences en échographie pleuropulmonaire, abdominale et vasculaire.…”