Clinical review: Special populations - critical illness and pregnancy

Abstract

Critical illness is an uncommon but potentially devastating complication of pregnancy. The majority of pregnancy-related critical care admissions occur postpartum. Antenatally, the pregnant patient is more likely to be admitted with diseases non-specific to pregnancy, such as pneumonia. Pregnancy-specific diseases resulting in ICU admission include obstetric hemorrhage, pre-eclampsia/eclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, amniotic fluid embolus syndrome, acute fatty liver of pregnancy, and peripartum cardiomyopathy. Alternatively, critical illness may result from pregnancy-induced worsening of pre-existing diseases (for example, valvular heart disease, myasthenia gravis, and kidney disease). Pregnancy can also predispose women to diseases seen in the non-pregnant population, such as acute respiratory distress syndrome (for example, pneumonia and aspiration), sepsis (for example, chorioamnionitis and pyelonephritis) or pulmonary embolism. The pregnant patient may also develop conditions co-incidental to pregnancy such as trauma or appendicitis. Hemorrhage, particularly postpartum, and hypertensive disorders of pregnancy remain the most frequent indications for ICU admission. This review focuses on pregnancy-specific causes of critical illness. Management of the critically ill mother poses special challenges. The physiologic changes in pregnancy and the presence of a second, dependent, patient may necessitate adjustments to therapeutic and supportive strategies. The fetus is generally robust despite maternal illness, and therapeutically what is good for the mother is generally good for the fetus. For pregnancy-induced critical illnesses, delivery of the fetus helps resolve the disease process. Prognosis following pregnancy-related critical illness is generally better than for age-matched non-pregnant critically ill patients.

Intensive care and pregnancy: Epidemiology and general principles of management of obstetrics ICU patients during pregnancy

“…In ICU parturients with hemodynamic instability, the monitoring of cardiac output may be of interest [35,36]. The devices used for cardiac output monitoring such as thermodilution, pulmonary artery catheters and thoracic [37]. Of note, a normal fetal monitoring suggests an adequate tissue perfusion [32].…”

Beyond maternal death: improving the quality of maternal care through national studies of ‘near-miss’ maternal morbidity

“…Multidisciplinary approaches are essential for these women and require urgent attention. 50 However, there is minimal guidance for nursing management of critically ill obstetric patients in the ITU. Critical care nurses report concerns about their competence and confidence in managing obstetric patients in the ICU, finding it hard to meet their needs.…”

Acute kidney injury in critically ill obstetric patients: a cross-sectional study in an intensive care unit in Northeast Brazil

“…23 These laboratory abnormalities are probably associated with liver disorders, coagulation disturbances and HELLP syndrome. 2,8,[24][25][26][27] Regarding treatment, the use of vasoactive drugs, antibiotics, diuretics and mechanical ventilation were more frequent among AKI patients, which reflect the clinical severity of these patients. Mechanical ventilation and use of vasoactive drugs are associated with maternal mortality according to previous studies.…”