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REVIEW

Management of the critically


ill obstetric patient

clinicians to identify women at risk of severe pregnancy-related


morbidity, each year women die from catastrophic events
including eclampsia, heart failure, intracranial haemorrhage and
hepatic capsular rupture. Critical care is a crucial part of the care
of these women, both in the management after life threatening
events, and in optimizing management of women at highest risk
of developing these complications.
Recent data from ICNARC (Intensive Care National Audit and
Research Centre) showed that 11% of all women aged 16e50 years
admitted to a critical care setting were either pregnant or had
recently been pregnant. 61% of these admissions were for obstetric
reasons. Only 18.5% of the admissions were women who were
currently pregnant, the vast majority of whom were admitted for
non-obstetric reasons, most frequently pneumonia. In contrast, the
majority of recently pregnant women were admitted to critical
care for obstetric reasons, the predominant diagnosis being haemorrhage. In this report currently pregnant and recently pregnant women were much less likely to die (critical care mortality of
2% compared to 11% in a control population) and on average had
a shorter critical care and hospital stay.
The Confidential Enquiry into Maternal Deaths is published by
the Centre for Maternal and Child Enquiries every 3 years and
assesses the causes and management of all maternal deaths that
occur in the UK. Over half the women who die spend some time in
a critical care setting. In the most recent reported triennium
(2006e8), sepsis was the leading cause of deaths directly related to
pregnancy, followed by haemorrhage and pre-eclampsia related
complications. In some cases women did not survive despite
optimal care, but in a significant number care was felt to be
suboptimal and may have contributed to the death. This highlights
the importance of an understanding of what critical care can offer,
and how best to utilize these services in a timely fashion when an
obstetric patient becomes unwell.
The term Critical Care is replacing the terms High Dependency Care and Intensive Care and patients are now described
according to what level of care they require. These levels of care, as
described by the Intensive Care Society, are defined in Table 1.

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.

Keywords acute fatty liver of pregnancy; acute respiratory distress


syndrome; amniotic fluid embolus; critical care; maternal mortality;
sepsis; systemic inflammatory response syndrome

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

Critical care organ system support


Many principles of therapy for organ dysfunction are the same,
irrespective of the underlying disease process. The approach to
organ support in the obstetric patient in most cases will be
similar to that in the general adult population, with the caveat
that a minority of therapies may need modification because of
pregnancy. Additionally, the targets set for individual organ
support modalities may be different in the presence of a viable
fetus, in view of a reduced tolerance to physiological derangement that would be tolerated by the mother in her own right.
Moreover, knowledge of normal physiological parameters in the
obstetric population at different gestations is vital to avoid
inappropriate interventions for findings that are not pathological,
such as aggressive fluid resuscitation for presumed hypovolaemia in a patient with a systolic blood pressure of 90 mmHg
and pulse of 100 beats per minute in the second trimester.
The goal of critical care management is to correct abnormal
physiology whilst the underlying disease process is treated. In
many cases the diagnosis will be evident, but often it is necessary

Matthew C Frise MRCP (UK) is a Specialty Registrar in General Internal


Medicine and Intensive Care at the John Radcliffe Hospital, Oxford
University Hospitals NHS Trust, Oxford, UK. Conflicts of interest: none
declared.
Charlotte J Frise MRCP (UK) is a Specialty Registrar in Obstetric Medicine
and Acute Medicine at the John Radcliffe Hospital, Oxford University
Hospitals NHS Trust, Oxford, UK. Conflicts of interest: none declared.
Catherine Nelson-Piercy MRCOG FRCP FRCOG is a Consultant in Obstetric
Medicine at Guys & St Thomas NHS Foundation Trust, London, UK.
Conflicts of interest: none declared.
*

Matthew C Frise and Charlotte J Frise contributed equally to this work.

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REVIEW

Levels of critical care with examples


Level of care

Types of patient

Obstetric examples

Level 0
Level 1

Normal ward care in an acute hospital


Patients at risk of their condition deteriorating
Those recently relocated from higher levels of
care whose needs can be met on an acute
ward with support from critical care
Single organ support or postoperative care
Those stepping down from higher levels of
care

Level 2

C
C

C
C

Level 3

Advanced respiratory support alone or


support of at least two organ systems

Low risk mother


Risk of haemorrhage
Women with underlying cardiac or other
medical conditions
Severe hypertension in pre-eclampsia
requiring intravenous antihypertensives
Liver failure in HELLP or AFLP
Non-invasive ventilation e.g. pulmonary
oedema or sickle cell chest crisis
Invasive mechanical ventilation in severe
Influenza
Renal replacement therapy in addition to
basic respiratory or cardiovascular support

Table 1

to institute life-sustaining treatments in the absence of a clear


diagnosis whilst investigations continue in parallel.
Admission to critical care should not simply be determined by
how unwell the patient is; the potential for rapid deterioration
and requirement for organ support in the near future is a primary
consideration. This is especially the case for cardiopulmonary
disease where intubation and mechanical ventilation may be
required, because of the risks associated with managing the
obstetric airway. Thus it may be reasonable to transfer a patient
who appears well to a critical care environment. The increasing
use of early warning scores to detect clinical deterioration is
a welcome development and existing systems are modified to
ensure that they are fit for purpose in the obstetric population.

From 20 weeks of gestation, cardiac output may reduce by


30e40% when supine, as a consequence of aortocaval
compression. Positioning of the critically ill obstetric patient is
therefore of particular importance; simple manoeuvres such as
tilting the patient onto her left side or using a Cardiff wedge may
relieve cardiovascular compromise.
In cases where intra-aortic balloon pumps are used, patients
are typically also receiving vasoactive drugs with or without
respiratory support and a critical care environment is essential.
Respiratory and airway
Changes in pulmonary physiology in pregnancy are driven by
hormonal influences (primarily progesterone) and the physical
effects of diaphragmatic splinting by a gravid uterus on ventilatory mechanics. Taken together with concomitant circulatory
changes and increased oxygen consumption, pregnant women
develop hypoxaemia more readily. A typical non-pregnant
patient undergoing elective general anaesthesia, who has been
breathing pure oxygen, may take up to 5 minutes to desaturate e
despite apnoea following induction of anaesthesia and neuromuscular blockade. Conversely, in a pregnant woman at term,
much less time may be available, especially in obese patients
whose functional residual capacity is severely reduced. The
problem is compounded by potential challenges from the airway
in pregnant patients; anaesthetists are more likely to encounter
difficulty with endotracheal intubation in obstetric patients for
several reasons. Large breasts impinge on the space available for
manipulation of the laryngoscope and special blades (e.g. shorthandled Macintosh or Polio blade) may be required. Oedema of
upper airway tissues can distort anatomy and restrict the view
available on direct laryngoscopy. Pregnant women are at a high
risk of aspiration even if fasted, due to compression of the
stomach by the gravid uterus, delayed gastric emptying and
incompetence of the lower oesophageal sphincter. Effective
cricoid pressure to reduce the risk of reflux and aspiration is
therefore required. Prophylactic histamine receptor (H2) antagonists are also recommended.

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.

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In addition to supplemental oxygen therapy, non-invasive


approaches are available to support the patient with respiratory
failure. Type 1 respiratory failure, hypoxaemia with a normal or
low arterial partial pressure of carbon dioxide (PaCO2), develops
as a result of ongoing perfusion of regions of lung tissue affected
by processes such as pneumonia which render them ineffective
for gas exchange. This causes shunting of deoxygenated blood
through the lungs and hypoxaemia that cannot be completely
corrected with supplemental oxygen. Continuous positive airway
pressure (CPAP) through a tight fitting mask or hood, with the
provision of a variable fraction of inspired oxygen (FiO2), can be
helpful in this setting by recruiting regions of lung to contribute
to gas exchange. Problems such as bibasal atelectasis and
pulmonary oedema may respond well to CPAP.
Type 2 respiratory failure carries the additional problem of
hypercapnia and results from processes which reduce the
amount of air that can physically be breathed in and out. The
PaCO2 is inversely proportional to minute ventilation (the
product of respiratory rate and tidal volume). Respiratory muscle
weakness from exhaustion, severe metabolic acidosis or neurological disorders may lead to hypercapnia despite adequate
oxygenation. Non-invasive positive-pressure ventilation (NIPPV)
uses the same type of masks as CPAP but delivers additional
support during inspiration to augment the patients respiratory
effort and increase tidal volume. This helps to clear CO2 and rest
the respiratory muscles, which are an important source of lactic
acid that can contribute to metabolic acidosis.
In cases where CPAP or NIPPV fail, are contra-indicated, or
when airway protection is necessary because of other factors
such as reduced consciousness level, tracheal intubation and
invasive mechanical ventilation is indicated. The aim is to ensure
sufficient tissue oxygenation whilst clearing CO2 efficiently. It
has been shown that ventilation using a low tidal volume and
low peak inspiratory pressures is most likely to avoid injury to
the lungs from barotrauma and volutrauma, so-called lung
protective ventilation. Using the lowest FiO2 possible is also
important to avoid the toxic effects of prolonged hyperoxia.
Arterial lines allow frequent arterial blood gas analysis to guide
modification of ventilator settings.

definition is severe hypoxaemia with a ratio of arterial partial


pressure of oxygen (PaO2) to FiO2 (P/F ratio) of less than 27 kPa in
the setting of diffuse bilateral pulmonary infiltrates on chest
radiography, not caused by cardiogenic pulmonary oedema. Acute
lung injury (ALI) is a related, less severe form with a P/F ratio of
less than 40 kPa. CPAP and NIPPV are sometimes tried in ALI as
a strategy for avoiding intubation, which is invariably required in
ARDS. However, concerns exist that this approach may unnecessarily delay intubation and increase aspiration risk making it
particularly unattractive in pregnancy. In both conditions averting
volume overload is essential to avoid exacerbating capillary leak.
The combination of a high respiratory rate, low tidal volume and
high positive end expiratory pressure (PEEP) has been shown to
be advantageous in ARDS but often leads to difficulty with CO2
clearance. The concept of permissive hypercapnia (accepting
a degree of respiratory acidosis if oxygenation is satisfactory) has
grown in acceptance and appears less deleterious than aggressive
attempts to correct a respiratory acidosis completely. In contrast to
the clear detrimental effects of a metabolic acidosis on the fetus,
the effects of permissive hypercapnia are uncertain.
If hypoxaemia is extreme and persists despite optimal ventilation and an FiO2 of 1.0, prone ventilation or inhaled nitric oxide
are often tried, but are of no proven benefit. Rescue therapies
exist for extracorporeal lung support. The Novalung (a device
mainly used for extraction of CO2 from the circulation but which
can also aid oxygenation) and ECMO (extracorporeal membrane
oxygenation) were both used successfully in pregnant and postpartum women during the 2009e10 H1N1 Influenza pandemic.
These techniques require particular expertise and carry a significant risk of complications related to vascular injury from very
large cannulae, bleeding and haemolysis.
Tracheostomy: patients requiring mechanical ventilation or
airway protection for a prolonged period often have a surgical
tracheostomy formed. These are much better tolerated than oral
endotracheal tubes thus reducing analgesia and sedation
requirements for ventilated patients. Respiratory support can
gradually be weaned with the tracheostomy in situ until the
patient is independent of a ventilator; this process may be prolonged by disuse atrophy of respiratory muscles or critical-illness
polyneuropathy, both of which are potential complications of
a critical care stay. The tracheostomy may remain in place for
a time thereafter, if required to assist with management of
respiratory secretions.

Obstructive sleep apnoea: a problem that is becoming more


common in the obstetric population is sleep disordered breathing
related to obesity and obstructive sleep apnoea (OSA). In the
general adult population, OSA is associated with hypertension,
insulin resistance and increased cardiovascular risk. In pregnancy, there is emerging evidence of an association with adverse
maternal and fetal outcomes. At present it is rare to encounter
a woman of child bearing age who has developed unrecognized
chronic ventilatory failure from OSA, with or without co-existent
obesity hypoventilation syndrome. CPAP or NIPPV may be
required in pregnancy when OSA complicates an acute respiratory illness such as pneumonia, or impedes extubation following
general anaesthesia or a period of mechanical ventilation.

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.

Acute respiratory distress syndrome: the lung has a limited


repertoire of responses to injury and acute respiratory distress
syndrome (ARDS) is the final common pathway for a number of
diseases. Sepsis, massive haemorrhage, amniotic fluid embolism
and aspiration may all lead to ARDS. The currently accepted

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Indications for renal replacement therapy are listed in Box 1. If


necessary acutely, continuous venovenous haemofiltration is
preferred to intermittent haemodialysis as it is more conducive to
maternal cardiovascular stability. Large bore double-lumen
central venous access is required in addition to anticoagulation
to prevent thrombosis of the circuit. Vasopressors may be
necessary to maintain blood pressure.

because of different nutritional requirements. The enteral route is


best; if the patients condition precludes eating then nasogastric or
nasojejunal routes are possible with the option of percutaneous
approaches if prolonged artificial feeding is foreseen. If total
parenteral nutrition is required, a dedicated central line lumen
should be reserved to minimize the risk of line sepsis but catheterassociated thrombosis and impaired cell-mediated immunity are
risks. Critically ill patients are at increased risk of stress ulceration
in the upper gastrointestinal tract so H2 receptor antagonists or
proton pump inhibitors are routinely prescribed.
Hyperglycaemia, even in the absence of a previous diagnosis
of diabetes mellitus, is clearly associated with adverse outcomes
in critical care populations, but in spite of numerous studies,
opinion is divided about optimal targets for glucose control.
Hyperglycaemia in pregnancy is associated with fetal morbidity
such as macrosomia, polyhydramnios and neonatal hypoglycaemia and thus attempts to control glucose tightly in pregnant women in critical care would seem sensible. At present,
evidence supports variable rate insulin infusions to correct
hyperglycaemia but hypoglycaemia as an unintended consequence must be avoided as this is potentially more harmful.

Indications for renal replacement therapy


C

C
C
C

Fluid overload (refractory to diuretics, typically anuric


patients)
Hyperkalaemia
Metabolic acidosis
Uraemic complications e pericarditis and encephalopathy

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

Cold, vasoconstricted, low CVP


Cold, vasoconstricted, high CVP
Flushed, vasodilated, tachycardic
Cold, vasoconstricted, marked tachypnoea
Vasodilated, may not be tachycardic

Massive obstetric haemorrhage


Myocardial infarction, cardiomyopathy
Sepsis, anaphylaxis
Pulmonary embolism
Spinal injury

Table 2

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said to have severe sepsis. If hypotension persists despite


aggressive fluid resuscitation, then septic shock is present and
the patient may require vasopressors to support the circulation
and maintain organ perfusion. These individuals are at risk of
multi-organ failure, disseminated intravascular coagulation
(DIC) and death. SIRS can also result from tissue injury and
cytokine release in conditions such as trauma or pancreatitis.

and intracranial haemorrhage. Eclampsia is the development of


seizures which can occur without preceding hypertension or
proteinuria. HELLP syndrome (Haemolysis, Elevated Liver
enzymes and Low Platelets) occurs in 5e20% of all preeclamptic pregnancies, but in a greater proportion of those
where it develops prior to 30 weeks of gestation. In addition to
the complications that may occur with pre-eclampsia, pregnancies affected by HELLP syndrome can also feature hepatic haematoma formation and capsular rupture, acidosis and DIC and
require close monitoring in a critical care setting.

Early goal directed therapy: in critical care, the concept of


grouping interventions into bundles to improve the chance of a
good outcome has recently gained acceptance and the use of
bundles is recommended in the recently published RCOG guidelines on Bacterial Sepsis in Pregnancy. With sepsis, the key issue
is early recognition and treatment. In septic shock, every hour
appropriate intravenous antibiotic therapy is delayed increases
mortality by up to 10%. Suspecting sepsis, measuring markers of
severity such as serum lactate, taking appropriate microbiological
specimens and then quickly commencing broad-spectrum antibiotics are central to this approach, alongside intravenous fluids and
vasoactive drugs if indicated.
Adjunctive therapies include low dose intravenous corticosteroids though this is not universally accepted. Activated protein
C has recently been withdrawn from clinical use after the finding
that it offered no advantage over optimal conventional care and
significantly increased bleeding complications.

Hypertension: the hypertension associated with these conditions


can be severe, and persist for weeks to months after delivery. If
uncontrolled this can result in intracranial haemorrhage, and on
average three women a year die from this complication.
The first line treatment is nifedipine, a calcium channel
blocker that directly relaxes arterial smooth muscle and causes
a steady reduction in blood pressure within 30 minutes of
administration. Caution is required with concomitant use of
magnesium sulphate, as this combination can lead to hypotension and potentiation of neuromuscular blockade. Labetalol is
a non-selective b adrenergic receptor blocker with some additional a1 effect, normally given orally but which can be given
intravenously as a bolus or infusion if hypertension is severe. If
the hypertension fails to respond to the use of nifedipine or
labetalol, or either agent is contra-indicated, intravenous
hydralazine is a good alternative and has been used for many
years in the management of pre-eclampsia.

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.

Seizures: magnesium sulphate is the drug of choice for


eclampsia related seizures and is also given as prophylaxis in
those women with severe pre-eclampsia. Up to 10% of women
develop repeated seizures despite magnesium sulphate administration, and if repeated boluses of magnesium fail to control
seizures, intravenous phenytoin or diazepam may be used.
Seizures refractory to treatment require sedation and intubation. Typical anaesthetic agents used in this setting include
propofol and midazolam, both of which have anticonvulsant
properties.

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).

Pulmonary oedema: the combination of increased capillary


permeability, lower oncotic pressure as a result of hypoalbuminaemia and increased circulating volume in pregnancy
leads to an increased risk of pulmonary oedema, particularly in
women with pre-eclampsia. This may be further complicated by
overzealous fluid administration to address the oliguria that may
be associated with pre-eclampsia, or by prolonged infusion of
oxytocin to augment labour. Patients who have developed
pulmonary oedema, or are at high risk of doing so, often benefit
from critical care admission for careful fluid balance and ventilatory support (either non-invasive or invasive) if significant
respiratory compromise persists despite pharmacological
therapy. Intravenous glyceryl trinitrate may be of benefit if
hypertension also requires treatment. The combination of postpartum haemorrhage and pulmonary oedema necessitates very
careful fluid balance in a critical care environment.

Potentially life threatening conditions in pregnancy


Hypertensive disorders
A subgroup of women with pre-eclampsia develop severe disease
and may require critical care to manage complications including
severe hypertension, AKI, liver dysfunction, pulmonary oedema

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Acute kidney injury: oliguria and a mild rise in creatinine are


common in pre-eclampsia, but can be severe if HELLP syndrome

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develops and occasionally requires renal replacement therapy.


This is usually only required for a short duration as it is likely
that renal function will gradually recover. Women with preeclampsia may develop polyuria following the oliguria which is
virtually universal after delivery. Polyuria may be significant in
the subsequent recovery phase. Oral fluids are usually sufficient
to maintain euvolaemia, but intravenous therapy may be needed
if the urine output greatly exceeds fluid intake and hypovolaemia
is developing.

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.

Liver impairment: the hepatic impairment seen in HELLP


syndrome is associated with significant maternal and fetal
morbidity and mortality, particularly if hepatic capsular rupture
occurs as a result of subcapsular bleeding. Capsular rupture is
estimated to occur in one in 45,000e250,000 deliveries and in the
majority of cases occurs in multiparous women. This requires
critical care support in conjunction with urgent surgical intervention, most often laparotomy and packing. The use of partial
liver resection, argon beam coagulation, embolization and
hepatic artery ligation have all been described. Transfer to the
critical care unit of a tertiary liver centre may be appropriate. In
a recent series describing all women admitted to a tertiary liver
unit with pregnancy-related liver failure in a 10-year period,
nearly 50% were related to HELLP.

Sudden maternal collapse


Cardiac arrest is rare, occurring in approximately one in 30,000
pregnancies. In addition to the causes of cardiac arrest in the
non-pregnant population (commonly occurring primary cardiac
events include arrhythmias or myocardial infarction, pulmonary
emboli, and electrolyte disturbance including hyperkalaemia),
pregnancy-related causes, including amniotic fluid embolism and
local anaesthetic toxicity, need to be considered in the differential
diagnosis.
Resuscitation in this setting should follow the guidelines
described by the Resuscitation Council (UK). After 20 weeks of
gestation the woman should be positioned with a left lateral tilt
on a firm surface, or undergo manual displacement of the uterus
to reduce aortocaval compression and the resulting cardiac
compromise, as cardiac output can otherwise be reduced to
around 10%. The efficacy of chest compressions is also reduced
by aortocaval compression. If there is no response to adequate
cardiopulmonary resuscitation (CPR) in the correct position
within 4 minutes, delivery should be undertaken to aid maternal
resuscitation with the aim to evacuate the uterus within 5
minutes of commencement of CPR. Prior to 20 weeks of gestation
this is not required as there is not significant aortocaval
compression.

Acute fatty liver of pregnancy


Acute fatty liver of pregnancy (AFLP) complicates approximately
one in 20,000 pregnancies and usually occurs in the third
trimester. It is more common in primagravidae, multiple pregnancies, or pregnancies with male fetuses and is associated with
acute hepatic failure as a result of microvesicular steatosis. To
aid identification of this condition, diagnostic criteria known as
the Swansea criteria can be used. Emergency delivery is indicated
and support in a critical care setting is often required
subsequently.
Peripartum cardiomyopathy
In contrast to previous definitions, recent European Guidelines
propose that peripartum cardiomyopathy be defined as an idiopathic condition presenting with heart failure secondary to left
ventricular systolic dysfunction towards the end of pregnancy or
in the months following delivery where no other cause is found.
It complicates one in 3000e15,000 pregnancies but this may be
an underestimate. If the systolic dysfunction is severe and
cardiogenic shock occurs, support in a critical care setting is
needed for the administration of inotropes and possibly an intraaortic balloon pump or left ventricular assist device if transplantation is being considered.

Pre-existing medical conditions


A wide range of medical conditions have a significant impact on
fetal and maternal morbidity and mortality, for example those
women surviving to child bearing age with chronic conditions
including cystic fibrosis or surgically corrected congenital heart
disease. Acquired diseases such as cardiomyopathy, chronic
kidney disease, pulmonary hypertension or the presence of an
organ transplant also require closer monitoring in pregnancy and
around the time of delivery. In the most recent Confidential
Enquiry into Maternal Deaths, cardiac disease was the leading
cause of maternal death. Critical care admission may therefore be
beneficial to provide a higher level of monitoring for this group of
women, in a setting where organ support can be instituted if
indicated.

Ovarian hyperstimulation syndrome


This condition is caused by the release of vasoactive products
from hyperstimulated ovaries which can occur as a result of
follicle stimulating drugs used in assisted conception. Increased
capillary permeability results in third space fluid losses and
intravascular depletion, which can cause renal and liver
dysfunction as well as acute respiratory distress syndrome,
pleural effusions and ascites. The condition is worsened by
bHCG, either exogenous administration prior to oocyte collection
or endogenous production due to a resulting pregnancy.

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246

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REVIEW

General considerations

and offer debriefing before or after discharge from hospital is


often welcomed, particularly as the maternal illness may have
important implications on plans for future pregnancies.
A

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

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 22:9

247

Approximately 1% of obstetric patients require admission to


Critical Care. Fewer than a fifth are pregnant at the time of
admission and the commonest admission diagnoses are
pneumonia and obstetric haemorrhage
The fundamental principles of critical care management for
obstetric patients are no different to the general adult population. Specific issues are the obstetric airway, physiological
changes in pregnancy and a lack of evidence surrounding
safety of commonly used drugs in pregnancy and lactation
Early warning scoring systems may aid the identification of
deteriorating obstetric patients, however it may be reasonable
to transfer some high risk patients to critical care areas to
permit closer monitoring if they are felt to be at risk of
deterioration
Obstetric patients requiring critical care admission are at high
risk of VTE so prophylactic anticoagulation is required

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