Supportive Management Of Critical Illness In The Pregnant Patient - $30.00
June 2012 (Volume 2, Number 3)
This issue includes 3 AMA PRA Category 1 CreditsTM and 3 AOA Category 2A or 2B CME credits.
Haney Mallemat, MD
Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
Shannon Arntfield, MD, FRCSC
Assistant Professor, Department of Obstetrics and Gynecology, Western University, London, Ontario, Canada
Rebecca Bloch, MD
Attending Physician, Department of Emergency Medicine, Maine Medical Center, Portland, ME
Diane Sixsmith, MD, MPH, FACEP
Department of Emergency Medicine, New York Hospital Queens, Flushing, NY; Assistant Professor of Emergency Medicine, Weill Medical College of Cornell University, New York, NY
Critical illness during pregnancy is rare in the United States. Despite improvements in prenatal and intensive care management, maternal and fetal mortality rates remain high. Early identification of critical illness is essential to provide aggressive support and resuscitation and reduce maternal mortality. Proper maternal resuscitation will improve the chance of fetal survival. This review describes the normal anatomic and physiologic changes that occur during the second and third trimesters of pregnancy and how they affect the critically ill patient. The importance of early support of respiration and circulation is discussed as well as differences between pregnant and nonpregnant women that affect resuscitation. Lastly, cardiopulmonary resuscitation in the pregnant patient and perimortem cesarean section are discussed.
Excerpt From This Issue
You are working your ED shift when the EMS command center alerts you that a critically ill 35-year-old woman is en route to your facility. The patient is in labor after trying to home birth with her midwife by her side. During labor, she suddenly developed dyspnea and lightheadedness. When EMS personnel arrived at the scene, they started oxygen via nasal cannula and inserted a peripheral IV line for administration of normal saline. Upon arrival at the ED, the patient is in mild distress but speaking in full sentences. She describes the sudden onset of her symptoms and the development of mild chest pain during transport to the hospital. She has a regular pulse rate of 135 beats per minute, blood pressure of 95/60 mm Hg, and respiratory rate of 36 breaths per minute. She is afebrile, and the pulse oximetry reading is 95% on 5 L/min of oxygen via nasal cannula. Fetal heart rate is noted to be 160 beats per minute. She is 1 week before her due date and has been receiving prenatal care without complications. She has been planning a home birth with a midwife, just as she had done for her only other pregnancy 4 years ago, when she had an uncomplicated delivery of a baby girl. A brief physical exam reveals a gravid female in mild to moderate distress. The cardiac exam shows tachycardia, a systolic ejection murmur, and elevated JVD. The pulmonary exam reveals diffuse bilateral rales. A sterile cervical exam reveals that she is still early in labor, having only 1 cm of cervical dilation. You decide to place her on 100% oxygen via nonrebreather mask and to start another IV line in her arm, with normal saline running at a maintenance rate. You ask to have the patient rolled onto her left lateral decubitus side during evaluation. Samples are collected for a CBC, chemistry analysis, measurement of ABG, type and screen, and urine and blood cultures. Point-of-care ultrasound reveals dilation of the ventricle with evidence of poor systolic function. Based on her history, physical, and bedside echocardiogram, your differential includes decompensated heart failure from peripartum cardiomyopathy. You have called obstetrics as well as pediatrics to prepare for an imminent delivery, but you do not want to transfer the patient upstairs until you are sure she is stable. As you prepare to stabilize this patient, what normal physiologic changes associated with pregnancy will influence your treatment decisions? How will you need to modify the resuscitation procedures used for nonpregnant patients in the stabilization of this pregnant woman?