This document discusses critical care for obstetric patients. It begins with an introduction and epidemiology section noting that while the proportion of obstetric patients in ICUs is low, the most common reasons for admission are postpartum hemorrhage and hypertensive disorders. It then covers obstetric critical care, basic principles for obstetric emergencies, transfer to critical care settings, the role of obstetricians, resuscitative hysterotomy, and supportive care. It provides recommendations including prioritizing maternal stabilization, consulting obstetricians, and not withholding necessary treatments due to fetal concerns. The document aims to guide management of critically ill obstetric patients.

1. Assistant Lecturer
OB/GYN Department
Benha Faculty of Medicine
2019

2.  Introduction
 Epidemiology
 OBSTETRIC CRITICAL CARE
 BASIC PRINCIPLES FOR OBSTETRIC
EMERGENCIES
 Transfer to critical care setting
 Role of the Obstetrician–Gynecologist
 Resuscitative hysterotomy
 SUPPORTIVE CARE
 Recommendations and Conclusions
Items to be discussed

3. ICU receives obstetric patients with medical &
surgical emergencies as well as specific obstetric
complications
 Proportion of obstetric patients in most ICUs is low
Relative inexperience in management & team-work
between ICU team & obstetrician.
Introduction

4. Approximately (0.7–13.5) obstetric patients per
1,000 deliveries are admitted to ICU
Most common indications are postpartum
hemorrhage and hypertensive disorders
Most of these (63–92%) are postpartum
admissions
not require major lifesaving interventions but rather
more intensive monitoring than can be provided
on antepartum or postpartum units
Epidemiology

5. median length of stay was 2.0 days for women
admitted antepartum and 1.1 day for those
admitted postpartum
The maternal death rate after ICU admission
differs significantly between high- and low-income
countries (median 3.3% versus 14.0%, respectively,
P=.002)
Epidemiology

6. OBSTETRIC CRITICAL CARE

7.  Hypertensive disorders
 Obstetric hemorrhage
 Sepsis
 Thromboembolic and PE
 Trauma
 Respiratory conditions
 Cardiovascular disorders
 DKA
 Gastrointestinal disorders
 overdose or poisoning
 neurologic disorders
Leading causes of ICU admission

8. Top Causes of
Maternal mortality

9. Clinically unstable ( hypotensive or hypoxemic)
At high risk of deterioration
 Need specialized ICU care such as mechanical ventilation
Laboratory work
• arterial blood gas
• serum lactate
 The Quick Sequential Organ Failure Assessment can also be
used to stratify risk in patients who have infection
 Patients require
• level 2 care (monitoring and simple interventions)
• level 3 care (major organ support)
Factors contribute to the decision to
move a pregnant patient to ICU

10. Maternal Early Warning Criteria From the
National Partnership for Maternal Safety

11. Physiological changes in pregnancy modify:
• Presentation of the problem
• Normal physiological variables
• Response to treatment
 Both mother & fetus are affected by the pathology
& subsequent treatment.
Mother’s welfare always takes precedence over
fetal concerns
 Fetal survival dependent on optimal management

17.  If a pregnancy is complicated by a critical illness or
condition, the woman should be cared for at a
hospital with obstetric services, an adult ICU,
advanced neonatal care services, and appropriate
hospital services such as a blood bank.
It is important not to discourage ICU admission;
rather, encouraged to use critical care services when
appropriate

18. Obstetric hemorrhage

19. Hypertensive Emergency
(1st Line Therapy)

20. Septic shock

21. Pre-transport evaluation of the woman and her
fetus must be performed, and maternal status must be
stabilized before transport
 when transport is unsafe or impossible, or when imminent
delivery is anticipated, arrangements can be made for
postpartum rather than antepartum maternal transport
 If there is a high probability that intubation and mechanical
ventilation will be needed during transport, it should be
accomplished before departure
Transfer Between Hospitals

22. During transport :
• continuous cardiac rhythm and pulse oximetry monitoring
• regular assessment of vital signs
• Venous access must be established before transport
• Left uterine displacement should be routine
 obstetrician–gynecologists at the receiving hospital give an
opinion about medical interventions before arrival, or
prepare for interventions needed
Transfer Between Hospitals

23.  communication between the obstetrician–gynecologist and
critical care services is crucial. In some cases (eg, planned
cesarean hysterectomy
 possible to request an ICU bed in advance (planned)
 involve critical care staff early in the transfer process
 During transport, the team must be able to assess BP, heart
rate, and oxygenation status.
 For a critically ill patient , the team also should have a
cardiac monitor with defibrillator, airway management
equipment, oxygen, and basic resuscitation medications.
 At least two health care professionals should accompany the
patient during transport
Transfer Within the Hospital

24.  obstetrician–gynecologist’s role will depend on:
• patient status (antepartum or postpartum)
• ICU model and type
 According to ICU model , his role is
• open model >>>>>> 1ry physician
• closed model >>>>>> only to be consulted
• semi-open model >>>>>> MDT
 patient care decisions made collaboratively multidisciplinary
care team.
 Decisions also should involve the patient, her family, or both.
Role of the Obstetrician–Gynecologist

25.  weighing the risks and benefits of interventions such as
medication administration and diagnostic Imaging
 fetal monitoring
 delivery planning when indicated.
 Daily rounds, frequent communication with the ICU team
 rapid response to calls for consultation are all important
 evaluation of vaginal or surgical site bleeding
 obstetric sources of infection,
 therapies (such as magnesium for eclampsia prophylaxis),
 surgical issues, such as re-exploration of the abdomen or
reclosure of abdominal and perineal or vaginal incisions.
Role of the Obstetrician–Gynecologist
Regardless of the type of ICU

26.  The underpinning principles are that the woman’s interests
are paramount, and optimal fetal status is generally
predicated on optimizing the maternal condition as much as
possible.
 Medical interventions and diagnostic imaging may be
modified to an extent but when indicated for maternal
health should not be withheld purely for fetal concerns.
 It is important not to discourage ICU admission; rather,
encouraged to use critical care services when appropriate
Role of the Obstetrician–Gynecologist
Regardless of the type of ICU

27. Maternal stabilization is the first priority
 Once woman is stable, determine GA to plan of care,
immediate decision-making.
 Drugs that cross the placenta may have fetal effects
 Known adverse effects on the woman and the fetus must
be carefully monitored, and risk–benefit ratios assessed
Neither necessary medications nor diagnostic imaging
should be withheld from a pregnant woman because of
fetal concerns.
Special considerations in care of a pregnant
woman in a critical care setting

28.  Administration of steroids for fetal benefit
 Indicated delivery should not be delayed for
administration of steroids in the late preterm period
 Fetal monitoring
 In postpartum period, obstetricians should evaluate
vaginal or surgical site bleeding, therapies, surgical issues
 Provision of lactation support and a breast pump may
also be considered when feasible.
special considerations in care of a pregnant
woman in a critical care setting

29. Resuscitative hysterotomy

30. Resuscitative hysterotomy

31. Resuscitative hysterotomy

32. Mechanical ventilation
Sedation
 Vasopressors
 hemodynamic monitoring
SUPPORTIVE CARE
 Defined as interventions that sustain life and prevent
complications, but do not treat the cause of the critical
illness

33.  Normal physiology, pregnancy maintain respiratory
alkalosis (PaCO2 32 mmHg and arterial pH 7.4 to
7.47) due to respiratory stimulation by progesterone
 Mechanical ventilation is similar for pregnant and non-
pregnant women
 The major pregnancy-specific considerations are related
PaCO2. Target PaCO2 should be 30 to 32 mmHg
 PaCO2 values <30 mmHg or >40 mmHg to be avoided
 A reasonable goal is a maternal PaO2 above 65 mmHg
Mechanical ventilation

34.  Intubation and mechanical ventilation are undertaken
when hypoxemia is profound and cannot be corrected by
noninvasive means, or when ventilation is failing
 Airway management in pregnancy can be challenging
 Increased airway edema and increased breast size make
positioning and direct laryngeal visualization more
difficult.
 The risk of failed intubation in obstetrics is eight times
higher than in the general population
 Once the decision to intubate is made, the patient should
be preoxygenated and suction should be available; the
most qualified personavailable should intubate.
 A plan for failed intubation must be made ahead of time,
Mechanical Ventilation

35.  Interventions other than vasopressors should be used
initially to manage hypotension, including the IV fluids
and left lateral decubitus position.
 If Hypotension persists initiate vasopressor, since
sustained hypotension decreases uterine blood flow.
 For pregnant women, suggest norepinephrine as the
initial agent, rather than ephedrine, epinephrine or
dopamine (Grade 2C).
 If refractory shock , suggest the use of phenylephrine
rather than ephedrine (Grade 2C)
Vasopressors

36.  Most drugs used for analgesia, sedation, and paralysis
cross the placenta >>>>>> Possible adverse effects
 Consultation with an obstetrician and a pharmacist
 A neonatologist should be present at delivery because
may respiratory depression in the newborn
 Analgesia: Any opioid is acceptable. However, NSAIDs
should be avoided during late pregnancy
 Sedation:
* Midazolam is superior to lorazepam
* Propofol classified as a pregnancy category B agent.
 Neuromuscular blocker: Cisatracurium may be
preferable as a first line agent
Sedation

37. All patients should undergo conventional ICU
monitoring.
 Invasive hemodynamic monitoring especially when
hypoxemic respiratory failure (pulmonary edema)
accompanied by hypotension and/or renal failure.
 Using a central venous catheter to measure the
central venous pressure, rather than a pulmonary
artery catheter
Arterial catheter if BP is labile or frequent ABG needed
Hemodynamic monitoring

38. Recommendations and Conclusions
ACOG 2019 level A

39. Recommendations and Conclusions
ACOG 2019 level B

40. Recommendations and Conclusions
ACOG 2019 level B

41. Recommendations and Conclusions
ACOG 2019 level C

42. Recommendations and Conclusions
ACOG 2019 level C

43. Recommendations and Conclusions
ACOG 2019 level C

44. Recommendations and Conclusions
ACOG 2019 level C

45. 09- Jul-18 Dr Shashwat Jani.
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