Pregnancy and critical Illness/CCM board review

8/10/2019 Pregnancy and critical Illness/CCM board review

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Mary E. Strek, MD, FCCP Professor of Medicine

University of Chicago

Critical Illness in Pregnancy San Antonio, 2013


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Disclosures

! # I perform clinical research studies for my institution

! # None relevant to todays lecture


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Maternal Deaths (US): 1998-2005

Obstet Gynecol 2010;116:1302-9

Deaths HIGHER now than in 20 yrs!

Cause of Death Percent Medical Conditions 13.2%

Hemorrhage 12.5%

Cardiovascular Disease 12.4%

Pregnancy Induced HTN 12.3%

Cardiomyopathy 11.5%

Infection 10.7%

Pulmonary Embolism 10.2%


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Educational Objectives

After this course, you will be able to:

! # Explain PHYSIOLOGIC adaptation of pregnancy

! # Recognize and treat CARDIAC disorders andSHOCK in pregnancy

! # Identify and manage PREECLAMPSIA

! # Diagnose and treat PULMONARY complications


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Audience Response Question #1

A woman in her last trimester of pregnancy is transferred to the ICU for

acute hypoxemic respiratory failure requiring intubation and mechanicalventilation. Prior to sedation, she is placed in the supine position. HRincreases from 96 to 125, BP falls from 100/70 to 85/60, SpO2 is 87%,Hgb is 10.5 g/dL.

The best rst action is?

A. Bolus Ringers lactate

B. Infuse norepinephrine

C. Turn patient to left lateral decubitus D. Apply fetal scalp monitor

E. Transfuse 1 unit PRBC


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Cardiovascular Changes

Circulatory ! Blood volume ! RBC and ! ! Plasma volume

" Colloid osmotic pressure

Cardiac ! Stroke volume and HR " SVR, PVR and blood pressure

! Cardiac output

Hegewald, Clin Chest Med 2011;32:1-13

Low resistance utero-placental unit activates renin-angiotensin:


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Rizk, Chest 1996;110:791-809

Time Course of Cardiac Changes

FALL in cardiacoutput from:

Uterine compression ofaorta/vena cava inSUPINE position


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Respiratory Changes in Pregnancy

Pulmonary ! Oxygen consumption (VO 2) ! Minute ventilation in excess ! VCO 2

! TV but NOT respiratory rate

Blood gas PO 2 ~ 105 in 1st trimester > 95 in 3rd trimester

PCO 2 ~ 28 32 mmHg Bicarbonate 18-21 mEq/L

pH 7.45

Increased progesterone causes:


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Pulmonary Function Tests in Pregnancy

! # 20% fall FRC fromdecreased chest wallcompliance

! # Increased IC from

widened A-P diameterchest

! # Modest decline TLC

! # No change FVC, FEV 1,NIF, PEF

UpToDate, 2008


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Renal Adaptation

! # Increased excretory load from fetus and increasedmaternal metabolism

! # Filtration rate (GFR) & urinary volume increase

! # Serum Cr < 0.09 mg/mL , BUN < 15 mg/dL

! # Caution in interpreting NORMAL values

Naylor, Crit Care Clin 2003;19:127-149


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Gastrointestinal Adaptation

! # Displacement of GI organs in abdomen

! # Progesterone related alteration in smooth muscle relaxation

! # Decreased lower esophageal sphincter tone

! # Hypomotility of the GI tract

! # Alkaline phosphatase increases, albumin decreases, nochange LFT s

Naylor, Crit Care Clin 2003;19:127-149


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Summary of Physiologic Changes

Exam

HR,

BP

Nasal congestion Physiologic S 3 Mild pedal edema

Labs Hgb, Cr, & albumin

CXR Cardiomegaly

RHC CVP, PAP & wedge nl Increased CO


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Oxygen Delivery

! # Uterine artery blood ow and oxygen content

! # Uterine vasculature maximally dilated at baseline

! # Uterine artery vasoconstriction from catecholaminesand maternal hypotension

! #Decreased utero-placental perfusion from uterinecontractions

Lapinsky, AJRCCM 1995;152:427-455


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Slide courtesy Dr. Michael O Connor

! # Concurrent exchange

mechanism

! # Maternal and fetal blood runin same direction

! # Difference in O2 tensionresults in transfer frommaternal to fetal circulation

! # Umbilical vein blood mixes

with deoxygenated blood infetal IVC

Maternal-Fetal Oxygen Transfer


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Maintenance of Fetal Oxygen Supply

! # Fetal environment relatively hypoxic ! # Mean umbilical vein pO 2 is low

! # Rarely exceeds 40 mm Hg

! # Fetal compensation ! # High hemoglobin concentration (15 g/dL)

! # Increased afnity fetal Hgb for O 2

! # Increased cardiac output: both ventricles pump to systemiccirculation

! # Preferential blood ow to fetal heart, brain, adrenals


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General Principles of ICU Management

! #Monitor fetal heart rate/Consult OB

! # Maximize O 2 delivery ! # Left lateral decubitus position

! # Supplemental oxygen ! # Noninvasive mask ventilation- Take care!

! # Early intubation/mechanical ventilation

! # Assess adequacy of blood ow

! # Exam may be misleading

! # Bedside USN


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Principles of Medication Use

! # Placenta is NOT a barrier

! # Drugs cross placenta ! # Exceptions: insulin, heparin

! # Pharmacokinetics ! # Increased plasma volume and GFR , decreased albumin and gastric

motility

! # May need higher or more frequent doses

! # FDA pregnancy risk classication

! # Data from trials lacking ! # Most drugs category C with varying quality of data

! # Inadequate as the sole source!!! Mehta, Clin Chest Med 2011;32:43-52


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A 38 yo woman who is 37 weeks pregnant wakes in themiddle of the night with indigestion, cold sweats andsubsternal chest pain. An ECG reveals ST segment elevationin the precordial leads. The troponin level is elevated. The

next step is:

A. Stress echocardiogram

B. Low molecular weight heparin SQ

C. CT angiogram (PE protocol) of chest D. Tissue plasminogen activator

E. Cardiac catheterization


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Major Causes of Shock in Pregnancy

! # Cardiogenic Shock

! # Hemorrhagic Shock

! # Septic Shock


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Cardiac Disease in Pregnancy

! # Myocardial Infarction

! # Incidence increasing, diagnosis often missed ! # Coronary artery dissection , spasm, thrombosis

! # Worsening of pre-existing cardiac disease ! # High-risk if NYHA class > II, EF < 40%, LV obstruction

! # Pulmonary HTN especially risky

! # Peripartum Cardiomyopathy ! # Last month pregnancy or 6 months post-partum

! # Risk factors: age, AA race, HTN, pre-eclampsia

! # Severe systolic dysfunction

Simpson Obstet Gynecol 2012;119:345-359


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Management of Cardiogenic Shock

! # Prompt diagnosis MI, aortic dissection

! # Percutaneous coronary intervention > thrombolytics

! # Dobutamine preferred vasoactive medication

!# Pulmonary vasodilators for pulm HTN

! # Meds to avoid ! # ACE-I and ARBs, nitroprusside, spironolactone

! # Amiodarone, statins, warfarin

! # Implantable debrillators for peripartum cardiomyopathy

Roth, J Am Coll Cardiol 2008;52:171-180


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Suspect Hemorrhagic Shock

! # Pre-partum: ! # Ectopic or abdominal pregnancy

! # Abortion

! # Placenta previa or abruption

! # Trauma (MVA, falls, assaults)

! # Post-partum:

! # Uterine atony

! # Retained placenta

Mercier, Anesthesiol Clin 2008;26:53-66


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Management of Hemorrhagic Shock

! # Resuscitate: ! # Large bore IV access ! # Type specic PRBC

! # Remove placenta and compress uterus ! # Contract uterus:

! # Methylergonovine IM! # Oxytocin IV

! # Intervene: ! # Arterial embolization uterine vessels

! # Balloon tamponade/ligation of arteries ! # Hysterectomy

Oyelese, Obstet Gynecol Clin N Am 2007;34:421-441


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Suspect Septic Shock

! # Pyelonephritis

! # Septic abortion (Clostridium!)

! # Chorioamnionitis

! # Postpartum endometritis

! # Pelvic thrombophlebitis

! # Incisional infection

Fein, Clin Chest Med 1992;13:709


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Management of Septic Shock

! # Early GOAL directed therapy

! # Treat for polymicrobial infection

! # Aminoglycosides TOXIC to fetus

! # Deliver if chorioamnionitis

! # Heparin and antibiotics for septic thrombophlebitis

Guinn, Obstet Gynecol Clin N Am 2007;34:459-479


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Modications of Maternal ACLS

Circ 2005;112:150-153

DOMAIN MODIFICATION

AIRWAY Inset early, Pre-oxygenation

BREATHING Careful ET placement

CIRCULATION Left tilt/wedge under right hip OR displaceuterus manually

DEFIBRILLATION Remove uterine or fetal monitors

LINES Avoid femoral lines

Consider emergency C-section early in resuscitation!


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A 32 yo woman has an uncomplicated normal spontaneousvaginal delivery. 48 hrs later she has a grand mal seizure. T37.5, R 16, P 104, BP 144/90, SpO2 96%. Labs: Hgb 10.5,WBC 7,500, BUN 32, Cr 1.2, UA 2 + protein. Which is the

most appropriate therapy?

A. Phenobarbital

B. Magnesium sulphate

C. Hydralazine D. Phenytoin

E. Diazepam


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Preeclampsia- Denitions

! # Preeclampsia (Incidence 2 8%, > 20 wks to postpartum ) ! # HTN ! # Proteinuria ! # Edema

! # May progress to convulsions (eclampsia) ! # HELLP (Incidence 10 20% of severe preeclamptics)

! # H emolysis ! # E levated Liver enzymes

! # Low P latelets

Steegers, Lancet 2010;376:631-644


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Pathophysiology Preeclampsia

Abnormal placental vascular development

Reduced placental perfusion

STAGE 1

STAGE 2 Release mediators from placenta into maternal circulation

Maternal intravascular inammatory response

Maternal endothelial dysfunction and clotting activation Young, Annu Rev Pathol Mech Dis 2010;5:173-192


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Multiple Organ System Dysfunction

ORGAN CLINICAL SYNDROME CNS Posterior reversible encephalopathy,

eclampsia, CVA

LUNGS ARDS

HEART CHF

KIDNEYS Acute kidney injury

LIVER Hepatocellular damage, rupture

Systemic vasculature Vasoconstriction

Coagulation HELLP, DIC


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Preeclampsia- Management

! # Early recognition and close observation

! # Well-timed delivery is curative!

! # Eclampsia

! # Multiorgan involvement

! # Fetal distress

! # Gestational age > 34 wks

! # Blood pressure control with labetalol or hydralazine

! # Seizure prophylaxis with magnesium sulfate

Podymow, Hypertension 2008;51:960-969


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Magnesium in Preeclampsia

! # Randomized trials MgSO 4 vs placebo or other therapy ! # 13 trials, N > 15,000 women

! # Magnesium sulfate 4 grams IV then infusion 1 g/h for 24 hours

! # Results

! # Risk eclampsia decreased by half (RR 0.41, NNT 100)

! # Risk of dying reduced by 46% (RR 0.54, 95% CI 0.26 to 1.10 ) ! # Superior to phenytoin and nimodipine

! #Side effects

! # Flushing 20%, respiratory depression, risk C-section

Duley, Cochrane Database Sys Rev 2003;2: CD 000025


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A 34 yo woman develops acute dyspnea and cardiovascular collapseduring labor and delivery. She is afebrile, RR 40/min, HR 130 beats/m, BP80/55 mmHg. SaO 2 is 85% on 100% face mask.

Labs: Hgb 9.0 g/dL, WBC 5,000/mm 3.

Which statement is correct?

A.# Neurologic sequelae is uncommon

B. LV dysfunction is common

C. DIC is uncommon

D. Fetal cells in the pulmonary circulation are diagnostic E. Right heart dysfunction is universal


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Respiratory Failure in Pregnancy

! # Amniotic uid or air embolism

! # Tocolytic-associated pulmonary edema

! # ARDS and Pneumonia

! # Aspiration

! # Acute asthma exacerbation

! # Venous thromboembolism


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Amniotic Fluid Embolism

! # Epidemiology

! # Risk increased in C-section and eclampsia ! # Maternal mortality 13-30%/NEURO sequelae high

! # Clinical Presentation ( during labor or delivery ) ! # Sudden onset dyspnea then cardiovascular collapse ! # Right then left ventricular failure ! # Shock, pulmonary edema/ARDS, DIC

! # Management ! # Intubation/mechanical ventilation ! # Treat biventricular heart failure. ECMO , Inhaled NO?! # Treat coagulopathy

Conde-Agudelo, Am J Obstet Gynecol 2009;201:445.e1-13


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Respiratory Infections

! # Decreased cell-mediated immune response

! # Severity increased

! # Coccidioidomycoses

! # Varicella pneumonia

! # Inuenza A (H1N1)

! # Increased propensity to pulmonary edema (ARDS)

Brito, Clin Chest Med 2011;32:121-132


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Inuenza A (H1N1) in Pregnancy

! # Retrospective study women hospitalized or died inuenza

! # 94 pregnant, 8 post-partum, 137 non-pregnant

! # Rapid antigen test falsely negative (38% of pts tested)

! # Results for pregnant patients ! # 95% in 2 nd or 3 rd trimester

! # 34% had risk factor (asthma, diabetes)

! # Increased risk mechanical ventilation

! # Delay in treatment increased risk ICU or death (RR 4.3)

! # Treat in inuenza season even if rapid test negative Louie, NEJM 2010;362:27-35


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Overview of Obstetric Asthma

! #

Most common respiratory disorder of pregnancy

! # High-risk condition for mother and fetus

! # Outcomes improved by optimal care

! # Management differs little from nonpregnant pt

! # Inhaled corticosteroids and bronchodilators safe

NAEPP Update 2004


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Treatment of Acute Asthma

! # Nebulized b 2-agonist bronchodilator

! # May mix with ipratropium bromide

! # Avoid epinephrine

! # Intravenous methylprednisolone

! # 120-180 mg/day in 3 or 4 divided doses

! # Consider inhaled helium-oxygen and IV magnesium

! # Avoid drugs that worsen asthma

! # Morphine, NSAIDs, beta-blockers ! # 15-methylprostaglandin F2 $ , methylergonovine

NAEPP Update 2004


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Intubation Risk and Response

Risk Response Low O 2 reserve: ! VO 2/ " FRC Pre-oxygenate

Airway highly vascular Avoid nasotracheal intubation

Airway edema Smaller diameter ET tube

Weight gain obscures anatomy Proper positioning

Aspiration risk

Bicitra, Rapid sequence induction

Munnur, Crit Care Med 2005;33:S259-S268


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Ventilator Strategies in Pregnancy

! # Keep PaO 2 high (> 90 mm Hg)

! # Monitor the fetus after ventilator changes

! # Lung protective low tidal volume ventilation (use nonpregpredicted IBW)

! # Permissive hypercapnia, PEEP OK but monitor fetus

! # Consider prone positioning, ECMO for refractory hypoxemia

Munnur, Clin Chest Med 2011;32:53-60


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Venous Thromboembolic Disease

! # Signicant cause maternal mortality US

! # DVT 1-5/1000 and PE 1/2000 pregnancies

! # Virchow s Triad in pelvic vessels

! # Hypercoagulability in pregnancy! # Venous stasis from gravid uterus

! # Endothelial damage delivery/Cesarean section

! #Occurs all 3 trimesters and postpartum

! # Atypical presentation (abdominal pain, fever)


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DVTs: Ileofemoral (70%)/LEFT sided (80%)

Fazel, N Engl J Med 2007;357:53-59


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Treatment of DVT and PE

! # Heparin ( LMWH preferred ) ! # Does NOT cross placenta

! # Half-life decreased in pregnancy- BID dosing best?

! # Can monitor anti-factor Xa levels

! # DC 24 hrs prior to induction labor or C-section

! # Coumadin ( Category X! ) ! # Crosses the placenta and causes teratogenicity !

! # DO NOT USE!

! # Thrombolytic therapy (TPA) has been given safely

Bates, Chest 2012;141:e691S-e736S


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Summary: Critical Illness in Pregnancy

! # Understanding physiologic adaptations of pregnancyessential to accurately assess CIP

! # Cardiac disorders more common; atypical presentation

! # MAGNESIUM preferred therapy for preeclampsia/eclampsia

! # Guideline based therapy = better outcomes in asthma

! # DVT may have altered presentation

References


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References! # Strek ME, Critical illness in pregnancy. In: Hall, Schmidt, Wood, eds. Principles

of Critical Care, 4 th ed.; in press

! # Neligan PJ, Clinical review: Special populations- critical illness andpregnancy. Crit Care 2011;15:227-236

! # Naylor DF, Critical care obstetrics and gynecology. Crit Care Clin 2003;19:127-149

! # Lapinsky SE, Critical care in the pregnant patient. AJRCCM 1995;152:427-455

! # Guinn DA, Early goal directed therapy for sepsis during pregnancy. ObstetGynecol Clin N Am 2007;34:459-479

! # Steegers EA, Pre-eclampsia. Lancet 2010;376:631-644

! # Brito V, Pneumonia complicating pregnancy. Clin Chest Med2011;32:121-132

! # Marik PE, Venous thromboembolism. Clin Chest Med 2011;31:731-740

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Pregnancy and critical Illness/CCM board review