Critical Care Critical Care Obstetrics: Obstetrics: A Multidisciplinary A Multidisciplinary Approach Approach Paul J. Wendel, M.D. Associate Professor Maternal-Fetal Medicine Division Department of Obstetrics and Gynecology College of Medicine University of Arkansas for Medical Sciences
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Critical Care Obstetrics: A Multidisciplinary Approach Paul J. Wendel, M.D. Associate Professor Maternal-Fetal Medicine Division Department of Obstetrics.
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Critical Care Obstetrics: Critical Care Obstetrics: A Multidisciplinary ApproachA Multidisciplinary Approach
Paul J. Wendel, M.D.Associate ProfessorMaternal-Fetal Medicine DivisionDepartment of Obstetrics and GynecologyCollege of MedicineUniversity of Arkansas for Medical Sciences
Case of 18 year-old foreign national from Marshall Island with history of rheumatic fever as child.
G1, P0 / 23 wks
Presents to NW Arkansas with UTI, fever, SOB, back pain
Rapidly progressive respiratory distress
O2 sat. on arrival 88% and ↓ to 80% with 100% rebreather
CXR – pulmonary edema/ARDSFHT’s – reassuringIntubated following progressive
O2 requirements
Echo – moderate mitral stenosis and mitral regurgitation
LV function normalHigh gradient across mitral
valve – functionally severe stenosis
Attempted transport to UAMS but due to lack of ventilator beds (ICU bed) transport to UAMS occurred 2 wks after initial admit in NW Arkansas
10 days on ventilator prior to transport
Prior to transportPatient febrileOn multiple abx, plus TB
meds4 units PRBC’s transfusedRecords indicated positive
Clinical ChallengesClinical ChallengesFetus at “extremes of viability”Hypotensive but fluid overloadedSevere mitral stenosisPulmonary edema/intubated but
needs O2 exchange for fetus
Febrile - ? SepticFOB not in picture/family present
Keep mother aliveNo fetal interventions
Multidisciplinary ApproachMultidisciplinary ApproachMICU Team
CardiologyPulmonaryAnesthesiology
ObstetricsNeonatologySocial WorkNursing
Goals of the TeamGoals of the TeamEfforts directed at maintenance of
mother’s life (family directive) When possible, maximize fetal compartment
Maintain oxygenationDiuresis of fluidIncrease pressors as needed for BP controlAvoid delivery if possible secondary to
fluid shifts/bleeding
PlanPlanSlow diuresis begun and continued
over one weekDigoxin/Beta blocker started to
increase cardiac output and increase filling time
Steroids started for ARDSAntibiotics were discontinued when
all cultures negative and fever resolved
MICU CourseMICU CourseAdmitted on 02/09/06 (25 wks)On 2/18-20/06 started having
contractions Cervix changed from fingertip to 3-4 cm
Swan Ganz catheter placed to determine need for vulvoplasty of mitral valve
Fetus remained reassuring on daily monitoring of heart rate pattern