Critical Care Medicine Unique to Pregnancy Timothy P. Rich, M.D. Pulmonary, Critical Care & Sleep Medicine Outline Epidemiology of obstetric critical care Sorting out critical illness in pregnancy Critical illness unique to pregnancy – Preeclampsia and Eclampsia – HELLP Syndrome – Amniotic Fluid Embolism – Acute Fatty Liver of Pregnancy – Tocolytic-Induced ARDS Important reminders Incidence of Obstetric Critical Illness Obstetrician’s perspective – 0.2 - 0.5% of deliveries require ICU Intensivist’s perspective – ~2% of ICU admissions – ~80% are post-partum – ~50-70% require mechanical ventilation Lapinsky SE, 2008
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Critical Care Medicine Unique to Pregnancy
Timothy P. Rich, M.D.
Pulmonary, Critical Care & Sleep Medicine
Outline
Epidemiology of obstetric critical careSorting out critical illness in pregnancyCritical illness unique to pregnancy– Preeclampsia and Eclampsia– HELLP Syndrome– Amniotic Fluid Embolism– Acute Fatty Liver of Pregnancy– Tocolytic-Induced ARDS
Important reminders
Incidence of Obstetric Critical Illness
Obstetrician’s perspective– 0.2 - 0.5% of deliveries require ICU
Intensivist’s perspective– ~2% of ICU admissions– ~80% are post-partum– ~50-70% require mechanical ventilation
Lapinsky SE, 2008
All very rare…
… all very serious …
… all very scary!
Sorting Out Critical Illness in the Pregnant Patient
Non-specific to pregnancy– Trauma, non-obstetric infections, etc
Note: amniotic fluid components are commonly present in maternal circulation.
Triad: hypoxia, hypotension, coagulopathy
Amniotic Fluid Embolism Epidemiology
1:20,000 deliveries (1:8,000 to 1:80,000)65% with AFE present before delivery50% of first-hour deaths from hypoxia, shock70% develop ARDS80% develop DICMortality- 60%-86%
Amniotic Fluid EmbolismPathophysiology
Amniotic fluid, fetal cells, hair, etc, enter maternal venous circulation via the placental bed of the uterus.Risk factors: – Rupture of amniotic sac– Rupture of uterine or cervical vein– Pressure gradient from uterus-to-vein– Uterine manipulation, abdomen trauma (?)– Use of misoprostol for labor induction (?)
LCHAD Deficiency: long-chain 3-hydroxyacyl-coenzyme A dehydrogenase
Deficiency leads to accumulation of medium and long chain FA in the fetus which re-enters the maternal circulation overwhelming the beta-oxidation enzymes
Acute fatty Liver of Pregnancy
23yo female, 34-wks gestation with “acute yellow atrophy”.
23yo female 34wks gestation with microvesicular steatosis… liver tx.
Acute fatty Liver of Pregnancy
Acute Fatty Liver of Pregnancy Genetics
LCHAD gene has been isolatedMissense mutation- E474Q
Autosomal recessive inheritanceMaternal heterozygous for mutation
Acute Fatty Liver of Pregnancy Treatment
Temporizing management– Consider a liver biopsy (r/o viral hepatitis)– Supportive care
Definitive management– Delivery… stress of FA overload is removed– May require a liver transplant
Tocolytic -InducedPulmonary Edema
Described in 1988 by Milos and Pisani
Beta-adrenergic agonists used to arrest premature contractions.
Tocolytics increase intracellular cAMP, thus relaxing smooth muscleTriad: hypoxemia, infiltrates, normotensiveRisk factors: – recent (<24hrs) or current po/IV tocolytic therapy
Tocolytic-Induced Pulmonary EdemaEpidemiology
Incidence 0-4.4% <24-hrs after useMortality < 5%
Tocolytic-Induced Pulmonary EdemaPathophsiology
Noncardiac > Cardiac etiology– Beta-adrenergic agonist activity– Increased ADH and renin release– Enhanced Na+ and water resorption– Volume overload– Increased hydrostatic pressure
In the setting of lower oncotic pressureUnlikely direct toxic effect or increased permeability
Pisani RJ, Ann Intern Med 1989, May 1; 110(9): 714-8La Chapelle A, A&A 2002, June; 94(6):1593-1594
Intensivist-PulmonologistCritical Care Nurse PractitionersCritical Care Registered NursesCritical Care PharmacistsRespiratory TherapistsNutrition ServicesSocial Work, Chaplaincy
Important Reminders
Eternal vigilanceKeep your differential broad
Use the “triads” for pattern recognitionManage the patient in the ICUAnd remember you are not alone…Consult– Intensivist, Cardiology, Pulmonary,