211 - Critical Care in Pregnancy

Question 1

Rate of maternal admission to ICU per 1000 deliveries? what % are post-partum?

Answer 1

1-10/1000 63–92% are postpartum

Question 2

What is the Sepsis in Obstetrics Score?

Answer 2

Scoring system for pregnant women with suspected infection who are being evaluated in the emergency department that predicts the need for ICU admission.

Question 3

What are the maternal vitals that should trigger bedside evaluation per the National Partnership for Maternal Safety

Answer 3

Question 4

What are the two most common causes for maternal ICU admission?

Answer 4

Massive obstetric hemorrhage and hypertensive disorders of pregnancy

Question 5

What is sepsis?

Answer 5

“life-threatening organ dysfunction caused by a dysregulated host response to infection

Question 6

What is SIRS and severe sepsis?

Answer 6

Old terms!

We now classify as infection (no organ dysfunction), sepsis (organ dysfunction), or septic shock (organ dysfunction necessitating pressors to keep MAP >65 OR lactate 2mmol/L AFTER fluid recussitation)

Question 7

what is qSOFA? what are the parameters?

Answer 7

Quick Sequential Organ Failure Assessment

• use to stratify patients with infection
• 2+ findings = positive screen –> indicate a need for further assessment

systolic blood pressure (BP) 100-mm Hg or less; respiratory rate 22 breaths per minute or more; or an altered mental status

Question 8

qSOFA and pregnancy?

Answer 8

Not validated for obstetric patients

Question 9

What is ARDS?

Answer 9

diffuse inflammation, increased fluid level in the lung due to increased vascular permeability, and loss of aerated lung units

onset of respiratory failure must be within 1 week of a known clinical event with evidence of bilateral opacities on chest imaging, and no other identifiable etiology such as cardiac failure or fluid overload

Question 10

What maternal conditions place patients at increased risk of ARDS?

Answer 10

• influenza
• pyelonephritis
• Preeclampsia
• amniotic fluid embolism

Question 11

What is the mortality rate of obstetric ARDS?

What is the ARDS prevalence in maternal deaths?

Answer 11

Mortality: old literature 22-44%, recent data from Canada = 3%

One study showed 33% of maternal deaths had ARDS

Question 12

How do you classify ARDS?

Answer 12

mild, moderate, severe

based on oxygenation as measured by the partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FIO2) ratio

Question 13

What is optimal ventilatory supports for ARDS:

• oxygen high or low
• PPV high or low

Answer 13

low/low

(not validated in ob patients)

Question 14

what are general parameters that may trigger ICU transfer?

Answer 14

instability (hypotension, hypoxemia)

high risk of deteriorization (increased work of breathing)

needs specialized ICU care (i.e. vent)

Question 15

What should you have during hospital-to-hospital transfer of critically ill mother?

Answer 15

• continuous cardiac rhythm and pulse oximetry monitoring
• regular assessment of vital signs
• Venous access
• Left uterine displacement
• If there is a high probability that intubation and mechanical ventilation will be needed during transport, it should be accomplished before departure

Question 16

What should you have during within-hospital transfer of critically ill mother?

Answer 16

• be able to assess BP, heart rate, and oxygenation status.
• cardiac monitor with defibrillator
• airway management equipment
• oxygen
• basic resuscitation medications.
• At least two health care professionals should accompany the patient (also to imaging, and in ICU in case emergent need to go back to L+D)

Question 17

CC and respiratory physiologic changed of pregnancy that affect resuscitation

Answer 17

Question 18

GI, uteroplacental, breast, and renal/urinary physiologic changed of pregnancy that affect resuscitation

Answer 18

Question 19

What is the importance and utility of EFM in critically ill patients?

Answer 19

Needs of mom > baby

EFM can give you cues about moms status (even if you wont change delivery plans based on it)

Question 20

Which artery to avoid in A-lines on pregnant patients?

Answer 20

Femoral due to risk of ischemia distal to cannulated site

Question 21

What is the role of resuscitative hysterotomy in the setting of maternal cardiopulmonary arrest? Who is a candidate? What are the 3rd trimeter outcomes for mom and baby?

Answer 21

Consider it as soon as there is a maternal cardiac arrest (get supplies), do it if recussitative efforts are failing.

Used to say 4-5 mins, data shows 50% injury-free survival rate as late as 25 minutes

>20wks (at or above umbilicus)

One study showed:

• mom: 45% died, 45% lived and ok, 10% lived with significant morbidity
• babies: 23% died, 57% lived and ok, 19% lived with significant morbidity

Question 22

How to do CRP on pregnant patients?

Answer 22

MANUAL left tilt of uterus (keep patient on her back for optimal compressions)