General Care of the Pregnant Patient in the Intensive Care Unit

Abstract

Pregnant women represent a small subset of all intensive care unit (ICU) admissions and may require intensive care for "obstetric" or "nonobstetric" reasons. Women may be admitted to the ICU at any stage of pregnancy or in the postpartum period. Pregnancy may be discovered at the time of admission to the ICU. Pregnancy impacts on ICU care in a variety of ways and requires a multidisciplinary approach to management. Pregnancy is associated with considerable physiological changes that affect most organ systems, including an expansion in blood volume, an increase in minute ventilation, and an increased risk of thrombosis. The enlarging uterus may be associated with mechanical complications due to compression and displacement of other structures. The growing fetus places considerable demands upon the mother, being reliant on maternal systems for oxygenation, nutrition and disposal of carbon dioxide, and other waste products. This "second patient" must be considered when managing the pregnant woman. Optimal management of the mother usually constitutes best treatment for the fetus. Maternal shock and physiological disturbance, medications, and ionizing radiation from diagnostic imaging may have harmful effects on the unborn child. Delivery of the fetus for either maternal or fetal indications may be necessary and should be planned for, even if considered unlikely to be required. Care of the postpartum woman has its own challenges, including managing lactation and facilitating mother/infant contact. In this article, the general care aspects of ICU treatment of the pregnant woman will be discussed, including monitoring, physiological target setting, and general supportive care.

Timing of delivery with coronavirus disease 2019 pneumonia requiring intensive care unit admission

“…Guidelines for management are primarily derived from clinical experience -not clinical trials -and tend to focus on treatment of the maternal condition, with only general recommendations regarding fetal assessment and indications for delivery. 20 With respect to COVID-19 pneumonia, principles of care are most similar to patients with acute respiratory distress syndrome (ARDS), with modifications in medication regimens, target laboratory and physiologic parameters, and maternal positioning. 21 Decisions regarding frequency of fetal monitoring and/or delivery are governed by maternal status and gestational age, with the fetal cardiotocograph proposed to represent an additional "vital sign" to both guide and determine efficacy of therapy.…”

COVID‐19‐related disease severity in pregnancy

“…65 to PaCO 2 levels as high as 60 mm Hg. [71][72][73] As more cases of severe and critical COVID-19 pneumonia are managed in pregnant patients, multidisciplinary care among critical care, infectious disease, and maternal-fetal medicine specialists will be needed to ensure optimal outcomes for both mother and fetus.…”

“…In order to maintain appropriate uterine blood flow, PaCO 2 should be maintained >30 mm Hg 71 . Additionally maternal hypercapnia, PaCO 2 > 40 mm Hg, can lead to fetal respiratory acidosis; however, studies have not identified adverse outcomes in fetuses exposed to PaCO 2 levels as high as 60 mm Hg 71‐73 . As more cases of severe and critical COVID‐19 pneumonia are managed in pregnant patients, multidisciplinary care among critical care, infectious disease, and maternal‐fetal medicine specialists will be needed to ensure optimal outcomes for both mother and fetus.…”

Pregnancy outcomes in anti-NMDA receptor encephalitis

“…In late stages of pregnancy, uteroplacental blood flow comprises a large part of the maternal cardiac output, making the fetus particularly sensitive to variations of maternal blood pressure. 34 For example, 3 patients underwent emergency cesarean sections due to signs of fetal distress, resulting in good outcome in 2 of them.…”