Monothematic meeting of Sfar
Intensive care and pregnancy: Epidemiology and general principles of management of obstetrics ICU patients during pregnancy,☆☆

https://doi.org/10.1016/j.accpm.2016.06.005Get rights and content

Abstract

In developed countries, the rate of obstetric ICU admissions (admission during pregnancy or the postpartum period) is between 0.5 and 4 per 1000 deliveries and the overall case-fatality rate is about 2%. The most two common causes of obstetric ICU admissions concerned direct obstetric pathologies: obstetric hemorrhage and hypertensive disorders of pregnancy. This review summarized the principles of management of critically ill pregnant patient. Its imply taking care of two patients in the same time. A coordinated multidisciplinary team including intensivists, anesthesiologists, obstetricians, pediatricians and pharmacists is therefore necessary. This team must work effectively together with regular staff aiming to evaluate daily the need to maintain the patient in intensive care unit or to prompt delivery. Keeping mother and baby together and fetal well-being must be balanced with the need of specialized advanced life support for the mother. The maternal physiological changes imply various consequences on management. The uterus aorto-caval compression implies tilting left the parturient. In case of cardiac arrest, uterus displacement and urgent cesarean delivery are needed. The high risk of aspiration and difficult tracheal intubation must be anticipated. Even during acute respiratory distress syndrome, hypoxemia and permissive hypercapnia must be avoided due to their negative impact on the fetus. Careful analysis of the benefit-risk ratio is needed before all drug administration. Streptococcal toxic shock syndrome and perineal fasciitis must be feared and a high level of suspicion of sepsis must be maintained. Finally the potential benefits of an ultrasound-based management are detailed.

Introduction

Physiological changes associated with pregnancy make the obstetric patients a specific intensive care unit (ICU) population. They represent a small but important population in which the intensivist is in charge of two patients instead of one. This review will discuss the epidemiology of this population. We then outline how parturients in the prepartum period can be treated according to the best knowledge of literature during pregnancy.

Section snippets

Method

This review was performed by a group including epidemiologists, anesthesiologists, intensivists and midwives.

Literature was explored using Pubmed database from 2000 to 2015. The following key words were used: pregnancy, obstetric, parturient and critical care, intensive care, critical illness, preeclampsia. Experimental studies, original studies, reviews and case reports were assessed. Manuscripts in English and French languages were considered for analysis.

Epidemiology

Although pregnancy and childbirth are generally healthy events, they nevertheless can be in some cases associated with maternal complications that can worsen and lead to maternal death. The current changes in the profile of parturient women (increase in the age at conception, in the rate of twin pregnancies or the rate of obese women) and in obstetric practices (more caesarean sections, inductions of labor) may lead to an increasing risk of maternal complications [1], [2], [3], [4], [5].

Conclusion

The ICU management of parturient during pregnancy is challenging due to the implication of two patients in the same time. A multidisciplinary management made by experienced practitioners and a good knowledge of the pregnancy-induced physiological changes are therefore necessary.

Disclosure of interest

The authors declare that they have no competing interest.

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  • Cited by (0)

    Article presented at Monothematic meeting of Société Française d’Anesthésie et de Réanimation (Sfar): “Urgence, anesthésie et réanimation de la femme enceinte”, Paris, May 16, 2016.

    ☆☆

    This article is published under the responsibility of the Scientific Committee of the “Journée monothématique 2016 de la Sfar”. The editorial board of the Anaesthesia Critical Care & Pain Medicine was not involved in the conception and validation of its content.

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