A critically ill obstetric patient
is one who, because of abnormal pregnancy, delivery,
puerperium or because of effects of pre-existing systemic
disease, anesthesia and surgery and other acquired condition
on a normal pregnancy, delivery or in puerperium develops
complications threatening her life for which she needs
intensive monitoring, therapy and/or life support system.
Medline literature review between 1987-94 revealed that
percentage of obstetrics patients requiring intensive care
is 0.1- 0.3. The mortality of critically ill,obstetric
patients ranges from 12% to 20.1
Some of the common causes for pregnancy
related ICU admissions are haemorrhage, hypertensive
disease, rheumatic valvular
heart disease, cerebral venous thrombosis, malaria, and
In low risk patients,
ICU admission may be necessitated in patients undergoing
emergency caesarian section along with considerable blood
loss when mechanical ventilation has to be prolonged for a
Detection of the patient requiring
critical care: Prompt recognition of a patient requiring
critical care can prevent a salvageable situation from
deteriorating. Important signs of serious injury and
illness include low-blood pressure or weak peripheral
pulses, cold termperature of extremities, and peripheral
cyanosis. Poor cardiac output produces constriction of
cutaneous arterioles and stimulation of sweat glands,
resulting in the characteristic cold, pale and clammy skin.
Subtle changes in mental status may indicate serious
hemodynamic or metabolic abnormalities. This should not be
mistaken for anxiety in a stressed patient. Other warning
signs include reduced urinary output, dyspnea or hyperpnea,
high termperature, unexplained fatigue, chest pains, and
tachycardia or palpitations.
After massive haemorrage, meticulous
monitoring of the patient’s pulse and BP is mandatory. The
consultant should make it a point to get the readings of the
ancillary staff cross checked, at least in high risk cases.
Recognising shock in an early stage may be missed otherwise,
especially on busy days.
Prolonged surgery or surgery following
massive haemorrhage will send the patient into shock. After
haemorrhagic shock has been tackled, the obstetrician should
continue to be vigilant, even after the vital parameters
begin to improve, because, such patients may go into
systemic inflammatory response and subsequent septic shock.
Principles of management of a patient needing critical
Management of a patient in an ICU should be systematic
and should include clinical monitoring ,Respiratory support
and Cardiovascular support, in addition to Correction of the
The following parameters should be assessed.
Mental status: Altered mental
status in a post-haemorrhage patient may indicate severe
shock with a deficit of more than 40% of blood volume. This
may be due to inadequate cerebral perfusion.
Heart rate: Tachycardia
generally alerts one to the possibility of hypovolemia, but
it could also be increased with cardiac impairment,
infection, anxiety, fear, fever, exercise, or pain and
Blood pressure. It should be
remembered that decreased arterial pressures during shock
states may be delayed because the compensatory adrenal
stress reaction tends to maintain blood pressure, at least
transiently, with declining blood flow. Severely reduced
cardiac output for periods of 40 minutes to 2 hours has been
demonstrated before a significant reduction in arterial
pressure. On the other hand, if fluids are used to restore
blood pressure, the cardiac output and oxygen transport may
still need to be corrected even if the blood pressure is
Respiration: An acute increase
in respiratory rate should prompt the physician to look for
signs of pulmonary embolism or pneumothorax.
Auscultation of the lungs in the
critically ill patient is very important. Pulmonary oedema,
pneumonia, atelectasis etc, are important events that may
develop in the moribund patient. Early detection with
confirmation with an X-ray is necessary to institute prompt
Besides conditions of the lung, dyspnea
may be caused by increased respiratory effort also2.
Abdominal loading, caused by ascites, obesity, or pregnancy
by itself could lead to elevation of the diaphragm, and may
result in less effective ventilation and dyspnea. Massive
hemoperitoneum/collection of pus in the abdomen could also
lead to abdominal loading and consequent impairment of
ventilation and should be thought of in a postoperative
patient with distended abdomen and dyspnea. Electrolyte
abnormalities, metabolic acidosis and renal failure may also
increase respiratory effort..
Urine output: Hourly out put
charts should be maintened 30ml/hour of urine is indicative
of good kidney function.
Electronic monitoring and invasive
Most ICU settings are equipped with
multi-parameter electronic monitors, which will give
continuous readings of pulse, cardiogram, and in some
monitors, blood pressure monitoring. The oxygenation status
of the patient is determined by the use of a pulse-oximetre
in most Indian ICU’s.
Pulse oximetry: Pulse oximetre
measures oxyhemoglobin saturation value (SPO2) which is
directly related to arterial partial pressure of
oxygen-PaO2(Amount of oxygen dissolved in plasma) .
A reading of 95% SpO2
or less could indicate hypoxia and should be investigated.
An SpO2 reading of 90% or less indicates significant hypoxia
and requires immediate action.
Pulse oximetre probes are usually kept on fingers and
in severe shock, if the pulse oximetre shows no reading, it
may mean that there is not adequate flow in the finger
capillaries for the probe to pick up a reading. Dyes like
methylene blue,nail polish and pigments like bilirubin can
affect pulse oximetry reading. Pulse oximetry reading may
be incorrect in patients with low perfusion, anemia and
increased venous pulsation. External light source may also
hinder correct readings.
Central venous pressure (CVP)
CVP is the pressure of blood in the thoracic vena
cava just before it (blood) enters the heart. Normal values
are between 5-10cmH2O. It can be measured by inserting a
catheter in the subclavian vein. Measuring CVP alone is
useful in detecting extreme cases of hypervolemia, fluid
overload or heart failure. CVP does not accurately reflect
left ventricular filling in patients with preeclampsia,
pulmonary and cardiac disease.
Pulmonary artery catheterization: The Swan-Ganz
pulmonary artery catheter introduced into the pulmonary
artery is used to measure, in addition to the Continuous
central venous pressure (CVP), the pulmonary artery
pressures and intermittent capillary wedge pressure (PCWP).
In certain patients, for eg; in patients with significant
cardiopulmonary disease, there may be a lack of co-relation
between measurements on the right and left sides of the
heart. Drugs/fluids used to optimize ventricular preload can
be monitored more accurately if the pulmonary artery
pressures are known in these patients, so as to avoid
invasive monitoring using the Swan Ganz catheter has its own
hazards and therefore it is recommended only in patients
where precise hemodynamic data can improve decision making
and where better interventions are possible.
be tested daily for Haemoglobin, blood counts, coagulation
parameters, electrolytes, creatinine and charted. Arterial
blood gases and pH are useful for screening pulmonary
function in critically ill patients.
Haemoglobin: A falling haemoglobin or an inadequately
rising Hb should alert one to the possibility of internal
Coagulation parameters: A rise in prothrombin
time, bleeding time, etc should be treated with fresh frozen
plasma/cryoprecipitate. Platelet deficiency should be
Hyponatremia should be treated. Hyponatremia is defined as
plasma sodium< 135mEq/L. Physical stress and
postoperative pain can contribute to hyponatremia and should
with hypovolemia: Give IV 0.9%Nacl if patient is nil
by mouth or oral salt containing water at a rate appropriate
for the estimated volume depletion. Treat till a safe
plasma sodium (generally 120-125mEq/L) is achieved.
with hypervolemia(Oedematous state): Treat with
diuretics, salt restriction, fluid restriction(intake
<output) and correction of potassium deficit.
with euvolemia: There is impaired water excretion wit
normal or high total body sodium. In such patients fluid
restriction is the most important treatment. Adequate
restriction of fluid intake will gradually increase serum
Pottassium: Hypokalemia is defined as persistent
reduction of serum potassium below 3.5mEq/L.
No potassium supplement; Increased oral intake of potassium
rich food (fruit juices, coconut water, banana, juicy
fruits, dry fruits, chocolate, coffee, soup) if patient can
take food. If patient cannot ingest , give IV potassium;
treat in high risk patients e.g. Congestive heart failure,
digitalis therapy, history of acute myocardial infarction or
ischaemic heart disease.
Needs difinitve treatment. Potassium chloride (KCL) is
usually the preparation of choice and will promote
correction of hypokalemia as well as of metabolic
chloride solution, available in the market contains 20mEq
potassium per 15ml solution (1gm=KCL+13.4mEq of
potassium)Oral potassium preparation may cause G.I.
irritation and shoud e taken with proper dilutionof in a
glass of water, after food. IV potassium supplementation
should be reserved for severe symptomatic hypokalemia(K+
<3mEq/L) or for patients who cannot ingest oral
potassium. To make tailor made potassium chloride infusion,
100mEq of potassium.(5 ampoules of 10ml., 15%KCl ampoules)
is mixed in 1 litre of isotonic saline. Alternately 2
Ampoules can be added to 1 bottle of isotonic saline.
Infusion of this saline at the rate of 100ml/hour (25
macrodrops or 100microdrops) will deliver 10mEq KCl per
hour. 10ml of 15%KCl =1.5gm KCl=20mEq of potassium. 1 ml of
15% KCl=2mEq of potassium.
Symptomatic hypocalcemia should be treated as emergency with
10% calcium gluconae (90mg elemental calcium/10ml) 10-20ml
IV slowly over 10
Respiratory support in the critically ill
has to be taken if the patient needs to be put on a
ventilator. The principal indications for ventilatory
support are airway protection and respiratory failure. A
compromised airway, or an airway at risk of compromise, may
be identified by physical examination and ancillary testing.
failure is almost always—and most appropriately—a clinical
diagnosis. The decision to intubate and mechanically
ventilate or to institute noninvasive ventilation support is
generally made on clinical grounds without delay for
- Apnea or hypopnea
- Respiratory distress with altered
- Clinically apparent increasing
work of breathing unrelieved by other interventions
- Obtundation and need for airway
Respiratory failure may also be easily
identified with laboratory or pulmonary function
data. Obtaining a PaCO2 is useful to confirm
respiratory failure when a broader differential diagnosis
exists—for example, comatosed patients who may be
hypercarbic but might have a reversible metabolic or
toxicological etiology for their conditions—but adequate
stabilization and ventilation of these patients should not
be delayed to wait for laboratory results.
Ventilatory support is indicated for
both hypercapnic respiratory failure and hypoxemic
respiratory failure. It is also indicated for treatment of
certain critical conditions such as correction of
life-threatening acidemia, for intentional hyperventilation
in elevated intracranial pressure or for suspicion of
clinical brain herniation from any cause.
PaO2 <55 mm Hg
PaCO2 >50 mm Hg and
Pulmonary function tests
Vital capacity <10 mL/kg
Negative inspiratory force <25
cm H2 O
FEV1 <10 mL/kg
- Controlled hyperventilation (e.g.,
in head injury).
- Severe circulatory shock
patient is in haemorrgagic shock,one should aim to rapidly
recognize the shock state, improve the circulating blood
volume, improve cellular perfusion, correct metabolic
disturbances while stopping haemorrhage.
access: Two large bore intravenous catheters and if
possible a central venous catheter should be secured. Any
large peripheral vein could be accessed. CVP can be measured
through the subclavian vein.
Oxygenation: All patients with haemorrhagic shock should
receive oxygen supplementation at nearly 12liters/min, by a
closed mask or nasal cannula. Mechanical ventilation is
indicated when there is ventilator failure or to relieve the
metabolic stress of work of breathing in selected patients.
Fluid replacement: The goals of fluid replacement
should be to obtain and maintain a systolic blood pressure
at about 100mm Hg,urine output greater than 30ml/hour and
maintain a pulmonary wedge pressure between 10 and 15mmHg.
Fluid replacement can be done with crystalloids, (Ringer
lactate, Dextrose normal saline, 0.9%normal saline)or
colloids. Commonly used colloids are, Dextran 40(10%soution
in isotonic saline),Dextran70(6%solution in isotonic
saline),Hetastarch(6%solution in isotonic
saline),Albumin(5and 25% solutions in isotonic saline).
Crystaloids are the initial volume expanding agents used in
the ratio of 3:1 to the estimated blood loss. Colloids can
remain in the intravascular compartment for longer and
smaller volume is required to achieve volume repletion.
Disadvantages are that anaphylaxis can occur, and there may
be decreased platelet and increased prothrombin time.
Blood and blood products: Order blood transfusions if
blood loss is ongoing and thought to be in excess of 2000 mL
or if the patient’s clinical status reflects developing
shock despite aggressive resuscitation. It is advisable
that such a patient should first receive 4 units of packed
red blood cells, to improve the oxygen carrying capacity,
after which whole blood should be administered to replace
volume loss and provide the coagulation factors and proteins
needed to maintain hemostasis and colloid osmotic pressure
Packed red blood cells (PRBCs) are the primary
transfusion product used to increase the oxygen-carrying
capacity. A typical volume of about 300 mL is mixed with
normal saline before infusion. Diluting PRBCs with Ringer's
lactate can cause calcium to precipitate with the citrate
used as a preservative in stored blood. A single unit of
PRBCs can be expected to raise the hemoglobin and hematocrit
by 1 g and by 3%, respectively, in a nonbleeding patient.
When coagulopathy begins to set in, fresh blood by itself
is not enough. Fresh-frozen plasma is a secondary
transfusion product indicated mainly in states of
coagulopathy or with massive transfusion. It comes in 250-mL
units and contains all the coagulation factors, especially
fibrinogen. One unit will raise the fibrinogen level by 10
mg/% in a nonbleeding patient. To avoid coagulopathy it is
best to transfuse 1 unit of fresh-frozen plasma to every 4
units of PRBCs/whole blood, in an actively bleeding patient.
If coagulopathy continues and fibrinogen levels are low,
consider giving cryoprecipitate. Cryoprecipitate is a
tertiary transfusion product that contains as much
fibrinogen as a unit of fresh-frozen plasma but in a volume
of only about 15 mL. It also contains factor VIII, factor
XIII, and von Willebrand's factor. It also will raise the
fibrinogen level about 10 mg/% per unit. Its main indication
for transfusion is in a hemorrhaging patient who is volume
replete but has low fibrinogen levels.
If platelet count is less than 1lakh, platelet
transfusion should be given. A unit of single-donor
platelets raises the platelet count by 30,000 to 60,000 in a
Use of Vasopressors or Ionotropic drugs:
If the BP continues to remain low in spite of adequate
fluid replacement, continuing to give fluids may not be
enough. Use of CVP or PCWP should be resorted to to know if
the patient has been hydrated enough. In such patients,
vasopressors have to be given.
Norepinephrine: In a patient with a
systolic BP<70, after hypovelemia has been corrected, the
pressor of choice should be Norepinephrine. . Dosage:
0.5-30umg/min IV. 1mg of Noradrenalin in 250 ml of 5%
Dextrose can be given at 3microdrops / minute upto 45
microdrops / minute. On an average, about 8-10 drops may be
enough. The use of norepinephrine is associated with
improved mean arterial pressure, sustained aortic and
mesenteric blood flow, and better tissue oxygenation when
compared with fluid resuscitation alone, irrespective of
time of administration. The early use of
norepinephrine plus volume expansion is
associated with a higher proportion of blood flow
redistributed to the mesenteric area, lower lactate levels,
and less infused volume.
Dopamine: If the systolic BP is >70
Dopamine could be used as a vasopressor. It is the most
commonly used vasopressor. Used in a dose of 3 to 10umg
/kg/min, dopamine activates the B1adrenergic receptors and
increases hea rt rate and myocardial contractility and hence
improves the cardiac output. Two ampoules of Dopamine,
(Each amp. Contains 200umg of the active drug in 5ml_ are
added to 400ml of NS and started at either 8-10microdrops
Dobutamine, Ephedrine, Vasopressin,
Metaraminol, Methoxamine, and Phenylephrine are other
While all efforts are made to maintain
a stable cardiovascular system, adequate attention should
also be given to
- Maintain electrolyte balance and
check if calcium levels are normal.
- Normalise body temperature
- Restore urine output. Recognise
the need for dialysis if kidney function fails.
- Reverse systemic acidosis and
bring down lactate levels.
- Stop the cause of haemorrhage.
Recognise re-bleed promptly. A falling Hb or an Hb
which does not rise inspite of multiple blood
transfusions should alert the clinician to the
possibility of a bleed/rebleed which may need a second
laparotomy. A bed side ultrasound would be helpful in
Sepsis is one of the five leading causes of
pregnancy-related death around the world. The maternal
mortality ratio is >1,000 per 100,000 live births (as
estimated by World Health Organization, the United Nations
Children’s Fund, and the United Nations Population Fund).
Management: .Any source of
infection should be identified and removed. For women with
an infected abortion the uterine contents must be removed
promptly by curettage. . Hysterectomy is seldom indicated
unless gangrene sets in. With pyelonephritis, ureteral
catheterization, percutaneous nephrostomy or flank
exploration may be life saving.
Antibiotics: Choice of antibiotic
should ideally be dictated by epidemiologic and hospital
data, which is not always available in the Indian set up.
Recommended antimicrobial regimens
for high-risk patients with intra-abdominal infection:
1. Aminoglycoside (amikacin,
gentamicin, netilmicin, tobramycin) plus an anti-anaerobe
(clindamycin or metronidazole)
2.Aztreonam plus clindamycin
3.Ciprofloxacin plus metronidazole
cephalosporin (cefepime, cefotaxime, ceftazidime,
ceftizoxime, ceftriaxone) plus an anti-anaerobe (clindamycin
Genital tract infections:For
genital tract infections, the following drugs may be chosen:
a.penicillin (5 million units IV every
6 hours) or ampicillin (2 g IV every 6 hours) plus
clindamycin (900 mg IV every 8 hours)
b.metronidazole (500 mg IV every 12
hours) plus gentamicin (1.5 mg/kg IV every 8 hours or 7
mg/kg ideal body weight IV every 24 hours) or aztreonam (1
to 2 g IV every 8 hours)
a.. imipenem-cilastatin (500 mg IV
every 6 hours)
b.meropenem (1 g every 8 hours).
Correction of hypotension: Fluid
therapy could be on the same lines as for haemorrhagic
shock. Blood transfusion should be cautiously given as it
may be assossiated with increased mortality. Patients can
tolerate and may even benefit from hemoglobin levels lower
than the traditional 10 g/dL If hypotension and organ
hypoperfusion do not respond to volume infusion, then
inotropic drugs (to improve cardiac performance) and
vasopressor therapy (for hypotension) are indicated.
Dopamine or norepinephrine is recommended as the first-line
Adjuvant management: Temperature
should be brought down using cooling blankets. Daily
haemodialysis or continuous venovenous haemofiltration
should be used in patients with overt acute renal failure.
Newer modalities of therapy:
1.Use of steroids in septic shock has
been controversial. A meta-analysis showed that
hydrocortisone in doses from 200-300mg for 5 days or more
reduced duration of shock, systemic inflammation, and
mortality without causing harm Only patients with refractory
septic shock and adrenal insufficiency benefit from
hydrocortisone and 50 micrograms /day oral fludrocortisone
can be added.
2. Vasopressin replacement therapy in
doses ranging from 0.01-0.04IU/min improved haemodynamics
and decreased catecholamine requirements.
However,vasopressin might induce myocardial, cutaneous, or
4. Use of polyvalent intravenous
immunoglobulins were found to reduce mortality in studies,
but high quality trials found no evidence that
immunoglobulins were beneficial. Immunoglobulins , in
experimental studies, have been postulated to improve
opsonization , prevent nonspecific complement activation ,
protect against the antibiotic-induced liberation of
endotoxin , neutralize endotoxin as well as a wide variety
of superantigens . Dose: 0.5mg/Kg/day.
In a patient with severe preeclamptic toxemia needing ICU
care, one should be alert to prevent eclampsia. PET may
present with severe hypertension with a potential for
end-organ damage, including retinal hemorrhage, papilledema,
pulmonary edema, severe headache, and renal failure. Acute
cerebral complications (eg, intracranial hemorrhage, massive
cerebral edema) are particularly worrisome because they
account for more than 75% of maternal deaths secondary to
PEC. The goal of treatment is to prevent end-organ damage
while still maintaining adequate uteroplacental perfusion.
If urgent lowering of blood pressure is required,
intravenous labetalol or intravenous hydralazine may be
used. Some evidence suggests that labetalol may be the
Pulmonary edema develops most commonly (70%–80% of cases)
in the postpartum period.
It can be explained by the
postpartum changes that include a significant drop in
colloid oncotic pressure and the increase in preload that
occurs with uterine contractions, the relief of vena caval
obstruction after delivery of the conception products, and
the mobilization of extravascular fluid that occurs in the
initial 24 to 72 hours postpartum. Pregnant women generally
respond to lower doses of diuretics than nonpregnant women,
and most patients respond to 10 mg of furosemide
administered intravenously. Renal failure in the setting of
PEC is usually rapidly reversible. For patients with
oliguria and rising creatinine, treatment with small fluid
boluses (250 mL) may improve urine output. Fluids should be
given with caution to prevent pulmonary oedema.
Pregnancy by itself is a thrombophilic condition and
thrombophilia prophylaxis should be given to patients with
risk of developing deep vein thrombosis to prevent pulmonary
embolism. Diagnosis of pulmonary embolism in pregnancy is
difficult, but if diagnosed , should be treated with
Acute fatty liver of pregnancy, Amniotic fluid embolism,
HELLP synfrome, Tocolytic induced pulmonary oedema and
peripartum cardiomyopathy are some of the other specific
conditions needing critical care, but treatment of all the
disorders is beyond the scope of this article.
In conclusion, critical care of the high risk
patient should be done as a team effort with the help of an
intensivist, but the obstetrician should be aware of all the
treatment and investigative modalities, by which he/she can
actively participate in the ICU care of the patient.
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