Central hemodynamic assessment of normal term pregnancy

A case-control study of reproductive factors and renal cell carcinoma among black and white women in the United States

OBJECTIVE

Renal cell carcinoma (RCC) incidence is higher among blacks than whites in the United States and has been associated with the frequency and timing of childbirth among women in some epidemiologic studies. We investigated whether reproductive factors are associated with RCC, overall and by race, within a population-based case-control study.

METHODS

Between 2002 and 2007, 497 female cases of incident RCC (136 black, 361 white) and 546 female controls (273 black, 273 white) within the Detroit and Chicago metropolitan areas were enrolled. Information on reproductive history and other factors was collected through in-person interviews. Multivariate-adjusted odds ratios (OR) and 95% confidence intervals (CI) were computed using unconditional logistic regression.

RESULTS

Reduced RCC risk was observed among women aged ≥30 years at first live birth, relative to an age of <20 years (OR 0.5, 95% CI 0.3-0.9). This association was present among both white (OR 0.4, 95% CI 0.2-0.9) and, though not statistically significant, black women (OR 0.6, 95% CI 0.2-1.8). In analyses restricted to clear cell adenocarcinoma, the most common RCC histological subtype, the association was particularly strong (OR 0.3, 95% CI 0.2-0.8). We did not observe clear evidence of association with RCC for other reproductive factors.

CONCLUSIONS

Our findings further support an association between late maternal age at first birth and reduced RCC risk, and suggest that the association may be particularly strong for clear cell adenocarcinoma.

Clinical therapeutics in pregnancy

Most drugs are not tested for use during pregnancy, consequently, labeling, which may include information about fetal safety, includes nothing about dosing, efficacy, or maternal safety. Yet these are concerns of health care providers considering treatment of disease during pregnancy. Therefore, the practitioner treats the pregnant woman with the same dose recommended for use in adults (typically men) or may decide not to treat the disease at all. However, is the choice of not treating a woman during pregnancy better than dealing with the challenges which accompany treatment? This paper, which summarizes metabolic and physiologic changes induced by pregnancy, illustrates that standard adult dosing is likely to be incorrect during pregnancy.

Special populations critical care considerations of the morbidly obese pregnant patient

The critically ill pregnant patient poses a unique challenge to the clinician, requiring a thorough understanding of normal and abnormal maternal and fetal physiology associated with pregnancy. The morbidly obese patient presents even greater challenges to the clinician, and morbidity and mortality are proportionately increased. Because increased numbers of obese pregnant women are now admitted to intensive care units, practitioners must be aware of the physiology associated with both pregnancy and obesity. A multidisciplinary approach is imperative to prevent both maternal and fetal morbidity and mortality for these very complex patients, especially when they are admitted to the ICU with critical illness.

Management of Worsening Aortic Dilation and Insufficiency in a 20-Week Pregnant Woman: A Case Report

Preexisting aortic disease can worsen during pregnancy as physiologic hemodynamic changes evolve. At a large academic institution, a patient with a remote history of vasculitis presented with a second trimester pregnancy with increasing aortic dilatation and aortic insufficiency. Extensive obstetric discussions encompassed maternal cardiac risks from continuing the pregnancy and fetal risks from maternal cardiac intervention. This patient desired termination of pregnancy to avoid further complications and to expedite surgical aortic repair.

Existing models fail to predict sepsis in an obstetric population with intrauterine infection

OBJECTIVE

Multiple scoring systems exist to identify inpatients who are at risk for clinical deterioration. None of these systems have been evaluated in an obstetric population. We examined the Systemic Inflammatory Response syndrome (SIRS) and Modified Early Warning score (MEWS) criteria in pregnant women with chorioamnionitis.

STUDY DESIGN

This was an 18-month retrospective analysis of patients with chorioamnionitis. SIRS and MEWS scores were calculated; clinical outcomes were ascertained, and test characteristics were calculated for the primary outcome of sepsis, intensive care unit transfer, or death.

RESULTS

Nine hundred thirteen women with chorioamnionitis were identified. Five women experienced sepsis; there was 1 death. Five hundred seventy-five of the 913 women (63%) met SIRS criteria (95% confidence interval, 59.8-66.2%; positive predictive value, 0.9%). Ninety-two of the 913 women (10.3%) had a MEWS score of ≥ 5 (95% confidence interval, 8.3-12.2%; positive predictive value, 0.05%).

CONCLUSION

SIRS and MEWS criteria do not identify accurately patients who are at risk for intensive care unit transfer, sepsis, or death among pregnant women with intrauterine infection and should not be used in an obstetric setting.

Epoprostenol treatment for idiopathic pulmonary arterial hypertension in pregnancy

Idiopathic pulmonary arterial hypertension is a rare condition associated with significant maternal mortality. We report the management of a 37-year-old multigravida with severe disease using epoprostenol, a multidisciplinary approach, and a planned delivery. Although the patient survived the pregnancy, her pulmonary function significantly worsened. Epoprostenol, a pulmonary vasodilator, should be considered when indicated during pregnancy. Neither fetal nor neonatal harm was identified.

Emergency department use during the postpartum period: implications for current management of the puerperium

OBJECTIVE

The purpose of this study was to define patterns of morbidity that are experienced by women in the postpartum period who seek care in the emergency department within 42 and 100 days of discharge.

STUDY DESIGN

We conducted a retrospective examination of discharge diagnosis codes and descriptions for emergency department visits and analyzed temporal patterns of both emergency department visits and hospital readmissions.

RESULTS

During 2007, 222,084 patients delivered in Hospital Corporation of America facilities in the United States. Among these women, there were 10,751 emergency department visits within 42 days of delivery (4.8%). Fifty-eight percent of the patients were seen for conditions that were related to pregnancy; 42% of the patients were seen for conditions unrelated to pregnancy. Fifty percent of patients in the postpartum period who were seen either in the emergency department (21,833 patients) or readmitted (5190 patients) during both 2007 and 2008 had this encounter within 10 days of discharge.

CONCLUSION

The scheduling and content of traditional postpartum education and clinical visits appear poorly suited to the prevention of puerperal morbidity.

Pulmonary hydatid cyst in a pregnant patient causing acute respiratory failure

A 21-year-old primigravida, at 32 weeks of gestation, presented with acute onset of respiratory failure and circulatory shock. Chest imaging showed findings suggestive of ruptured hydatid cyst, which was confirmed by histology post-thoracotomy. Tissue cultures from the removed cyst grew Mycobacterium tuberculosis also. She was successfully managed in the intensive care unit and was then discharged home on antituberculosis medications in addition to albendazole after prolonged hospitalization and a need for chest tube for bronchopleural fistula. Acute respiratory failure and anaphylactic shock secondary to ruptured pulmonary hydatid cyst and superimposed pulmonary tuberculosis in a pregnant lady should be considered in patients living in endemic areas.

The 2010 Canadian Cardiovascular Society guidelines for the diagnosis and management of heart failure update: Heart failure in ethnic minority populations, heart failure and pregnancy, disease management, and quality improvement/assurance programs

Since 2006, the Canadian Cardiovascular Society heart failure (HF) guidelines have published annual focused updates for cardiovascular care providers. The 2010 Canadian Cardiovascular Society HF guidelines update focuses on an increasing issue in the western world - HF in ethnic minorities - and in an uncommon but important setting - the pregnant patient. Additionally, due to increasing attention recently given to the assessment of how care is delivered and measured, two critically important topics - disease management programs in HF and quality assurance - have been included. Both of these topics were written from a clinical perspective. It is hoped that the present update will become a useful tool for health care providers and planners in the ongoing evolution of care for HF patients in Canada.

A longitudinal study of the relationship between maternal cardiac output measured by impedance cardiography and uterine artery blood flow in the second half of pregnancy

OBJECTIVE

To study serial changes in maternal systemic and uterine artery haemodynamics and establish reference ranges for the second half of pregnancy.

DESIGN

Prospective longitudinal observational study.

SETTING

University hospital in Norway.

POPULATION

Low-risk pregnant women.

METHODS

Fifty-three low-risk pregnancies were evaluated at approximately 4-weekly intervals. Maternal systemic haemodynamics was assessed with impedance cardiography. Uterine artery blood velocity and diameter were measured using Doppler ultrasonography and uterine artery volume blood flow (Q(uta)) was calculated as the product of mean velocity and cross-sectional area of the uterine artery. The fraction of cardiac output (CO) distributed to the uterine circulation was calculated as: Q(uta)/CO x 100.

MAIN OUTCOME MEASURES

CO, Q(uta), uterine vascular resistance (R(uta)) and the fraction of CO distributed to the uterine circulation.

RESULTS

The CO increased (P = 0.0063) until 34 weeks and remained stable until term. Total Q(uta) increased from 299 to 673 ml/minute and R(uta) halved from 0.26 to 0.13 mmHg/ml/minute (P < 0.0001). The fraction of CO distributed to the uterine circulation increased from 5.6% to 11.7% (P < 0.0001).

CONCLUSION

During the second half of pregnancy, Q(uta) and the fraction of maternal CO distributed to the uterine circulation increase approximately two-fold, mainly as a result of decrease in R(uta).

Trauma care and managing the injured pregnant patient

Trauma is the leading cause of maternal death in the United States. Nurses must optimize the well-being of 2 patients in the pregnant trauma patient. Rapid assessment, initiating immediate interventions for life-threatening injuries, and transport to a trauma center are critical to optimize maternal and fetal outcome. Understanding these factors can facilitate an effective resuscitation and optimize the outcome for both mother and baby.

Reproductive factors and risk of renal cell cancer: the Nurses' Health Study

Few prospective studies have examined associations between reproductive factors and risk of renal cell cancer (RCC). The authors prospectively examined whether postmenopausal hormone (PMH) use, oral contraceptive use, parity, and other reproductive factors were associated with RCC risk among 118,219 US women in the Nurses' Health Study. A total of 247 RCC cases were confirmed between 1976 and 2004. Multivariate relative risks, adjusted for known risk factors, were calculated using Cox proportional hazards models. Compared with 1 or 2 childbirths, the multivariate relative risks were 1.75 (95% confidence interval (CI): 1.21, 2.53) for 4 childbirths and 1.50 (95% CI: 1.00, 2.23) for > or =5 childbirths (P(trend) = 0.02). Comparing an age at first birth of > or =28 years with an age at first birth of < or =22 years, the multivariate relative risk was 0.66 (95% CI: 0.43, 1.01; P(trend) = 0.01). Compared with 1-3 childbirths and an age at first birth of > or =26 years, the multivariate relative risk was 2.17 (95% CI: 1.49, 3.14) for > or =4 childbirths and an age at first birth of <26 years. No clear associations were observed for PMH use or duration, time since last PMH use, oral contraceptive use or duration, age at menarche, age at menopause, or history of hysterectomy or oophorectomy.

Management of the unconscious pregnant patient

The management of the unconscious pregnant patient encompasses many aspects of obstetrics and critical care. It is not uncommon to have to manage such a patient, therefore one needs to be well prepared. There is a spectrum of altered consciousness, brain death being the most extreme. The causes of unconsciousness can be general or pregnancy specific. It is important to consider the physiological changes in pregnancy when managing these patients. The immediate resuscitative measures are mostly the same as for the nonpregnant with a few modifications. It is important to remember that there are two patients involved and this can complicate management issues. A multidisciplinary approach would be prudent. The intermediate and long-term management should also involve the family. The issues of perimortem and somatic support for foetal maturity are also discussed.

Pregnancy in women with prosthetic heart valves

Pregnancy in women with mechanical valve prostheses has a high maternal complication rate including valve thrombosis and death. Coumarin derivatives are relatively safe for the mother with a lower incidence of valve thrombosis than un-fractionated and low-molecular-weight heparin, but carry the risk of embryopathy, which is probably dose-dependent. The different anticoagulation regimens are discussed in this review. When valve thrombosis occurs during pregnancy, thrombolysis is the preferable therapeutic option. Bioprostheses have a more favourable pregnancy outcome than mechanical prostheses but due to the high re-operation rate in young women they do not constitute the ideal alternative. When women with native valve stenosis need pre-pregnancy intervention, mitral balloon valvuloplasty is the best option in mitral stenosis, while the Ross operation or homograft implantation may be the preferable surgical regimen in aortic stenosis. (Neth Heart J 2008;16:406-11.).

Oral and maxillofacial surgery for the pregnant patient

This article describes clinical approaches for the perioperative management of the pregnant oral and maxillofacial surgical patient. The following topics are discussed: ethical principles of treatment during pregnancy, physiologic changes and their treatment considerations, fetal and maternal risks of various medications, medical problems occurring during pregnancy, and common minimally invasive approaches that the surgeon can apply to minimize the risk to the mother and unborn child. The strategies discussed provide successful treatment outcomes during this important time in the female surgical patient's life.

Physiological changes of pregnancy and monitoring

Advances in medical care have led to increasing numbers of complex, high-risk obstetric patients. Specialist training and a sound knowledge of normal maternal physiology are essential to optimize outcomes. One of the earliest observed changes is peripheral vasodilatation; this causes a fall in systemic vascular resistance and triggers physiological changes in the cardiovascular and renal systems, with 40-50% increases in cardiac output and glomerular filtration rates. Safety concerns over Swan Ganz catheters have driven the increasing interest in alternative techniques, such as echocardiography, thoracic bioimpedance and pulse contour analysis, although their exact roles in future obstetric high-dependency care have yet to be established. Analysis of arterial blood gases is fundamental to the management of sick patients, and correct interpretation can be aided by a systematic approach. Observation charts are almost ubiquitous in all aspects of medicine, but little evidence exists to support their use in the high-dependency setting.

Aims of obstetric critical care management

The aims of critical care management are broad. Critical illness in pregnancy is especially pertinent as the patient is usually young and previously fit, and management decisions must also consider the fetus. Assessment must consider the normal physiological changes of pregnancy, which may complicate diagnosis of disease and scoring levels of severity. Pregnant women may present with any medical or surgical problem, as well as specific pathologies unique to pregnancy that may be life threatening, including pre-eclampsia and hypertension, thromboembolic disease and massive obstetric haemorrhage. There are also increasing numbers of pregnancies in those with high-risk medical conditions such as cardiac disease. As numbers are small and clinical trials in pregnancy are not practical, management in most cases relies on general intensive care principles extrapolated from the non-pregnant population. This chapter will outline the aims of management in an organ-system-based approach, focusing on important general principles of critical care management with considerations for the pregnant and puerperal patient.

Physiologic changes in pregnancy

Pregnancy is associated with physiologic changes that affect virtually every organ system in the mother. These physiologic changes allow the parturient to support the growing uterus and fetus and to withstand labor and the postpartum course. Because the gravida may require surgery while pregnant, it is important to have an appreciation of these physiologic changes. These maternal adaptive responses have significant implications for anesthetic, operative, and perioperative management.

Systemic hemodynamic and regional blood flow changes in response to chronic reductions in uterine perfusion pressure in pregnant rats

Preeclampsia (PE) is associated with increased total peripheral resistance (TPR), reduced cardiac output (CO), and diminished uterine and placental blood flow. We have developed an animal model that employs chronic reductions in uterine perfusion pressure (RUPP) in pregnant rats to generate a “preeclamptic-like” state during late gestation that is characterized by hypertension, proteinuria, and endothelial dysfunction. Although this animal model has many characteristics of human PE, the systemic hemodynamic and regional changes in blood flow that occur in response to chronic RUPP remains unknown. Therefore, we hypothesized that RUPP would decrease uteroplacental blood flow and CO, and increase TPR. Mean arterial pressure (MAP), CO, cardiac index (CI), TPR, and regional blood flow to various tissues were measured using radiolabeled microspheres in the following two groups of conscious rats: normal pregnant rats (NP; n = 8) and RUPP rats ( n = 8). MAP was increased (132 ± 4 vs. 99 ± 3 mmHg) in the RUPP rats compared with the NP dams. The hypertension in RUPP rats was associated with increased TPR (2.15 ± 0.02 vs. 0.98 ± 0.08 mmHg·ml−1·min−1) and decreased CI (246 ± 20 vs. 348 ± 19 ml·min−1·kg−1, P < 0.002) when contrasted with NP dams. Furthermore, uterine (0.16 ± 0.03 vs. 0.38 ± 0.09 ml·min−1·g tissue−1 ) and placental blood flow (0.30 ± 0.08 vs. 0.70 ± 0.10 ml·min−1·g tissue−1) were decreased in RUPP compared with the NP dams. These data demonstrate that the RUPP model of pregnancy-induced hypertension has systemic hemodynamic and regional blood flow alterations that are strikingly similar to those observed in women with PE.

Assessment and management of cardiac disease in pregnancy

Approximately 1% of pregnancies are affected by congenital or acquired cardiac disease. The obstetric care provider requires an understanding of the expected cardiorespiratory adaptations to pregnancy in order to anticipate when and how the cardiac patient may decompensate. Although the majority of women with cardiac disease in pregnancy can expect a positive outcome, women should be evaluated for predictors of poor perinatal outcome to aid in determining the appropriate location for and surveillance in labour. Women affected with congenital heart disease require counselling about the risk of recurrence in their offspring. The discussion of contraceptive needs for the woman with cardiac disease is critical in the appropriate planning of her family.

Outcome of pregnancy in women with congenital heart disease: a literature review

A search of peer-reviewed literature was conducted to identify reports that provide data on complications associated with pregnancy in women with structural congenital heart disease (CHD). This review describes the outcome of 2,491 pregnancies, including 377 miscarriages (15%) and 114 elective abortions (5%). Important cardiac complications were seen in 11% of the pregnancies. Obstetric complications do not appear to be more prevalent. In complex CHD, premature delivery rates are high, and more children are small for gestational age. The offspring mortality was high throughout the spectrum and was related to the relatively high rate of premature delivery and recurrence of CHD.

Peripartum cardiomyopathy

OBJECTIVE

To determine the clinical and echocardiographic profiles of women with peripartum cardiomyopathy and ascertain the natural course of the disease.

METHODS

Fifty-six women with peripartum cardiomyopathy were followed up for a mean period of 6.1 years and their clinical and echocardiographic profiles were studied as well as their outcomes.

RESULTS

The mean+/-SD age at presentation was 31+/-5 years and mean parity was 2.6+/-1. Of the 56 patients, 18 (32.1%) had NYHA Class II, 24 (42.9%) had NYHA Class III, and 14 (25%) had NYHA Class IV symptoms, and 21 (37.5%) and 35 (62.5%), respectively, presented with features of heart failure during pregnancy and the postpartum. During follow-up, the left ventricular ejection fraction improved from 31%+/-7.2% to 43%+/-8% (P</=0.05). Nine patients (16.1%) became pregnant, with a mortality of 55.5% during pregnancy and 23.2% during follow-up.

CONCLUSION

Women with peripartum cardiomyopathy present with severe left ventricular dysfunction late in the pregnancy or early in the puerperium. A considerable number of women still die from this condition despite the use of angiotensin-converting enzyme inhibitors and beta-blockers. A subsequent pregnancy carries a very high risk of mortality.

Pregnancy and delivery in women after Fontan palliation

OBJECTIVES

To evaluate the outcome of pregnancy in women after Fontan palliation and to assess the occurrence of infertility and menstrual cycle disorders.

DESIGN AND PATIENTS

Two congenital heart disease registries were used to investigate 38 female patients who had undergone Fontan palliation (aged 18-45 years): atriopulmonary anastomosis (n = 23), atrioventricular connection (n = 5) and total cavopulmonary connection (n = 10).

RESULTS

Six women had 10 pregnancies, including five miscarriages (50%) and one aborted ectopic pregnancy. During the remaining four live-birth pregnancies clinically significant complications were encountered: New York Heart Association class deterioration; atrial fibrillation; gestational hypertension; premature rupture of membranes; premature delivery; fetal growth retardation and neonatal death. Four of seven women who had attempted to become pregnant reported female infertility: non-specified secondary infertility (n = 2), uterus bicornis (n = 1) and related to endometriosis (n = 1). Moreover, several important menstrual cycle disorders were documented. In particular, the incidence of primary amenorrhoea was high (n = 15, 40%), which resulted in a significant increase in age at menarche (14.6 (SD 2.1) years, p < 0.0001, compared with the general population).

CONCLUSION

Women can successfully complete pregnancy after adequate Fontan palliation without important long-term sequelae, although it is often complicated by clinically significant (non-)cardiac events. In addition, subfertility or infertility and menstrual disorders were common.

A systematic approach to the physiologic adaptations of pregnancy

When a woman learns that she is pregnant, her emotions are like a roller coaster. To her, she is pregnant. She begins to plan all the things that could be and is in constant motion to await the 9 months until the arrival of her bundle of joy. However, to those of us in the perinatal nursing field, it means so much more. The pregnant woman's body goes through some profound anatomical, physiologic, and biochemical changes to adapt to and support the entire pregnancy, which ultimately support the growing fetus. Although these physiologic changes are normal, often they can be misinterpreted as disease. These changes may also unmask or worsen a preexisting condition or disease, ultimately because the pregnant woman's body cannot adequately adapt to the changes of pregnancy. It is essential to know and understand the physiology-the inner workings-of both the mother and the fetus. This includes the basic adaptations related to pregnancy, placental physiology and action, uterine activity physiology, and fetal heart rate regulation, although this article will focus on maternal and uterine physiology only.

Role of anion gap and different electrolytes in hypertension during pregnancy (preeclampsia)

The present study was designed to determine the changes in serum sodium, anion gap, different antioxidants and free radicals in preeclamptic patients and control subjects. Serum sodium, chloride, bicarbonate, calcium, potassium and magnesium were estimated and anion gap was determined in 100 proteinuric hypertensive and 100 normotensive pregnant women. Mean serum sodium, chloride and bicarbonate level (133.26 +/- 13.1, 104.97 +/- 11.37, and 22.01 +/- 4.66 mEq/l, respectively) were significantly higher in proteinuric hypertensive women as compared to controls (125.85 +/- 10.4, 101.90 +/- 6.3, 19.34 +/- 3.21 mEq/l, respectively) whereas anion gap level (6.28 +/- 16.147) was nonsignificantly higher in proteinuric hypertensive as compared to normotensive (4.61 +/- 11.84). Total serum sodium concentration increases in preeclamptic subjects, the exact distribution of serum sodium in various compartments of the body are not clear and correlation of serum sodium and anion gap with proteinuria is also not known. The levels of different antioxidants were decreased in preeclamptic patients as compared to the controls while the level of free radicals elevated in preeclamptic subjects as compared to controls. In our study, anion gap level was found to be rather non-significantly higher in proteinuric hypertensive women as compared to normotensive women.

Hemodynamic assessment in a pregnant and peripartum patient

PATHOPHYSIOLOGY

Critical care in obstetrics has many similarities in pathophysiology to the care of nonpregnant women. However, changes in the physiology of pregnant woman necessary to maintain homeostasis for both mother and fetus, especially during critical illness, result in complex pathophysiology. Understanding the normal physiologic changes during pregnancy, intrapartum, and postpartum is the key to managing critically ill obstetric patients with underlying medical diseases and pregnancy-related complications.

HEMODYNAMIC MONITORING

When the pathophysiology of critically ill obstetric patients cannot be explained by noninvasive hemodynamic monitoring and the patient fails to respond to conservative medical management, invasive hemodynamic monitoring may be helpful in guiding management. Most important, the proper interpretation of hemodynamic data is predicated on knowledge of normal values during pregnancy and immediately postpartum. Invasive hemodynamic monitoring with pulmonary artery catherization has been used in the obstetric population, particularly in patients with severe preeclampsia associated with pulmonary edema and renal failure.

Measure of hemodynamic patterns by thoracic electrical bioimpedance in normal pregnancy and in preeclampsia

OBJECTIVE

To compare the differences in the hemodynamics between normal pregnancy and preeclampsia, using thoracic electrical bioimpedance.

STUDY DESIGN

We compared heart rate, end-diastolic volume, systolic volume, cardiac output, ejection fraction and peripheral vascular resistances in 18 healthy pregnant women with 15 with preeclamptic women at the following intervals: third trimester, 48 h post-partum, 2 and 6 months post-partum. We took the measurements by thoracic electrical bioimpedance. Statistical analysis was performed by means of Wilcoxon rank-sum test and p < 0.05 was considered statistically significant.

RESULTS

The heart rate was lower in the preeclampsia group during the third trimester and the systolic volume was also lower at 48 h post-partum; this implies a lower cardiac output in women with preeclampsia during pregnancy and in the immediate puerperium. The systemic vascular resistances were higher in preeclampsia in the third trimester and at 48 h post-partum. At 2 and 6 months post-partum, the hemodynamic situation had equalized in both groups.

CONCLUSIONS

Preeclampsia is a situation of low cardiac output and high peripheral resistances compared with a normal pregnancy.

Burns in Pregnancy

BACKGROUND

Treatment of a major burn injury during pregnancy must incorporate modifications in management resulting from gestational physiologic changes.

CASE

A 25-year-old woman, at 34 weeks of gestation, sustained a major burn injury at home. She required ventilatory support, invasive hemodynamic monitoring, and massive fluid resuscitation. Labor was augmented and a spontaneous vaginal delivery of a healthy neonate was achieved. Later, wound autografting was performed.

CONCLUSION

Pregnancy-induced physiologic changes affect key factors in the management of the burned patient, including airway management and hemodynamic support. Multidisciplinary management is essential to achieve the best possible outcome.

Physiologic changes in pregnancy and their impact on critical care

OBJECTIVES

To describe the major pregnancy-induced physiologic changes that affect the care of patients who are critically ill.

METHODS

We reviewed relevant textbooks and articles pertaining to physiologic alterations produced by pregnancy. Those changes that have a bearing on patients admitted to an intensive care unit were abstracted, summarized, and organized by organ system.

CONCLUSIONS

Several organ systems manifest significant change in function during pregnancy. The cardiovascular and pulmonary systems are the two most important with regard to critical care.

Acute pulmonary edema in pregnancy

Pulmonary edema is a secondary disease process characterized by an excess accumulation of fluid in the pulmonary interstitial and alveolar spaces, preventing adequate diffusion of both oxygen and carbon dioxide. The excess fluid accumulation interferes with maternal oxygenation and, if not identified and corrected, can lead to maternal and fetal hypoxemia. The purpose of this article is to review principles of oxygen transport and the pathophysiology, diagnosis, management, and nursing implications of acute pulmonary edema in pregnancy.

Sepsis during pregnancy

OBJECTIVES

To provide a current review of the literature regarding the assessment and management of sepsis during pregnancy.

DESIGN

A comprehensive review of current English-language literature search was performed with Ovid MEDLINE using the Medical Subject Headings pregnancy and sepsis, with Medical Subject Headings or keywords seeking randomized controlled trials and clinical reports, and by reviewing the bibliographies of clinical practice guidelines.

RESULTS

Sepsis-related maternal morbidity and mortality is a significant and persistent problem in the modern critical care obstetric unit. The management of sepsis during pregnancy is challenging. The obstetric intensivist must simultaneously discern the effect of maternal physiologic changes on fetal vulnerability and the effect of the fetus on maternal status throughout the various phases of pregnancy. Little direct evidence exists to validate the extrapolation of some sepsis treatment modalities from other nonpregnant patient populations. Nevertheless, early detection, accurate diagnosis, and aggressive appropriate treatment strategies may significantly improve outcome. Approaches like the Surviving Sepsis Campaign guidelines are unproven but seem reasonable and practical.

CONCLUSIONS

Sepsis during pregnancy is uncommon yet potentially fatal. Diagnostic and therapeutic guidelines should predominantly pattern those currently utilized for nonpregnant patients.

Cardiac complications relating to pregnancy and recurrence of disease in the offspring of women with atrioventricular septal defects

AIMS

In most pregnancy reports, atrioventricular septal defects (AVSD) are not differentiated from more simple septal defects, thus underestimating the risks of pregnancy. To investigate the magnitude and determinants of risk during pregnancy in female patients with balanced AVSD.

METHODS AND RESULTS

Using a nation-wide registry (CONCOR), 79 female patients with balanced/isolated AVSD were identified. A total of 29 patients had 62 pregnancies, including 12 miscarriages (19%) and two elective abortions. Detailed recordings of each completed (>20 weeks gestation) pregnancy (n=48, 26 women) were obtained. Cardiovascular events complicated almost 40% of the completed pregnancies. In particular, post-partum persistence of pregnancy-related New York Heart Association (NYHA) class deterioration [23% mainly patients with residual atrial septal defects (ASD)] and deterioration of pre-existing left AV-valvular regurgitation (17%) were frequently recorded. Additional cardiac complications were arrhythmias (19%) and symptomatic heart failure (2%). Congenital heart disease (CHD) recurred in six children (12%): AVSD (n=4, three with left-sided hypoplasia), patent ductus arteriosus (n=1), and ASD (n=1). Three children died including two children with left-sided hypoplasia.

CONCLUSION

Pregnancy is not always well tolerated in women with AVSD, predominantly due to NYHA class deterioration and worsening of pre-existing AV-valvular regurgitation. Offspring mortality is high (6.3%), primarily due to recurrence of complex CHD.

Evaluation of B-type natriuretic peptide (BNP) levels in normal and preeclamptic women

OBJECTIVE

B-type natriuretic peptide (BNP) is synthesized in cardiac ventricles in response to volume expansion. This study evaluated BNP levels to determine trends during pregnancy, and to assess BNP as a diagnostic tool in preeclampsia.

STUDY DESIGN

We studied 163 BNP levels in 118 pregnant women, ranging from first trimester to term. An additional 34 patients with preeclampsia were studied and compared to 25 normal control patients at term. Plasma BNP values were determined using a standard assay.

RESULTS

The median BNP levels during the 1st, 2nd, 3rd trimester, and at term were equivalent (18.4, 17.9, 15.5, and 17.8 pg/mL, respectively, P = .796). The median BNP levels in normal patients, mild preeclamptics, and severe preeclamptics were 17.8, 21.1, and 101 pg/mL, respectively, with the severe group being significantly higher than the mild group (P = .003) and any phase of normal pregnancy (P < .001 in each case). A BNP cut-off of <40.6 pg/mL had a negative predictive value of 92% in excluding preeclampsia.

CONCLUSION

In normal pregnancies, median BNP values are <20 pg/mL, and stable throughout gestation. In severe preeclampsia BNP levels are elevated. This may reflect ventricular stress and/or subclinical cardiac dysfunction associated with preeclampsia.

Pregnancy, fertility, and recurrence risk in corrected tetralogy of Fallot

OBJECTIVE

To determine in women with surgically corrected tetralogy of Fallot the risk of pregnancy for mother and fetus, whether fertility was compromised, and the recurrence risk of congenital heart disease.

DESIGN

Data were collected from 83 patients through interviews and review of medical records.

RESULTS

In 29 patients 63 pregnancies were observed, of which 13 ended in an abortion. Fifty successful pregnancies were observed in 26 patients. During six successful pregnancies (12%) complications (symptomatic right sided heart failure, arrhythmias, or both) occurred. Both patients who developed symptomatic heart failure had severe pulmonary regurgitation. No clear relation between offspring mortality, premature birth or being small for gestational age, and cardiac characteristics of the mother was identified. Fifty seven patients were childless (41 (72%) voluntarily). Recurrence risk for congenital heart disease was 2.2%. Infertility was uncommon.

CONCLUSIONS

Although complications did occur in five of 26 (19%) of the patients with a corrected tetralogy of Fallot, pregnancy was generally well tolerated in this largest report so far. No obvious predictors for maternal events or child outcome were determined, except for a possible relation between severe pulmonary regurgitation and symptomatic heart failure.

Cardiopulmonary complications of pregnancy

OBJECTIVES

To provide an up-to-date review of the literature on the assessment and management of pulmonary and cardiac conditions that may affect women during pregnancy and the postpartum period.

DESIGN

A review of the current literature was performed.

RESULTS

Pregnancy may be complicated by a variety of pregnancy-specific and other cardiopulmonary complications. Management requires knowledge of the cardiopulmonary physiologic changes occurring in pregnancy, the pregnancy-specific conditions that may occur, and the effect of a fetus on maternal care.

CONCLUSIONS

Admission of the pregnant or postpartum woman to the intensive care unit is uncommon but may require specialized knowledge for successful management.

Valvular Heart Disease and Pregnancy

Pregnancy in patients with valvular heart disease (VHD) continues to pose a challenge to both physicians and their patients and could be associated with an unfavorable maternal as well as fetal outcome. The purpose of this paper is to review the available clinical data and provide recommendations for the management of patients with VHD during gestation.