Management of Complex Cardiac Issues in the Pregnant Patient

The Main Changes in Pregnancy—Therapeutic Approach to Musculoskeletal Pain

Background and Objectives: During pregnancy, women undergo various physiological and anatomical changes that are accentuated as the pregnancy progresses, but return to their previous state a few weeks/months after the pregnancy. However, a targeted therapeutic approach is needed. Most of the time, during this period, these changes precipitate the appearance of pain, musculoskeletal pain being the most common. Pregnant women should avoid treating musculoskeletal pain with medication and should choose alternative and complementary methods. Exercise along with rest is the basis for treating chronic musculoskeletal pain. Side effects of physical therapy are rare and, in addition, it is not contraindicated in pregnant women. The benefits of this type of treatment in combating pain far outweigh the risks, being an easy way to improve quality of life. The objective of this article is to discuss the management of musculoskeletal pain during pregnancy, to identify the main musculoskeletal pain encountered in pregnant women along with drug treatment, and to expose the beneficial effects of alternative and complementary methods in combating pain. Materials and Methods: A literature search was conducted using medical databases, including PubMed, Google Scholar, and ScienceDirect, using the keywords “changes of pregnancy”, “musculoskeletal pain”, “pregnancy pain”, “pain management”, “pharmacological approach”, “alternative and complementary treatment” and specific sites. Information was collected from studies whose target population included pregnant women who complained of musculoskeletal pain during the 9 months of pregnancy; pregnant women with other pathologies that could increase their pain were not included in this review. Results: The articles related to the most common non-obstetric musculoskeletal pain in pregnancy along with pharmacological treatment options and alternative and complementary methods for musculoskeletal pain management during pregnancy were selected. Conclusions: The results were used to guide information towards the safest methods of therapy but also to raise awareness of the treatment criteria in order to compare the effectiveness of existing methods. Treatment must consider the implications for the mother and fetus, optimizing non-pharmacological therapeutic options.

Critical Care Management of the Parturient with Cardiac Disease

Parturient with heart disease forms a challenging group of patients and requires specialized critical care support in the peripartum period. Maternal heart disease may remain undiagnosed till the second trimester of pregnancy, presenting frequently after 20 weeks of gestation, due to increased demands imposed on the cardiovascular system and pose a serious risk to the life of mother and fetus. Management of critically ill parturient with heart disease must be tailored according to individual assessment of the patient and requires a strategic, multidisciplinary, and protocol-based approach. A dedicated obstetric intensive care unit (ICU) and team effort are the need of the hour.

HOW TO CITE THIS ARTICLE

Garg R, Hariharan UR, Malik I. Critical Care Management of the Parturient with Cardiac Disease. Indian J Crit Care Med 2021;25(Suppl 3):S230-S240.

Placenta in the Critically Ill Mother

The placenta is a temporary, multifunctional organ composed of both maternal and fetal components. It maintains homeostasis to ensure the growth of the fetus and well-being of the mother. Abnormalities in placental development have been known to be responsible for several disorders of pregnancy. Conditions coincident with pregnancy can upset the homeostasis and result in critical illness, which can greatly impact placental function and in turn affect the fetus. Decreased blood flow, acidemia, hypercarbia, and hypoxia seen in critically ill pregnant mothers can result in fetal death. Understanding the physiological changes and functioning of the maternal-fetal-placental unit will aid in better management of critically ill mothers.

How to cite this article

Taggarsi DA, Krishna B. Placenta in the Critically Ill Mother. Indian J Crit Care Med 2021;25(Suppl 3):S200-S205.

Mitral Stenosis in Pregnancy: A Comprehensive Review of a Challenging Cardio-Obstetric Clinical Entity

BACKGROUND

Mitral stenosis is one of the most commonly encountered valvular heart diseases during pregnancy, the majority are rheumatic in origin and poorly tolerated due to cardiocirculatory changes that occur during pregnancy, labor and postpartum.

OBJECTIVE

The distinctive physiological events that arise during pregnancy and labor and the influence of mitral stenosis are tackled in this article.

METHODS

Through PUBMED and MEDLINE searches, we reviewed the literature of the last decade as well as the recommendations from guidelines of high-impact worldwide.

RESULTS

Cardiac decompensation usually takes place late in pregnancy as the hemodynamic burden of pregnancy become more pronounced as well as after delivery due to an abrupt increase of preload secondary to autotransfusion and aorto-caval decompression. The maternal and fetal complications correlate with the New York Heart Association (NYHA) functional classification and the grade of mitral stenosis. Medical therapy should be tried first. If symptoms continue in spite of optimal medical therapy, invasive procedures are recommended. Several studies revealed that vaginal delivery under epidural anesthesia is endurable and of low-risk unless obstetrically contraindicated.

CONCLUSION

Pregnancy and mitral stenosis remain a complex entity and a well-known trigger of maternal mortality during pregnancy and peri-partum period if not managed adequately. A good appreciation and recognition of the physiology of pregnancy and its impact on the pre-existing mitral stenosis and the presence of a specialized multidisciplinary team to handle such cases significantly decrease maternal and fetal mortality and morbidity.