Advanced Practice: Supportive Management of Critical Illness in Pregnancy
● Resuscitation of mother means resuscitation of baby.
● Early OB consult and fetal monitoring.
● Estimated fetal age important as delivery is often the definitive management.
● Considered a difficult and high risk airway:
○ Lower pulmonary reserve and quicker to desaturate → preoxygenate well.
○ Higher aspiration risk as progesterone relaxes lower esophageal sphincter.
○ Consider using smaller tube as there may be some edema.
● Same RSI meds → all are pregnancy class B and C
● Maintain low threshold to intubate with rising PaCO2 → ↑CO2 = acidotic baby.
● Ventilator Settings:
○ PaCO2 at 30-32 speculated to be normal
○ Goal PaO2 >70 as PaO2 < 60 associated with rapid fetal compromise
○ Use the lowest PEEP to achieve this goal as venous return already has to deal with gravid uterus
● Obtain IV access above diaphragm as uterus clamps down on lower extremity venous return → avoid femoral central venous access.
● BP goal unclear: MAP 65 extrapolate; AHA recommends SBP > 100 or 80% of baseline.
● Position patient in left lateral decubitus or with right hip wedge to help venous return.
● No data on normal saline versus lactated ringers.
● No evidence for optimal blood transfusion goal → Hgb > 7.0 as extrapolated target.
● Optimal pressor not known
○ Consider ephedrine for maternal hypotension.
○ Consider milrinone for inotropic support as it was studied directly in pregnancy.
Mallemat, H. Supportive Management of Critical Illness in the Pregnant Patient. Emergency Medicine Practice. June 2012; Volume 2, Number 3