CRITICAL CARE AND PREGNANCY

Increasingly, women who are pregnant or who have recently been deliver ed are being admitted to intensive care units. The pregnant woman who requires intensive care medicine is unique for a number of reasons and represents a substantial challenge to the health care team because of these differences. In the critically ill pregnant woman there are at least two patients to be considered, the mother and the fetus. The pre gnant woman has many physiologic adaptations as a consequence of pregn ancy that will alter the definition of normal for a number of variable s that are routinely monitored in intensive care units. Thus critical care obstetrics involves knowledge both of critical care medicine and of the pathophysiologic changes of pregnancy. Furthermore, pregnancy e ntails a host of disease processes that are unique to pregnancy itself , such as severe preeclampsia and amniotic fluid embolus. The purposes of this chapter are multiple. The physiologic changes of pregnancy ar e reviewed with emphasis on cardiorespiratory changes during pregnancy , circulatory changes in pregnancy, labor hemodynamics, postpartum hem odynamics, and pulmonary physiology as they apply to the parturient pa tient. Leading causes of maternal mortality including obstetric hemorr hage, hypertensive disease, and embolic phenomena are reviewed. Furthe rmore, the microangiopathic hemolytic anemias, thrombotic thrombocytop enic purpura, hemolytic uremic syndrome, and acute renal failure as th ey relate to the pregnant woman are reviewed in detail. Physical traum a that complicates one of every 12 pregnancies is emerging as a leadin g cause of nonobstetric maternal death. Both blunt abdominal trauma an d penetrating trauma in the pregnant woman are discussed. Guidelines a re given for the evaluation and treatment of the mother as well as for the evaluation and treatment of the fetus. Controversies related to m aternal cardiac arrest and resuscitation in pregnancy are explored as well as die role of perimortem cesarean section in contemporary obstet rics. Finally, the fetal effects of various drugs commonly used in cri tical care medicine are reviewed.