Obstetrical Critical Care

Airways - 8x higher failure rate (13x fatal) -> generally anesthesia does airway

Decreased FRC.

Differences:

Hemodynamics (increased plasma volume, CO increases 30-50% by SV and HR, SVR decreases, and so normal blood pressure decreases. ==> consequence is that more blood loss can occur without hemodynamic changes

12-14 weeks and beyond: Aorta and IVC compresses and decreases CO -> L tilt 15-20 degrees to displace the uterus.

Respiratory physiology: FRC decreases, O2 consumption increased 20-30%, airway edema -> decreased ability to tolerate apnea. (MV increases due to greater tidal volume; chronic compensated respiratory alkalsosis 30 paco2, HCO3 18-20 is normal ==> BiPAP? Physiologic rationale. Theoretical risk of aspiration but hasn’t empirically panned out.

Thresholds for respiratory support

PaO2 threshold needs to be 70 or above. PaCO2 up to 60 is what the OB’s recommend due to a concern of vasoconstriction of the placenta.

RRT on Ob patients

Put in left lateral decubitus; git UE IV CPR is ucnhanged if arrest, but do left uterine displacement with hands. If no ROSC at 4 minutes; deliver the fetus/baby

Antenatal infection - septic abortions, chorizo, pyelo, aspirations Post delivery - endometritis, STIs

PE: high risk. Lovenox. Pregnancy is contraindication to lysis in guideline -> higher risk of bleed (esp if post-delivery - 18 vs 50%). However, sometimes needed

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Peri-partum hemorrhage: leading cause of maternal mortality. Due to increased vascularity of uterus. Tone, trauma, tissue, thrombin (coagulopathy). 1-3% within 24h. Placental abruption, prevue, eclampsia, advanced maternal age are risk factors (tho most have no RF). Jada, bakri balloons are used to help mechanically.

HTN - d/o Severe HTN = SBP above 160 or SBP above 110 Pre-eclampsia - HTN above 140 + proteinuria; or transom, AKI, thrombocyte, HA, Pulm edema Eclampsia - seizure

Labetolol, nifedipine (reflex tachy and headache), or hydralazine.

HELLP - variant of pre-eclampsia with normal BP Hepatic rupture -> hematoma should prompt eval for embolization of surgical packing.

Acute fatty liver of pregnancy - compared to HELP, more clinically apparent liver dysfunction. Transaminases usually 5-10x upper limit of normal.

Amniotic fluid embolism - dyspnea -> hypotension, Brady arrest. No difference in echo finding vs PE. They will often been profoundly delirious and generally have cardiovascular collapse. Biggest difference: AFE causes huge DIC, PE doesn’t. Pressors > Fluids. 1:1:1 transfusion.