Management of the Pregnant ICU Patient

Critically ill pregnant women require management by experienced clinicians. Maternal mortality and serious morbidity may be avoided if serious complications are recognized early and managed appropriately. This review reflects published evidence and, where this is lacking, the experience of a tertiary obstetric intensive care unit. Severe preeclampsia is the most common obstetric indication for intensive care admission, and one of the major causes of maternal death throughout the world. It may develop insidiously or have a fulminant onset, and may result in multiorgan failure. Neurologic, respiratory, renal, and liver dysfunction may occur; eclampsia is the single most lethal complication. Critical care of women with severe preeclampsia requires an understanding of the underlying pathophysiology, and in particular, the distinct hemodynamic changes that characterize this disorder. The principles of hemodynamic management include control of severe hypertension and volume expansion. Pulmonary artery catheterization is indicated in selected women. Left ventricular filling pressures may rise rapidly in response to small fluid challenges, with the result that these patients are very susceptible to pulmonary edema. Right-sided filling pressures are not similarly affected; therefore, central venous pressure measurements cannot be used to guide fluid management. Other major causes of maternal mortality are cardiac disease, obstetric hemorrhage, sepsis, pulmonary embolism, and amniotic fluid embolism. Air embolism may occur in relation to normal and complicated delivery, and is most likely underdiagnosed. These conditions also require prompt and effective management, and may necessitate admission to intensive care.