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Review Article

Critical care in obstetrics

Address for correspondence: Sunil T Pandya1,2,3, Kiran Mangalampally1

Dr. Sunil T Pandya, 1
Department of Anaesthesia, Pain Medicine and Surgical and Obstetric Critical Care, Century
Prerna Anaesthesia and Hospital, 2Department of Anaesthesia, Pain Medicine and Obstetric Critical Care, Fernandez Hospital,
Critical Care Services Pvt Ltd., 3
Prerna Anaesthesia and Critical Care Services Pvt Ltd., Hyderabad, Telangana, India
Hyderabad, Telangana, India.
E‑mail: suniltp05@gmail.com
ABSTRACT

Pregnancy is a normal physiologic process with the potential for pathologic states. Pregnancy
has several unique characteristics including an utero‑placental interface, a physiologic stress that
can cause pathologic states to develop, and a maternal–foetal interface that can affect two lives
simultaneously or in isolation. Critical illness in pregnant women may result from deteriorating
preexisting conditions, diseases that are co‑incidental to pregnancy, or pregnancy‑specific
conditions. Successful maternal and neonatal outcomes for parturients admitted to a maternal
Access this article online critical care facility are largely dependent on a multidisciplinary input to medical or surgical condition
Website: www.ijaweb.org from critical care physicians, obstetric anaesthesiologists, obstetricians, obstetric physicians,
foetal medicine specialists, neonatologists, and concerned specialists. Pregnant women requiring
DOI: 10.4103/ija.IJA_577_18
maternal critical care unit admission are relatively low in developed nations and range from
Quick response code
0.9% to 1%; but in our country, the admission rates of critically ill parturients range from 3% to
8%. Two‑thirds of pregnant women requiring critical care are often unanticipated at the time of
conception. In this review, we will look at critical illnesses in pregnant women with a specific focus
on pregnancy‑induced illnesses.

Key words: Critical care, hypertension, pregnancy, resuscitation

INTRODUCTION underlying pathology such as eclampsia, pulmonary

oedema, and trauma in pregnancy.
Maternal mortality rates remain relatively high in
India although there is a declining trend in recent There are several important physiologic changes in
years.[1] The National Family Health Survey 4 from pregnancy that may influence resuscitation. There
India (2015–2016) reported that institutional births is an increase of 30%–50% in cardiac output during
increased from 38.7% to 78.9%, and child births by pregnancy due to increased stroke volume and
caesarean sections increased to 17.2% from 8.5%.[1] increased maternal heartbeat.[9,10] The mean arterial
The maternal mortality rates (per 100,000 live births) pressure is reduced due to decreased systemic
have also shown a decline from 254 in 2004–2006 vascular resistance that may be mediated by an
to 167 in 2011–2013.[2] Approximately 800 maternal increase in progesterone, oestrogen, and nitric oxide,
deaths occur daily worldwide.[3] A study from the which are endogenous vasodilators.[11] The enlarging
Netherlands reported a case fatality rate of 1:53 among uterus may compress the aorta to produce increased
pregnant women with severe maternal morbidity.[4] afterload and compress the inferior vena cava leading
Knowledge deficit, communication lapses, and poor to decreased cardiac return.[12] This can lead to
resuscitation skills are identified as major contributors
This is an open access journal, and articles are distributed under the terms of
to poor outcomes in persons requiring resuscitation.[5‑8] the Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License,
which allows others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are licensed under
PHYSIOLOGIC CHANGES IN PREGNANCY the identical terms.

For reprints contact: reprints@medknow.com

A normal pregnant parturient is an anatomically
challenging and physiologically compromised How to cite this article: Pandya ST, Mangalampally K. Critical care
patient. These changes are exaggerated when there is in obstetrics. Indian J Anaesth 2018;62:724-33.

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Pandya and Mangalampally: Obstetric critical care

hypotension in the supine position, which is the most importance of early recognition and management
favourable position for resuscitation.[12,13] Left uterine of severely ill pregnant women and routine use
displacement (LUD) is a very important manoeuvre of Maternal Early Warning Scoring Systems to be
during resuscitation to improve cardiac output as used for obstetric patients.[20] Early recognition
it enhances the preload by more than 25% in a term of critical illness is essential for a favorable
gravida and also reduces afterload. LUD can be done outcome for mother and baby. Prognostic criteria
by either manually, by lifting the uterus with two such as Acute Physiological and Chronic Health
hands cephalad and displacing towards left side, or by Evaluation (APACHE) scoring and Sequential Organ
putting a double pillow or wedge under the right hip. Functional Assessment (SOFA) score may not predict
mortality as accurately in pregnancy as they do outside
Functional residual capacity (FRC) decreases by 10% to of pregnancy. One of the reasons for this difference
25% in pregnancy as the uterus enlarges and elevates is the physiologic change in pregnancy such as an
the diaphragm.[14] Pregnancy results in increased increase in heart rate, change in white cell count, or
tidal volume and minute ventilation mediated by even a decrease in normal values for creatinine that
elevated serum progesterone levels that may result in can affect the score. In many cases, delivery results
mild alkalosis and compensatory renal excretion of in a drastic improvement in the disease course and a
bicarbonate.[14,15] Reduced FRC reserves and increased lower mortality, even when initial indicators suggest
oxygen consumption lead to rapid development of a high mortality.
hypoxia in response to apnoea in pregnant women.[16]
The oxyhaemoglobin dissociation curve shifts to the There are certain disease‑related obstetric risks
right in the woman (a higher partial pressure of oxygen scoring systems. Shock Index (SI), defined as the
is required to achieve maternal oxygen saturation) while ratio between heart rate and systolic blood pressure,
it shifts to the left in the foetus. Pregnancy also leads has been proposed as a useful and reliable tool to
to altered renal tubular functions, a narrowing of the predict hypovolaemic states and early haemodynamic
oncotic pressure–wedge pressure gradient that increases compromise (e.g., major obstetric haemorrhage) in
risk for pulmonary oedema, progesterone‑mediated obstetric populations even when the individual vital
gastroesophageal sphincter relaxation, and prolonged signs are within the normal values. Score less than 0.9
intestinal transit times, and altered drug metabolism. indicates that risk of massive resuscitation is low and
[17‑19]
Upper airway oedema occurring as a result of >1.4 indicates urgent intervention or stabilisation and
hormonal changes may reduce visualisation during transfer to tertiary care facility.
laryngoscopy and increase risk of bleeding. Creatinine
clearance is increased in pregnancy to 120–160 mL/min The miniPIERS (Pre‑eclampsia Integrated Estimate
and serum creatinine level decreases to 0.4–0.7 mg/dL. of RiSk) risk prediction model provides a simple
tool to identify pregnant women at increased risk of
The interpretation of arterial blood gas analyses in death or major complications of pre‑eclampsia. This
parturients is little different, because of the above model included the following: parity (nulliparity
physiological changes. The pH is 7.44, little alkalotic, versus multiparity), gestational age on admission,
and PaCO2 is in the range of 28–32 mmHg. Base deficit up headache/visual disturbances, chest pain/dyspnoea,
to −5 is considered normal and bicarbonates are in the vaginal bleeding with abdominal pain, systolic blood
range of 20–22 mmol/L. PaCO2 >35 mmHg is considered pressure, and dipstick proteinuria. The full PIERS
as imminent respiratory failure and >40 mmHg is model is used to identify women with pre‑eclampsia
respiratory failure. Pregnancy is a hyperoxic state, at high risk of adverse maternal outcomes in need
and PaO2 is in the range of 95–105 mmHg. Hence, of immediate interventions. This model requires
during management of parturients with respiratory laboratory testing of platelet count, serum creatinine,
failure, it is aimed to maintain PaO2 >70 mmHg. These lactate dehydrogenase, and aspartate transaminase
factors and the gestational age of the foetus have to be and alanine aminotransaminase levels.
considered during resuscitation.
Recently, the obstetrically modified quick‑SOFA score
RECOGNISING A CRITICALLY ILL PARTURIENT (omqSOFA) requires only clinical data for assessment
and thus can be performed quickly without waiting
The Confidential Enquiry into Maternal and Child for the results of biochemical or laboratory tests
Health in the United Kingdom highlighted the [Table 1].

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OBSTETRIC VERSUS NON‑OBSTETRIC DISORDERS and endocrine disorders (diabetic keto‑acidosis). In

the developed nations, pneumonia, bronchial asthma,
The majority of cases that get admitted to critical care trauma, cancers, drug abuse, complicated urinary
unit are primarily obstetric disorders. They constitute infections, preexisting autoimmune disorders, chronic
nearly 50%–80% of admissions during pregnancy and pulmonary disease, endocrine disorders, and pulmonary
the puerperium in all parts of the world. More than 80% thromboembolism are common.
of these admissions are because of pre‑eclampsia and its
complications, haemorrhage, and sepsis. Non‑obstetric Furthermore, with the advances in medicine both
disorders in pregnancy show large geographic variations. In in developing and developed nations, intensive care
South‑East Asian countries including India, we more often units (ICUs) are increasingly challenged with a unique
see critical illness in pregnancy complicated by tropical subgroup of pregnant women with disorders such as
and other infectious diseases such as malaria, leptospirosis, surgically corrected complex congenital heart disease
dengue, viral hepatitis, influenza, tuberculosis, rheumatic and organ transplant. Pregnant women with these
valvular heart diseases, cerebral sinus venous thrombosis, conditions have increased morbidity and tend to
require intensive medical care.[21] Common conditions
Table 1: Obstetrically modified qSOFA score (obstetrically associated and aggravated or render the pregnant women
modified qSOFA)
Clinical parameter Score
susceptible to critical illness.[21] are depicted in Table 2.
Systolic blood pressure ≤90 mmHg (≤100 mmHg in 1
nonpregnant patient) PRINCIPLES OF MANAGEMENT OF A CRITICALLY ILL
Respiratory rate ≥25/min (≥22/min in nonpregnant patient) 1 PARTURIENT
Altered mentation (any state other than alert) (Glasgow 1
Coma Scale <15 in nonpregnant patient)
The initial assessment of a sick parturient should be
SOFA – Sequential organ failure assessment; Infection + omqSOFA
≥2 – maternal sepsis; omqSOFA – Obstetrically modified Qsofa no different from critically ill nonpregnant patient.

Table 2: Causes of critical illness in pregnancy

Causes of critical illness in pregnancy Preexisting diseases that may Increased susceptibility during
worsen during pregnancy pregnancy
Obstetric causes Cardio‑vascular Renal
Hypertensive crisis Valvular heart diseases AKI
Severe pre‑eclampsia Coarctation of aorta Infections
Magnesium toxicity Systemic hypertension Uro‑sepsis
HELLP Congenital heart diseases Hepatitis E infection
Eclampsia Coronary heart disease Varicella pneumonia
Abruption/rupture Pulmonary hypertension Falciparum malaria
Uterine inversion Marfan’s with aortic root dilation >4 cm H1N1 and other strains of influenza
Retained products Postheart transplant Hematologic
Adherent placenta Respiratory DIC
Acute fatty liver of pregnancy Lung transplant HUS/TTP
Obstetric haemorrhage Cystic fibrosis DVT
Ruptured ectopic Renal ‑ CKD Endocrine
sepsis (chorioamnionitis) Endocrine Gestational diabetes
Septic abortions Prolactinomas Sheehan’s syndrome
Endometritis Diabetic Ketosis Central nervous system
Ovarian hyper‑stimulation syndrome Connective tissue disorders: Intracranial bleeds
Amniotic fluid embolism Scleroderma Cerebral sinus venous thrombosis
Peripartum cardiomyopathy Polymyositis Respiration
Tocolytic‑induced pulmonary oedema, heart failure Lupus Pulmonary embolism
Nonobstetric causes Neurologic Air embolism
ARDS Epilepsy Aspiration
AKI Intracranial neoplasms
Urosepsis Liver ‑ cirrhosis, budd chiari syndrome
Diabetic keto‑acidosis Hematologic ‑ sickle cell disease
Acute pancreatitis
Drug abuse
HELLP – Haemolysis, elevated liver enzymes, low platelets; AKI – Acute kidney injury; DIC – Disseminated intravascular coagulation; CKD – Chronic kidney disease;
HUS – Haemolytic uraemic syndrome; TTP – Thrombotic thrombocytopaenic purpura; DVT – Deep vein thrombosis; ARDS – Acute respiratory distress syndrome

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Airway, Breathing and Circulation (ABC) are assessed

and parturient is stabilised and transferred to
appropriate level of care, as follows, and critical care
pathway is established.

Levels of care: Level 0 – patients whose needs can be

met through normal ward care, Level 1 – patients at
risk of their condition deteriorating and needing a
higher level of observation or those recently relocated
from higher levels of care, Level 2 – patients requiring Figure 1: Obstetric critical care unit common organ dysfunction
audit trend at Fernandez Hospital from 2012 to 2015, Department of
invasive monitoring/intervention that includes Anaesthesia, Pain Medicine and Obstetric Critical Care
support for a single failing organ system (excluding
advanced respiratory support), Level 3 – patients well‑being. Essentially there are subtle differences
requiring advanced respiratory support (mechanical which the clinician should be aware, the bottom line
ventilation) alone or basic respiratory support along being what is good for the mother is good for the foetus.
with support of at least one additional organ, and Level
4 – patients requiring highly advanced supports such AIRWAY
as extra corporeal membrane oxygenation (ECMO)
and intra‑aortic balloon pump. Airway evaluation and management remains the top
priority as pregnant patients tolerate hypoxaemia very
The components of care pathways for the critically poorly and they desaturate very rapidly. Furthermore,
ill pregnant woman include recognition, response, the risk of difficult intubation in pregnancy is increased
and Levels 2, 3, and 4 critical care. Recognition is 8–10 times and the clinician involved in the patient
the detection of clinical deterioration in pregnant care has to be well versed with the difficult airway
woman that is life‑threatening but potentially guidelines (Difficulty Airway Society, UK – DAS
reversible and transferred to appropriate level. guidelines and All‑India Difficult Airway Association
Response is the provision of a multidisciplinary guidelines).[23,24] The ICU should be equipped with all
care plan with obstetric interventions/specialty difficult airway equipments such as second‑generation
interventions (e.g., radiological intervention as needed. laryngeal mask airway (LMA) and video‑laryngoscopes,
Level 2 critical care is the care provided in a delivery and skills of doing crico‑thyrotomy should also be
suite of a maternity unit or in a high dependency unit, present.
justifying the recent terminology of mobile maternal
critical care unit. Levels 3 and 4 critical care is the care BREATHING AND VENTILATION
provided in a critical care unit.
Adequacy of gas exchange is assessed and efforts to
ORGAN DYSFUNCTION AND ORGAN SUPPORT IN A maintain it are ascertained. Supplemental oxygen,
CRITICALLY ILL PARTURIENT high concentration oxygen mask, transnasal high‑flow
humidified oxygen, and noninvasive ventilation (NIV)
Common organ dysfunction or failure in a critically ill have all been reported to maintain targeted gas
parturient varies whether it is obstetric or non‑obstetric exchange. From our institute’s protocol and NIV
in aetiology. In several studies and with our institute’s policy, we have data of >300 patients who received
experience, the lung is the most frequently involved NIV to maintain safe targets, with zero incidence of
organ, followed by haematological, cardiovascular, aspiration and 2% incidence of conversion to invasive
renal, central nervous systems, and the multiorgan ventilation. However, NIV and transnasal high‑flow
dysfunction syndrome.[22] oxygen have not been adequately studied and should
be used with caution and by experienced teams only
The trend of organ dysfunction of sick parturients to mitigate the risk of aspiration. Tracheal intubation is
admitted in our unit is presented in Figure 1. The goal of performed and lung protective mechanical ventilation
organ supports should be ‘giving best to both the lives’ is initiated without any further delay, if the ventilation
(mother and the foetus). The organ supports provided targets are not achieved (PaO2 >65–70 mmHg and
in a critically ill parturients should not only provide PaCO2 <45 mmHg, PaO2 – FiO2/PF ratio >150 mmHg).
targeted goals in mother but also take care of foetal Plateau pressure should be maintained less than

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28 cm of H2O and PEEP should be used judiciously. starvation is avoided. The caloric requirement is
Permissive hypercapnoea (upper permissible limit increased during labour and highest in the lactating
of PaCO2 <50 mmHg) is poorly tolerated in pregnant period. Accordingly, extra allowances are made.
women, as a PaCO2 gradient of 10 mmHg is needed Enteral route is well tolerated and should be the
for foeto‑maternal transfer, failing which foetal primary choice. Feeds appropriate to the disease
respiratory acidosis sets in and compromises foetal conditions are made and administered.[25]
survival. For refractory hypoxaemia [severe acute
respiratory distress syndrome (ARDS)], joint family ECMO
multidisciplinary counseling has to be mandated,
and pros and cons of options are to be discussed. The Successful outcomes following use of both
options may include semi‑prone ventilation (personal veno‑venous ECMO (VV ECMO) and veno‑arterial
experience of four cases) and complete prone ECMO (VA ECMO) have been reported for both
ventilation postnatal has been reported with antepartum and postpartum period.[26] Initiating
variable success rate; termination of pregnancy, ECMO during pregnancy requires specialised and
if >22 weeks gestational age – foetal viability issues multidisciplinary input especially about the mode of
and prognostication should be properly explained and delivery and timing of delivery.
veno‑venous extra-corporeal membrane oxygenation
(ECMO), if available or transfer to a unit where such OTHER ORGAN SUPPORTS
facility and experience to handle a pregnant patient on
ECMO exists. Renal and other organ supports are the same as in
nonpregnant patients. Organ protective strategies
CIRCULATION should be wisely followed and hospital‑acquired
infection control policies should strictly be followed
The crux of circulation is maintaining adequate and outcomes audited.
utero‑placental perfusion. Common shock states
in pregnancy (hypovolaemic haemorrhagic, septic, MATERNAL MONITORING IN OBSTETRIC CRITICAL
and cardiogenic shock) should be appropriately and CARE UNIT
aggressively treated with two large bore (14G or 16G)
peripheral venous access and minimally invasive All critically ill parturients requiring moderate to stiff
monitoring (arterial line mandatory and central line if organ supports merit invasive monitoring. There are
possible). Preferably, femoral route for venous or arterial no defined standards, but CVP (internal jugular, most
access is avoided, and sub clavian route for Central Venous preferred) and invasive arterial pressure monitoring
Pressure (CVP) line is usually avoided as coagulopathy are mandatory. CVP values are spuriously high in
is very common in situations of shock in pregnancy. antepartum patients with gestational age beyond
Internal jugular route is safe and ultrasound‑guided 24–26 weeks and should be wisely judged for volume
central venous access is strongly recommended. If the replacement. Similarly, IVC ultrasound in a term
gestational age is greater than 20 weeks, it is ensured that gravid may not be accurate. Volume assessment is done
LUD is maintained, using a 27° wedge. best by trans‑thoracic echocardiography. Continuous
cardiac output monitoring devices have become
Crystalloid resuscitation and appropriate transfusion popular in the recent past.[27] Most studies have been
triggers and end points should be followed. For sepsis, carried out in healthy parturients. However, our own
revised survival sepsis guidelines (2018) should be institute’s experience in using continuous cardiac
followed. output monitoring devices in sick pregnant women,
from pulse volume and stroke volume variation,
One should not hesitate to start appropriate shows that cardiac output indices are more useful
vasopressors and inotropes for fear of foetal transfer. in postpartum period compared with antepartum
Thumb rule is what is good for the mother and period (because the aorto‑caval component).
stabilises the foetus.
DECISION TO DELIVER AND MODE OF DELIVERY
GI SUPPORT
Once the mother is stabilised, foetal evaluation should
Pregnancy is a high calorific state. They are prone be done and the following principles are followed:
for ketosis very early if starved. Hence, prolonged a multidisciplinary team approach is essential with
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intensivist, obstetrician, foetal medicine specialist, administered if Rh‑negative mother has received
obstetric anaesthesiologist, and concerned specialist multiple random donor platelets. This is done to
jointly involved in patient care and counseling. minimise the risk of Rh iso‑immunisation in future
Risk of preterm delivery should be explained at pregnancies.
admission and delivery set should be kept in the
ICU. Primarily, all resuscitation efforts should BREAST FEEDING IN ICU
focussed be towards maternal stabilisation. If the
foetal age is greater than 22–24 weeks gestational After delivery, early maternal bonding is established.
age, steroids should be considered for foetal lung Very few drugs contraindicate breastfeeding;
maturity. If time permits and there is no medical encourage breast feeds early even if the mother is on
contraindication, betamethasone (two intramuscular ventilator support. Early maternal bonding facilitates
doses of 12 mg, 24 h apart) is given. The clinician rapid weaning from mechanical ventilation, and even
has to keep in mind that the combination of steroids, the incidence of lactation failure rates is lower, after a
tocolytics, and occult septic foci can be lethal. Role major illness (our institution audit).
of tocolytics should best be decided jointly by the
obstetrician and anaesthesiologist and or intensivist. SAFE RADIATION IN PREGNANT WOMEN
It is better to avoid Beta 2 agonists. Foetal well‑being
is closely monitored in critically ill parturient. The Radiology and Imaging exams are part of routine
biophysical profile has gained popularity as a test of exams for pregnant women. These include very low
foetal well‑being. This includes foetal breathing, tone, dose exams, low to moderate dose exams and very
movement, amniotic fluid volume, and the results of high dose exams.[28] Radiation may affect both the
a nonstress test. If foetal delivery is imminent, loading mother and the growing foetus. Table 3 shows the safe
dose of magnesium sulphate 4 g IV slowly followed radiation limits in a parturient.
by 1G/hour infusion is administered for 4 h for foetal
brain protectionM mode (Abdominal versus vaginal) OBSTETRIC SPECIFIC DISORDERS
and timing of delivery should be discussed with the
family and decision should be taken keeping in mind Hypertensive disorders in pregnancy
the maternal safety. Pre‑eclampsia is defined as hypertension and
proteinuria occurring in pregnant women after
Type of anaesthesia – General versus neuraxial should 20 weeks of gestation and resolving within 6–12 weeks
be taken keeping in mind the coagulation parameters, after delivery. Pre‑eclampsia may be classified as mild
airway needs, and haemodynamic stability. Several or severe. Severe pre‑eclampsia is defined as a systolic
factors have to be considered. These include foetal blood pressure >160 mm of Hg and/or a diastolic
oxygen delivery, the determinants of which are blood pressure >110 mm Hg, proteinuria >5 g per
haemoglobin, haemoglobin saturation, utero‑placental 24 h, oliguria <400 mL per 24 h, cerebral irritability,
blood flow (maximally dilated). The utero‑placental epigastric or right upper quadrant pain, and/or
blood flow is dependent on the  mean arterial pressure. pulmonary oedema.
Maternal hypotension is the single most important
factor to reduce foetal blood flow. The lethal triad Eclampsia is a severe complication of pre‑eclampsia
for foetal demise: hypotension, hypoxia and anaemia defined by the presence of seizures in the absence
should be minimised or prevented. Maintaining of other neurologic disorders. Seizures may result
maternal haemoglobin of 7g/dL and above, adequate from severe intracranial vasospasm, intracranial
cardiac output, and circulating blood volume are hypertension, ischemia, and vasogenic and cytotoxic
the basic fundamental requirements in managing a oedema leading to endothelial dysfunction. Eclampsia
critically ill parturient in ICU and operating room. may progress to hepatic failure, haemorrhage, or
Coagulopathy should be completely corrected before infarctions.
surgery or vaginal delivery. Kleihauer–Betke analysis
should be performed to detect the presence of foetal Haemolysis, elevated liver enzymes, low
red cells in maternal circulation in all Rh‑negative platelets (HELLP) syndrome includes microangiopathic
maternal trauma victims, massive abruption, and or haemolytic anaemia, elevated liver function tests,
amniotic fluid embolism (AFE). If positive, anti‑D and thrombocytopaenia. HELLP syndrome usually
immunoglobulin should be administered. It is also occurs before 37 weeks of gestation and overlaps with

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Table 3: Safe radiation exposure in a parturient (borrowed from ACOG guidelines, 2017)

Radiation exposure in pregnancy and foetal dose
Type of radiologic exam Foetal dose (mGy) Remarks
Chest X‑ray ‑ two views <0.0005‑0.01 Very low‑dose examinations (<0.1 mGy)
X‑ray spine (AP and Lat) <0.001
Mammography (two views) 0.001‑0.01
X‑ray of any extremity <0.001
X‑ray abdomen 0.1‑0.3 Low to moderate dose examination (0.1‑10 mGy)
X‑ray lumbar spine 1.0‑10
IVP 5‑10
CTPA/CT chest 0.01‑0.66
Limited CT pelvimetry <1
Abdominal CT 1.3‑35 High‑dose examination (10‑50 mGy)
Pelvic CT 10‑50
18F PET/CT whole‑body scintigraphy 10‑50
AP and Lat: Anteroposterior and lateral; CT – Computed tomography; CTPA – CT pulmonary angiography; PET – Positron emission tomography;
18F – 2(Fluorine‑18) fluoro‑2deoxy‑D‑glucose; Radiographics 2012;32:897‑911

pre‑eclampsia. HELLP syndrome may result from may occur. Multiorgan failure and cardiac arrest may
generalised endothelial and microvascular injury occur. Aggressive multiorgan support, correction
from complement and coagulation cascade activation, of coagulopathy, massive transfusion protocol,
increased vascular tone, and platelet aggregation. This emergency delivery of foetus, Caesarean section with
results in liver haemorrhage and necrosis and can possible ligation of uterine/internal iliac arteries, and
lead to large hepatic haematomas, capsular tears, and even hysterectomy have been performed as life‑saving
intraperitoneal bleeds. measures. Successful use of V‑A ECMO has also been
reported. With current good ICU support and care,
Acute fatty liver of pregnancy (AFLP) is also considered survival rates up to 80% and above can be expected.
as an extension of HELLP syndrome and many clinicians
consider these disorders as HELLP–AFLP complex. Sepsis
They are often multiorgan disorders and treatment Four specific infectious complications are of interest
is termination of pregnancy. The mimickers of these in pregnancy – chorioamnionitis, pyelonephritis,
disorders are haemolytic uraemic syndrome (HUS), endometritis, and pneumonia. Chorioamnionitis results
thrombotic thrombocytopaenic purpura (TTP), from change in pH of the vagina and increased glycogen
postpartum thrombotic micro‑angiopathy (PTMS), content. There is a loss of barrier for bacterial entry
and sepsis, and they should be appropriately worked and it may also result from chorionic villi sampling,
up. ADAMTS‑13 assay helps in differentiating them. amniocentesis, and abortions. Pneumonia maybe
Very few laboratories perform this test in the world. In caused by aspiration of gastric contents due to loss of
management of TTP and HUS, plasmapheresis plays a lower oesophageal tone and elevation of the diaphragm.
very important role and conventional haemodialysis Pregnancy may also cause a level of immunosuppression
may not help in HUS, TTP, and PTMS. and lead to fungal or viral pneumonia especially in those
already at risk. Pyelonephritis may result from colonisation
Amniotic fluid embolism of the renal system with Gram‑negative bacteria as a result
Amniotic fluid embolism syndrome presents with of lower or loss of ureteral sphincter tone that is associated
acute severe hypoxic respiratory failure, associated with progesterone. Mortality from sepsis is significant
with shock, disseminated intravascular coagulopathy, although progression to sepsis in pregnancy is low.
and seizures.[29,30] AFE usually presents within 24 h of Infections may involve the endometrium, spread through
delivery and has a very high maternal mortality rate the uterine wall, peritonitis, or lead to thrombophlebitis
and long‑term neurologic sequelae in survivors.[29,30] of the pelvic veins.
The cause for AFE is unclear but may result from a
hypersensitivity reaction or anaphylaxis to amniotic Clinically, sepsis includes signs of systemic
fluid.[29,30] AFE can lead to acute lung injury, inflammation followed by coagulopathy, vascular
hypoxaemia, hypoxic pulmonary vasoconstriction, and anomalies, and progressive multiorgan failure.
acute right heart failure. Acute diastolic dysfunction Conventional survival sepsis guidelines are followed
followed by acute systolic failure of the left ventricle with judicious fluid therapy.[31]

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Ovarian hyperstimulation syndrome Treatment is mainly supportive and consists of

Ovarian hyperstimulation syndrome (OHSS) is judicious hydration, correction of dyselectrolytaemia,
caused by controlled ovarian stimulation with antiemetics, pain management (avoid nonsteroidal
gonadotropins during infertility treatment.[32] There anti‑inflammatory drugs), anti‑deep vein thrombosis
is a sudden enlargement of the ovaries with multiple prophylaxis, maintenance of colloid oncotic pressure,
cysts that lead to vascular permeability and acute and relief of abdominal compartment syndrome by
transfer of fluid into external spaces leading to pleural tapping. Pleurocentesis is done for hydrothorax. Watch
effusion and ascites. Increased haemoconcentration for torsion ovaries and thrombosis. Continue heparin
and blood viscosity may result and lead to for up to 1 week after the symptoms resolve and if the
thromboembolic events with cardiovascular and patient conceives, up to first trimester.
neurological complications. Pregnancy increases
the risk for OHSS possibly related to an increase in Cardiac Arrest in pregnancy
endogenous human chorionic gonadotrophin (hCG) The principles of resuscitating a pregnant woman
and mediated through vascular endothelial growth are nearly the same as resuscitating any nonpregnant
factor. person; however, one has to consider that there are
two lives in a pregnant woman – the woman and the
OHSS can be classified as mild (incidence is 20%–33% foetus. Resuscitation maybe necessary in a maternal
of in  vitro fertilization (IVF) cycles), moderate near miss that is defined as a woman who nearly died
(3%–6%), and severe and critical (0.1%–2% incidence) but survived a complication that occurred during
categories. The following risk factors[33] have been pregnancy, childbirth, or within 42 h of birth.
identified: poly cystic ovarian syndrome, previous
history of OHSS. Anti‑Muellerian hormone (AMH) In the event of cardiac arrest, published guidelines
concentration [AMH >0.47 pmol/L (3.36 ng/mL)] is should be followed.[34-37] Common causes of
a useful predictor of developing OHSS (sensitivity cardiac arrest in pregnancy can be remembered
90.5%, specificity 81.3%). Antral follicle count (AFC) by the acronym – ABCDE UPS. A – Anaphylaxis,
≥24 is correlated with an increased risk of moderate to Anaesthetic; B – Bleeding, Bleeds in Brain, Bleeds in
severe OHSS in comparison to an AFC <24 (8.6% versus Liver; C – Cardiac; D – Drugs (Magnesium toxicity),
2.2%). Combination of  ≥18 follicles on ultrasound E – Eclampsia, Embolism (Amniotic, Air and
(diameter  ≥11  mm) and estradiol E2  ≥5000  ng/L on Thrombo‑embolism); U – Uterine (Abruptio, Rupture,
the day of hCG trigger is more useful (sensitivity 83%, couvelaire, Inversion); P (Pulmonary – ARDS,
specificity 84%) than E2 concentrations alone in the Pulmonary oedema, Placental – Adherent placenta,
prediction of severe OHSS. Retained placenta), and S – Sepsis. ABC and CAB
should proceed simultaneously as they are prone to
OHSS is classified into mild, moderate, severe, and severe hypoxaemia. Supine position with LUD is
critical. Severe and critical types need ICU‑based recommended during chest compressions. Venous
symptomatic and supportive care. access in upper limb or neck is recommended.
Standard 200J shock is given using biphasic
Mild OHSS is associated with abdominal bloating defibrillator if the rhythm is shockable. If return of
and mild abdominal pain; ovarian size is usually spontaneous circulation (ROSC) cannot be established
<8 cm2. Moderate OHSS in addition to above in 4 min, resuscitative hysterotomy [peri mortem
symptoms has nausea ± vomiting; there is ultrasound caesarean section (PMCS)] should be done at the site
evidence of ascites, and ovarian size is usually of cardiac arrest. Do not delay PMCS beyond 4 min, if
8–12 cm2. Severe OHSS presents with clinical gestational age is beyond 22–24 weeks. Association of
ascites (±hydrothorax), oliguria (<300 mL/day or Obstetric Anaesthesiologists (AOA), India guidelines
<30 mL/hour), haematocrit >0.45, hyponatraemia recommend vascular compression of aorta or clamping
(sodium <135 mmol/L), hypo‑osmolality (osmolality of aorta/common iliacs (needs practice or availability of
<282 mOsm/kg), hyperkalaemia (potassium >5 vascular surgeon) if PMCS is being done in a lady with
mmol/L), hypoproteinaemia (serum albumin <35 g/L), placenta percreta. AOA guidelines further recommend
and ovarian size is usually >12 cm2. Critical OHSS prophylactic compressive sutures on uterus if it is
is associated with tense ascites, large hydrothorax, flabby post delivery. Use of oxytocin in atonic uterus
oliguria/anuria, thromboembolism, and acute can lead to recurrent cardiac arrest. Judicious balance
respiratory distress syndrome. of various uterotonic agents is recommended. V‑A

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Pandya and Mangalampally: Obstetric critical care

ECMO can used if ROSC cannot be established with their outcomes are often dramatically better than
the above methods. Standard postresuscitation care expected from the initial severity of illness.
in ICU is given, and usual organ supportive and
protective strategies are followed. Financial support and sponsorship
Nil.
Ethical dilemmas in obstetric critical care
Critically ill pregnant women sometime can pose Conflicts of interest
ethical dilemmas in critical care.[38] Brain dead There are no conflicts of interest.
parturient with foetus near viability age, dilemma
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