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ISSN: 2167-0846
Journal of Pain & Relief
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Emergency and Critical Care Challenges during Pregnancy

Sukhminder Jit Singh Bajwa*
Department of Anaesthesiology and Intensive Care Medicine, Gian Sagar Medical College and Hospital, India
Corresponding Author : Sukhminder Jit Singh Bajwa
Department of Anaesthesiology and Intensive Care Medicine
Gian Sagar Medical College and Hospital India,
Tel: 09915025828/01752352182
E-mail:[email protected]
Received July 11, 2012; Accepted July 11, 2012; Published July 16, 2012
Citation: Singh Bajwa SJ (2012) Emergency and Critical Care Challenges during Pregnancy. J Pain Relief S1:e001. doi: 10.4172/2167-0846.1000S1-e001
Copyright: © 2012 Singh Bajwa SJ. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Maternal mortality continues to be a challenging issue throughout the world. The causes of higher maternal mortality vary slightly among various developing and developed nations across the globe. From the published data, pulmonary embolism leads the list of fatal aetiology in developed nations like US whereas the data from developing nations though lacking but reveals haemorrhage and hypertensive disorders as the main aetiologic factors [1,2]. In developed countries like United States, only 0.2-0.9% of obstetric patients gets admitted in critical care units. The availability of well equipped modern labour rooms, excellent delivery services and specialized obstetric units are responsible for such a smaller number of obstetric admissions to intensive care units. The approximate data depicts that only about 40,000-1,20,000 women in US require critical care services in proportion to 4.3 million births per year [3-5]. The exact similar data for developing nations is very difficult to obtain but it reflects a very dismal picture as the maternal mortality rates are quite high in most of the Asian and African countries.
Obstetric patients requiring intensive care can have complicated clinical course as compared to non-pregnant patients during various surgical and medical emergencies [6-8]. Factors such as hypoxemia, hypotension, severe infection, severe anemia, etc. can influence the obstetric outcome as both the parturient and foetus becomes extremely vulnerable to these clinical insults. Airway management becomes difficult during pregnancy as the generalized oedema affects the supraglottic tissues and tongue thus narrowing the lumen of airways. Moreover, the degree of difficulty in laryngoscopy and intubation is further compounded by the positioning issues as the aorto-caval compression by the gravid uterus mandates elevation of right hip by 10-12 cm. As the gravid uterus compresses upon the inferior vena cava after 20 weeks, saphenous and femoral vein should not be used for administration of resuscitative medication during any medical or surgical emergencies. Modification of cardio-pulmonary resuscitation (CPR) procedure is required in pregnant state as compared to nonpregnant patient as the issues of foetal viability acquire an important dimension [1,2]. Before 22-24 weeks, the resuscitative efforts should focus on the maternal survival and requires no modifications in CPR. After 24 weeks, if abdominal palpation reveals uterine fundal height above umbilicus, efforts should be directed towards adequate positioning to minimize aorto-caval compression and one should be ready to undertake operative delivery if required [1,2]. While delivering shock treatment with defibrillator placement of the pads should be adjusted to accommodate the gravid uterus besides positioning issues. The resuscitation should be carried out as per ACLS guidelines but for treating maternal hypotension, ephedrine is preferable over epinephrine and dopamine as the latter can cause uteroplacental vasoconstriction. The prognosis for viable foetus is better if delivery occurs within 5 minutes of cardiac arrest but operative intervention should not be deferred even if the time limit crosses 5 minutes. Absolutely no time should be lost in checking foetal viability before peri-mortem caesarean section. However, the presence and close co-ordination of obstetrician, anaesthesiologist, emergency physician and paeditrician can really help in delivering effective resuscitation interventions.
The diseases, both specific and non specific to pregnancy, affects equally in terms of increasing the morbidity and mortality in obstetric patients [9]. The respiratory diseases like acute exacerbation of asthma, pneumonitis, pulmonary edema, ARDS and acute lung injury can have serious implications both for the mother and the foetus and special considerations during these episodes include maintaining oxygen saturation greater than 90% [10]. Cardiovascular diseases, such as rheumatic heart disease, mitral stenosis and other valvular lesions can cause cardiac failure which necessitates intensive care admission. The cardiac surgery during pregnancy is extremely challenging and should be avoided unless a life saving procedure is required. Renal diseases like pyelonephritis can be accentuated in presence of sepsis which again propels the patient to the intensive care unit. Coagulation disorders, hepatic derangements including HELLP syndrome warrants urgent intensive care intervention in many instances as these disease entities can prove fatal sometimes [11,12]. The neurological disorders can mimic the picture of eclampsia and appropriate therapy involves a complete investigation profile. Gestational diabetes, thyroid disorders and other endocrinal diseases can also be responsible for medical emergencies in obstetric patients requiring urgent critical care. Trauma and surgical emergencies though occur with equal frequency in both obstetric and non-obstetric population, require urgent attention especially in the critically ill obstetric patients [1,2,13]. The decision to perform surgery again have to be taken after evaluating the pros and cons of surgical procedure as the critically ill patients may not be able to sustain the anaesthetic and surgical insults and foetal compromise is most likely to occur as well during these circumstances [6,7].
The role of anaesthesiologist, emergency physician and intensivist is equally challenging in such critically ill patients as they have a grossly deranged pathophysiology. The role of anaesthesiologist is very vital in these situations as majority of the ICU’s throughout the world are being managed by the anaesthesiologists. Provision of quality intensive care requires acquisition of special procedural skills and thorough up to date knowledge of pathophysiological aspects of various clinical disease entities. Obstetrician’s involvement is of prime importance when managing such cases in ICU irrespective of whether it is a closed or an open ICU. Their supervision and co-operation can decrease the maternal mortality and morbidity to a large extent. The outcomes are always best whenever a multidisciplinary approach is adopted in managing critically ill obstetric patients [14].
 
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