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Chapter 222. Critical Care of the Pregnant Patient

Meghan Hayes, MD; Ghada Bourjeily, MD

  1. What are physiologic changes of pregnancy pertinent to critical care?

  2. What are common reasons for pregnant women to require critical care?

  3. What factors impact airway intubation during pregnancy?

  4. What issues arise in hemodynamic monitoring during pregnancy?

  5. What vasopressors can and should be used during pregnancy?

  6. Are there special considerations for resuscitation during pregnancy?

The majority of critical care admissions for pregnant and peripartum women are for obstetric disorders, primarily hypertensive complications (particularly hemorrhagic stroke) or intrapartum hemorrhage. Medical indications, such as sepsis, respiratory failure, cardiomyopathy, or ischemic stroke are less common. Maternal mortality in developed nations remains rare (10 to 16 per 10,000 births); however the proportion attributable to medical disorders has been increasing as women with underlying medical conditions and older women conceive, perhaps with assisted reproductive technology. Standard scoring systems, such as APACHE scores, overestimate mortality in pregnant and peripartum women, particularly if they have an obstetric indication for critical care. Delivery or surgery may contribute to rapid improvement. A small proportion of obstetric patients require critical care. Hospitalists and intensivists may have limited experience managing these patients.

Physiologic Adaptations

Virtually every organ system adapts to accommodate pregnancy and delivery. Hemodynamic alterations prepare for blood loss of one-half to one liter at delivery. Blood volume increases by 50% (Table 222-1).

Table 222-1 Cardiac, Respiratory and Hematologic Physiologic Changes in Pregnancy
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Table 222-1 Cardiac, Respiratory and Hematologic Physiologic Changes in Pregnancy
Direction of ChangePercentage of Change or Normal Range in Pregnancy
Blood volume↑30–40% increase
Heart rate↑Increases by 10–20 bpm
Cardiac output↑30–60% increase
Systemic vascular resistance↓25–30% decrease
Blood pressure↓10–15 mm Hg decrease in first two trimesters
Colloid oncotic pressure↓10–15% decrease
Total lung capacity↓4–5% decrease
Functional residual capacity↓20% decrease
Diffusion capacity↔No change
Tidal volume↑Increased
Respiratory rate↔No change
Minute ventilation↑50% increase
PaO2↑Average 100–105
PcaCo2↓Average 28–32
pH↑Mild respiratory alkalosis
A-a gradient↑Increase in late gestation to approximately 20
Protein S↓
Activated Protein C resistance, fibrinogen, factor V, VIII, IX, X,↑
Plasminogen activator inhibitor type 1 and 2↑
Activity of tissue plasminogen↓

Modified from Miller MA, Bourjeily, G. Management of the critically ill pregnant patient. Pulmonary and Critical Care Update (PCCU). April 2009, 23 (Lesson 8); with permission.

Cardiac output increases by 30% to 50% and total peripheral resistance decreases by 20%, leading to blood pressure declining by 10 to 15 mm Hg in the first half of pregnancy, then returning to baseline in the second half. Diastolic blood pressure decreases more than systolic; pulse pressure is widened. Central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP) remain unchanged. Blood flow distribution is altered such that up to 25% of maternal cardiac output is ...

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