Table 5 Principles of obstetric critical care
From: Preeclamptic heart failure — perioperative concerns and management: a narrative review
System | Considerations |
|---|---|
Respiratory support | - Noninvasive ventilation • Has been used but with caution, keeping in mind the high risk of gastric inflation, regurgitation, and aspiration - Tracheal intubation • Histamine receptor antagonist or proton-pump inhibitor in anticipation, sodium citrate solution, head-up tilt • Cricoid pressure controversial • Preoxygenation can be done using high-flow nasal cannula • Short-handled laryngoscope, ensure optimal positioning including “ramp” for patients with high BMI, and smaller-sized endotracheal tubes - Invasive mechanical ventilation • Plateau pressure — 35-cm H2O, tidal volume 6 mL/kg (ideal body weight) • Optimal PEEP titration with driving pressure ≤ 15-cm H2O • Arterial oxygen partial pressure threshold — 70 mm Hg. Consider using fetal heart rate monitor to monitor for signs of fetal hypoxia if a lower threshold is used • Maternal optimization of oxygenation and ventilation should not routinely include fetal delivery, unless fetal indications are present |
Circulatory support | - In case of any hemodynamic instability, always rule out possible aorto-caval compression - Judicious use of intravenous fluids - Low threshold for initiating invasive monitoring - Evidence-based use of vasodilators, vasopressors, and inotropes - Bedside-focused transthoracic echocardiography to diagnose etiology and initiating appropriate treatment |
Pharmacotherapeutic agents | - Ideal sedative is still elusive - Most sedatives will have depressant actions on the fetus, if birth is planned soon after - Opioid infusions are associated with risk of respiratory depression in the fetus - Midazolam infusions carry risk of acute fetal benzodiazepine withdrawal |
Nutrition | - Most nutrition trials have excluded parturients; hence, appropriate caloric goals are unknown - Prokinetics might be needed in view of impaired gastric emptying |
Prophylaxis for deep venous thrombosis | - All patients to receive prophylaxis unless otherwise contraindicated |
Fetal care | - In the absence of specific maternal indication, cardiotocography is usually not a routine practice if the patient is not laboring - Obstetrician, anesthesiologist, and neonatologist must be kept informed prior and available on standby if delivery is planned in the obstetric critical care unit - Cardiotocogram, uterotonic agents, cesarean kit, and neonatal resuscitation equipment be kept ready |