Critical Care Obstetrics

Cover
Title Page
Copyright Page
Contents
Notes on Contributors
Foreword
Preface
Part One Basic Critical Care Clinical and Surgical Principles
	Chapter 1 Epidemiology of Critical Illness in Pregnancy
		Introduction
		Pregnancy-related hospitalizations
		Maternal mortality
		Perinatal mortality
		Pregnancy-related ICU admissions
			Illnesses responsible for obstetric ICU admissions
			Causes of mortality in obstetric ICU admissions
			Perinatal loss with obstetric ICU admissions
		Summary
		Acknowledgments
		References
	Chapter 2 Organizing an Obstetrical Critical Care Unit: Care without Walls
		Background
		Critical care for obstetric patients
		Unit design: ICU without walls
		Patient population
		Members of the team
			Physician staffing
			Nursing staffing
			Additional staffing
			Obstetric ICU monitoring: Modalities and considerations
			Point-of-care ultrasound
			Thromboelastography
			Prophylaxis
		Guidelines, bundles, development, and education
		Summary
		References
	Chapter 3 Critical Care Obstetric Nursing
		Introduction
		Standards of nursing care
		Critical care technology: critical concepts and application to clinical practice
			Hemodynamic and oxygen transport monitoring: concepts for CCOB nursing
			Arterial pressure monitoring
			Central pressure monitoring
			Heparin flush
			Data collection: technical considerations
		Interpretation of hemodynamic and oxygen transport data
			Hemodynamic profile
			Oxygen transport profile
			Mechanical ventilation during pregnancy: selected concepts for CCOB nursing practice
		Levels of maternal care
		Care environment
		Nursing education and training
		Nurse-led bedside rounds
		Nursing practice guidelines, policies, procedures, and care bundles
			Intensive Care ABCDEF Bundle
			Early warning signs of maternal compromise
			Fetal and uterine monitoring
			Planning for labor and birth
		References
	Chapter 4 Pregnancy-Induced Physiologic Alterations
		Cardiovascular system
			Blood volume
			Blood pressure
			Heart rate
			Cardiac output and stroke volume
			Systemic vascular resistance
			Regional blood flow
			Effect of posture on maternal hemodynamics
			Central hemodynamic changes associated with pregnancy
			Hemodynamic changes during labor
			Hemodynamic changes during the postpartum period
		Respiratory system
			Changes in the upper airways
			Changes in the mechanics of respiration
			Physiologic changes in pregnancy
			Changes in maternal acid–base status
		Genitourinary system
			Alterations in renal tract anatomy
			Alterations in renal physiology
		Gastrointestinal system
			Alterations in gastrointestinal anatomy
			Alterations in gastrointestinal physiology
			Hepatobiliary changes in pregnancy
		Hematologic system
			Changes in red blood cell mass
			Changes in white blood cell count
			Changes in platelet count
			Changes in coagulation factors
		Endocrine system
			The pituitary gland
			The thyroid gland
			The adrenal glands
			The endocrine pancreas
		Immune system
		Conclusion
		References
	Chapter 5 Maternal Blood Gas Physiology
		Introduction
		Essential physiology
			Acid–base homeostasis
			Acid–base disturbances
			Respiratory and acid–base changes during pregnancy
		Oxygen delivery and consumption
			Relationship of oxygen delivery to consumption
			Oxygen delivery and consumption in pregnancy
			Blood gas analysis
			Sample collection
			The blood gas analyzer
			Pulse oximetry
			Mixed venous oxygenation
			Blood gas interpretation
			Graphic nomogram
			A systematic approach to an acid–base abnormality
		Respiratory components of the arterial blood gas
			Partial pressure of arterial oxygen: PaO2
			Assessment of lung function
			Oxygenation of peripheral tissues
			Partial pressure of arterial carbon dioxide: PaCO2
			The metabolic component of the arterial blood gas: bicarbonate
		Disorders of acid–base balance
			Metabolic acidosis
			Metabolic alkalosis
			Respiratory acidosis
			Respiratory alkalosis
		Conclusion
		References
	Chapter 6 Fluid and Electrolyte Balance
		Introduction
		Fluid resuscitation
		Isotonic crystalloid solutions
		Colloid solutions
			Indications
			Oliguria
			Side effects
		Sodium disorders
			Hyponatremia
			Pregnancy-specific causes of hyponatremia
			Clinical presentation
		Hypernatremia
			Etiology
			Clinical presentation
			Diagnosis
			Management
		Potassium disorders
		Hypokalemia
			Etiology
			Clinical presentation
			Diagnosis
			Management
			Hyperkalemia
			Etiology
			Clinical presentation
			Diagnosis
			Management
		Calcium disorders
		Hypocalcemia
			Etiology
			Clinical presentation
			Treatment
		Hypercalcemia
			Etiology
			Clinical presentation
			Treatment
		Magnesium disorders
			Hypomagnesemia
			Clinical presentation
			Diagnosis
			Treatment
			Hypermagnesemia
			Clinical presentation
			Diagnosis
			Treatment
		References
	Chapter 7 Interventional Radiology in Pregnancy
		Introduction
		Indication and timing of interventional procedures
		Intraprocedural sedation
		Intraprocedural imaging guidance and radiation dose reduction
		Interventions for venous access
		Interventions for venous thromboembolism
		Interventions for visceral artery aneurysms
		Interventions for vascular malformations
		Interventions in the urinary tract
		Interventions in the biliary tract
		Interventions for postpartum hemorrhage
		Interventions for postpartum hemorrhage in settings of abnormal placentation
		Interventions post-cesarean section
		Complications of interventional procedures
		Conclusion
		Key points
		Acknowledgments
		References
	Chapter 8 Fetal Considerations in the Critically Ill Gravida
		Introduction
		Detection of fetal distress in the critically ill obstetric patient
			Baseline fetal heart rate
			A persistent slow FHR or an intrinsic bradycardia
			A sudden rapid and sustained deterioration of the fetal heart rate
			Tachycardia
			Baseline fetal heart rate variability
			Sinusoidal fetal heart rate pattern
		Periodic changes or FHR changes in response to uterine contractions
			Accelerations
			Variable deceleration
			Late decelerations
		Overview of periodic changes
		Two important “FHR” patterns
			The prolonged FHR deceleration
			Recording the maternal heart rate: a confounding variable during labor
		FHR patterns in the brain-damaged infant
			Reactive admission test and subsequent fetal brain damage
			Acute fetal brain injury – “this is an example of the door remaining open and the pump is not pumping”
			The persistent nonreactive FHR pattern
		Fetal monitoring in the ICU made simple
		Maternal and surgical conditions
			Anaphylaxis
			Eclampsia
			Disseminated intravascular coagulopathy
			Maternal brain death or persistent vegetative state
		Perimortem cesarean delivery
		References
		Goals of therapy
		Critical laboratory tests
		Consultation
		Perimortem cesarean
	Chapter 9 Fetal Effects of Drugs Commonly Used in Critical Care
		Introduction
		Maternal analgesia and sedation
			Midazolam
			Lorazepam
			Dexmedetomidine (Precedex)
			Propofol
			Ketamine
			Haloperidol
			Morphine
			Fentanyl
			Pancuronium
			Vecuronium
		Cardiovascular drugs
			Advanced cardiovascular life support drugs
		Other cardiovascular drugs
			Inotropes
			Diuretics
			Vasodilators
			Anticoagulation
		Thrombolytic therapy
		Endocrine emergencies
			Insulin
			Corticosteroids: hydrocortisone and dexamethasone
			Thyroxine
			Antithyroid medications: propylthiouracil, methimazole, and radioactive iodine
		Mannitol
		Resource
		Conclusion
		Key points
		References
	Chapter 10 Maternal–Fetal Oxygenation
		Maternal adaptations favoring fetal oxygenation
		Placental factors to enhance fetal oxygenation
		Placental transfer of oxygen and carbon dioxide
		Fetal adaptations favoring fetal oxygenation
		Fetal oxygenation survival with a low PO2
		Maternal oxygen therapy in obstetrics and maternal hyperoxygenation (MHO)
		Oxygen therapy for acute fetal distress
		Oxygen therapy for the fetus with IUGR
		Oxygen therapy in cases of congenital heart disease
		Oxygen therapy for fetal distress due to maternal hypoxia
		Conclusion
		References
	Chapter 11 Cardiopulmonary Resuscitation (CPR) in Pregnancy
		Introduction
		Epidemiology
		Etiology
		Management
		Aortocaval compression
			Compression
			Airway
			Circulation
			Defibrillation
			Extraction of the fetus/delivery
		Medications
		Extracorporeal membranous oxygenation (ECMO) and extracorporeal life support (ECLS)
		Post-arrest care
		Summary
		References
	Chapter 12 Neonatal Resuscitation in the Critical Care Setting
		Introduction
		Elements of birth depression
			Causes of birth depression
			Response to hypoxia
			Primary and secondary apnea
			Use of the Apgar score
			Resuscitation at the threshold of viability
			Resuscitation in the delivery room: ethical and legal aspects
			Resuscitation in areas other than the delivery room
		Elements of a resuscitation
			Overview
			Importance of establishing ventilation
		Preparation for a resuscitation
			Anticipation
			Equipment
			Adequate personnel
		Initial steps and evaluation
			To its mother or not?
			Initial steps
		Medications
			Epinephrine
			Volume expanders
			The drug-depressed infant
		Immediate care after establishing adequate ventilation and circulation
			Prolonged assisted ventilation
			Dopamine
			Glucose
			Fluids
			Thermal management
			Feeding
			Other problems
		Special problems during resuscitation
			Meconium aspiration
			Pneumothorax
			Diaphragmatic hernia
			Hydrops fetalis
		Screening for congenital anomalies
			External physical examination
			Internal physical examination
		Conclusion
		References
	Chapter 13 Ventilator Management in Critical Illness
		Introduction
		Respiratory failure
			Ventilation/perfusion (V/Q) mismatch shunt (QS/QT)
			Dead space
			Arterial oxygen tension (PaO2)
			Alveolar–arterial oxygen tension gradient
		Oxygen delivery and consumption
			Relationship of oxygen delivery to consumption
			Oxygen delivery and consumption in pregnancy
		Assessing oxygenation
			Pulse oximetry
			Mixed venous oxygenation
			Impairment of oxygenation
		Therapy
			Noninvasive positive pressure ventilation
			High-flow nasal cannula
			Mechanical ventilatory support in pregnancy
			Intubation
		Ventilator modes
			Controlled mechanical ventilation
			Assist control
			Synchronized intermittent mandatory ventilation
			Pressure support ventilation
			Pressure-regulated volume control ventilation
			Other ventilator modes
		Alternative maneuvers during mechanical ventilation
			Prone ventilation
			Extracorporeal membrane oxygenation
			Nitric oxide
			Lung-protective strategy mechanical ventilation
			Special considerations during mechanical ventilation
		Weaning from mechanical ventilation
			Predicting weaning outcome
			Weaning techniques
			Failed weaning
		Respiratory system interactions
			Neurologic issues
			Cardiovascular factors
			Psychologic problems
		Conclusion
		References
	Chapter 14 Vascular Access
		Introduction
			Catheter type
		Preparing for catheter insertion
			Skin preparation
			Catheterization techniques – general
			Special techniques for catheter insertion
		Complications – general
			Catheter malposition
			Thrombosis, stenosis, and occlusion
			Embolism
		Specific venous access sites
			Internal jugular vein
			External jugular vein
			Subclavian vein
			Femoral vein
		Specific arterial access sites
			Radial artery
			Modified Allen test
			Brachial artery
			Axillary artery
			Dorsalis pedis artery
			Femoral artery
		Catheter-related infection
		Conclusion
		Acknowledgment
		References
	Chapter 15 Nutritional Support
		Introduction
		Normal nutrition in pregnancy
		Malnutrition in pregnancy
		Nutritional assessment during pregnancy
		Weight gain during pregnancy
		Routes for nutritional support
		Calculation of nutritional requirements
		Amino acids
		Carbohydrates
		Fat emulsions
		Fluid and electrolytes
		Monitoring and complications
		References
	Chapter 16 Acute Kidney Injury and Renal Replacement Therapy
		Definition of acute renal failure
		Changes of renal function in pregnancy
			Etiologies of acute kidney injury
			Urinary obstruction as a cause of AKI
		Management: general principles
		Renal replacement therapy
		Summary
		References
	Chapter 17 Cardiopulmonary Bypass
		Introduction
		Maternal and fetal risks of cardiopulmonary bypass
		Alternatives to CPB
		Surgical timing and concurrent cesarean section
		Mechanics of cardiopulmonary bypass
		Physiology of CPB
			Maternal effects
			Fetal effects
		Management of cardiopulmonary bypass
			Anesthesia and maternal hemodynamics
			Fetal heart rate monitoring
			Myometrial activity and tocolysis
			Temperature during CPB
			Pump prime
			Cardioplegia
			CPB flows and perfusion pressure
			Pulsatility
			Blood gases: acid–base, oxygenation, and ventilation
		Summary
		References
	Chapter 18 ECMO in Obstetrics
		Introduction
		VV-ECMO
			Indications
		Principles of VV-ECMO and pregnancy considerations
			Cannulation
		Mechanical ventilation and gas exchange targets
		Hemodynamic targets
		Lung rest strategies
		Fetal consideration during ECMO
		Timing of delivery
		Maternal and neonatal outcomes on ECMO
		Principles of venoarterial ECMO
		Anticoagulation during ECMO (VV and VA)
		Complications of ECMO (VV and VA)
		VA-ECMO in pregnancy
		Conclusions
		References
	Chapter 19 Antibiotics, Antivirals, and Antifungals in Critical Care
		Introduction
		Pharmacokinetics and pharmacodynamics of antimicrobials
		Pharmacokinetics
			Drug absorption
		Drug distribution
		Drug metabolism and clearance
		Drug elimination
		Pharmacodynamics
		Mechanism of antibiotic action
		Antibiotics resistance
		Antibiotic treatment in critically ill pregnant patients
			Time to antibiotics
		Biomarkers to initiate antibiotics
		Antimicrobial choice
		Methicillin-resistant Staphylococcus aureus (MRSA)
		Multidrug-resistant bacteria
		Antibiotics dosing
		Continuous prolonged or intermittent administration of  time-dependent antibiotics
		Duration of antibiotic therapy
		Pharmacokinetics and pharmacodynamics of antivirals
		Pharmacokinetics, drug absorption, drug metabolism, and clearance
			Acyclovir
			Ganciclovir
			Foscarnet
			Oseltamivir
			Ribavirin
		Antiviral use and treatment in critically ill pregnant patients
		Fungal therapy
		Pharmacokinetics and pharmacodynamics of antifungals: azoles and echinocandins
		Antifungal treatment in critically ill pregnant patients
		Diagnosis of antifungal infections
		Treatment and duration
		References
	Chapter 20 Noninvasive Monitoring in Critical Care
		Introduction
		Approach to monitoring
		Role in diagnosis and therapy
		Evidence and implementation
		Physiology of monitoring
		Oxygen consumption, oxygen delivery, and cardiac output
		The Frank–Starling mechanism in clinical practice
		Routine noninvasive monitoring
		Measurement of oxygenation
		Invasive assessment of arterial oxygenation
		Assessing ventilation and evaluating for acidemia
		Assessment of blood pressure
		Ascertaining cardiac output
		End-organ monitoring in critical illness
		Noninvasive monitoring and the fetus
		Point-of-care ultrasound for maternal indications
		Assessment of cardiac function
		Assessment of fluid responsiveness
		A dynamic approach to noninvasive hemodynamic monitoring
		References
	Chapter 21 Critical Care Drills in Obstetrics
		Obstetric emergencies
			Shoulder dystocia
			Postpartum hemorrhage
			Emergent cesarean delivery
			Eclampsia
			Breech vaginal delivery
			Operative vaginal delivery
			Maternal cardiac arrest
			Endocrine emergencies
		Location
		Teamwork and behaviors
		Communication
		Simulators
		Education
		Frequency and skill retention
		Outcomes
		In situ testing of new facilities
		Scenarios
		Debriefing
		Conclusions
		Resources
		Disclaimer
		References
		Appendix: In Situ Critical Care Simulation Example
	Chapter 22 Maternal–Fetal Transport in the High-Risk Pregnancy
		Introduction
		Epidemiology of maternal mortality
		Role and rationale for regionalization of maternal care
		Transport program components
			Maternal indications and contraindications for transport
			Logistical considerations in maternal–fetal transport
			Air versus ground transport
			Personnel
			Patient handoff
		Condition-specific considerations for common transport indications
			Preterm labor adequate
		Opportunities to improve the system of risk-based care
		References
Part Two Acute Emergencies
	Chapter 23 Seizure and Status Epilepticus
		Introduction
		Etiology
		Seizure prophylaxis
		Evaluation of new-onset seizures in pregnancy
		Treatment of seizures
		Status epilepticus
		Subsequent management and prognosis
		Key points
		References
	Chapter 24 Acute Spinal Cord Injury
		Introduction
		Maternal primary survey and specific considerations due to SCI
			Airway
			Breathing
		Circulation
			Autonomic nervous system impact on circulatory system following SCI
			Initial management of hypotension
			Risk of pulmonary edema
			Spinal neurogenic shock
			Treatment of neurogenic shock
			Maternal hemodynamic status and assessment
			Paradoxical bradycardia
		Other early management concerns
			Mother first with exceptions
			Emergency cesarean delivery
			Diagnostic imaging
			Corticosteroids: no longer recommended for maternal neural protection
			Recognition and prevention of autonomic dysreflexia
			Treatment of autonomic dysreflexia
			Treatment of autonomic dysreflexia due to labor and delivery
			Potential confusion of AD with preeclampsia
			Expectant obstetric management after initial stabilization
			Prevention of a “silent,” unattended, unnoticed delivery
			Presentation of labor in the patient with spinal cord injury
			Technical considerations of vaginal delivery
		Additional medical SCI complications
			Neurogenic bowel
			Stress ulcer prophylaxis
			Neurogenic bladder
			Pressure injuries
			Venous thromboembolism
			Orthostatic hypotension
			Psychological challenges
			Pain
			Spasticity
			Breastfeeding
		Rehabilitation
		Summary
		References
	Chapter 25 Severe Acute Asthma
		Introduction
		Maternal and fetal physiologic considerations during pregnancy
		Interrelationship between asthma and pregnancy
			Effects of pregnancy on asthma
			Effects of asthma on pregnancy
		Assessment of asthma during pregnancy
		Management of asthma during pregnancy
			2-agonists
			Inhaled corticosteroids
			Systemic corticosteroids
			Anticholinergics
			Other controller medications
			Antihistamines
			Influenza vaccination
		Management of acute asthma during pregnancy
			Emergency department management
			Hospital/intensive care management
			Mechanical ventilation
		Management of asthma during labor and delivery
		Obstetric management of the pregnant asthmatic patient
		Summary
		References
	Chapter 26 Acute Respiratory Distress Syndrome in Pregnancy
		Introduction
		Definition
		Epidemiology
		Pathophysiology and etiology
			Sepsis
			Aspiration
			Preeclampsia
			Tocolytic-induced pulmonary edema
			Amniotic fluid embolism
			Transfusion-related acute lung injury (TRALI)
			Venous air embolism
		Clinical features
		Management
			High-flow oxygen therapy (HFOT)
			Noninvasive positive pressure ventilation (NIPPV)
			Positive pressure ventilation: invasive ventilation
			Salvage modes
			Adjunct therapies
			ARDS due to COVID-19 (C-ARDS) in pregnant patients
		Summary
		References
	Chapter 27 The Acute Abdomen During Pregnancy
		Introduction
		Physiologic changes
		Differential diagnosis
		Diagnostic imaging
		Laparoscopy during pregnancy
		Appendicitis during pregnancy
			Presentation
			Diagnostic imaging
			Mortality and morbidity
			Preparing for surgery
		Cholecystitis during pregnancy
			Presentation
			Diagnosis
			Clinical management
			Medical management
			Active surgical management
		Bowel obstruction during pregnancy
			Presentation
			Diagnosis
			Clinical management
		Adnexal torsion during pregnancy
		Bariatric surgery and acute abdomen in pregnancy
		Summary
		References
	Chapter 28 Acute Pancreatitis
		Introduction
		Pathology and pathophysiology
		Etiology
			Biliary disease in pregnancy
			Hypertriglyceridemia
			Drugs
		Diagnosis
			Clinical manifestations
			Laboratory evaluation
			Radiologic evaluation
			Differential diagnosis
		Natural history and complications
		Clinical predictors of severity
		Management
			Initial management
			Management of underlying predisposing conditions
			Management of complications
		Conclusion
		References
	Chapter 29 Pneumonia During Pregnancy (Bacterial and Viral)
		Introduction
		Respiratory changes in pregnancy
		Pneumonia diagnosis
		Assessment of severity
		Identification of causative agent
		Bacterial pneumonia treatment
		Viral pneumonias
			Influenza A and B
			Diagnosis of influenza pneumonia
			Treatment
			Complications of viral pneumonia
			Prevention
			Coronavirus disease 2019 (COVID-19) pneumonia / Severe acute respiratory syndrome (SARS-CoV-1) epidemic
			Varicella
			Fungal pneumonia
			Pneumocystis pneumonia
			Concepts in management
		References
	Chapter 30 Acute Fatty Liver of Pregnancy
		Introduction
		Epidemiology
		Pathogenesis
		Clinical presentation
		Diagnosis
		Treatment
		Supportive care
		Summary
		References
	Chapter 31 Disseminated Intravascular Coagulation
		Introduction
		Pathophysiology
			Abruptio placenta
			Massive postpartum hemorrhage
			Preeclampsia with severe features, eclampsia, and HELLP syndrome
			Acute fatty liver of pregnancy
			Amniotic fluid embolism
			Sepsis syndrome
			Intrauterine fetal death
		Diagnosis of DIC
		Scoring for DIC
		Use of viscoelastic assays
		Management of obstetrical DIC
			Multidisciplinary approach
			Treatment of obstetric causes
			Supportive care
			Blood and blood products
		Conclusion
		References
	Chapter 32 Endocrine Emergencies
		Introduction
		Diabetic ketoacidosis
			Predisposing factors
			Pathophysiology of DKA
			Clinical presentation and diagnosis
			Management
			Fluid and electrolytes
			Insulin therapy
			Metabolic acidosis
			Fetal status
		Thyroid disorders
			Physiology of pregnancy
			Hypothyroidism
			Hyperthyroidism
			Thyroid storm
			Parathyroid abnormalities
		Adrenal dysfunction
			Pheochromocytoma
			Adrenal crisis
		References
	Chapter 33 Acute Psychiatric Conditions in Pregnancy: : Critical Care Obstetrics
		Introduction
		Acute depression and anxiety
		Suicide and suicidality
		Acute mania and psychosis
		Substance use disorder in pregnancy
		Birth trauma and postpartum posttraumatic stress
		Ethical considerations
		Conclusion
		References
	Chapter 34 Diabetic Ketoacidosis
		Normal regulation of ketogenesis
		Diabetic ketoacidosis
		Pregnancy predisposes to the development of ketoacidosis
		Evaluation
		Effective serum osmolality
		Corrected sodium
		The anion gap
		Diagnosis
		Measurement of ketones
		Treatment
			Fluids
			Potassium
			Insulin
			Other electrolytes
			Bicarbonate
			DKA order set
		Monitoring the response to treatment
			Monitoring of the fetus
		Resolution
		Prevention of DKA
			Conclusion
		Summary
		References
Part Three Shock in Pregnancy
	Chapter 35 Hypovolemic Shock
		Introduction
		Impact of obstetric hemorrhage
		Causes of obstetric hemorrhage
		Hypovolemic shock
		Identifying hypovolemic shock
		Management of hypovolemic shock in pregnancy
		Oxygenation
		Pharmacologic agents
		Initial volume replacement
		Blood safety
		Blood product transfusion
		Massive transfusion protocols
		Monitoring volume status during hypovolemic shock and resuscitation
		Further evaluation
		Hemostasis
		Key points
		References
	Chapter 36 Blood Component Therapy and Massive Transfusion
		Introduction
		Blood donation, collection, and storage
			Blood donation
			Blood collection and immediate storage
			Separation of whole blood into components
			Leukocyte reduction (LR)
		Blood components: description and indications
			Red blood cells
			Red blood cells washed
			Red blood cells frozen and red blood cells deglycerolized
			Platelets
			Pathogen-reduced platelets and large volume delay sampling platelets
			Fresh frozen plasma and thawed plasma
			Liquid plasma
			Cryoprecipitate
			Blood component alternatives
			Whole blood
		Transfusion practices
			Administration of blood and blood components
		Obstetric hemorrhage
		Massive transfusion
		Patients with bleeding or hematological diathesis
		Autologous blood
			Preoperative autologous donation
			Acute normovolemic hemodilution
			Intraoperative blood salvage
			Directed donation
		Transfusion reactions
			Acute transfusion reactions workup for transfusion reactions
		Concluding comments
		References
	Chapter 37 Etiology and Management of Hemorrhage (Includes Accreta)
		Placental abruption
		Uterine rupture
		Placenta accreta spectrum (PAS)
		Primary postpartum hemorrhage
			Etiology of primary postpartum hemorrhage
		Uterine inversion
		Treatment of uterine atony
			Emergency procedures
			Medical treatment of uterine atony
		Surgical management of postpartum hemorrhage
			Uterine tamponade
			Uterine brace suture
			Uterine devascularization
			Bilateral uterine artery ligation
			Bilateral internal iliac artery ligation
			Arterial embolization
			Internal iliac artery occlusion
			Common iliac artery occlusion
			Intermittent aortic occlusion
			Hysterectomy
		Bleeding disorders
			Idiopathic thrombocytopenia purpura (ITP)
			von Willebrand’s disease
			Hemophilia
			Secondary postpartum hemorrhage
		Conclusion
		Key points
		References
	Chapter 38 Septic Shock
		Introduction
		Screening tools for sepsis and septic shock
		Pathophysiology of septic shock
		Clinical presentation of septic shock
		Predisposing factors in obstetrics
		Pregnancy and septic shock
		Diagnosis of septic shock in pregnancy
		Treatment of septic shock
			Resuscitation
			Volume expansion
			Vasoactive drug therapy
			Oxygenation
			Acute respiratory distress syndrome
			Antimicrobial therapy
			Surgical therapy
			Coagulation cascade
			Renal function
			Gastrointestinal tract and nutrition
		Other supportive therapies
			Blood products
			Glucose control
			Bicarbonate therapy
			Prophylaxis against venous thromboembolic events
			Other considerations
		Alternative treatment modalities
			Corticosteroids
			Prostaglandins
			Immunotherapy
			Manipulation of the coagulation cascade
		References
	Chapter 39 Cardiogenic Shock
		Introduction
		Pathogenesis
		Acute myocardial infarction
		Peripartum cardiomyopathy
		Mitral stenosis
		Aortic stenosis
		Arrhythmias
		Aortic dissection
		Pulmonary hypertension
		Cardiogenic shock due to right heart failure
		Summary
		References
	Chapter 40 Anaphylactic Shock in Pregnancy
		Introduction
		Nomenclature
		Epidemiology
		Pathophysiology
		Diagnosis
		Precipitants
			Antibiotics
			Intravenous iron
			Vaccines
		Treatment of anaphylaxis
		Management of the patient after the acute episode of anaphylaxis
		Conclusions
		References
	Chapter 41 Amniotic Fluid Embolism
		Introduction
		Historic considerations
		Experimental models
		Clinical presentation
			Hemodynamic alterations
			Pulmonary manifestations
			Coagulopathy
			Pathophysiology
			Clinical signs and symptoms
		Differential diagnosis of amniotic fluid embolism
		Diagnosis
		International criteria for diagnosis of amniotic fluid embolism
		Treatment
		Recurrence risks of AFE In Subsequent Pregnancies
		Conclusions
		References
Part Four Medical/Surgical Management
	Chapter 42 Pregnancy-Related Stroke
		Introduction
		Definitions
		Classification of stroke
			Incidence and chronology of PRS
		Pregnancy physiology and pathophysiology that influence stroke risk
			Hematological changes
			Cerebral blood flow
		Risk factors and conditions predisposing to PRS
		Presenting symptoms
		General evaluation, assessment, and management of stroke
			Evaluation and assessment by history and physical exam
			Structured neurologic exam
			Neuroimaging
			Laboratory evaluation
			Cardiac assessment
		General management of stroke in pregnancy
			Stabilization of the patient
			Team approach, stroke team, and specialized centers
			Fluid management and electrolyte disturbances
			Positioning of the patient
			Glycemic control
			Avoid hyperthermia
			Assessment for dysphagia
			Management of specific stroke concerns and alternations of care related to in pregnancy
		Intracranial hemorrhagic strokes
			Pathophysiology
			Management: spontaneous hemorrhage
		Ischemic stroke
			Management
			Who is a candidate for reperfusion therapy?
			Relative contraindications to IV Alteplase (r-TPA)
			Intravenous thrombolytic therapy
			Administration and monitoring
			Other treatment options
			Adult-strength aspirin
		Special pregnancy considerations
			Medications
			Neuroimaging
			Fetal considerations
			Anesthesia and surgery
			Timing and mode of delivery
		Pregnancy-related risks of stroke
			Hypertensive disorders of pregnancy – gestational hypertension, preeclampsia (with and without severe features (SF) and eclampsia)
			Cerebral venous and sinus thrombosis
			Postpartum cerebral angiopathy
		Key points for stroke care and management during pregnancy
		References
	Chapter 43 Cardiac Disease and Pregnancy
		Introduction
		Counseling the pregnant cardiac patient
		Physiologic considerations
		Congenital cardiac lesions
			Atrial septal defect
			Ventricular septal defect
			Patent ductus arteriosus
		Pulmonary hypertension and Eisenmenger syndrome
		Ebstein anomaly
		Coarctation of the aorta
		Tetralogy of Fallot
		Transposition of the great vessels
			Levo-transposition
			Dextro-transposition
		Pulmonic stenosis
		Aortic stenosis
		Functional single ventricle and Fontan procedure
		Fetal considerations
		Acquired cardiac lesions
			Pulmonic and tricuspid lesions
			Mitral stenosis
			Mitral regurgitation
			Mitral valve prolapse
			Aortic stenosis
			Aortic insufficiency
		Peripartum cardiomyopathy
		Hypertrophic cardiomyopathy
		Marfan syndrome
		Myocardial infarction
		Spontaneous coronary artery dissection
		Anticoagulation and prosthetic heart valves
		Prevention of infective endocarditis
		Maternal arrhythmias
		Pregnancy after cardiac transplantation
		References
	Chapter 44 Anesthesia Considerations for the Critically Ill Gravida with Cardiac Disease
		Introduction and epidemiology
		Cardiopulmonary changes in pregnancy
		Congenital heart disease
			Left-to-right shunts
		Acquired heart disease
			Rheumatic mitral stenosis
			Mitral regurgitation
			Aortic stenosis
			Aortic regurgitation
		Anticoagulation therapy in a parturient
		Ischemic heart disease
			Pathophysiology
		Pulmonary hypertension
			Pathophysiology
			Pharmacologic therapies
			Anesthetic considerations
		Peripartum cardiomyopathy
			Pathophysiology
			Anesthetic considerations
		Heat transplantation
			Pathophysiology
			Anesthetic considerations
		Cardiovascular surgery during pregnancy
			Cardiopulmonary bypass in pregnancy
		Summary
		References
	Chapter 45 Thromboembolic Disease
		Incidence and risk factors
		Normal hemostasis
			Changes in hemostasis in pregnancy
		Thrombophilias
			Deep venous thrombosis
			Diagnostic studies
		Pulmonary embolus
			Clinical diagnosis
			Ventilation–perfusion lung scan
			Computerized tomography pulmonary angiogram
			Anticoagulant therapy
		Antepartum management
		Intrapartum management
		Postpartum management
		Prophylaxis of thromboembolism
			Inferior vena cava filter placement
			Thrombolytic therapy
			Surgical intervention
		References
	Chapter 46 Pulmonary Hypertension in Pregnancy
		Introduction
		Pulmonary hypertension – definition and classification
		WHO clinical classification groups of pulmonary hypertension
			WHO Group 1
			WHO Group 2
			WHO Group 3
			WHO Group 4
			WHO Group 5
			Epidemiology of pulmonary hypertension
			Epidemiology of pulmonary hypertension in pregnancy
		Clinical features of pulmonary hypertension
		Diagnosis of pulmonary hypertension in pregnancy
			Diagnosis of CTEPH
		Cardiopulmonary changes during pregnancy, labor, and postpartum
			Management of PAH
		Fluid management
			PAH-specific therapy
			Hemodynamic monitoring
			Manner of delivery
			Selection of anesthesia
			Postpartum care
		CTEPH
			Pregnancy and CTEPH
			Management of CTEPH
		Termination
		Summary
		References
		Appendix 46.1: Management of pulmonary hypertension during pregnancy
	Chapter 47 Sickle Cell Disease and Pregnancy
		Introduction
		Epidemiology
		Pathophysiology
		Clinical features
		Maternal and fetal outcomes in SCD
		Preconception considerations
			Genetic screening and counseling
			Assessment of SCD status preconception
		Antepartum care
			Antenatal visits and laboratory testing
			Medications
			Red blood cell transfusion therapy
		Complications
			Acute pain crisis
		Acute chest syndrome
		Stroke
			Venous thromboembolism
			Delayed hemolytic transfusion reactions and hyperhemolysis
			Splenic sequestration
			Aplastic crisis
		Delivery
		Postpartum care
		Infant care
		Contraception
		Conclusion
		References
	Chapter 48 Thrombotic Thrombocytopenic Purpura, Hemolytic–Uremic Syndrome, and HELLP
		Thrombotic thrombocytopenic purpura (TTP)
		Clinical features
		Laboratory findings
		Pathophysiology of TTP
			von Willebrand factor and ADAMTS13
			Familial TTP
			Acquired TTP
		Treatment of TTP
		Investigational treatments
		TTP during pregnancy
		Differential diagnosis
		Hemolytic–uremic syndrome
			Clinical features, laboratory findings, causes, and pathophysiology
			Treatment
			Pregnancy and HUS
		HELLP syndrome
			Clinical features
			Laboratory features
			Causes and pathogenesis
			Treatment
			Differential diagnosis
		Key points
			Thrombotic thrombocytopenic purpura
			Hemolytic–uremic syndrome
			HELLP
		References
	Chapter 49 Complications of Preeclampsia
		Introduction
		Etiology of preeclampsia
		Clinical definitions and diagnosis of preeclampsia
		General management principles for preeclampsia
			Intravenous fluid therapy in preeclampsia
			Seizure prophylaxis and management of eclampsia
			Antihypertensive therapy for preeclampsia with severe features
			Severe hypertension
			Analgesia and anesthesia for preeclampsia
			Hemodynamic monitoring for preeclampsia
		Cardiopulmonary complications of preeclampsia
			Pulmonary edema
			Hypertensive cardiomyopathy
			Ventricular arrhythmias
		Renal complications with preeclampsia
			Acute renal failure
			Oliguria
		HELLP syndrome
		Liver and gastrointestinal complications of preeclampsia
			Subcapsular liver hematoma and liver rupture
			Pancreatitis
		Neurologic complications with preeclampsia
			Cerebral hemorrhage
			Cerebral edema
			Posterior reversible encephalopathy syndrome
			Temporary blindness
			Eclampsia
		Uteroplacental–fetal complications of preeclampsia
			Preeclampsia prevention
			Early screening for preeclampsia
		Conclusions
		References
	Chapter 50 Systemic Lupus Erythematosus and Antiphospholipid Syndrome
		Introduction
		Systemic lupus erythematosus in pregnancy
			Background
			SLE exacerbation (flare) during pregnancy
		Obstetric complications in women with SLE
		Neonatal lupus erythematosus
		Diagnosis of SLE and detection of SLE exacerbation (flare)
		Medications used for SLE during pregnancy
			Glucocorticoids
			Hydroxychloroquine
			Immunosuppressants
			Nonsteroidal anti-inflammatory drug (NSAID) preparations
			Novel therapies (biologic agents)
		Treatment of SLE flare during pregnancy
		Breastfeeding
		Antiphospholipid syndrome in pregnancy
			The pathogenesis of antiphospholipid syndrome
			Clinical features of APS during pregnancy
			Treatment of antiphospholipid syndrome during pregnancy
			Postpartum and catastrophic antiphospholipid syndrome
		References
	Chapter 51 Trauma in Pregnancy
		Introduction
		Maternal physiologic adaptations applicable to trauma during pregnancy
		Management of trauma
			Prehospital care of the pregnant trauma patient
			Primary survey
			Investigations
			Secondary survey and treatment
			Fetal evaluation
		The fetal patient
			Volume resuscitation in pregnancy
			Resuscitative hysterotomy and aortal occlusion
		Manifestations of trauma during pregnancy
			Blunt abdominal trauma
			Penetrating abdominal trauma
			Thoracic trauma
			Traumatic brain injury
			Traumatic orthopedic injury
			Spinal trauma in pregnancy
		Conclusion
		References
	Chapter 52 Thermal and Electrical Injury
		Introduction
		Classification
			Thermal burns
			Chemical burns
			Electrical burns
		Maternal concerns
			Cardiovascular system
			Pulmonary system
			Integumentary system
		Management strategies
			Resuscitation period
			Postresuscitation period
			Inflammation–infection period
			Rehabilitation
		Maternal complications
			Acute renal failure
			Sepsis and ARDS
			Fractures
			Mortality
		Fetal complications
			Preterm labor
			Fetal monitoring
			Pregnancy loss
			Fetal distress and stillbirths
		Conclusions
		Key points
		References
	Chapter 53 Overdose, Poisoning, and Envenomation during Pregnancy
		Definitions
		Scope of the problem
			Substance-use disorder
			Pregnancy and medications
			Toxic exposures during pregnancy
		Toxicologic considerations in pregnancy
		Evaluation of the poisoned pregnant patient
			Initial evaluation
			Altered mental status
			Secondary evaluation
		Toxic identification
		Decontamination procedures
			Skin
			Gastrointestinal [29,30,31,40]
		Acetaminophen
			Toxicology
			Metabolism
			Serum half-life
			Lethal dosage
			Maternal considerations
			Symptoms
			Signs
			Diagnostic tests
			Short-term problems
			Long-term problems
			Fetal and neonatal considerations
			Disposition considerations
			Follow-up
		Amphetamines
			Toxicology
			Metabolism
			Lethal dose
			Maternal considerations
			Symptoms
			Signs
			Diagnostic tests
			Short-term problems
			Long-term problems
			Fetal considerations
			Management considerations [70–75]
			Discharge considerations
			Follow-up
		Antidepressants
			Toxicology
			Maternal considerations
			Fetal considerations
			Management considerations [87–91]
			Discharge considerations
			Follow-up
		Aspirin
			Toxicology
			Metabolism
			Serum half-life
			Lethal dosage
			Maternal considerations
			Fetal considerations
			Management considerations [92–94,96–100]
			Disposition considerations
			Follow-up
		Barbiturates
			Toxicology
			Maternal considerations
			Symptoms
			Signs
			Diagnostic tests
			Short-term problems
			Long-term problems
			Fetal considerations [103,104]
			Management considerations [108–111]
			Discharge considerations
			Follow-up
		Benzodiazepines
			Toxicology
			Maternal considerations
			Fetal considerations
			Management considerations [80,115,116]
			Discharge considerations
			Follow-up
		Carbon monoxide
			Toxicology
			Maternal considerations
			Fetal considerations
			Management considerations
			Discharge considerations
			Follow-up
		Cocaine [133–135,139–156]
			Toxicology
			Maternal considerations
			Fetal considerations
			Management considerations
		Ethanol [157–175]
			Toxicology
			Maternal considerations
			Fetal considerations
			Management considerations
			Discharge considerations
			Follow-up
		Iron* [176–183]
			Toxicology
			Maternal considerations
			Fetal considerations
			Management considerations
			Discharge considerations
			Follow-up
		Organophosphates (and carbamates) [184–213]
			Toxicology
			Maternal considerations
			Fetal considerations
			Management considerations
			Discharge considerations
			Follow-up
		Envenomations during pregnancy [214–262]
			Snakebites
			Scorpions
		Maternal critical illness and the opioid epidemic
		Summary
		References
	Chapter 54 The Organ Transplant Patient in the Obstetric Critical Care Setting
		Background
		Prepregnancy evaluation
		Prenatal care
		Immunosuppression during pregnancy
			Corticosteroids
			Azathioprine
			Calcineurin inhibitors
			Mammalian target of rapamycin inhibitors
			Mycophenolic acid compounds
		Renal transplant
		Pancreas or pancreas/kidney transplant
		Liver transplantation
		Heart transplant
		Lung transplant
		Bone marrow transplant
		Uterine transplant
		Special circumstances
			Labor and delivery
			Obstetric emergencies
			Immunization
		References
	Chapter 55 Fetal Surgery Procedures and Associated Maternal Complications
		Introduction
		Open fetal surgery
		Closed surgical therapies
		Maternal complications
			Hypoxemia with increased oxygen requirements
			Ileus
			Deep venous thrombosis and pulmonary embolism
			Mirror syndrome
		Summary
		References
	Chapter 56 Cancer in the Pregnant Patient
		Introduction
		Surgical principles during pregnancy
		Cervical dysplasia and cancer
			Intraepithelial neoplasia
			Cervical carcinoma
		Management of adnexal masses occurring in pregnancy
		Ovarian cancer
		Other gynecologic malignancies in pregnancy
		Non-gynecological cancers in pregnancy
			Breast
			Melanoma
			Other non-gynecological cancers
		Conclusion
		Key points
		References
	Chapter 57 Mass Casualties and the Obstetrical Patient
		Domestic events
		International events
		References
	Chapter 58 Biological, Chemical, and Radiological Exposures in Pregnancy
		Introduction
		Background
			Biological agents
			Toxins or chemicals
			Radiation
		Summary
		References
Part Five Ethical and Legal Considerations
	Chapter 59 Ethics in the Obstetric Critical Care Setting
		Introduction
		Ethical principles
		Informed consent
		Competency
		Status of the fetus
		Practical applications of ethical principles to high-risk obstetrics
			Maternal–fetal conflict
			Review of prominent court cases
			Problems with emphasizing maternal autonomy viewpoint
			Preventable ethics
			Mentally incapacitated patient
			Issues regarding brain death: background
			Ethics of case reports
			COVID-19 pandemic: ethical considerations
			Suggestions for writing condolence letters
		Conclusion
		References
	Chapter 60 Medical–Legal Considerations in Critical Care Obstetrics
		Negligence and causation
		Foreseeability of harm
			Notice
		The standard of care for the specialist and nonspecialist
		The duty to refer the patient to a specialist [12]
		Standard of care for nurses [13]
		Critical conduct intervals [2]
		Informed consent [16]
		The prevailing standards for patient informed consent
		What must be disclosed?
		Informed consent is not necessary
			The emergency exception [29]
			Patient incompetence [28]
			Waiver [30]
			Therapeutic privilege or affirmative defense: emotional state of patient [16]
		Informed refusal [34,35]
		General guidelines for informed consent
		The duty to warn [36]
			Limiting one’s liability
		Hypothetical cases
			Hypothetical case #1
			Hypothetical case #2
			Hypothetical case #3
			Hypothetical case #4
			Hypothetical case #5
		Discussion
			Hypothetical case #6
		References
Index
EULA