Principles and Practice of Maternal Critical Care

Foreword
Foreword
Preface
Preface
Preface
Contents
Contributors
Part I: Epidemiology
	1: Maternal Deaths in Developed Countries: Epidemiology and Preventable Causes
		1.1	 Introduction
		1.2	 Epidemiology of Maternal Mortality
			1.2.1	 Incidence and Trends of Maternal Mortality
			1.2.2	 Risk Factors for Maternal Deaths
		1.3	 Leading Causes of Preventable Maternal Deaths
			1.3.1	 Cardiovascular Disease and Cardiomyopathy
			1.3.2	 Other Medical Non-cardiovascular Disease
			1.3.3	 Infection and Sepsis
			1.3.4	 Obstetrical Hemorrhage
			1.3.5	 Thrombotic Pulmonary Embolism
			1.3.6	 Hypertensive Disorders of Pregnancy and Cerebrovascular Accidents
			1.3.7	 Amniotic Fluid Embolism
			1.3.8	 Anesthesia
		1.4	 Conclusions
		References
	2: Identifying the Critically Ill Parturient
		2.1	 The Modern Parturient: A Changing Demographic
		2.2	 Maternal Hemodynamic Screening Tools: Balancing Sensitivity and Specificity
		2.3	 Predicting Adverse Outcomes in Infection
		2.4	 Beyond Infection
		2.5	 The Identification and Management of High-Risk Pregnant and Postpartum Women
		2.6	 Accounting for Comorbidities in Screening for the High-Risk Parturient
		2.7	 Antenatal and Early Pregnancy Screening
		2.8	 Maternal Screening Tools: A Valuable Tool Looking Forward
		References
	3: Maternal Near Miss
		3.1	 Maternal Mortality and Maternal Morbidity
		3.2	 The Advantages of Studying Maternal Near Miss Events
		3.3	 Definition and Terminology
		3.4	 Identification of Maternal Near Miss
		3.5	 Development of the Near Miss Concept: The WHO Approach
		3.6	 Causes and Incidence of Near Miss Events
		3.7	 Risk Factors
		3.8	 Healthcare Organizational Factors Contributing to Maternal Mortality
		3.9	 Conclusions
		References
	4: The Epidemiology of Maternal Intensive Care Unit Admissions
		4.1	 Maternal Mortality
		4.2	 Severe Maternal Morbidity and Maternal Near Miss Definitions
		4.3	 Prevalence of Critical Maternal Events
		4.4	 Maternal Intensive Care Admission
			4.4.1	 General Considerations
		4.5	 Levels, Patterns, and Trends
		4.6	 Key Characteristics of Women Admitted to ICUs During Pregnancy and/or Peripartum
		4.7	 Causes of ICU Admission
		4.8	 Severity of Cases Admitted to ICU
		4.9	 Surveillance and Future Research Considerations
		References
Part II: The Coagulation System
	5: Physiology and Pathology of Coagulation in Pregnancy
		5.1	 Normal Physiology of Coagulation in Pregnancy
		5.2	 Hypercoagulable Conditions and Pregnancy
			5.2.1	 Antiphospholipid Syndrome
			5.2.2	 Protein C Deficiency
			5.2.3	 Protein S Deficiency
			5.2.4	 Factor V Leiden Mutation
			5.2.5	 Antithrombin III Deficiency
		5.3	 Acquired Hypocoagulable Conditions and Pregnancy
			5.3.1	 Disseminated Intravascular Coagulation
			5.3.2	 Therapeutic Anticoagulation
			5.3.3	 Drug-Related Coagulopathy
		5.4	 Non-acquired Hypocoagulable Conditions and Pregnancy
			5.4.1	 von Willebrand’s Disease (vWD)
			5.4.2	 Thrombotic Thrombocytopenic Purpura
			5.4.3	 Autoimmune Thrombocytopenic Purpura (ATP)
		5.5	 Blood Management Strategies in Pregnant Women
		5.6	 Conclusion
		References
	6: Peripartum Hemorrhage
		6.1	 Introduction
		6.2	 Diagnostic Considerations for Obstetric Hemorrhage
		6.3	 Management Considerations for Obstetric Hemorrhage
			6.3.1	 Antepartum Hemorrhage (APH)
			6.3.2	 Postpartum Hemorrhage (PPH)
		6.4	 Definitions
		6.5	 Prevention
		6.6	 Identification
		6.7	 Management of PPH
		6.8	 Pharmacological Management
			6.8.1	 Uterotonics
		6.9	 Tranexamic Acid (TXA)
		6.10	 Recombinant Factor VIIa (rFVIIa)
		6.11	 Blood Component Therapy
		6.12	 Pitfalls
		6.13	 Transfusion-Related Lung Injury and Transfusion-Associated Circulatory Overload
		6.14	 Further Hemorrhage and Venous Thromboembolism
		6.15	 Other Complications of Global Hypoperfusion/Post-circulatory Arrest
		References
	7: Fluid Management
		7.1	 Normal Maternal Physiology
			7.1.1	 Gain in Weight, Total Water and Plasma Volume During Pregnancy
			7.1.2	 The Urogenital and Renin-Angiotensin System and Plasma Osmolality During Pregnancy
			7.1.3	 Maternal Haemodynamic and Uteroplacental Blood Flow During Pregnancy
		7.2	 Fluid Management
			7.2.1	 State-of-the- Art Care Regarding Fluid Therapy in Critically Ill Adult Patients in General
			7.2.2	 Fluid Management During Massive Transfusion
			7.2.3	 Fluid Management During Pre-Eclampsia/Eclampsia
			7.2.4	 Fluid Management During Severe Sepsis
			7.2.5	 Fluid Management and Potential Impact on the Foetus
		7.3	 Summary
		References
	8: Management and Prevention of Thrombotic and Embolic Phenomena During Pregnancy: Deep Vein Thrombosis, Pulmonary Embolism, and Amniotic Fluid Embolism
		8.1	 Introduction
		8.2	 Venous Thromboembolism
			8.2.1	 Physiologic Changes Associated with Pregnancy: Hypercoagulable State
			8.2.2	 Prevention
		8.3	 Thromboembolic Events
			8.3.1	 Clinical Presentation
			8.3.2	 Diagnosis
		8.4	 Pulmonary Embolism
			8.4.1	 Clinical Presentation
			8.4.2	 Anticoagulation Management of Thromboembolic Events
			8.4.3	 Management of Massive Pulmonary Embolism
		8.5	 Amniotic Fluid Embolism
			8.5.1	 Clinical Presentation and Diagnosis
			8.5.2	 Management of Amniotic Fluid Embolism
			8.5.3	 Prevention
		8.6	 Conclusion
		References
Part III: The Cardiovascular System
	9: Cardiovascular Changes in Pregnancy
		9.1	 Introduction
		9.2	 Physiologic Changes During Pregnancy
			9.2.1	 Blood Volume
			9.2.2	 Blood Pressure
			9.2.3	 Heart Rate
			9.2.4	 Stroke Volume
			9.2.5	 Cardiac Output
			9.2.6	 Systematic Vascular Resistance
			9.2.7	 Cardiac Structural Changes
			9.2.8	 Aortocaval Compression
		9.3	 Physiologic Changes During Labor and Delivery
		9.4	 Physiologic Changes Postpartum
		9.5	 Brain Natriuretic Peptide
		9.6	 Conclusion
		References
	10: Preexisting Heart Disease in Pregnancy
		10.1	 Epidemiology of Preexisting Heart Disease
		10.2	 Infertility and Complicated Valvular Lesions
		10.3	 Risk Assessment for Heart Disease
		10.4	 Management Strategies in Specific Lesions
			10.4.1	 WHO III Congenital Heart Diseases
			10.4.2	 Management of Pregnancy with Systemic Right Ventricle
			10.4.3	 Cyanotic Heart Disease Without Pulmonary Hypertension
			10.4.4	 Management of Pregnancy with Cyanotic Heart Disease Without Pulmonary Hypertension
			10.4.5	 Single-Ventricle Physiology/Fontan Palliation
			10.4.6	 Management of Pregnancy with Single-Ventricle Physiology/Fontan Palliation
			10.4.7	 Valvular Heart Disease in Pregnancy
				10.4.7.1	 Rheumatic Heart Disease
				10.4.7.2	 Simple Valvular Lesions
				10.4.7.3	 Mitral Stenosis
				10.4.7.4	 Aortic Stenosis
			10.4.8	 Mitral and Aortic Regurgitation
		10.5	 Marfan Syndrome
		10.6	 Antiarrhythmic Treatment in Pregnancy
		10.7	 Management of Heart Failure in Pregnant Women with Preexisting Heart Disease
		10.8	 Prosthetic Valves
			10.8.1	 Anticoagulation
			10.8.2	 Anticoagulation Protocols
			10.8.3	 Valve Thrombosis (“Stuck Valve”)
		10.9	 Conclusion
		References
	11: Maternal Cardiomyopathy and Critical Care Medicine
		11.1	 Introduction
		11.2	 Cardiomyopathy
			11.2.1	 Definition
			11.2.2	 Subtypes
		11.3	 Diagnosis
			11.3.1	 Signs and Symptoms
			11.3.2	 Imaging and Procedural Diagnostic Modalities
			11.3.3	 Laboratory Investigations
		11.4	 Pharmacologic Considerations
			11.4.1	 Intravascular Volume Reduction
			11.4.2	 Afterload-Reducing Medications
			11.4.3	 Vasopressors and Inotropes
			11.4.4	 Anti-arrhythmic Agents
			11.4.5	 Targeted Therapy for Cardiomyopathy
			11.4.6	 Medications for Prevention of Thromboembolism
		11.5	 Management of Decompensated Heart Failure
		11.6	 Management of Delivery
		11.7	 Conclusion
		References
	12: Pulmonary Hypertension
		12.1	 Overview of the Disease
		12.2	 Pulmonary Arterial Hypertension (WHO Classification Group 1)
		12.3	 Pulmonary Hypertension (WHO Classification Groups 2–5)
		12.4	 Failure of the Physiologic Adaptation to Pregnancy in Women with Pulmonary Hypertension
		12.5	 Clinical Presentation of PH During Pregnancy
		12.6	 Diagnosis and Assessment
			12.6.1	 Transthoracic Echocardiography
			12.6.2	 Right Heart Catheterization
		12.7	 Management of PH During Pregnancy
		12.8	 Pharmacological Therapies for Pulmonary Vasodilation
		12.9	 Management of Right Ventricular Failure in Women with PH
		12.10	 Extracorporeal Membrane Oxygenator
		12.11	 Mode of Delivery
		12.12	 Management of Delivery
			12.12.1	 Hemodynamic Monitoring
			12.12.2	 Hematologic Monitoring
			12.12.3	 Anesthesia Considerations
		12.13	 Termination of Pregnancy
		12.14	 Postpartum Considerations
			12.14.1	 Uterotonic Medications
				12.14.1.1	 Oxytocin
				12.14.1.2	 Second-Line Uterotonics (Prostaglandins, Ergot Alkaloid Derivatives)
			12.14.2	 Postpartum Monitoring
		12.15	 Long-Term Considerations
			12.15.1	 Maternal Outcomes
			12.15.2	 Fetal and Neonatal Outcomes
		12.16	 Conclusion
		12.17	 Addendum
		References
	13: Point-of-Care Ultrasound in the Critically Ill Pregnant Woman
		13.1	 Definition and Applications
		13.2	 Point-of-Care Transthoracic Echocardiography During Pregnancy
		13.3	 Cardiovascular POCUS During Pregnancy
		13.4	 Maternal Cardiac Arrest
		13.5	 Point-of-Care Abdominal Ultrasonography During Pregnancy
			13.5.1	 POCUS Assessment of Pregnant Women with Non-pregnancy-Related Conditions
		13.6	 POCUS to Identify Obstetrical Complications
			13.6.1	 Emergency Screening of Women of Childbearing Age (Possible or Confirmed Pregnancies) for Severe Acute Causes of Hemodynamic Compromise
			13.6.2	 Use of POCUS to Screen Pregnant Woman for Obstetric Diseases that Cause Gradual Maternal Deterioration
		13.7	 Pregnant Women: The HELLP Syndrome
		13.8	 Conclusion
		References
	14: Extracorporeal Membrane Oxygenation During Pregnancy and the Peripartum Period
		14.1	 Introduction
		14.2	 Literature Review
		14.3	 Technical Aspects of ECMO Management
			14.3.1	 ECMO Circuit
			14.3.2	 Pump
			14.3.3	 Oxygenator or Membrane Lung
			14.3.4	 Cannulation
		14.4	 Which Configuration for Which Patients?
		14.5	 ECMO Indications and Contraindications
			14.5.1	 Contraindications
			14.5.2	 Indications
				14.5.2.1	 VV ECMO for ARDS
				14.5.2.2	 VA ECMO for Cardiogenic Failure
				14.5.2.3	 VA ECMO for Refractory Cardiac Arrest
		14.6	 Referral ECMO Centers and Mobile ECMO Teams
		14.7	 ECMO Management
			14.7.1	 Anticoagulation
			14.7.2	 ECMO Settings
				14.7.2.1	 VV ECMO
				14.7.2.2	 VA ECMO
		14.8	 Respiratory Management
			14.8.1	 Ventilator Setting for ARDS
			14.8.2	 Hypoxemia During VV ECMO
			14.8.3	 Hypoxemia During VA ECMO
		14.9	 Weaning from ECMO
		14.10	 Delivery and Bleeding Complications
			14.10.1	 Bleeding Complications
			14.10.2	 Delivery
		References
Part IV: The Immune System
	15: Physiological Changes of the Immune System During Pregnancy
		15.1	 Physiological Changes in the Immune System in Pregnancy
		15.2	 Clinical Implications of the Altered Immune Response in Pregnancy
			15.2.1	 Response to Infection
			15.2.2	 Autoimmune Disease
				15.2.2.1	 SLE and Pregnancy
		15.3	 Antibodies and the Placental Barrier
			15.3.1	 Neonatal “Passive” Immunity to Infection
			15.3.2	 Direct Effects of Autoantibodies on the Fetus/Neonate
			15.3.3	 Implications for Use of “Biologic” Drugs
		15.4	 Conclusion
		References
	16: Hypertension, Preeclampsia, and Eclampsia
		16.1	 Introduction
		16.2	 Epidemiology
		16.3	 Maternal Mortality
		16.4	 Maternal Morbidity
		16.5	 Definitions of Hypertensive Disorders in Pregnancy
		16.6	 Risk Factors
		16.7	 Pathogenesis
		16.8	 Clinical Features
		16.9	 Clinical Management
		16.10	 Monitoring
		16.11	 Eclampsia Prophylaxis
		16.12	 Blood Pressure Management
		16.13	 Oxygenation
		16.14	 Fluid Administration
		16.15	 Delivery of the Fetus
		16.16	 Conclusion
		References
	17: Viral Infections in Obstetric Critical Care
		17.1	 Introduction
		17.2	 Influenza and Other Respiratory Viruses
		17.3	 Neurotropic Viruses
		17.4	 Hepatitis and Herpes Viruses
		17.5	 Arboviral Infections
		17.6	 Conclusion
		References
	18: Infection during Early Pregnancy and Septic Abortions
		18.1	 Introduction
		18.2	 Immune Response in Pregnancy
		18.3	 The Use of Modified Scoring Systems for Sepsis and Septic Shock in Pregnancy
		18.4	 Sexually Transmitted Diseases (STD)
			18.4.1	 Gonorrhoea
			18.4.2	 Chlamydia
			18.4.3	 Syphilis
		18.5	 Genital Tract Infections
		18.6	 Vaginitis
		18.7	 Septic Abortions
		18.8	 Investigation of Pregnant Women with Suspected Sepsis
		18.9	 Summary
		Flow Diagram
		References
	19: Infections in Late Pregnancy and Puerperium
		19.1	 Introduction
		19.2	 The Complexity of Defining Maternal Sepsis
		19.3	 Maternal Sepsis
			19.3.1	 Risk Factors
				19.3.1.1	 Categories of Infection Occurring during Pregnancy and the Peripartum Period
			19.3.2	 Pregnancy-Specific Infections
				19.3.2.1	 Chorioamnionitis (CA)
				19.3.2.2	 Toxic Shock Syndrome
				19.3.2.3	 Surgical Site Infection and Necrotizing Soft Tissue Infections
			19.3.3	 Infections Exacerbated during Pregnancy
				19.3.3.1	 Urinary Tract Infections
				19.3.3.2	 Listeria Monocytogenes
				19.3.3.3	 Toxoplasmosis
			19.3.4	 Malaria
			19.3.5	 Fetal Considerations in Maternal Infections
		19.4	 Conclusions
		References
Part V: The Respiratory System
	20: Physiologic Changes in the Airway and the Respiratory System Affecting Management in Pregnancy
		20.1	 Introduction
		20.2	 Upper Airway Anatomy during Pregnancy
			20.2.1	 The Nasal Cavities
			20.2.2	 The Larynx
			20.2.3	 The Pharynx
		20.3	 The Mallampati Score in the Peripartum Period
			20.3.1	 The Mallampati Score in Normal Labor and Delivery
			20.3.2	 The Mallampati Score with Hypertensive Disease of Pregnancy
			20.3.3	 Correlating Mallampati Score and Actual Intubation Difficulty during Cesarean Delivery
		20.4	 Respiratory Anatomical and Physiological Changes during Pregnancy
			20.4.1	 Chest Wall Configuration
			20.4.2	 Static Lung Function during Pregnancy
			20.4.3	 Dynamic Respiratory Parameters during Pregnancy
			20.4.4	 Peak Expiratory Flow, Forced Expiratory Volume, and Forced Vital Capacity
			20.4.5	 Pulmonary Function Tests in Women with Asthma
			20.4.6	 Pulmonary Function Tests in Women with Preeclampsia
			20.4.7	 Pulmonary Function Tests in Women with Multiple Gestation (Twins)
		20.5	 Diffusing Capacity
		20.6	 Ventilation and Gas Exchange
			20.6.1	 Oxygen Consumption and Carbon Dioxide Production
			20.6.2	 The Partial Pressure of Oxygen in Arterial Blood (PaO2)
			20.6.3	 Partial Pressure of Arterial Carbon Dioxide (PaCO2)
		20.7	 Conclusions
		References
	21: Airway Management during Pregnancy and the Peripartum Period
		21.1	 Incidence of Difficult Airway and Failed Intubation in Obstetrics
		21.2	 Maternal Airway Challenges
			21.2.1	 Maternal Anatomic and Physiologic Factors
				21.2.1.1	 Airway Edema
				21.2.1.2	 Respiratory, Metabolic Changes, and Denitrogenation
				21.2.1.3	 Obesity and Weight Gain
				21.2.1.4	 Breast Enlargement
				21.2.1.5	 Gastroesophageal Changes and Aspiration Risk
			21.2.2	 Environmental/Situational and Anesthetic Factors
		21.3	 Safe General Anesthesia for Healthy Pregnant Patients
			21.3.1	 Algorithms for Management of Difficult Intubation
		21.4	 Airway Management of the Critically ill Pregnant Patient
			21.4.1	 Hazards of ICU Airway Management
			21.4.2	 Equipment and Readiness
				21.4.2.1	 Drugs
			21.4.3	 Airway Assessment
			21.4.4	 Rapid Sequence Induction and Intubation (RSI)
			21.4.5	 Optimizing Oxygenation Preintubation
			21.4.6	 Videolaryngoscopy
			21.4.7	 Confirmation of Tracheal Intubation
			21.4.8	 Awake Intubation
			21.4.9	 Failed Intubation
			21.4.10	 Emergency Invasive Airway Access
		21.5	 Conclusion
		References
	22: Introduction to Lung Ultrasound Techniques and Diagnosis in the Seriously Ill Pregnant Woman
		22.1	 Introduction
		22.2	 Physiological Changes to Respiratory System during Pregnancy
		22.3	 Role of Lung Ultrasound in Pregnancy
		22.4	 Concepts and Techniques Used in Lung Ultrasound
			22.4.1	 How Lung Ultrasound Works
			22.4.2	 Basic Principles of Lung Ultrasound
			22.4.3	 Type of Probe for Lung Ultrasound
			22.4.4	 Positioning for Lung Ultrasound
			22.4.5	 Methods to Study Lung Ultrasound
		22.5	 Selective List of Signs and Artifacts Used in Lung Ultrasonography
		22.6	 Critical Respiratory Illness during Pregnancy
		22.7	 Common Protocols Used in Lung Ultrasonography
			22.7.1	 BLUE (Bedside Lung Ultrasound in Emergency) Protocol
			22.7.2	 FALLS Protocol
		References
	23: Management of Ventilation
		23.1	 Introduction
		23.2	 Causes of Acute Maternal Respiratory Failure
			23.2.1	 Cardiogenic Pulmonary Edema
			23.2.2	 Acute Respiratory Distress Syndrome (ARDS)
			23.2.3	 Other Conditions
		23.3	 Ventilatory Targets (Table 23.2)
			23.3.1	 Oxygen
			23.3.2	 Carbon Dioxide (PaCO2)
		23.4	 Ventilation Management
			23.4.1	 Noninvasive Ventilation
			23.4.2	 Invasive Mechanical Ventilation
		23.5	 Other Aspects of Management
			23.5.1	 Role of Delivery
			23.5.2	 Imaging
			23.5.3	 Drug Therapy
		23.6	 Outcome after Mechanical Ventilation during Pregnancy
		References
Part VI: The Neuromuscular System
	24: Brain Function Monitoring of Critically Ill Pregnant Patients
		24.1	 Physiologic Changes in Brain Function during Pregnancy
			24.1.1	 Cerebral Blood Flow (CBF)
		24.2	 The Neuroprotective Role of Estrogen and Progesterone
		24.3	 Brain Function Monitoring in the Intensive Care Unit (ICU)
		24.4	 Brain Function Monitoring in Critically Ill Pregnant Patients
		24.5	 Brain Monitoring in Specific Pathologic States during Pregnancy (Table 24.1)
			24.5.1	 Preeclampsia/Eclampsia
			24.5.2	 Intracranial Hemorrhage
			24.5.3	 Intracranial Tumors
			24.5.4	 Other Cerebral Disorders in Pregnancy
		24.6	 Summary
		References
	25: Maternal Stroke
		25.1	 Introduction
		25.2	 Definitions, Epidemiology, and Risk Factors
			25.2.1	 Epidemiology
			25.2.2	 Risk Factors
		25.3	 Anatomy, Signs, and Symptoms of Stroke
		25.4	 Management of Acute Stroke
			25.4.1	 Acute Ischemic Stroke
			25.4.2	 Intracerebral Hemorrhage (ICH)
			25.4.3	 Subarachnoid Hemorrhage
			25.4.4	 Cerebral Venous Sinus Thrombosis
			25.4.5	 Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome
			25.4.6	 Blood Pressure Management after Acute Stroke
				25.4.6.1	 Early Poststroke Risks and Care
			25.4.7	 Delivery after Antepartum Stroke
		25.5	 Long-Term Effects of Pregnancy-Associated Stroke
			25.5.1	 Recovering from Stroke
			25.5.2	 Long-Term Prognosis
		References
	26: Neurological Crises
		26.1	 Maternal Seizures
		26.2	 Maternal Weakness
			26.2.1	 Myasthenia Gravis Crisis
		26.3	 Summary
		References
Part VII: Maternal Cardiac Arrest
	27: Maternal Resuscitation
		27.1	 Introduction
		27.2	 Physiological Changes in Pregnancy
		27.3	 Resuscitation
		27.4	 Cardiac Compressions and Defibrillation
		27.5	 Airway, Oxygenation and Ventilation
		27.6	 Circulation
		27.7	 Relieving Aortocaval Compression
		27.8	 Monitoring
		27.9	 Drugs
		27.10	 Reversible Causes
		27.11	 Perimortem Caesarean Delivery
		27.12	 Vaginal Delivery
		27.13	 When to Stop
		27.14	 Aftermath
		27.15	 Human Factors and Teamwork
		27.16	 Conclusion
		References
	28: Intensive Care Management of the Pregnant Patient after Cardiac Arrest
		28.1	 Introduction and Epidemiology
		28.2	 Pathophysiology of the Post-Cardiac Arrest Syndrome
		28.3	 Stage of Pregnancy and Change in Physiology Relevant to the ICU Physician
		28.4	 Immediate Management after Return of Spontaneous Circulation
			28.4.1	 Circulation
		28.5	 Logistics of ICU Care
		28.6	 Determining the Cause of the Arrest
		28.7	 Mechanical Ventilation
		28.8	 Targeted Temperature Management
		28.9	 Sedation
		28.10	 Blood Pressure Management
		28.11	 Fluid and Glucose Management
		28.12	 Management of Seizures
		28.13	 General Intensive Care Management
		28.14	 Extracorporeal Membrane Oxygenation (ECMO) and Mechanical Assist Devices
		28.15	 Prognostication
		28.16	 Further Care and Rehabilitation
		28.17	 Conclusions
		References
	29: The Brain-Dead Mother in Intensive Care Unit: Ethics, Physiology and Management
		29.1	 Introduction: Concepts and Controversies in Defining Death
		29.2	 Epidemiology of Maternal Brain Death
		29.3	 Brain Death Testing
		29.4	 Ethical and Legal Considerations
			29.4.1	 Beneficence
			29.4.2	 Non-Maleficence
			29.4.3	 Autonomy
			29.4.4	 Justice
		29.5	 Physiological Changes in Brain Death and Organ Support
			29.5.1	 Cardiovascular Changes and Management
			29.5.2	 Respiratory Changes and Management
			29.5.3	 Endocrine Changes and Management
			29.5.4	 Temperature Regulation
			29.5.5	 Nutrition
			29.5.6	 The Coagulation System
			29.5.7	 Infections
			29.5.8	 Fetal Monitoring, Tocolytics and Timing of Delivery
		29.6	 Potential Future Developments
		29.7	 Conclusion
		References
Part VIII: The Renal System
	30: Renal Physiology during Normal Pregnancy
		30.1	 Introduction
			30.1.1	 Anatomical Changes
			30.1.2	 Renal Haemodynamics
		30.2	 Changes in Glomerular Filtration Rate (GFR)
		30.3	 Calculating the GFR in Pregnancy
		30.4	 Tubular Function
		30.5	 Acid-Base and Electrolyte Balance
		30.6	 Conclusion
		References
	31: Renal Failure and Renal Replacement Therapy During Pregnancy and the Peripartum Period
		31.1	 Introduction
		31.2	 Acute Kidney Injury
			31.2.1	 Definition
				31.2.1.1	 Role of AKI Biomarkers
			31.2.2	 Epidemiology
			31.2.3	 Etiology of AKI
				31.2.3.1	 Common Pregnancy-Specific Causes of AKI
					Hypertensive Disorders of Pregnancy
					Volume Depletion
					Infection
					Obstruction
					Cardiovascular Collapse
				31.2.3.2	 Other Causes of AKI that May be Co-incident but Not Specific to Pregnancy
					Thrombotic Thrombocytopenic Purpura/Hemolytic-Uremic Syndrome
					Primary Renal Diseases, Including Autoimmune Disease and Vasculitis
					Drug Nephrotoxicity
			31.2.4	 Diagnostic Work-Up
			31.2.5	 Treatment
				31.2.5.1	 General Measures
				31.2.5.2	 Treatment of Specific Causes of AKI
					Control of Hypertensive Disorders of Pregnancy
					Relief of Obstruction
					Management of Amniotic Fluid Embolism
				31.2.5.3	 Renal Replacement Therapy
					Timing of RRT
					Modality of RRT
					Dose of RRT
					Anticoagulation
				31.2.5.4	 Perioperative Management of AKI
			31.2.6	 Long-Term Prognosis
			31.2.7	 End-Stage Renal Disease
			31.2.8	 Renal Transplant Recipients
				31.2.8.1	 Immune Suppression and Rejection
		References
Part IX: The Endocrine and Metabolic Systems
	32: Nutrition in Critical Illness During Pregnancy
		32.1	 Introduction
		32.2	 Metabolic Changes During Pregnancy
		32.3	 Nutritional Assessment During Normal Pregnancy
		32.4	 Nutritional Assessment in the Intensive Care Unit
		32.5	 Nutritional Concerns During Critical Illness and Pregnancy
		32.6	 Carbohydrate and Insulin Metabolism
		32.7	 Fat Metabolism
		32.8	 Proteins
		32.9	 Micronutrients
		32.10	 Feeding the Critically Ill Mother
		32.11	 Conclusions
		References
	33: Acute Fatty Liver of Pregnancy, Liver Failure, and Liver Transplantation
		33.1	 Introduction
		33.2	 Epidemiology
		33.3	 Pathogenesis
			33.3.1	 The Hibernating Bear: A Good Analogy for AFLP Pathogenesis
		33.4	 Acquired Predisposition
		33.5	 Placental Pathogenesis
		33.6	 Timing of AFLP Manifestation: Why Does AFLP Manifest in Late Pregnancy?
		33.7	 Manifestations
		33.8	 Diagnosis
		33.9	 Management of AFLP (Fig. 33.2)
		33.10	 Delivery Considerations
			33.10.1	 Intensive Care Treatment
		33.11	 Outcomes: Maternal and Fetal
		33.12	 Conclusion
		References
Part X: Surgical Dilemmas in Critically Ill Women
	34: Trauma During Pregnancy
		34.1	 Introduction
		34.2	 The Unique Physiology of Pregnancy
			34.2.1	 Additional Anatomical Considerations
		34.3	 The Epidemiology of Trauma in Pregnancy
		34.4	 Initial Management of Maternal Trauma
			34.4.1	 The Primary and Secondary Survey
			34.4.2	 Fetal Assessment
			34.4.3	 Extracorporeal Membrane Oxygenation for Maternal Salvage
			34.4.4	 Perimortem Cesarean Delivery
		34.5	 Management in the Intensive Care Unit
			34.5.1	 Complications Specific to the Injuries of Pregnant Women
			34.5.2	 Massive Transfusion
			34.5.3	 Delivery Considerations
			34.5.4	 Special Considerations in Treatment of Conventional Trauma
		34.6	 Repetitive Imaging
			34.6.1	 Predicting Maternal and Pregnancy Outcomes Following Trauma
		34.7	 Summary
		References
	35: Non-obstetric Intra-Abdominal Surgery During Pregnancy
		35.1	 Introduction
		35.2	 Pre-surgery Diagnostic Imaging
			35.2.1	 Ionizing Radiation Techniques
		35.3	 Maternal Considerations and Outcomes
			35.3.1	 Maternal Morbidity
			35.3.2	 Maternal Mortality
		35.4	 Fetal and Neonatal Outcomes
			35.4.1	 Miscarriage
			35.4.2	 Preterm Delivery
		35.5	 Anesthesia Considerations
		35.6	 Specific Intra-abdominal Surgical Conditions
			35.6.1	 Appendicitis
			35.6.2	 Recommended Surgical Approach to Appendectomy
		35.7	 Biliary Tract Disease
			35.7.1	 Recommended Surgical Approach to Cholecystectomy
		35.8	 Hernias
		35.9	 Obesity and Bariatric Surgery
		35.10	 Robotic Surgery
		35.11	 Conclusions
		References
	36: Neurosurgical Crises and Brain Surgery
		36.1	 Introduction
		36.2	 Initial Workup
		36.3	 Intensive Care Considerations
			36.3.1	 Management of Increased Intracranial Pressure (ICP)
			36.3.2	 Glucose Control
			36.3.3	 Timing of Neurosurgery Versus Delivery
		36.4	 Approach to Anesthesia for Surgery
			36.4.1	 Awake Craniotomy
			36.4.2	 General Anesthesia
		36.5	 Brain Tumors
			36.5.1	 Management of Intracranial Tumors in Pregnant Women
				36.5.1.1 Gliomas
				36.5.1.2 Meningioma
				36.5.1.3 Pituitary Adenomas
		36.6	 Cerebrovascular Disease
			36.6.1	 Arterio-venous Malformation (AVM)
			36.6.2	 Aneurysm
				36.6.2.1 Management of a Pregnant Women with an Aneurysm
			36.6.3	 Cavernous Malformation
		36.7	 Spinal Surgery
		36.8	 Conclusion
		References
	37: Maternal Critical Care in a Disaster
		37.1	 Introduction
			37.1.1	 Historical Disaster Preparedness
			37.1.2	 Why Disaster Preparedness for Pregnant and Peripartum Women Is Unique
		37.2	 Organization and Resources
			37.2.1	 Organizational Support of Disaster Readiness
			37.2.2	 Framework of an Obstetric Disaster Plan
		37.3	 Terminology
		37.4	 Tools
			37.4.1	 Hospital Stratification
			37.4.2	 Availability of a Disaster Plan
			37.4.3	 Specifics for Evacuation
			37.4.4	 Specifics for Surge
		37.5	 Disaster Training
		References
Part XI: Medications and Complications
	38: Medication Use During Pregnancy in the Intensive Care Unit
		38.1	 Introduction
		38.2	 Drugs That Control Cardiac Rhythm (Anti-arrhythmic Drugs)
		38.3	 Adrenergic Blockers
			38.3.1	 Alpha adrenergic blockers
			38.3.2	 Beta adrenergic blockers
			38.3.3	 Combined Alpha and Beta Adrenergic Blockers
		38.4	 Digoxin
		38.5	 Vasopressors and Inotropes
		38.6	 Antibiotics
			38.6.1	 Aminoglycoside Antibiotics
			38.6.2	 Cephalosporins
			38.6.3	 Fluoroquinolones
			38.6.4	 Metronidazole (Flagyl)
		38.7	 Antifungal Drugs
		38.8	 Antiviral Drugs
			38.8.1	 Antiretroviral Drugs
			38.8.2	 Other Antiviral Drugs
		38.9	 Drugs for Decreasing Intracerebral Pressure (ICP)
		38.10	 Anticonvulsant Therapy
		38.11	 Nitric Oxide
		38.12	 Peptic Ulcer Prophylaxis
		38.13	 Anti-histamines and Anti-emetics
		38.14	 Analgesics
			38.14.1 Paracetamol
			38.14.2 Dipyrone
			38.14.3 Opioids
			38.14.4 Non-steroidal Anti-inflammatory Drugs (NSAIDs) Including Aspirin
		38.15	 Anesthetic Agents
		38.16	 Conclusions
		38.17	 Appendix
			38.17.1 Pregnancy and Breastfeeding Drug Classifications
		References
	39: Management of Pain During Maternal Critical Illness
		39.1	 Introduction
			39.1.1	 Pain in the Context of Pregnancy
			39.1.2	 Physiologic Changes During Pregnancy and Their Impact on Pain Tolerance and Analgesia
				39.1.2.1	 Pulmonary Physiology and Physiopathology
				39.1.2.2	 Cardiovascular Physiology and Physiopathology
				39.1.2.3	 Gastrointestinal Physiology and Physiopathology
				39.1.2.4	 Hematological and Immune Physiology and Physiopathology
			39.1.3	 Pain Management in the Obstetric Population
		39.2	 Neuraxial Analgesia
			39.2.1	 Continuous Epidural Analgesia
				39.2.1.1	 Indications
				39.2.1.2	 Procedure and Medications
				39.2.1.3	 Side Effects and Complications
			39.2.2	 Intrathecal Morphine
				39.2.2.1	 Indication
				39.2.2.2	 Procedure and Medication
				39.2.2.3	 Side Effects and Complications
				39.2.2.4	 Absolute and Relative Contraindications for Neuraxial Procedures
		39.3	 Trunk Blocks
			39.3.1	 Indications
			39.3.2	 Procedures and Medications
				39.3.2.1	 Transversus Abdominis Plane (TAP) Block
				39.3.2.2	 Quadratus Lumborum Block (QLB)
				39.3.2.3	 Serratus Anterior Plane Block
				39.3.2.4	 Additional Trunk Blocks
			39.3.3	 Side Effects and Complications
		39.4	 Limb Plexus Blocks
			39.4.1	 Indications
			39.4.2	 Procedures and Medications
			39.4.3	 Contraindications
		39.5	 Systemic Analgesia
			39.5.1	 Stepwise Systemic Multimodal Analgesia for the Obstetric Patient
			39.5.2	 Nonsteroidal Anti-inflammatory Drugs (NSAIDs) and Acetaminophen
				39.5.2.1	 Indication
				39.5.2.2	 Contraindications
			39.5.3	 Opioids
				39.5.3.1	 Indication
				39.5.3.2	 Medication and Mode of Administration
				39.5.3.3	 Contraindication
				39.5.3.4 Side Effects and Complications
					Maternal
					Fetal/Neonatal
			39.5.4	 Ketamine
			39.5.5	 Dexmedetomidine
			39.5.6	 Gabapentinoids
		39.6	 Systemic Sedation
		39.7	 Clinical Scenarios Specific to the Obstetric Patient
			39.7.1	 The Opioid-Tolerant Obstetric Patient
			39.7.2	 Sickle Cell Crisis During Pregnancy
			39.7.3	 Blunt Thoracic Trauma in the Obstetric Patient
			39.7.4	 Acute Pancreatitis
			39.7.5	 Preeclampsia and Complications Associated with Hypertensive Disorders of Pregnancy
			39.7.6	 Fatty Liver of Pregnancy
			39.7.7	 Specific Postpartum Considerations in the Breastfeeding Patient
		39.8	 Conclusion
		References
	40: Anaphylaxis in Pregnancy
		40.1	 Introduction
		40.2	 Risk Factors
		40.3	 Causes
		40.4	 Symptoms
		40.5	 Differential Diagnosis
		40.6	 Diagnosis
		40.7	 Management
			40.7.1	 Caveats to Application of Anaphylaxis Treatment Protocols During Late Pregnancy and in Labor
		40.8	 Summary
		References
Appendix