Principles and Practice of Maternal Critical Care

593 Pages·2020·14.6 MB·English

by  Sharon Einav, Carolyn F. Weiniger, Ruth Landau

Principles and
Practice of Maternal
Critical Care
Sharon Einav
Carolyn F. Weiniger
Ruth Landau
Editors
123
Principles and Practice of Maternal
Critical Care
Sharon Einav • Carolyn F. Weiniger
Ruth Landau
Editors
Principles and Practice
of Maternal Critical Care
Editors
Sharon Einav Carolyn F. Weiniger
Intensive Care Unit Division of Anesthesia
Shaare Zedek Medical Center Critical Care and Pain
and Hebrew University Faculty Tel Aviv Sourasky Medical Center
of Medicine Tel Aviv
Jerusalem Israel
Israel
Ruth Landau
Department of Anesthesiology
Columbia University Medical Center
New York, NY
USA
ISBN 978-3-030-43476-2 ISBN 978-3-030-43477-9 (eBook)
https://doi.org/10.1007/978-3-030-43477-9
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Foreword
I begin this foreword with a personal story. For 26 years of residency training
and academic clinical practice, I provided care for high-risk obstetric patients
at three major tertiary care academic medical centers. I took care of my fair
share of complex obstetric patients, and I thought that I acquired reasonable
expertise in the care of critically ill parturients. In 2005, I became the chief
academic officer/associate medical school dean at a mid-sized, community-
based academic medical center in a small upper Midwestern town. I continued
to practice clinical anesthesiology as my schedule permitted, but the obstetric
service was small, and it included mostly low-risk patients.
In 2014, I returned to my professional roots as a full-time obstetric
anesthesiologist, and I became Chief of the Obstetric Anesthesia Division at
Vanderbilt University Medical Center, which is the major high-risk obstetric
referral center for a wide geographic area, and where we have almost 5000
deliveries each year. I naively thought that the transition would not be too
difficult. I had done this type of work before, and surely, I thought, it would
not be too challenging to do it again. But soon I was stunned and at times
overwhelmed by the complexity and acuity of our high-risk obstetric
population. As I discussed my experience with obstetric anesthesia colleagues
around the country and abroad, I learned that this phenomenon was not
unique to Vanderbilt. I have now concluded that the complexity of obstetric
practice has drastically changed over the last two decades. Obstetric patients
in developed countries have more complicated problems, are often sicker, and
are more likely to require critical care than ever before. Sadly, maternal
mortality has increased in some developed countries, especially the United
States. Likewise, indices of maternal morbidity also reflect the escalating
severity of maternal illness.
For these reasons, I was delighted to learn of the timely publication of this
new textbook, which is focused on maternal critical care. The book is
thoughtfully and skillfully edited by three prominent critical care medicine
physicians and obstetric anesthesiologists. The chapters are written by a
multidisciplinary group of anesthesiologists, critical care medicine (CCM)
physicians, maternal–fetal medicine (MFM) physicians, pain medicine
physicians, epidemiologists, and fetal pharmacology experts from around the
globe, including Australia, Austria, Canada, Denmark, Finland, France, India,
Ireland, Israel, Italy, Singapore, the United Kingdom, and the United States.
By design, this book was written for a worldwide audience. All authors were
asked to especially consider the care of the mother who is receiving care in an
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intensive care unit (ICU) or who needs ICU care and is managed by CCM
physicians as part of a multidisciplinary team. This book specifically focuses
on the care of the critically ill mother, and the severe aspects of her disease or
condition.
This book is designed for all healthcare professionals who provide care for
critically ill pregnant (or recently pregnant) women. The content was included
to help those physicians and other providers who infrequently take care of
critically ill obstetric patients. Some chapters discuss the timing for surgery
during pregnancy according to maternal needs, and what drugs may be safely
given to pregnant women. The chapter on cardiac disease in pregnancy states
that bridging therapy—given for fetal benefit—endangers mothers with a
mechanical heart valve. The chapter on acute fatty liver of pregnancy
emphasizes that the decision to deliver the baby is often life-saving for the
mother. Likewise, the discussion of perimortem cesarean delivery emphasizes
that this procedure is done not only to save the baby’s life, but also as a
critically important, often life-saving part of maternal resuscitation.
I want to add some personal editorial comments, as well as some
suggestions for present and future training and clinical practice. First, not all
sick parturients who need a higher level of care are admitted to an ICU. The
American College of Obstetricians and Gynecologists [1] has stated that
“some patients can be successfully monitored in an intermediate care unit …
sometimes referred to as Obstetric Intermediate Care Units,” ideally located
as part of—or immediately adjacent to—the Labor and Delivery Unit. This
unit may handle invasive monitoring, but typically does not provide
mechanical ventilation. It helps reduce the frequency of moving sick laboring
women far away from the preferred location of vaginal or cesarean delivery.
Meanwhile, we badly need clinical validation of obstetric-specific screening
tools that help identify what patients are likely to need an advanced level and
location of ICU care (e.g., what mothers are at high risk for sepsis/septic
shock and/or organ failure). This book includes a chapter dedicated to that
subject, and the senior author of that chapter has developed a comorbidity
index for use in obstetric patients [2]. Maternal early warning criteria have
also been described; these criteria may need some refinement, and they need
to be implemented more widely [3].
Second, we desperately need to improve both obstetrician and obstetric
anesthesiologist training in CCM worldwide. At present in the United States,
a 3-year MFM fellowship requires only one month of CCM training. In 2010,
the American Board of Anesthesiology (ABA) and the American Board of
Obstetrics and Gynecology (ABOG) began a partnership, so that ABOG dip-
lomats could complete a 1-year anesthesiology CCM fellowship and then
take the ABA CCM certification exam, and if successful, obtain certification
in CCM. At the time of writing this foreword, a total of 10 ABOG diplomats
have obtained CCM certification through this pathway [4]. The ABOG also
has a partnership with the American Board of Surgery (ABS), and over the
last three decades, approximately 16 ABOG diplomats have obtained certifi-
cation in surgical critical care (SCC) from the ABS [5]. On the obstetric anes-
thesiology side, the ACGME-accredited obstetric anesthesiology fellowship
program curriculum currently does not require a single month of CCM expe-
rience. In the future, I hope that more anesthesiology trainees will choose to
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complete 2 years of fellowship training—1 year in obstetric anesthesia, and
the second year in CCM. Approval of a pathway for subspecialty certification
in obstetric anesthesia would then allow those physicians to obtain dual cer-
tification in both obstetric anesthesia and CCM. In the meantime, obstetric
anesthesiologists and MFM physicians would do well to acquire expertise in
new bedside diagnostic tools, such as point-of- care echocardiography and
ultrasonography, whether performed on the Labor and Delivery Unit or in the
ICU. These and other new assessment tools (e.g., minimally invasive cardiac
output monitoring) need to be studied, validated, and refined for use in preg-
nant women.
Finally, given the shortage of CCM physicians in many places, consider-
ation may be given to selected use of telemedicine to assist local physicians in
the care of critically ill obstetric patients who cannot be transferred to a center
with greater resources. Greater emphasis should be made on identifying those
pregnant women who are at high risk for critical illness, so that advance prepa-
rations can be made to ensure that they receive peripartum care in centers with
the resources needed to provide optimal care [6].
Notwithstanding the efforts to provide a higher level of maternal care on
the Labor and Delivery Unit, it seems likely that an increasing number of
critically pregnant women will require care from a multidisciplinary team in
an ICU setting. This book was created with those patients in mind. I
congratulate the editors and authors for preparing this comprehensive,
resource-rich text. It should be accessible to all those who provide care for
critically ill pregnant women.
David H. Chestnut
Division of Obstetric Anesthesiology
Vanderbilt University Medical Center
Nashville, TN, USA
References
1. American College of Obstetricians and Gynecologists. Critical care in
pregnancy. ACOG technical bulletin no. 211. Obstet Gynecol.
2019;133:e303–19.
2. Bateman BT, Mhyre JM, Hernandez-Diaz S, et al. Development of a
comorbidity index for use in obstetric patients. Obstet Gynecol.
2013;122:957–65.
3. Mhyre JM, D’Oria R, Hameed AB, et al. The maternal early warning
criteria: a proposal from the National Partnership for Maternal Safety.
Obstet Gynecol. 2014;124:782–6.
4. Personal communication, the American Board of Anesthesiology and the
American Board of Obstetrics and Gynecology, 14 June 2019.
5. Personal communication, the American Board of Surgery and the
American Board of Anesthesiology, 31 May 2019.
6. Clapp MA, James KE, Kaimal AJ. The effect of hospital acuity on severe
maternal morbidity in high-risk patients. Am J Obstet Gynecol.
2018;219:111.e1–7.
Foreword
It is a privilege to have been asked to write the foreword for this textbook on
maternal and obstetric critical care, edited by a leading authority in this field,
Dr. Sharon Einav, co-edited by two experts in obstetric anesthesiology, Dr.
Carolyn Weiniger and Dr. Ruth Landau, and written by an international team
of almost 100 experts.
Maternal/obstetric critical care concerns only a relatively small minor-
ity of critically ill admissions overall although there is some evidence that
demand for maternal/obstetric critical care is increasing, particularly in
the developed world, in part related to the increasing numbers of older
pregnant mothers with higher rates of comorbidities. This is a highly chal-
lenging population of patients, especially as conditions can be life-threat-
ening not only for the mother but also for the child(ren) she carries.
However, although much has been written about the critically ill neonate,
there are few articles and even fewer textbooks dedicated to coverage of
the critically ill mother, making this endeavor all the more impressive and
important.
This comprehensive volume covers all aspects of maternal/obstetric
critical care, from complications associated with early pregnancy,
through to puerperal sepsis and postpartum hemorrhage. After the first
section on epidemiology the editors have grouped chapters according to
seven organ systems: the coagulation system, cardiovascular system,
immune system, respiratory system, neuromuscular system, renal sys-
tem, and endocrine and metabolic systems. There is a separate section
on cardiac arrest during pregnancy, including ethical considerations,
one on surgical considerations, and one on issues of medication and its
complications. Importantly, the book includes chapters covering key
challenges and relevant topics of particular current interest, including
extracorporeal membrane oxygenation, viral infection, point-of-care
ultrasound, and disaster management. The book finishes with a sum-
mary chapter on general aspects of intensive care for all pregnant ICU
patients.
The topics covered in this comprehensive volume are important for all
involved in taking care of obstetric patients and all responsible for the
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management of acutely ill patients. I congratulate Dr. Einav for her initiative
in drawing together this useful book on a very important subject that is poorly
covered in the current literature.
Jean-Louis Vincent
Université Libre de Bruxelles
Brussels Belgium
Department of Intensive Care
Erasme University Hospital
Brussels Belgium
Preface
Pregnancy is viewed as joyous period, a time spent looking forward to good
things to come. So when things go wrong during pregnancy, a chasm opens
between expectations and reality. Unfortunately, this gap needs to be bridged
by the treating physicians, not just the family. Awareness of this cognitive
dissociation is a major step towards improved medical care of these women.
Pregnant women can get critically ill. Pregnant women are still dying because
of suboptimal medical care worldwide. This book, we hope, will be another
step, among many being made around the world, to make pregnancy safer.
Creating this book was a challenge. Not for lack of willing authors. On the
contrary—each and every one of the wonderful authors of this book immedi-
ately stepped up to the task and did so professionally and with grace. Creating
a book is always a challenge, one would think. But creating this book entailed
more than just the regular challenge of deciding on the table of contents and
finding outstanding authors. This book on maternal critical care was a chal-
lenge because it required that each and every one of those contributing to this
book undergo a paradigm shift in terms of how we view critically ill pregnant
or peripartum women. It required that focus be shifted from the pregnancy to
the woman carrying the pregnancy. And this was no simple task.
The chapters in this book underwent rigorous screening by the editors to
ensure that the patient being discussed within always remains the woman, not
her pregnancy. As a result, some of the chapters were written and then
rewritten entirely. All of the chapters were revised several times. To our sor-
row, two chapters had to be left out entirely. It was a slow process during
which all of us, editors and authors together, not only created a book but also
learned to change the way we think of our pregnant patients. The presence of
a pregnancy distracts attention away from the woman carrying it, and it was
our role to return the spotlight to the patient before us.
This book would never have come to fruition without the perseverance and
constant support of my co-editors. My profound thanks to Carolyn Weiniger.
Without her professional input, organizational skills, optimism, and tact, this
book could never have been finished. I could not have chosen a better right-
hand woman for making this ambitious project a reality. My thanks also go to
Ruth Landau for her elegant writing, her ability to coax the best out of any text,
and her ever tactful yet piercingly observant comments. To Nechama Kaufman
for diligently checking and rechecking the references, dotting the i’s and
crossing the t’s. Nechama—your hard work, candid comments, insightful
ideas, and (brilliant) English edits are invaluable. But most invaluable is your
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