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Contents

List of Contributors

Foreword to the Sixth Edition

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

Summary

Acknowledgments

References

Chapter 2 Organizing an Obstetrical Critical Care Unit: Care without Walls

Background

Relevance

Unit design: ICU without walls

Patient population

Members of the team

Guidelines, bundles, development, and education

Summary

References

Chapter 3 Critical Care Obstetric Nursing

Introduction

Standards of nursing care: framework for critical care obstetric nursing

Critical care technology: critical concepts and application to clinical practice

Levels of maternal care

References

Chapter 4 Pregnancy‐Induced Physiologic Alterations

Cardiovascular system

Respiratory system

Genitourinary system

Gastrointestinal system

Hematologic system

Endocrine system

Immune system

Conclusion

References

Chapter 5 Maternal Blood Gas Physiology

Introduction

Essential physiology

Oxygen delivery and consumption

Respiratory components of the arterial blood gas

Disorders of acid–base balance

Conclusion

References

Chapter 6 Fluid and Electrolyte Balance

Fluid resuscitation

Crystalloid solutions

Colloid solutions

Hyponatremia

Hypernatremia

Abnormalities in potassium metabolism

Abnormalities in calcium metabolism

Magnesium imbalances

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 abnormal placentation

Interventions for postpartum hemorrhage

Interventions post cesarean section

Complications of interventional procedures

Conclusion

References

Chapter 8 Fetal Considerations in the Critically Ill Gravida

Introduction

Detection of fetal distress in the critically ill obstetric patient

Periodic changes or FHR changes in response to uterine contractions

Overview of periodic changes

Two important “FHR” patterns

Fetal acid–base assessment

FHR patterns in the brain‐damaged infant

Fetal monitoring made simple during labor

Maternal and surgical conditions

Perimortem cesarean delivery

References

Chapter 9 Fetal Effects of Drugs Commonly Used in Critical Care

Introduction

Maternal analgesia and sedation

Cardiovascular drugs

Other cardiovascular drugs

Thrombolytic therapy

Endocrine emergencies

Mannitol

Resources

Conclusion

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

Oxygen therapy for acute fetal distress

Oxygen therapy for the fetus with IUGR

Conclusion

References

Chapter 11 Cardiopulmonary Resuscitation (CPR) in Pregnancy

Introduction

Epidemiology

Etiology

Management

Aortocaval compression

Medications

Extracorporeal membranous oxygenation (ECMO) and extracorporeal life support (ECLS)

Post‐arrest care

Summary

References

Chapter 12 Neonatal Resuscitation

Introduction

Elements of birth depression

Elements of a resuscitation

Preparation for a resuscitation

Initial steps and evaluation

Medications

Immediate care after establishing adequate ventilation and circulation

Special problems during resuscitation

Screening for congenital anomalies

Conclusion

References

Chapter 13 Ventilator Management in Critical Illness

Introduction

Respiratory failure

Oxygen delivery and consumption

Assessing oxygenation

Therapy

Ventilator modes

Alternative maneuvers during mechanical ventilation

Weaning from mechanical ventilation

Respiratory system interactions

Conclusion

References

Chapter 14 Vascular Access

Introduction

Catheter type

Preparing for catheter insertion

Complications – general

Specific venous access sites

Specific arterial access sites

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 Dialysis in Pregnancy

Introduction

Incidence of dialysis in pregnancy with acute kidney injury

Incidence of dialysis in pregnancy with chronic kidney disease

Incidence of pregnancy in established end‐stage renal disease

Overview of dialysis

Modalities of dialysis

Dialysis and pregnancy

Modification of the dialysis prescription

Anemia

Dietary guidelines

Dialysis and uteroplacental perfusion

Maternal complications

Fetal complications (Table 16.5)

Antepartum management

Summary

Disclaimer

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

Management of cardiopulmonary bypass

Summary

References

Chapter 18 Noninvasive Monitoring in Critical Care

Introduction

The measurement of cardiac output (CO)

Doppler ultrasound and the physiology of pregnancy

Doppler ultrasound and critical care

Doppler ultrasound and preeclampsia

Doppler ultrasound and cardiomyopathy

Echocardiography and Doppler ultrasound in rare medical disorders

The role of transesophageal Doppler

Oximetry in the intensive care environment

Capnometry

Transcranial Doppler ultrasound

Doppler ultrasound: bias and confounders

Cerebral perfusion pressure

Thoracic ultrasonography (TUS) and lung ultrasound in the critically ill (LUCI)

Conclusion

References

Chapter 19 Obstetric Analgesia and Anesthesia

Introduction

History of obstetric anesthesia

Anatomy of labor pain

Labor pain characteristics

Labor analgesia

References

Chapter 20 Critical Care Drills in Obstetrics

Obstetric 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: Preterm Premature Rupture of Membranes and Postpartum Hemorrhage

Introduction

Roles and responsibilities

Simulation

Summarize and review lessons learned and process improvements

Chapter 21 Maternal‐Fetal Transport in the High‐Risk Pregnancy

Introduction

Epidemiology of maternal mortality

Role and rationale for regionalization of maternal care

Transport program components

References

Part Two Acute Emergencies

Chapter 22 Seizures and Status Epilepticus

Introduction

Etiology

Seizure prophylaxis

Evaluation of new‐onset seizures in pregnancy

Treatment of seizures

Status epilepticus

Subsequent management and prognosis

References

Chapter 23 Acute Spinal Cord Injury

Introduction

Maternal primary survey and specific considerations due to SCI

Circulation

Other early management concerns

Additional medical SCI complications

Rehabilitation

Summary

References

Chapter 24 Severe Acute Asthma

Introduction

Maternal and fetal physiologic considerations during pregnancy

Interrelationship between asthma and pregnancy

Assessment of asthma during pregnancy

Management of asthma during pregnancy

Management of acute asthma during pregnancy

Management of asthma during labor and delivery

Obstetric management of the pregnant asthmatic

Summary

References

Chapter 25 Acute Respiratory Distress Syndrome in Pregnancy

Introduction

Definition

Epidemiology

Pathophysiology and etiology

Clinical features

Management

Summary

ARDS care pathway algorithm

References

Chapter 26 Cardiogenic Pulmonary Edema

Introduction

Pathophysiology

Hydrostatic pulmonary edema

Lung mechanics and gas exchange

Diagnosis

Treatment

Prevention

References

Chapter 27 The Acute Abdomen during Pregnancy

Introduction

Physiologic changes

Differential diagnosis

Diagnostic imaging

Laparoscopy during pregnancy

Appendicitis during pregnancy

Cholecystitis during pregnancy

Bowel obstruction during pregnancy

Adnexal torsion during pregnancy

Bariatric surgery and acute abdomen in pregnancy

Summary

References

Chapter 28 Acute Pancreatitis

Introduction

Pathology and pathophysiology

Etiology

Diagnosis

Natural history and complications

Clinical predictors of severity

Management

Conclusion

References

Chapter 29 Acute Renal Injury

Definition of acute renal failure

Changes of renal function in pregnancy

Etiologies of acute kidney injury

Management: general principles

Prognosis

Summary

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

Diagnosis of DIC

Scoring for DIC

Management of obstetrical DIC

Conclusion

References

Chapter 32 Endocrine Emergencies

Introduction

Diabetic ketoacidosis

Thyroid disorders

Adrenal dysfunction

References

Chapter 33 Acute Psychiatric Conditions in Pregnancy

Introduction

Assessment of depression

Suicidality

Agitation and psychosis

Conclusions

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

Monitoring the response to treatment

Resolution

Prevention of DKA

Summary

References

Part Three Shock in Pregnancy

Chapter 35 Hypovolemic Shock

Introduction

Impact of obstetric hemorrhage

Causes of obstetric hemorrhage

Hypovolemic shock

Oxygenation

Pharmacologic agents

Initial volume replacement

Blood product transfusion

Monitoring volume status during hypovolemic shock and resuscitation

Further evaluation

Hemostasis

References

Chapter 36 Blood Component Therapy and Massive Transfusion

Introduction

Blood donation, collection, and storage

Blood components: description and indications

Transfusion practices

Obstetric hemorrhage

Massive transfusion

Patients with bleeding or hematological diathesis

Autologous blood

Transfusion reactions

Concluding comments

References

Chapter 37 Etiology and Management of Hemorrhage

Placental abruption

Uterine rupture

Primary postpartum hemorrhage

Uterine inversion

Treatment of uterine atony

Surgical management of postpartum hemorrhage

Bleeding disorders

Conclusion

References

Chapter 38 Septic Shock

Systemic inflammatory response syndrome

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

Other supportive therapies

Alternative treatment modalities

References

Chapter 39 Cardiogenic Shock

Introduction

Pathogenesis

Acute myocardial infarction

Peripartum cardiomyopathy

Mitral stenosis

Aortic stenosis

Arrhythmias

Aortic dissection

Pulmonary hypertension

Summary

References

Chapter 40 Anaphylactic Shock in Pregnancy

Introduction

Definitions

Epidemiology

Precipitants

Pathophysiology

Clinical presentation

Timing and length of reaction

Diagnosis

Approach to anaphylaxis

Differential diagnosis

Conclusions

References

Chapter 41 Amniotic Fluid Embolism

Introduction

Historic considerations

Experimental models

Clinical presentation

Differential diagnosis of amniotic fluid embolism

Diagnosis

International criteria for diagnosis of amniotic fluid embolism

Treatment

References

Part Four Medical and 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

Risk factors and conditions predisposing to PRS

Presenting symptoms

General evaluation, assessment, and management of stroke

General management

Specific considerations

Intracranial hemorrhagic strokes

Ischemic stroke

Special pregnancy considerations

Pregnancy‐related risks of stroke

Subsequent pregnancies

Key points

References

Chapter 43 Cardiac Disease and Pregnancy

Introduction

Counseling the pregnant cardiac patient

Physiologic considerations

Congenital cardiac lesions

Pulmonary hypertension and Eisenmenger’s syndrome

Ebstein’s anomaly

Coarctation of the aorta

Tetralogy of Fallot

Transposition of the great vessels

Pulmonic stenosis

Aortic stenosis (AS)

Functional single ventricle and Fontan procedure

Fetal considerations

Acquired cardiac lesions

Peripartum cardiomyopathy

Hypertrophic cardiomyopathy

Marfan syndrome

Myocardial infarction

Anticoagulation and prosthetic heart valves

Prevention of bacterial endocarditis

Maternal arrhythmias

Pregnancy after cardiac transplantation

References

Chapter 44 Anesthetic Considerations in the Critically Ill Gravida with Cardiac Disease

Introduction and epidemiology

Cardiovascular system physiological changes in pregnancy

Congenital heart disease (CHD)

Acquired heart disease

Anticoagulation therapy in a parturient

Ischemic heart disease

Pulmonary hypertension (Table 44.9)

Peripartum cardiomyopathy

Arrhythmias in pregnancy

Pregnancy and the transplanted heart

Cardiovascular surgery during pregnancy

Summary

References

Chapter 45 Thromboembolic Disease

Incidence and risk factors

Normal hemostasis

Thrombophilias

Deep venous thrombosis

Pulmonary embolus

Antepartum management

Intrapartum management

Postpartum management

Prophylaxis of thromboembolism

Thrombolytic therapy

References

Chapter 46 Pulmonary Hypertension in Pregnancy

Physiologic changes

Clinical presentation

Diagnosis

Management of PAH

Chronic thromboembolic pulmonary hypertension

Termination

Summary

References

Chapter 47 Sickle Cell Disease and Pregnancy

Introduction

Epidemiology

Pathophysiology

Clinical features

Maternal and fetal outcomes in SCD

Pre‐pregnancy considerations

Antepartum care

Acute painful crisis

Acute chest syndrome

Stroke

Venous thromboembolism

Pulmonary hypertension

Delivery

Postpartum care

Infant care

Conclusion

References

Chapter 48 Thrombotic Thrombocytopenic Purpura, Hemolytic‐Uremic Syndrome, and HELLP

Thrombotic thrombocytopenic purpura (TTP)

Clinical features

Laboratory findings

Pathophysiology of TTP

Treatment of TTP

Investigational treatments

TTP during pregnancy

Differential diagnosis

Hemolytic‐uremic syndrome

HELLP syndrome

References

Chapter 49 The Placenta as a Critical Care Issue

Introduction

Placental abruption

Placenta previa

Vasa previa

Morbidly adherent placenta (placenta accreta, increta, and percreta)

Conclusion

References

Chapter 50 Complications of Preeclampsia

Introduction

Etiology of preeclampsia

Clinical definitions and diagnosis of preeclampsia

General management principles for preeclampsia

Cardiopulmonary complications of preeclampsia

Renal complications with preeclampsia

HELLP syndrome

Liver and gastrointestinal complications of preeclampsia

Neurologic complications with preeclampsia

Uteroplacental‐fetal complications of preeclampsia

Conclusions

References

Chapter 51 Systemic Lupus Erythematosus and Antiphospholipid Syndrome

Introduction

Systemic lupus erythematosus in 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

Treatment of SLE flare during pregnancy

Breastfeeding

Antiphospholipid syndrome in pregnancy

References

Chapter 52 Trauma in Pregnancy

Introduction

Maternal physiologic adaptations applicable to trauma during pregnancy

Management of trauma

The fetal patient

Manifestations of trauma during pregnancy

Conclusion

References

Chapter 53 Thermal and Electrical Injury

Introduction

Classification

Maternal concerns

Management strategies

Maternal complications

Fetal complications

Conclusions

References

Chapter 54 Overdose, Poisoning, and Envenomation during Pregnancy

Definitions

Scope of the problem

Toxicologic considerations in pregnancy

Evaluation of the poisoned pregnant patient

Toxic identification

Decontamination procedures

Acetaminophen

Amphetamines

Antidepressants

Aspirin

Barbiturates

Benzodiazepines

Carbon monoxide

Cocaine

Ethanol

Iron

Organophosphates (and carbamates)

Envenomations during pregnancy

Summary

References

Chapter 55 The Organ Transplant Patient in the Obstetric Critical Care Setting

Background

Pre‐pregnancy evaluation

Prenatal care

Immunosuppression during pregnancy

Renal transplantation

Other organ transplantation

Labor and delivery

Obstetric emergencies

The baby

References

Chapter 56 Fetal Surgery Procedures and Associated Maternal Complications

Introduction

Open fetal surgery

Closed surgical therapies

References

Chapter 57 Cancer in the Pregnant Patient

Introduction

Surgical principles during pregnancy

Cervical dysplasia and cancer

Management of adnexal masses occurring in pregnancy

Ovarian cancer

Nongynecologic cancers in pregnancy

Conclusion

References

Chapter 58 Mass Casualties and the Obstetrical Patient

Domestic events

International events

References

Chapter 59 Biological, Chemical, and Radiological Exposures in Pregnancy

Introduction

Clinical vignette

Background

Summary

References

Part Five Ethical and Legal Considerations

Chapter 60 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

Conclusion

Acknowledgments

References

Chapter 61 Medical‐Legal Considerations in Critical Care Obstetrics

Negligence and causation

Foreseeability of harm

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

Informed refusal [34,35]

General guidelines for informed consent

The duty to warn [36]

Hypothetical cases

Discussion

References

Index

EULA