Critical Care Obstetrics: Critical Care Obstetrics: A Multidisciplinary ApproachA Multidisciplinary Approach

Paul J. Wendel, M.D.Associate ProfessorMaternal-Fetal Medicine DivisionDepartment of Obstetrics and GynecologyCollege of MedicineUniversity of Arkansas for Medical Sciences

Case of 18 year-old foreign national from Marshall Island with history of rheumatic fever as child.

G1, P0 / 23 wks

Presents to NW Arkansas with UTI, fever, SOB, back pain

Rapidly progressive respiratory distress

O2 sat. on arrival 88% and ↓ to 80% with 100% rebreather

CXR – pulmonary edema/ARDSFHT’s – reassuringIntubated following progressive

O2 requirements

Echo – moderate mitral stenosis and mitral regurgitation

LV function normalHigh gradient across mitral

valve – functionally severe stenosis

Attempted transport to UAMS but due to lack of ventilator beds (ICU bed) transport to UAMS occurred 2 wks after initial admit in NW Arkansas

10 days on ventilator prior to transport

Prior to transportPatient febrileOn multiple abx, plus TB

meds4 units PRBC’s transfusedRecords indicated positive

fluid balance each day

25 wks gestation – vertexPresumed ARDSIntubatedHypotensive on/pressorsFebrile

On Arrival to UAMSOn Arrival to UAMS

Clinical ChallengesClinical ChallengesFetus at “extremes of viability”Hypotensive but fluid overloadedSevere mitral stenosisPulmonary edema/intubated but

needs O2 exchange for fetus

Febrile - ? SepticFOB not in picture/family present

Keep mother aliveNo fetal interventions

Multidisciplinary ApproachMultidisciplinary ApproachMICU Team

CardiologyPulmonaryAnesthesiology

ObstetricsNeonatologySocial WorkNursing

Goals of the TeamGoals of the TeamEfforts directed at maintenance of

mother’s life (family directive) When possible, maximize fetal compartment

Maintain oxygenationDiuresis of fluidIncrease pressors as needed for BP controlAvoid delivery if possible secondary to

fluid shifts/bleeding

PlanPlanSlow diuresis begun and continued

over one weekDigoxin/Beta blocker started to

increase cardiac output and increase filling time

Steroids started for ARDSAntibiotics were discontinued when

all cultures negative and fever resolved

MICU CourseMICU CourseAdmitted on 02/09/06 (25 wks)On 2/18-20/06 started having

contractions Cervix changed from fingertip to 3-4 cm

Swan Ganz catheter placed to determine need for vulvoplasty of mitral valve

Fetus remained reassuring on daily monitoring of heart rate pattern

MICU CourseMICU CourseAdmit 02/09 – 25 wks

02/14 – Afebrile – abx stopped 02/18 –Diuresis completed

O2 saturation improvedPEEP/O2 requirements down

02/18 – Swan placed 02/18-20 – Contractions/cervical change 02/20-22 – 6-7 cm dilated/bulging bag

Head @ 0 stationCardiac status improved and pressors weaned to

minimal doses

February 22February 22Conference with familyFetus now 27 4/7 wksCardiac status improved

CO demands could be toleratedPulmonary status improvedFamily agrees to c/s if “distress”

February 23February 23

Labor augmentation started 0700Neonatology/Anesthesia/OB/

MICU readyPlan only for c/s @ bedside if

terminal bradycardiaForceps ready for 2nd stage

February 23February 23

11:52 a.m.Spontaneous deliveryNo cord/Apgars 51/65

Neonatology presentNo lacerationsCord gases A 7.28/-2.0; V

7.30/-1.4

Subsequent CourseSubsequent CourseSwan d/c’ed 02/26 secondary to new

fever (? line source)Extubated 02/26Sedation stopped/pt became responsiveCT Scan-mild cerebral atrophyPT/OT involved for rehabilitationEventually discharged 03/08/06

Infant OutcomeInfant Outcome1146 gms/Apgars 5/6Head u/s – nl x2HMD – s/p Survanta x3Currently on Methadone

maintenance secondary to maternal Ativan/Fentanyl useCurrently 1774 gmsOG feeds/2 liters NC O2 in

isolette

Monday Morning QuarterbackMonday Morning QuarterbackMitral stenosisUTI PyelonephritisTachycardia/fluids

pulmonary edema

Diuresis/Prolonged filling time necessary to improve pulmonary function

Delayed delivery allowed for recovery to tolerate delivery