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Quick Test posted on 06.25.08:
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Pregnancy and Surgery
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- Understanding the normal physiology of pregnancy is essential to evaluate the adequacy of cardiopulmonary function in the critically ill
gravid woman.
- Pregnancy results in an increased cardiac output, which in late pregnancy may be diminished in the supine position by vena
caval compression from the enlarged uterus.
- The reduced functional residual capacity (FRC) and increased oxygen consumption noted in
normal pregnancy increase the risk of hypoxemia during intubation or hypoventilation.
- Hyperventilation during pregnancy results in a primary
respiratory alkalosis and a compensatory metabolic acidosis with the following typical arterial blood gas values: PO2 >100 mm Hg,
PCO2 27 to 32 mm Hg, and serum bicarbonate concentration 18 to 21 mEq/L.
- Fetal viability depends on adequate oxygen delivery.
As a result of the dilutional anemia of pregnancy, cardiac output becomes the critical determinant of fetal oxygen delivery and must be maintained.
- Hemorrhage in pregnancy may be massive and require extraordinary fluid resuscitation.
- Vasoactive drugs should be used with caution
in the pregnant patient, since they may reduce uterine blood flow.
- Control of increased afterload may require intravenous agents: Sodium
nitroprusside should be used only for imminently life-threatening conditions, since cyanide toxicity may result in fetal injury or demise. Nicardipine
is an intravenous calcium channel blocker that is preferable to nitroprusside, and experience with labetalol, a combined alpha-beta blocker, is growing
and promising.
- Preeclampsia is a multisystem disorder characterized by hypertension, central nervous system dysfunction, coagulopathy, pulmonary
edema, renal failure, and liver function abnormalities.
- Cardiopulmonary resuscitation must be modified in pregnancy and includes emergent
cesarean section in selected patients.
- Pregnancy may represent a state of increased risk of pulmonary edema formation; acute hypoxemic
respiratory failure is most often due to tocolytic therapy, and if due to tocolytics, usually resolves with supportive care.
- Successful
management of critical illness in pregnancy requires continuous integration of the intensive care team with obstetric and neonatal consultants;
mechanisms should exist for emergent involvement of the appropriate personnel.
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Table 105–3. Maternal Mortalitya in the United States, 1991–1999
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| Cause | Percentage |
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| Embolism | 19.6 | | Hemorrhage | 17.2 | | Hypertensive disease | 15.7 | | Infection | 12.6 | | Cardiomyopathy | 8.3 | | Cerebrovascular accident | 5.0 | | Anesthetic complications | 1.6 | Otherb
| 19.2 |
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aDirect maternal deaths.
bThe majority of the other maedical conditions were cardiovascular, pulmonary, and neurologic problems.
SOURCE: From MMWR.26
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Quick Test Questions QUESTION 1: Which of the following statements concerning appendicitis during pregnancy is true?
QUESTION 2: A 30-year-old, gravida 2 para 1, female is undergoing a Cesarean section at term secondary to known placenta previa. After delivery of the infant and placental extraction, uterine atony is noted with increased hemorrhage. Ligation of which of the following pelvic arteries would safely reduce hemorrhage?
QUESTION 3: The leading cause of trauma during pregnancy in industrialized nations is
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