The Pregnant ICU Patient

• Pregnancy physiology: ↓SVR so BP falls, ↑plasma volume causing dilutional anemia, compensated respiratory alkalosis, and aortocaval compression after 20 wk (use LEFT TILT).
• Begin perimortem cesarean by 4 min of arrest and deliver by 5 min when gestation is >20–24 wk; it improves BOTH resuscitations.
• Amniotic fluid embolism care is supportive with aggressive correction of coagulopathy.
• Drug safety in pregnancy differs, so check before imaging or medications, and monitor the fetus from ≥24 wk.

Acute pulmonary embolism

First tests: Clinical pretest probability, 12-lead ECG, Full blood count, Sodium, potassium, bicarbonate, urea and creatinine.

Only if indicated: D-dimer, CT pulmonary angiography, Ventilation/perfusion imaging, Bedside echocardiography, Troponin and BNP/NT-proBNP, Venous compression ultrasound.

Repeat monitoring: Oxygenation, BP and perfusion.

Severe acute asthma

First tests: SpO2 and respiratory assessment, Peak expiratory flow.

Only if indicated: Arterial blood gas, Chest X-ray, Sodium, potassium, bicarbonate, urea and creatinine, Blood lactate.

Repeat monitoring: SpO2 and respiratory assessment, Peak expiratory flow.

Acute heart failure / pulmonary edema

First tests: 12-lead ECG, Chest X-ray, Bedside echocardiography, Sodium, potassium, bicarbonate, urea and creatinine, Full blood count.

Only if indicated: BNP or NT-proBNP, High-sensitivity cardiac troponin, Liver biochemistry.

Repeat monitoring: Sodium, potassium, bicarbonate, urea and creatinine, Urine output and fluid balance.

Acute kidney injury

First tests: Sodium, potassium, bicarbonate, urea and creatinine, Urine output and fluid balance, Urinalysis and microscopy.

Only if indicated: Renal tract ultrasound, Arterial blood gas, Targeted immune/hemolysis studies, Creatine kinase.

Repeat monitoring: Sodium, potassium, bicarbonate, urea and creatinine, Urine output and fluid balance.

Critical illness in pregnancy / postpartum

First tests: Full blood count, Sodium, potassium, bicarbonate, urea and creatinine, Liver biochemistry, Urgent maternal and obstetric assessment.

Only if indicated: PT/INR, aPTT and fibrinogen, Blood group and crossmatch, Bedside echocardiography, Fetal monitoring / obstetric ultrasound, Pregnancy-appropriate PE diagnostic imaging.

Repeat monitoring: Full blood count.

Suspected amniotic fluid embolism

First tests: Immediate maternal cardiorespiratory assessment, Full blood count, PT/INR, aPTT and fibrinogen, Blood group and crossmatch.

Only if indicated: Bedside echocardiography, Arterial blood gas.

Repeat monitoring: PT/INR, aPTT and fibrinogen.

• Differential Diagnosis of Respiratory Distress
• Asthma
• Amniotic Fluid Embolus
• Differential Diagnosis of Pulmonary Edema in Pregnancy
• Pulmonary Embolism (PE)
• Acute Kidney Injury in Pregnancy
• Managing Shock in Pregnancy
• Differential Diagnosis of Shock in Pregnancy
• Postpartum Hemorrhage