Critical Care Obstetrics: A Multidisciplinary Approach

1. Critical Care Obstetrics: A Multidisciplinary Approach Paul J. Wendel, M.D. Associate Professor Maternal-Fetal Medicine Division Department of Obstetrics and Gynecology College of Medicine University of Arkansas for Medical Sciences

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

3. G1, P0 / 23 wks • Presents to NW Arkansas with UTI, fever, SOB, back pain • Rapidly progressive respiratory distress

4. O2 sat. on arrival 88% and ↓ to 80% with 100% rebreather • CXR – pulmonary edema/ARDS • FHT’s – reassuring • Intubated following progressive O2 requirements

5. Echo – moderate mitral stenosis and mitral regurgitation • LV function normal • High gradient across mitral valve – functionally severe stenosis

6. 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

7. Prior to transport • Patient febrile • On multiple abx, plus TB meds • 4 units PRBC’s transfused • Records indicated positive fluid balance each day

8. On Arrival to UAMS • 25 wks gestation – vertex • Presumed ARDS • Intubated • Hypotensive on/pressors • Febrile

9. Clinical Challenges • Fetus at “extremes of viability” • Hypotensive but fluid overloaded • Severe mitral stenosis • Pulmonary edema/intubated but needs O2 exchange for fetus • Febrile - ? Septic • FOB not in picture/family present • Keep mother alive • No fetal interventions

10. Multidisciplinary Approach • MICU Team • Cardiology • Pulmonary • Anesthesiology • Obstetrics • Neonatology • Social Work • Nursing

11. Goals of the Team • Efforts directed at maintenance of mother’s life (family directive) • When possible, maximize fetal compartment • Maintain oxygenation • Diuresis of fluid • Increase pressors as needed for BP control • Avoid delivery if possible secondary to fluid shifts/bleeding

12. Plan • Slow diuresis begun and continued over one week • Digoxin/Beta blocker started to increase cardiac output and increase filling time • Steroids started for ARDS • Antibiotics were discontinued when all cultures negative and fever resolved

13. MICU Course • Admitted 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

14. MICU Course • Admit 02/09 – 25 wks • 02/14 – Afebrile – abx stopped • 02/18 –Diuresis completed • O2 saturation improved • PEEP/O2 requirements down • 02/18 – Swan placed • 02/18-20 – Contractions/cervical change • 02/20-22 – 6-7 cm dilated/bulging bag • Head @ 0 station • Cardiac status improved and pressors weaned to minimal doses

15. February 22 • Conference with family • Fetus now 27 4/7 wks • Cardiac status improved • CO demands could be tolerated • Pulmonary status improved • Family agrees to c/s if “distress”

16. February 23 • Labor augmentation started 0700 • Neonatology/Anesthesia/OB/MICU ready • Plan only for c/s @ bedside if terminal bradycardia • Forceps ready for 2nd stage

17. February 23 • 11:52 a.m. • Spontaneous delivery • No cord/Apgars 51/65 • Neonatology present • No lacerations • Cord gases A 7.28/-2.0; V 7.30/-1.4

18. Subsequent Course • Swan d/c’ed 02/26 secondary to new fever (? line source) • Extubated 02/26 • Sedation stopped/pt became responsive • CT Scan-mild cerebral atrophy • PT/OT involved for rehabilitation • Eventually discharged 03/08/06

19. Infant Outcome • 1146 gms/Apgars 5/6 • Head u/s – nl x2 • HMD – s/p Survanta x3 • Currently on Methadone maintenance secondary to maternal Ativan/Fentanyl use • Currently 1774 gms • OG feeds/2 liters NC O2 in isolette

20. Monday Morning Quarterback • Mitral stenosis • UTI  Pyelonephritis • Tachycardia/fluids •  pulmonary edema • Diuresis/Prolonged filling time necessary to improve pulmonary function • Delayed delivery allowed for recovery to tolerate delivery