General

● Resuscitation of mother means resuscitation of baby.

● Early OB consult and fetal monitoring.

● Estimated fetal age important as delivery is often the definitive management.

Airway

● Considered a difficult and high risk airway:

○ Lower pulmonary reserve and quicker to desaturate → preoxygenate well.

○ Higher aspiration risk as progesterone relaxes lower esophageal sphincter.

○ Consider using smaller tube as there may be some edema.

● Same RSI meds → all are pregnancy class B and C

● Maintain low threshold to intubate with rising PaCO2 → ↑CO2 = acidotic baby.

● Ventilator Settings:

○ PaCO2 at 30-32 speculated to be normal

○ Goal PaO2 >70 as PaO2 < 60 associated with rapid fetal compromise

○ Use the lowest PEEP to achieve this goal as venous return already has to deal with gravid uterus

Circulation

● Obtain IV access above diaphragm as uterus clamps down on lower extremity venous return → avoid femoral central venous access.

● BP goal unclear: MAP 65 extrapolate; AHA recommends SBP > 100 or 80% of baseline.

● Position patient in left lateral decubitus or with right hip wedge to help venous return.

● No data on normal saline versus lactated ringers.

● No evidence for optimal blood transfusion goal → Hgb > 7.0 as extrapolated target.

● Optimal pressor not known

○ Consider ephedrine for maternal hypotension.

○ Consider milrinone for inotropic support as it was studied directly in pregnancy.

References

Mallemat, H. Supportive Management of Critical Illness in the Pregnant Patient. Emergency Medicine Practice. June 2012; Volume 2, Number 3