Clinical obstetrics and gynecology
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Severe sepsis is a major cause of mortality among critically ill patients. Early recognition accompanied by early initiation of broad-spectrum antibiotics with source control and fluid resuscitation improves outcomes. ⋯ Cases refractory to first-line vasopressors (norepinephrine) will require second-line vasopressors (epinephrine or vasopressin) and low-dose steroid therapy. Resuscitation goals should include optimization of central venous oxygenation and serum lactate.
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Clin Obstet Gynecol · Dec 2014
ReviewMechanical ventilation during pregnancy: sedation, analgesia, and paralysis.
Pregnant women occasionally require mechanical ventilation. Ventilated patients commonly need some form of analgesia and/or sedation with or without paralytics. ⋯ In the vast majority of cases, guidelines and recommendations regarding the use of these agents should be followed as recommended for nonpregnant individuals. This article discusses the most relevant issues of sedatives, analgesics, and neuromuscular blockers used in modern critical care practice.
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Acute respiratory distress syndrome (ARDS) is an uncommon condition in pregnant patients. The causes of ARDS are associated with obstetric causes such as amniotic fluid embolism, preeclampsia, septic abortion, and retained products of conception or nonobstetric causes that include sepsis, aspiration pneumonitis, influenza pneumonia, blood transfusions, and trauma. ⋯ Medical therapies such as nitric oxide and corticosteroids play a complimentary role. Extracorporeal life support is beneficial in the management of the parturient with severe ARDS.
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Hypertensive disorders of pregnancy complicate 7% to 10% of pregnancies and are among the major causes of maternal and perinatal morbidity and mortality. Recently American College of Obstetricians and Gynecologists Taskforce on Hypertension during Pregnancy modified the diagnosis and management of hypertension in pregnancy, recommending prompt diagnosis, admission, close monitoring, and treatment. ⋯ Labetalol, hydralazine, or nifedipine are considered first-line treatment, and either can be used to stabilize the patient with similar outcomes. Definite treatment is delivery of the fetus and should be considered based on the etiology of the hypertensive crisis and gestational age.
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Hemorrhage is the most common cause of maternal mortality worldwide, and represents the third most common obstetrical cause of maternal death in the United States. Although uterine atony was previously a major cause of peripartum hemorrhage, more recently, it appears that abnormal placentation is the leading etiology and the main indication of peripartum hysterectomy. Early identification and aggressive management of obstetrical hemorrhage is of utmost importance to prevent maternal morbidities and mortality.