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Principles and Practice of Maternal Critical Care Sharon Einav Carolyn F. Weiniger Ruth Landau Editors 123 Principles and Practice of Maternal Critical Care Sharon Einav • Carolyn F. Weiniger Ruth Landau Editors Principles and Practice of Maternal Critical Care Editors Sharon Einav Carolyn F. Weiniger Intensive Care Unit Division of Anesthesia Shaare Zedek Medical Center Critical Care and Pain and Hebrew University Faculty Tel Aviv Sourasky Medical Center of Medicine Tel Aviv Jerusalem Israel Israel Ruth Landau Department of Anesthesiology Columbia University Medical Center New York, NY USA ISBN 978-3-030-43476-2 ISBN 978-3-030-43477-9 (eBook) https://doi.org/10.1007/978-3-030-43477-9 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword I begin this foreword with a personal story. For 26 years of residency training and academic clinical practice, I provided care for high-risk obstetric patients at three major tertiary care academic medical centers. I took care of my fair share of complex obstetric patients, and I thought that I acquired reasonable expertise in the care of critically ill parturients. In 2005, I became the chief academic officer/associate medical school dean at a mid-sized, community- based academic medical center in a small upper Midwestern town. I continued to practice clinical anesthesiology as my schedule permitted, but the obstetric service was small, and it included mostly low-risk patients. In 2014, I returned to my professional roots as a full-time obstetric anesthesiologist, and I became Chief of the Obstetric Anesthesia Division at Vanderbilt University Medical Center, which is the major high-risk obstetric referral center for a wide geographic area, and where we have almost 5000 deliveries each year. I naively thought that the transition would not be too difficult. I had done this type of work before, and surely, I thought, it would not be too challenging to do it again. But soon I was stunned and at times overwhelmed by the complexity and acuity of our high-risk obstetric population. As I discussed my experience with obstetric anesthesia colleagues around the country and abroad, I learned that this phenomenon was not unique to Vanderbilt. I have now concluded that the complexity of obstetric practice has drastically changed over the last two decades. Obstetric patients in developed countries have more complicated problems, are often sicker, and are more likely to require critical care than ever before. Sadly, maternal mortality has increased in some developed countries, especially the United States. Likewise, indices of maternal morbidity also reflect the escalating severity of maternal illness. For these reasons, I was delighted to learn of the timely publication of this new textbook, which is focused on maternal critical care. The book is thoughtfully and skillfully edited by three prominent critical care medicine physicians and obstetric anesthesiologists. The chapters are written by a multidisciplinary group of anesthesiologists, critical care medicine (CCM) physicians, maternal–fetal medicine (MFM) physicians, pain medicine physicians, epidemiologists, and fetal pharmacology experts from around the globe, including Australia, Austria, Canada, Denmark, Finland, France, India, Ireland, Israel, Italy, Singapore, the United Kingdom, and the United States. By design, this book was written for a worldwide audience. All authors were asked to especially consider the care of the mother who is receiving care in an v vi Foreword intensive care unit (ICU) or who needs ICU care and is managed by CCM physicians as part of a multidisciplinary team. This book specifically focuses on the care of the critically ill mother, and the severe aspects of her disease or condition. This book is designed for all healthcare professionals who provide care for critically ill pregnant (or recently pregnant) women. The content was included to help those physicians and other providers who infrequently take care of critically ill obstetric patients. Some chapters discuss the timing for surgery during pregnancy according to maternal needs, and what drugs may be safely given to pregnant women. The chapter on cardiac disease in pregnancy states that bridging therapy—given for fetal benefit—endangers mothers with a mechanical heart valve. The chapter on acute fatty liver of pregnancy emphasizes that the decision to deliver the baby is often life-saving for the mother. Likewise, the discussion of perimortem cesarean delivery emphasizes that this procedure is done not only to save the baby’s life, but also as a critically important, often life-saving part of maternal resuscitation. I want to add some personal editorial comments, as well as some suggestions for present and future training and clinical practice. First, not all sick parturients who need a higher level of care are admitted to an ICU. The American College of Obstetricians and Gynecologists [1] has stated that “some patients can be successfully monitored in an intermediate care unit … sometimes referred to as Obstetric Intermediate Care Units,” ideally located as part of—or immediately adjacent to—the Labor and Delivery Unit. This unit may handle invasive monitoring, but typically does not provide mechanical ventilation. It helps reduce the frequency of moving sick laboring women far away from the preferred location of vaginal or cesarean delivery. Meanwhile, we badly need clinical validation of obstetric-specific screening tools that help identify what patients are likely to need an advanced level and location of ICU care (e.g., what mothers are at high risk for sepsis/septic shock and/or organ failure). This book includes a chapter dedicated to that subject, and the senior author of that chapter has developed a comorbidity index for use in obstetric patients [2]. Maternal early warning criteria have also been described; these criteria may need some refinement, and they need to be implemented more widely [3]. Second, we desperately need to improve both obstetrician and obstetric anesthesiologist training in CCM worldwide. At present in the United States, a 3-year MFM fellowship requires only one month of CCM training. In 2010, the American Board of Anesthesiology (ABA) and the American Board of Obstetrics and Gynecology (ABOG) began a partnership, so that ABOG diplomats could complete a 1-year anesthesiology CCM fellowship and then take the ABA CCM certification exam, and if successful, obtain certification in CCM. At the time of writing this foreword, a total of 10 ABOG diplomats have obtained CCM certification through this pathway [4]. The ABOG also has a partnership with the American Board of Surgery (ABS), and over the last three decades, approximately 16 ABOG diplomats have obtained certification in surgical critical care (SCC) from the ABS [5]. On the obstetric anesthesiology side, the ACGME-accredited obstetric anesthesiology fellowship program curriculum currently does not require a single month of CCM experience. In the future, I hope that more anesthesiology trainees will choose to Foreword vii complete 2 years of fellowship training—1 year in obstetric anesthesia, and the second year in CCM. Approval of a pathway for subspecialty certification in obstetric anesthesia would then allow those physicians to obtain dual certification in both obstetric anesthesia and CCM. In the meantime, obstetric anesthesiologists and MFM physicians would do well to acquire expertise in new bedside diagnostic tools, such as point-of- care echocardiography and ultrasonography, whether performed on the Labor and Delivery Unit or in the ICU. These and other new assessment tools (e.g., minimally invasive cardiac output monitoring) need to be studied, validated, and refined for use in pregnant women. Finally, given the shortage of CCM physicians in many places, consider- ation may be given to selected use of telemedicine to assist local physicians in the care of critically ill obstetric patients who cannot be transferred to a center with greater resources. Greater emphasis should be made on identifying those pregnant women who are at high risk for critical illness, so that advance prepa- rations can be made to ensure that they receive peripartum care in centers with the resources needed to provide optimal care [6]. Notwithstanding the efforts to provide a higher level of maternal care on the Labor and Delivery Unit, it seems likely that an increasing number of critically pregnant women will require care from a multidisciplinary team in an ICU setting. This book was created with those patients in mind. I congratulate the editors and authors for preparing this comprehensive, resource-rich text. It should be accessible to all those who provide care for critically ill pregnant women. David H. Chestnut Division of Obstetric Anesthesiology Vanderbilt University Medical Center Nashville, TN, USA References 1. American College of Obstetricians and Gynecologists. Critical care in pregnancy. ACOG technical bulletin no. 211. Obstet Gynecol. 2019;133:e303–19. 2. Bateman BT, Mhyre JM, Hernandez-Diaz S, et al. Development of a comorbidity index for use in obstetric patients. Obstet Gynecol. 2013;122:957–65. 3. Mhyre JM, D’Oria R, Hameed AB, et al. The maternal early warning criteria: a proposal from the National Partnership for Maternal Safety. Obstet Gynecol. 2014;124:782–6. 4. Personal communication, the American Board of Anesthesiology and the American Board of Obstetrics and Gynecology, 14 June 2019. 5. Personal communication, the American Board of Surgery and the American Board of Anesthesiology, 31 May 2019. 6. Clapp MA, James KE, Kaimal AJ. The effect of hospital acuity on severe maternal morbidity in high-risk patients. Am J Obstet Gynecol. 2018;219:111.e1–7. Foreword It is a privilege to have been asked to write the foreword for this textbook on maternal and obstetric critical care, edited by a leading authority in this field, Dr. Sharon Einav, co-edited by two experts in obstetric anesthesiology, Dr. Carolyn Weiniger and Dr. Ruth Landau, and written by an international team of almost 100 experts. Maternal/obstetric critical care concerns only a relatively small minor- ity of critically ill admissions overall although there is some evidence that demand for maternal/obstetric critical care is increasing, particularly in the developed world, in part related to the increasing numbers of older pregnant mothers with higher rates of comorbidities. This is a highly challenging population of patients, especially as conditions can be life-threat- ening not only for the mother but also for the child(ren) she carries. However, although much has been written about the critically ill neonate, there are few articles and even fewer textbooks dedicated to coverage of the critically ill mother, making this endeavor all the more impressive and important. This comprehensive volume covers all aspects of maternal/obstetric critical care, from complications associated with early pregnancy, through to puerperal sepsis and postpartum hemorrhage. After the first section on epidemiology the editors have grouped chapters according to seven organ systems: the coagulation system, cardiovascular system, immune system, respiratory system, neuromuscular system, renal system, and endocrine and metabolic systems. There is a separate section on cardiac arrest during pregnancy, including ethical considerations, one on surgical considerations, and one on issues of medication and its complications. Importantly, the book includes chapters covering key challenges and relevant topics of particular current interest, including extracorporeal membrane oxygenation, viral infection, point-of-care ultrasound, and disaster management. The book finishes with a sum- mary chapter on general aspects of intensive care for all pregnant ICU patients. The topics covered in this comprehensive volume are important for all involved in taking care of obstetric patients and all responsible for the ix x Foreword management of acutely ill patients. I congratulate Dr. Einav for her initiative in drawing together this useful book on a very important subject that is poorly covered in the current literature. Jean-Louis Vincent Université Libre de Bruxelles Brussels Belgium Department of Intensive Care Erasme University Hospital Brussels Belgium Preface Pregnancy is viewed as joyous period, a time spent looking forward to good things to come. So when things go wrong during pregnancy, a chasm opens between expectations and reality. Unfortunately, this gap needs to be bridged by the treating physicians, not just the family. Awareness of this cognitive dissociation is a major step towards improved medical care of these women. Pregnant women can get critically ill. Pregnant women are still dying because of suboptimal medical care worldwide. This book, we hope, will be another step, among many being made around the world, to make pregnancy safer. Creating this book was a challenge. Not for lack of willing authors. On the contrary—each and every one of the wonderful authors of this book immediately stepped up to the task and did so professionally and with grace. Creating a book is always a challenge, one would think. But creating this book entailed more than just the regular challenge of deciding on the table of contents and finding outstanding authors. This book on maternal critical care was a challenge because it required that each and every one of those contributing to this book undergo a paradigm shift in terms of how we view critically ill pregnant or peripartum women. It required that focus be shifted from the pregnancy to the woman carrying the pregnancy. And this was no simple task. The chapters in this book underwent rigorous screening by the editors to ensure that the patient being discussed within always remains the woman, not her pregnancy. As a result, some of the chapters were written and then rewritten entirely. All of the chapters were revised several times. To our sor- row, two chapters had to be left out entirely. It was a slow process during which all of us, editors and authors together, not only created a book but also learned to change the way we think of our pregnant patients. The presence of a pregnancy distracts attention away from the woman carrying it, and it was our role to return the spotlight to the patient before us. This book would never have come to fruition without the perseverance and constant support of my co-editors. My profound thanks to Carolyn Weiniger. Without her professional input, organizational skills, optimism, and tact, this book could never have been finished. I could not have chosen a better right- hand woman for making this ambitious project a reality. My thanks also go to Ruth Landau for her elegant writing, her ability to coax the best out of any text, and her ever tactful yet piercingly observant comments. To Nechama Kaufman for diligently checking and rechecking the references, dotting the i’s and crossing the t’s. Nechama—your hard work, candid comments, insightful ideas, and (brilliant) English edits are invaluable. But most invaluable is your xi