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ACUTE PULMONARY EDEMA IN

PREGNANCY

Acute pulmonary oedema in pregnant women


uncommon but life-threatening event
Superimposed issues of the physiological
changes of pregnancy and the presence of the
fetus, as well as the contributory effect of
poorly understood pathophysiology of
pregnancy related disease such as preeclampsia.

Epidemiology of critical care in OB


Top causes of mortality in obstetric patients
admitted to the ICU1
Etiology

N (of 1354)

Percentage

Hypertension

20

21.5

Pulmonary

20

21.5

Cardiac

11

11.8

Hemorrhage

8.6

CNS

8.6

Sepsis/Infection

6.4

Malignancy

6.4

Data summarized from 16 studies

Dildy et al. Critical Care Obstetrics, 4th edition.

Pregnancy physiology
Cardiovascular adaptations:
10% by 7th week

Increased plasma volume


Hemodilution
Blood pressure variability
Increased heart rate

Plateau at 50% by 32 weeks


Larger increase in multiples
(1570xmlSVR)
vs. 1960 ml)
(CO
Accompanied by RBC mass

Important
for fetal growth
Increased cardiac output (HR
x SV)
(IUGR with lower PV)

SVR variability

Result of contribution from


mother & fetus

Pregnancy physiology
Cardiovascular adaptations:
RBC mass < PV

Increased plasma volume


Hemodilution
Blood pressure variability
Increased heart rate

Better placental perfusion?


Blood viscocity
Stasis
Placental
thrombosis
(CO
x SVR)
Protective during delivery

Increased cardiac output (HR x SV)

SVR variability

Pregnancy physiology
Cardiovascular adaptations:
BP = CO x SVR

Increased plasma volume


Hemodilution
Blood pressure variability
Increased heart rate

Influenced by GA & position


10% by 7th week
(likely due to progesterone)
Initial drop is SBP 2 to SVR
(MAP in 1st trimester)

Increased cardiac output (HR x SV)

BP decreases until 28 weeks

SVR variability

Points of concern:
Method & Position

Pregnancy physiology
Cardiovascular adaptations:
20% in pregnancy

Increased plasma volume


Hemodilution

Likely 2 to SVR
Some impact from FT4

Blood pressure variability (CO x SVR)


Increased heart rate

Must always be weary of other


causes

Playsximportant
Increased cardiac output (HR
SV) role in certain

SVR variability

diagnoses
(i.e. mitral stenosis)

Pregnancy physiology
Cardiovascular adaptations:
CO = HR x SV

Increased plasma volume


Hemodilution

Reflects LV capacity
Increases by 10th week

Blood pressure variability (CO x SVR)


Increased heart rate

Peaks (30-50%) at 26 weeks


(4.5 L/min 6.0 L/min)

Increased cardiac output

2 to HR before 20 weeks

SVR variability

2 to SV after 20 weeks

Pregnancy physiology
Cardiovascular adaptations:

Increased plasma volume


Hemodilution

Measure of impedance to
maternal after load
Decreases in 1st/2nd trimester
(Nadir by 14-24 weeks)

Blood pressure variability (CO x SVR)


rd

Increases in 3 trimester

Increased heart rate

Inversely proportional to CO

Increased cardiac output (HR x SV)

SVR variability

Pregnancy physiology
Cardiovascular adaptations (during labor):

CO (35%) & HR (7%) during contractions


SupineLateral position=22%CO & 27%SV
CO

during contractions:

17% at less than 3 cm


23% at 4-7 cm
35% at 8 cm or more

(Offset by regional anesthesia)

Pregnancy physiology
Cardiovascular adaptations (post partum):

Impacted by blood loss at delivery


Increased CO (59%) & SV (71%) within 1-3 hours
Maximal diuresis on days 2-5

Vaginal
Loss
Hct

500 ml
+5.2%

vs.

Cesarean
1000 ml
-5.8%

Pregnancy physiology
Pulmonary adaptations:
Mucosal edema

Upper airways
Mechanics of respiration
Physiologic changes
Acid-base changes

Mucosal vascularity
Rhinitis & Epistaxis

Pregnancy physiology
Pulmonary adaptations:
8% thoracic circumference

Upper airways
Mechanics of respiration
Physiologic changes
Acid-base changes

5 cm elevation of diaphragm
Increase in dyspnea
15% by 10 weeks
50% by 19 weeks
76% by 31 weeks

Pregnancy physiology
Pulmonary adaptations:

Upper airways
Mechanics of respiration
Physiologic changes
Acid-base changes

FEV1

Unchanged

FRC

10-25%

TLC

minimally

Minute Vent

20-40%

Alveolar Vent

50-75%

Pregnancy physiology
Pulmonary adaptations:

Upper airways
Mechanics of respiration
Physiologic changes
Acid-base changes

Pregnancy=Compensated
respiratory alkalosis

CO2 diffuses faster than O2

Decreased PaCO2 (27-34)

Increased bicarb (18-21)

pH between 7.40 and 7.45

PaO2 (101-104)
A-a gradient (14.3)

Pregnancy physiology
Other adaptations:

Genitourinary
Gastrointestinal
Hematologic
Endocrine
Immune

Pulmonary-Pulmonary Edema
Causes:
Hydrostatic
Systolic dysfunction
Diastolic dysfunction
Valvular disease

Permeability
Pneumonia
Septic shock
ARDS

Other (i.e. decreased colloid)


Tocolytic induced
Preeclampsia

Pulmonary-Pulmonary Edema
Treatment (general):
Sit patient upright
Administer oxygen (may use CPAP until diuresis)
Furosemide (aim for 2L diuresis in 3-4 hours)
Morphine (2-5 mg IV)
Treatment (Specific):
Systolic dysfunction (afterload reduction/inotrop/diuretic)
Diastolic dysfunction (anti-HTN)

Management
Acute pulmonary edema requires emergency
management. Furosemide is given in 20- to 40-mg
intravenous doses along with therapy to control
dangerous hypertension.
Ante/post artum? Fetus dead/alive?
cardioactive drugs lower peripheral resistance and
in turn severely diminish uteroplacental circulation.
The cause of cardiogenic failure echocardiography,
Not an indication for emergency cesarean delivery.
Indeed, in most cases, these women are better served
by vaginal delivery.