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

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

 G 1, P 0 / 23 wks  Presents to NW Arkansas with UTI, fever, SOB, back pain  Rapidly progressive respiratory distress

 O 2 sat. on arrival 88% and ↓ to 80% with 100% rebreather  CXR – pulmonary edema/ARDS  FHT’s – reassuring  Intubated following progressive O 2 requirements

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

 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

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

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

Clinical Challenges  Fetus at “extremes of viability”  Hypotensive but fluid overloaded  Severe mitral stenosis  Pulmonary edema/intubated but needs O 2 exchange for fetus  Febrile - ? Septic  FOB not in picture/family present Keep mother alive No fetal interventions

Multidisciplinary Approach  MICU Team Cardiology Pulmonary Anesthesiology  Obstetrics  Neonatology  Social Work  Nursing

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

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

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

MICU Course  Admit 02/09 – 25 wks 02/14 – Afebrile – abx stopped 02/18 –Diuresis completed O 2 saturation improved PEEP/O 2 requirements down 02/18 – Swan placed 02/18-20 – Contractions/cervical change 02/20-22 – 6-7 cm dilated/bulging bag 0 station Cardiac status improved and pressors weaned to minimal doses

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”

February 23  Labor augmentation started 0700  Neonatology/Anesthesia/OB/ MICU ready  Plan only for bedside if terminal bradycardia  Forceps ready for 2 nd stage

February 23  11:52 a.m.  Spontaneous delivery  No cord/Apgars 5 1 /6 5  Neonatology present  No lacerations  Cord gases A 7.28/-2.0; V 7.30/-1.4

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

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 O 2 in isolette

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