Sterile speculum and bimanual exams: atony/retained products
Kleihauer–Betke test: the KB test is the standard method of quantitating fetal–maternal hemorrhage (FMH). It allows calculation of the percentage of red blood cells in the mother’s blood that are of fetal origin.
CBC, BMP, type and cross, coagulation panel, blood gas, Electrocardiogram.
FAST and cardiac ultrasound exam.
Centers should have a protocol for assessment and management of post‐partum hemorrhage.
Quantify blood loss.
Monitor vital signs.
Uterine atony is the most common cause of post‐partum hemorrage:
Bromocriptine 2.5 mg twice daily for 2 weeks, then 2.5 mg daily for 2 weeks
Requires concomitant anticoagulation due to thrombotic risk
Definitive end‐stage therapy
Ventricular assist device Cardiac transplant
End‐stage heart failure without recovery after 6 months
Full recovery in 25–85% of cases.
Progression to end‐stage heart failure in 13–25% of cases.
Mortality at 6 months: 3–30%.
Pulmonary embolic disease
Embolic occlusion of a pulmonary artery by venous thrombus or leaked fetal amniotic fluid that may result in hemodynamic changes due to mechanical obstruction, vasoconstriction, or inflammatory mediated myocardial depression.
Venous thromboembolism (VTE) incidence: 5–12 events per 10 000 pregnancies ante‐natally, 3–7 events per 10 000 pregnancies post‐partum.
VTE risk in pregnancy is increased 7–10× relative to the general population. The risk returns to baseline at 6 weeks post‐partum.
Amniotic fluid embolism (AFE) complicates 2–7 per 10 000 pregnancies
VTE: inhibition of fibrinolysis, venous stasis, endothelial activation.
AFE: leakage of amniotic fluid into systemic circulation, resulting in endovascular dysfunction, mechanical obstruction, and myocardial depression.
History: prior VTE, shortness of breath, chest pain, unilateral lower extremity erythema, edema, erythema. May present as sudden cardiac arrest.
Consider expedited caesarean section in unstable patients.
Stable patients: enoxaparin 1 mg/kg twice a day, dalteparin 200 U/kg each day or 100 U/kg twice a day, tinzaparin 175 U/kg each day. Titrate to factor Xa level: target range 0.5–1.1 U/mL.
Unstable patients or near delivery: heparin 80 U/kg bolus, infusion of heparin 18 U/kg, titrate to aPTT. Hold heparin 4 hours prior to delivery, resume 6 hours after vaginal delivery or 12 hours after cesarean.
AFE: perfusion is rarely intact. Manage via BLS, ACLS, inotropic support, airway management.
Avoid excessive fluids.
After ROSC: immediate delivery in the case of viable fetus (>23 weeks).
If no ROSC: perimortem cesarean section at 4 minutes.
Evaluate for coagulopathy and treat if present.
AFE: mortality is greater than 60%. Cardiac arrest survival <10%.
PE: 15–18% mortality at 3 months.
Pre‐eclampsia and eclampsia
Pre‐eclampsia: new hypertension after >20 weeks of gestational age.
Severe pre‐eclampsia: pre‐eclampsia with organ dysfunction.
Eclampsia: seizure or acute neurological deficits in a patient with pre‐eclampsia.
2–8% of all pregnancies.
25% progress to severe pre‐eclampsia.
Eclampsia: 1–3 per 1000 pregnant women.
Pre‐eclampsia: endovascular dysfunction, possibly due to placental hypoxemia and inflammation. Can occur in the absence of placental abnormalities.
Eclampsia: cerebral vasospasm, arterial insufficiency, local ischemia, disruption of the blood–brain barrier with cerebral edema.
Pre‐eclampsia: history of pre‐eclampsia, primiparity, obesity, family history of pre‐eclampsia, multiple pregnancies, history of hypertension or diabetes. Smoking decreases risk.
Pre‐eclampsia: BP >140 mmHg on two separate readings more than 4 hours apart with either >300 mg urine protein/24 hours or protein : creatinine ratio ≥0.3.
Severe pre‐eclampsia: hypertension with proteinuria (as above) or organ system failure.
Vascular hypertension: BP >160 mmHg systolic or 110 mmHg diastolic on two readings more than 4 hours apart.
CNS: cerebral dysfunction or visual symptoms.
Hepatic: right upper quadrant pain or transaminases more than twice the upper limit of normal.
Renal: serum creatinine >1.1 mg/dL or doubled above baseline.
Pulmonary: pulmonary edema.
Eclampsia: Grand mal seizure after 20 weeks gestation with hypertension.
Mild: control hypertension.
Severe: seizure prophylaxis, control hypertension, supportive care, delivery.
Eclampsia: magnesium infusion, supportive care, delivery.
Table of treatment of severe pre‐eclampsia
Focus of treatment
Hydralazine: 5–20 mg IV every 30 minutes Labetalol: 10–20 mg IV every 10 minutes, double dose with re‐dosing up to 80 mg per dose and total maximum of 220 mg
First line: magnesium sulfate IV piggyback 4–6 g loading dose over 30 minutes with 2 g/h infusion. May load IM. Goal: serum magnesium level 4.8–8.4 mg/dL Continue through delivery Monitor for magnesium toxicity
Definitive management for all viable fetuses Early viable gestations: may delay delivery for corticosteroid administration
Prevention/management of complications
Monitor closely for magnesium toxicity.
If patient suffers cardiac arrest while receiving magnesium, in addition to resuscitation, stop magnesium and treat toxicity empirically with calcium.
Pre‐eclampsia: 0.2% mortality with 5% risk of significant morbidity; 50 000–70 000 deaths worldwide annually.
Eclampsia: 2–3 deaths per 10 000 live births in developed countries; 16 – 69 deaths per 10 000 live births in developing countries.
Dulu A, Ragsdale ES, Goffman D. Critical care issues in pregnancy. In: Oropello JM, Pastores SM, Kvetan V (eds), Critical Care. New York: McGraw‐Hill, 2017, pp. 829–50.
Einav S, Kaufman N, Sela HY. Maternal cardiac arrest and perimortem caesarean delivery: evidence or expert‐based? Resuscitation 2012; 83(10):1191–200.
Hegewald MJ, Crapo RO. Respiratory physiology in pregnancy. Clin Chest Med 2011; 32:1–13.
Lam MTC, Dierking E. Intensive care unit issues in eclampsia and HELLP syndrome. Int J Crit Illn Inj Sci 2017; 7(3) 136–41.