Aortic Aneurysm in Pregnancy

Aortic aneurysms in pregnancy are rare but often fatal due to the natural physiologic changes of pregnancy and comorbidities specific to pregnancy, which increase the risk for aortic dissection and rupture. These physiologic changes are most pronounced in the third trimester and during the peripartum period, when approximately one third of dissections occur. In patients with known aortic aneurysms or conditions that make them prone to aortic aneurysms, preconception counseling can make pregnancy safer and more manageable. Aortic aneurysms diagnosed during pregnancy are usually due to underlying connective tissue diseases or aortopathies that have not been previously diagnosed. These women require multidisciplinary care including but not limited to obstetrics and gynecology, maternal fetal medicine, neonatology, cardiology, cardiothoracic surgery, cardiothoracic anesthesia, and genetics. Decisions include screening for dissection, when to proceed with surgical management, the best mode and timing for delivery, postpartum care, and contraception.

Perioperative Management and Preemptive ECMO Cannulation of a Parturient with Cystic Fibrosis Undergoing Cesarean Delivery

Physiologic changes of pregnancy and cystic fibrosis pathology provide a unique set of circumstances. Pulmonary disease accounts for over 90% of the morbidity and mortality of patients with cystic fibrosis. These abnormalities create anesthetic challenges due to multiple organ systems being affected including the respiratory, gastrointestinal, cardiovascular, and genitourinary tracts, where patients present with chronic respiratory failure, pancreatic insufficiency, poor nutrition, and cardiac manifestations. We present the perianesthetic management of a parturient with cystic fibrosis who successfully underwent preterm cesarean delivery under neuraxial anesthesia with preemptive bilateral femoral venous sheaths placed for potential extracorporeal membrane oxygenation (ECMO) initiation.

Medical Complications in Pregnancy

Medical complications and intercurrent disease have long presented challenges to obstetricians and other medical providers caring for pregnant women. Contemporary medical practice and treatments have only added to these challenges. Advances in disease management mean that patients with some conditions (e.g., cystic fibrosis) whose life expectancies in the past would have precluded pregnancy are now living to reproductive age. Furthermore, treatments to restore fertility allow the barrier of age, as well as anatomic and genetic barriers, to be surmounted. All of these advances emphasize the need for careful and considered collaboration between clinicians caring for women of reproductive age who are not pregnant and those who care for them during pregnancy. This review discusses pregnancy planning and counseling, principles of teratogenesis, physiologic changes in pregnancy, cardiovascular disease, diabetes mellitus, thyroid disease, thrombophilia, asthma, infectious diseases, renal disease, autoimmune diseases, cancer, neurologic diseases, substance use, intrahepatic cholestasis, and pregnancy-specific conditions. Tables list elements of preconception care and counseling, the Food and Drug Administration drug classification system for pregnancy, selected drugs with suspected or known teratogenic potential, and physiologic changes of pregnancy. This review contains 15 tables and 83 references. Key Words: Headache, maternal mortality, obstetric medicine, pregnancy, pulmonary embolism

Medical Complications in Pregnancy

Medical complications and intercurrent disease have long presented challenges to obstetricians and other medical providers caring for pregnant women. Contemporary medical practice and treatments have only added to these challenges. Advances in disease management mean that patients with some conditions (e.g., cystic fibrosis) whose life expectancies in the past would have precluded pregnancy are now living to reproductive age. Furthermore, treatments to restore fertility allow the barrier of age, as well as anatomic and genetic barriers, to be surmounted. All of these advances emphasize the need for careful and considered collaboration between clinicians caring for women of reproductive age who are not pregnant and those who care for them during pregnancy. This review discusses pregnancy planning and counseling, principles of teratogenesis, physiologic changes in pregnancy, cardiovascular disease, diabetes mellitus, thyroid disease, thrombophilia, asthma, infectious diseases, renal disease, autoimmune diseases, cancer, neurologic diseases, substance use, intrahepatic cholestasis, and pregnancy-specific conditions. Tables list elements of preconception care and counseling, the Food and Drug Administration drug classification system for pregnancy, selected drugs with suspected or known teratogenic potential, and physiologic changes of pregnancy. This review contains 15 tables and 83 references. Key Words: Headache, maternal mortality, obstetric medicine, pregnancy, pulmonary embolism

Neurologic Diseases in Pregnancy

Neurologic conditions commonly affect women during pregnancy. The severity of some chronic conditions, such as headaches, epilepsy, and multiple sclerosis, may be affected by pregnancy. Due to teratogenicity, some medications used prior to pregnancy should be avoided or used at a lower dose during pregnancy. The physiologic changes of pregnancy put women at risk for new neurologic conditions, including posterior reversible encephalopathy syndrome, venous sinus thrombosis, and restless legs syndrome. Compression neuropathies may arise during pregnancy or delivery. Increased experience with neuroimaging has provided reassurance that magnetic resonance imaging may be used safely during pregnancy. This review contains 7 figures, 7 tables, and 30 references Key Words: epilepsy, headache, multiple sclerosis, myasthenia gravis, neurology, neuropathy, pregnancy, posterior reversible encephalopathy syndrome, stroke, venous sinus thrombosis

Pulmonary Edema in Obstetrics: Essential Facts for Critical Care Nurses

Pulmonary edema is an acute pregnancy complication that, if uncorrected, can result in increased maternal and fetal morbidity and mortality. Although pulmonary edema is relatively rare in the general obstetrics population, pregnant patients are at increased risk for pulmonary edema because of the physiologic changes of pregnancy. The risk may be exacerbated by certain pregnancy-related diseases, such as preeclampsia. Prompt identification and appropriate clinical management of pulmonary complications is critical to prevent adverse outcomes in pregnant patients. This article reviews the collaborative treatment of pulmonary edema in pregnant women with complex critical illnesses.

Cardiac Drugs in Pregnancy

Heart disease complicating pregnancy is an indirect cause of maternal mortality and its incidence in India is 1 to 4%. Cardiac disease in pregnant women is most commonly due to rheumatic heart disease (RHD), congestive heart failure, and less commonly due to ischemic heart disease or cardiomyopathy. Though the frequency of RHD has decreased worldwide, it is still predominant in developing countries such as India. Around 15 to 52% of cardiac abnormalities first diagnosed during routine antenatal checkups or due to the signs and symptoms caused by physiologic changes of pregnancy. The most common clinical features of cardiac lesions such as breathlessness, pedal edema, and murmurs that mimic normal physiologic changes in pregnancy pose a diagnostic difficulty for obstetricians.

Contemporary best practice urolithiasis in pregnancy

Urolithiasis is the most common nonobstetric complication in the gravid patient. The experience can provoke undue stress for the mother, fetus, and management team. The physiologic changes of pregnancy render the physical exam and imaging studies less reliable than in the typical patient. Diagnosis is further complicated by the need for careful selection of imaging modality in order to maximize diagnostic utility and minimize obstetric risk to the mother and ionizing radiation exposure to the fetus. Ultrasound remains the first-line diagnostic imaging modality in this group, but other options are available if results are inconclusive. A trial of conservative management is uniformly recommended. In patients who fail spontaneous stone passage, treatment may be temporizing or definitive. While temporizing treatments have classically been deemed the gold standard, ureteroscopic stone removal is now acknowledged as a safe and highly effective definitive treatment approach. Ultimately, a multidisciplinary, team-based approach involving the patient, her obstetrician, urologist, radiologist, and anesthesiologist is needed to devise a maximally beneficial management plan.

Diabetic Emergencies in Pregnancy

Diabetes in pregnancy is rising in incidence, and with this increase comes additional maternal and fetal risks. Precise diagnosis and timely management of diabetic obstetrical emergencies is critical. In particular, providers must recognize that diabetic ketoacidosis (DKA) may be seen at much lower glucose levels in pregnant patients compared with nonpregnant patients due to physiologic changes of pregnancy. Fluid resuscitation, correction of acidosis and careful electrolyte, glucose, and insulin replacement remain the mainstays of therapy in DKA during pregnancy. Although maternal mortality has decreased over recent decades, fetal mortality remains high, and therefore a multidisciplinary team should guide assessment and treatment of DKA. Decision for early delivery must weigh both the maternal and fetal status and consider adequacy of resuscitative efforts. This chapter provides a brief overview of diabetes in pregnancy with a focus on the diagnosis and management of diabetic emergencies in the obstetrical patient.