acute pulmonary edema in pregnancy
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ACUTE PULMONARY
EDEMA IN PREGNANCY
By: Doc Mo
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Acute pulmonary oedema n pre!nant"omen
• uncommon #ut l$e%t&reatenn! e'ent
• (upermpo)ed ))ue) o$ t&ep&y)olo!cal c&an!e) o$ pre!nancyand t&e pre)ence o$ t&e $etu)* a) "ella) t&e contr#utory e+ect o$ poorlyunder)tood pat&op&y)olo!y o$
pre!nancy related d)ea)e )uc& a)pre%eclamp)a,
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Epidemiology of critical care in OBTop causes of mortality in obstetric patients
admitted to the ICU1
Data summarized from 16 studies
Dildy et al. Critical Care Obstetrics, 4 th edition.
Etiology N (of 13!" #ercentage
Hypertension 2 21.!
"ulmonary 2 21.!
Cardiac 11 11.#Hemorrha$e # #.6
C%& # #.6
&epsis'(nfection 6 6.4
)ali$nancy 6 6.4
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#regnancy physiology
Cardio$ascular adaptations%
• Increased plasma volume
• Hemodilution
• Blood pressure variability (CO x SVR)
• Increased heart rate
• Increased cardiac output (HR x SV)• SVR variability
-./0 #y 1t& "ee2
Plateau at 3/0 #y 45"ee2)
Lar!er ncrea)e nmultple)(1570 ml vs. 1960 ml)
Accompaned #y -RBC
ma))
Important $or $etal !ro"t&(↑IUGR with lower PV)
Re)ult o$ contr#uton
$rom mot&er 6 $etu)
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#regnancy physiology
Cardio$ascular adaptations%
• Increased plasma volume
• Hemodilution
• Blood pressure variability (CO x SVR)
• Increased heart rate
• Increased cardiac output (HR x SV)• SVR variability
-RBC ma)) 7 -P8
Better placentalper$u)on9
↓ Blood visoit! ↓ "t#sis↓ Pl#e$t#l throm%osis
Protect'e durn! del'ery
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#regnancy physiology
Cardio$ascular adaptations%
• Increased plasma volume
• Hemodilution
• Blood pressure variability
• Increased heart rate
• Increased cardiac output (HR x SV)• SVR variability
BP CO ; (8R
In
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#regnancy physiology
Cardio$ascular adaptations%
• Increased plasma volume
• Hemodilution
• Blood pressure variability (CO x SVR)
• Increased heart rate
• Increased cardiac output (HR x SV)• SVR variability
-5/0 n pre!nancy
L2ely 5> to =(8R
(ome mpact $rom -@T
Mu)t al"ay) #e "eary o$ot&er cau)e)
Play) mportant role n
certan da!no)e)(i.e. mitr#l ste$osis)
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#regnancy physiology
Cardio$ascular adaptations%
• Increased plasma volume
• Hemodilution
• Blood pressure variability (CO x SVR)
• Increased heart rate
• Increased cardiac output
• SVR variability
CO R ; (8
Re to R #e$ore 5/ "ee2)
5> to (8 a$ter 5/ "ee2)
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#regnancy physiology
Cardio$ascular adaptations%
• Increased plasma volume
• Hemodilution
• Blood pressure variability (CO x SVR)
• Increased heart rate
• Increased cardiac output (HR x SV)
• SVR variability
Mea)ure o$ mpedance tomaternal a$ter load
Decrea)e) n .)tF5nd
trme)ter(#dir %! 1-2- wee&s)
Increa)e) n 4rd trme)ter
In'er)ely proportonal to
CO
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#regnancy physiology
Cardio$ascular adaptations (during labor"%
• ↑CO (!") # $HR (%") durin& contractions
• Supine'ateral position"↑CO # %"↑SV
• ↑CO durin& contractions*• +%" at less than cm• " at ,-% cm• !" at . cm or more
(O//set by re&ional anesthesia)
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#regnancy physiology
Cardio$ascular adaptations (post partum"%
• Impacted by blood loss at delivery
• Increased CO (!0") # SV (%+") 1ithin +- hours
• 2aximal diuresis on days -!
Va&inal vs3 Cesarean'oss !44 ml +444 ml
5 Hct 6!3" -!3."
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#regnancy physiology
#ulmonary adaptations%
• 7pper air1ays
• 2echanics o/ respiration
• 8hysiolo&ic chan&es
• 9cid-base chan&es
-Muco)al edema
-Muco)al 'a)cularty
-R&nt) 6 Ep)ta;)
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#regnancy physiology
#ulmonary adaptations%
• 7pper air1ays
• 2echanics o/ respiration
• 8hysiolo&ic chan&es
• 9cid-base chan&es
?0- t&oracccrcum$erence
3 cm ele'aton o$
dap&ra!m
Increa)e n dy)pnea153 %! 10 wee&s503 %! 19 wee&s763 %! 41 wee&s
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#regnancy physiology
#ulmonary adaptations%
• 7pper air1ays
• 2echanics o/ respiration
• 8hysiolo&ic chan&es
• 9cid-base chan&es
@E8. Unc&an!ed
@RC =./%530
TLC = mnmally
Mnute 8ent-5/%/0
Al'eolar 8ent -3/%130
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#regnancy physiology
#ulmonary adaptations%
• 7pper air1ays
• 2echanics o/ respiration
• 8hysiolo&ic chan&es
• 9cid-base chan&es
Pre!nancyCompen)atedre)pratory al2alo))
↓
CO5 d+u)e) $a)ter t&an
O5↓
Decrea)ed PaCO5 (274-)
↓
Increa)ed #car# (121)↓
p #et"een 1,/ and1,3
-PaO5 (10110-)
-A%a !radent .,4
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#regnancy physiology
Other adaptations%
• :enitourinary
• :astrointestinal
• Hematolo&ic
• ;ndocrine
• Immune
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#ulmonaryulmonary Edema
Causes%• Hydrostatic
• Systolic dys/unction•
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#ulmonaryulmonary EdemaTreatment (general"%
• Sit patient upri&ht •
9dminister oxy&en (may use C898 until diuresis)• ?urosemide (aim /or ' diuresis in -, hours)• 2orphine (-! m& IV)
Treatment ('pecific"%• Systolic dys/unction (a/terload reduction@inotrop@diuretic)• A)
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Management
• Acute pulmonary edema reure) emer!encymana!ement, @uro)emde ) !'en n 5/ to / m!ntra'enou) do)e) alon! "t& t&erapy to control
dan!erou) &yperten)on,• AnteFpo)t artum9 @etu) deadFal'e9
• cardoact'e dru!) lo"er perp&eral re))tance andn turn )e'erely dmn)& uteroplacental crculaton,
T&e cau)e o$ cardo!enc $alure
ec&ocardo!rap&y*• Not an ndcaton $or emer!ency ce)arean del'ery,
Indeed* n mo)t ca)e)* t&e)e "omen are #etter
)er'ed #y 'a!nal del'ery,
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