Acute Pulmonary Edema in Pregnancy

8/9/2019 Acute Pulmonary Edema in Pregnancy

1/20

ACUTE PULMONARY

EDEMA IN PREGNANCY

By: Doc Mo


2/20

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,


3/20

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


4/20

#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)


5/20




• Hemodilution




-RBC ma)) 7 -P8

Better placentalper$u)on9

↓ Blood visoit! ↓ "t#sis↓ Pl#e$t#l throm%osis

Protect'e durn! del'ery


6/20




• Hemodilution

• Blood pressure variability



BP CO ; (8R

In


7/20




• Hemodilution




-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)


8/20




• Hemodilution



• Increased cardiac output

• SVR variability

CO R ; (8

Re to R #e$ore 5/ "ee2)

5> to (8 a$ter 5/ "ee2)


9/20




• Hemodilution



• 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


10/20


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)


11/20


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."


12/20


#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;)


13/20



• 7pper air1ays




?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


14/20



• 7pper air1ays




@E8. Unc&an!ed

@RC =./%530

TLC = mnmally

Mnute 8ent-5/%/0

Al'eolar 8ent -3/%130


15/20



• 7pper air1ays




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


16/20


Other adaptations%

• :enitourinary

• :astrointestinal

• Hematolo&ic

• ;ndocrine

• Immune


17/20

#ulmonaryulmonary Edema

Causes%• Hydrostatic

• Systolic dys/unction•


18/20

#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)


19/20


20/20

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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Acute Pulmonary Edema in Pregnancy