CLINICAL OBSTETRICS AND GYNECOLOGY Volume 53, Number 2, 360368 r 2010, Lippincott Williams & Wilkins

Acute Respiratory Failure in Pregnancy

HUGH E. MIGHTY, MD Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, School of Medicine, Baltimore, Maryland
Abstract: The maternal respiratory tract undergoes significant anatomic and physiologic changes during pregnancy, which increase maternal susceptibility to respiratory failure. Respiratory failure in pregnancy is relatively rare, but it remains one of the leading conditions requiring intensive care unit admission in pregnancy and carries a high risk of maternal and fetal morbidity and mortality. Acute respiratory failure can result from a variety of conditions, most of which are not pulmonary in origin. Early diagnosis of underlying disease is critical, as it will guide the management approach. Treatment goals during respiratory failure in the pregnant woman are similar to those outside of pregnancyto maintain adequate ventilation and to provide hemodynamic and nutritional support. Additionally, the obstetrician will need to monitor fetal status and help to determine the best timing for delivery. Key words: respiratory failure, ARDS, obstetric, critical care, mechanical ventilation

Background
Acute respiratory failurethe inability of the respiratory system to maintain adequate gas exchange or adequate ventilationoccurs in fewer than 0.1% of pregnancies.1 Although acute respiratory failure in pregnancy is rare, it is one of the most common indications for obstetric admissions into the intensive care unit and is an important cause of maternal
Correspondence: Hugh E. Mighty, MD, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland, School of Medicine, 250 W. Pratt Street, Suite 880, Baltimore, MD. E-mail: hmighty@upi.umaryland.edu
CLINICAL OBSTETRICS AND GYNECOLOGY /

mortality.2 In a retrospective review of 93 critically ill obstetric patients, El-Sohl and Grant found that respiratory illness and the need for mechanical ventilation were both higher in the obstetric population than in the nonobstetric population.3 Acute respiratory failure in pregnancy can result from either obstetric-related conditions, such as severe preeclampsia and amniotic fluid embolism, or from conditions not directly related to pregnancy, such as pneumonia and asthma. Pregnancyrelated changes in the respiratory tract, however, affect maternal predisposition to complications from these conditions, including respiratory failure, and can affect the overall management of the pregnant woman. For example, the mucosal edema seen in pregnancy puts a pregnant woman at an 8-fold higher risk of failed tracheal intubation over the general population of surgical patients.4 Table 1 summarizes some of the pregnancy-related changes in respiratory anatomy and physiology and their impact on the course and management of respiratory failure.

Common Causes of Respiratory Failure in Pregnancy

The causes of respiratory failure are summarized in Table 2. Some of the more
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Acute Respiratory Failure

TABLE 1.
Type of Change Anatomical

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Physologic Changes
Description Increase in subcostal angle from 601 to 1301 Rise in diaphragm Rise in intra-abdominal pressure + decreased tone of esophageal sphincter Minute ventilation increases 40-50% (Achieved mostly though increase in tidal volume) Increased tidal volume Decreased functional residual capacity Cause Impact on Risk or Management of Respiratory Failure Decreased chest compliance may affect mechanical ventilation To accommodate enlarging uterus Increased risk of aspiration

Physiological

To meet increased maternal, fetal and placental oxygen requirements and increased need for CO2 elimination To meet increased oxygenation needs Larger expiratory volume

Fall in arterial PaCO2 which results in compensated metabolic alkalosis. Limits use of permissive hypercapnea Affects volume settings during ventilation and may change propensity to barotraumas Lower alveolar closing pressures with increased risk of alveolar collapse

common causes of respiratory failure are discussed in further detail below.

PULMONARY EDEMA

In recent years, the use of beta-agonists for tocolysis has decreased. However, the
TABLE 2. Selected Causes of Respiratory Failure in Pregnancy

The constellation of changes seen in pregnancy and in the peripartum period is believed to predispose the gravida to the development of hydrostatic pulmonary edema. These include increases in cardiac output with concurrent changes in systemic vascular resistance and colloid oncotic pressure. Women with underlying disease processes, especially chronic or acute hypertensive conditions, severe preeclampsia, or cardiac diseases, such as pulmonary hypertension or outflow tract obstructions, are at particular risk of pulmonary compromise. Iatrogenic pulmonary edema can be seen with tocolytic therapy using beta-2 agonists. In a large, retrospective study, half of all the obstetric patients who developed pulmonary edema had undergone tocolytic therapy or had underlying cardiac disease.5 In this series, all the women who developed pulmonary edema as a result of tocolysis were being treated with multiple tocolytics simultaneously.

Pregnancy specific Amniotic fluid embolism Pulmonary edema owing to tocolytics Pulmonary edema owing to preeclampsia/ eclampsia Nonpregnancy specific Pneumonia Aspiration Community-acquired Aspiration of gastric contents Pulmonary embolism Venous air embolism Cardiogenic pulmonary edema Asthma ARDS Pulmonary edema Preeclamspia/Eclampsia Aspiration Choriomanionitis Amniotic fluid embolism Placental abruption Hemorrhage Sepsis Infections Trauma

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Mighty in pregnancy have had pneumonia in the course of their pregnancy.6 The increased risk of complications from influenza and pneumonia is believed to arise from normal physiologic changes in pregnancy, such as decreased functional residual capacity and a reduction in cell-mediated immunity. Women with underlying disease, especially those with compromised immune function, such as HIV infection, are particularly susceptible to complications. Prevention of disease, including influenza vaccinations for women during pregnancy, and early diagnosis and treatment of infection with antivirals or antibiotics are critical in avoiding complications, including acute respiratory distress syndrome (ARDS) and respiratory failure.
STATUS ASTHMATICUS

increased use of magnesium sulfate, steroids for fetal lung maturity, and IV hydration has contributed to the incidence of pulmonary edema. Infection and multiple gestation, and even the increased demands of labor and birth may also promote pulmonary edema. Signs and symptoms of pulmonary edema include basilar crackles, shortness of breath, and bilateral air space loss on chest x-ray. Most women with tocolytic-induced pulmonary edema will respond to discontinuation of the tocolytic, cautious diuresis, and supplemental oxygen therapy. These women will usually experience a transient noncardiogenic pulmonary edema and will generally not require mechanical ventilation. To minimize the risk of pulmonary edema in the patient undergoing tocolytic therapy, regardless of the modality (magnesium sulfate, beta-2 agonists, etc.), the minimal effective dose and duration of therapy should be chosen. If diuretics are administered in a pregnant patient, care should be taken to maintain adequate uterine perfusion with the understanding that pregnant women will usually respond to lower doses of diuretics than nonpregnant women. Antihypertensive agents may be helpful in decreasing afterload and may be indicated for the management of elevated blood pressures in the preeclamptic or eclamptic patient. If aggressive antihypertensive therapy is indicated, however, invasive hemodynamic monitoring may be necessary.
INFLUENZA AND PNEUMONIA

The pathogenesis, signs and symptoms, and diagnostic procedures for pneumonia are similar for both the pregnant and nonpregnant women. Infection rates among pregnant women do not seem to differ significantly from women of reproductive age outside of pregnancy. The rate of morbidity and mortality from both influenza and pneumonia, however, are significantly higher in pregnancy. One third of women with respiratory failure www.clinicalobgyn.com

Asthma is the most common respiratory condition of pregnancy.7 Approximately, 20% to 35% of pregnant patients with asthma will experience an asthma exacerbation during pregnancy. For reasons that are not fully understood, severe asthma exacerbations seem to be most common during the second trimester of pregnancy. Initial management of the pregnant patient suffering from acute, life-threatening bronchopsasm consists of administration of supplemental oxygen, intravenous fluids, intravenous steroid, and beta-agonist therapy to alleviate bronchospasm and airway inflammation. A careful balance has to be maintained between relieving airway spasm and avoiding fluid overload. The combination of the edematous airway seen in pregnancy with bronchial overresponsiveness seen in asthmatic patients can make these patients very difficult to intubate and ventilate. Rather than waiting for the need for emergent ventilation, intubation should be considered early for patients not exhibiting the expected improvement with initial therapy. Objective measurement of improvement with airflow analyzers (peak flow meters), improved respiratory effort, and arterial blood gases will help to determine the

Acute Respiratory Failure patients trend either towards improvement or deterioration.

ASPIRATION

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Increased gastric pressure, decreased esophageal sphincter tone, and delayed gastric emptying place pregnant patients at increased risk for aspiration. The laboring patient is exposed to additional risks for aspiration, including sedation, analgesia, increased intra-abdominal pressure related to contractions and pushing efforts, and recumbent positioning. Those women undergoing emergent cesarean section under general anesthesia are particularly at risk of aspiration. In addition to being an independent risk factor for respiratory failure, aspiration of gastric contents can lead to aspiration pneumonia, acute bronchospasm, and ARDS. Strategies to avoid aspiration include the use of regional anesthesia and avoidance of general anesthesia, minimizing gastric contents by limiting or avoiding food intake during labor, administration of H2 blockers to decrease acidity of gastric contents, and the use of cricoid pressure, if intubation is necessary.
AMNIOTIC FLUID AND VENOUS AIR EMBOLISM

lism is significantly increased in pregnancy and is one of the leading causes of maternal death. Diagnosis of pulmonary embolus in pregnancy includes a careful history and physical examination. The examiner should look for specific risk factors, including obesity, advanced maternal age, family or personal history of thromboembolic events, and prolonged immobility; he should also look for signs and symptoms, including dyspnea, calf pain or swelling, chest pain, tachycardia, and dizziness. When the history and physical are suggestive of pulmonary embolism , confirmatory evidence can be sought with an arterial blood gas, a chest radiograph, and/or a rapid CT scan (spiral CT) of the chest. Additionally, when the above are inconclusive, a ventilationperfusion scan can aid with the diagnosis. If pulmonary embolus is suspected, anticoagulation therapy with heparin is indicated. Supportive therapy, including mechanical ventilation is indicated in those with signs of acute respiratory failure.

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

Both amniotic fluid and venous air embolus are rare events that carry high morbidity andespecially, in the case of amniotic fluid embolismhigh mortality rates. Both of these types of pulmonary emboli present with severe dyspnea, hypoxemia, tachypnea, tachycardia, and hypotension. Cardiac arrest often ensues, sometimes, within minutes. In those patients who survive the initial event, ARDS and DIC are common. Management is supportive and will usually include ventilatory assistance.
PULMONARY EMBOLUS

In addition to being independent risk factors for respiratory failure, most of the conditions described above can also lead to respiratory failure through ARDS. Table 2 lists the common causes of ARDS. ARDS is a form of acute lung injury in which there is hypoxemia and diffuse pulmonary inflammation resulting in increased alveolar-capillary permeability and decreased lung compliance. As defined by the American-European Consensus Conference, ARDS is a lung injury that meets the following criteria8:
(1) Acute onset. (2) Presence of bilateral infiltrated on chest radiograph. (3) Pulmonary artery wedge pressure <18 mmHg or absence of clinical evidence of left atrial hypertension. (4) PaO2 to FiO2 ratio of no more than 200.

Owing to the hypercoagulability associated with pregnancy and the increased tendency toward venous stasis as pregnancy progresses, the risk of pulmonary embo-

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Mighty while making adjustments to optimize ventilation in recognition of the anatomic and physiologic impact of pregnancy and, when possible, the oxygenation needs of the fetus. Increased risk of aspiration and mucosal edema with a decreased area of glottic opening leads to an 8-fold increase in the risk of failed intubation.4 More modern techniques of fiber optic-guided intubation have led to decreased incidence of intubation failures. Decreased lung residual capacity can lead to more rapid development of hypoxia, hypercarbia, and acidosis during even short periods of apneaas seen either during acute insults or during procedures, such as endotracheal intubation. The chronic compensated respiratory alkalosis of pregnancy promotes the elimination of fetal metabolic waste. This, however, leads to decreased buffering capacity in the presence of maternal metabolic acidosis and decreased reserves for further respiratory compensation. Oxygenation needs of the fetus require maternal PaO2 and oxygen saturation that are higher than those in the nonpregnant population as outlined in Table 3.
NONINVASIVE POSITIVE PRESSURE VENTILATION

ARDS-related maternal mortality rates reported in the literature vary widely from 9% to 44%.9 One of the largest retrospective study of ARDS cases (n = 41) reported a maternal mortality rate of 24.4%.10 Maternal deaths related to ARDS are most commonly owing to respiratory failure, multiple-system organ failure, sepsis, complications from mechanical ventilation, and cardiac arrest. Neither the etiology of ARDS, nor the presence of preexisting conditions is predictive of maternal outcomes, but the risk of developing ARDS increases as the number of risk factors increases. Perinatal mortality from ARDS is also high-most commonly reported to be between 20% and 30%.9 Infants who survive have a high risk of morbidity, especially because of complications from premature birth and/or from perinatal asphyxia. The most common initial complaint in ARDS is shortness of breath.11 Other symptoms include fever, chills, and loss of consciousness. Early recognition of the patient at risk for respiratory failure, expedient transfer to a critical care unit, and collaborative management of the patient by an intensivist and obstetrician will help to optimize outcomes. Management goals are to stabilize the patient, identify, and treat the underlying condition(s), limit the extent of lung injury, prevent complications, and provide necessary ventilation, hemodynamic, and nutritional support. In pregnancy, management must also include monitoring and evaluation of fetal status and a plan for delivery.
AIRWAY MANAGEMENT AND MECHANICAL VENTILATION

Positive pressure ventilation is delivered through a tight-fitting mask. There are limited data about its use and effectiveness in pregnancy. Routine use is not advised owing to difficulties in obtaining a proper fit for adequate oxygenation and the theoretical risk of aspiration.
TABLE 3.
Markers SaO2 Maternal PaCO2 Tidal volume Maternal pH Peak or plateau pressures

As admissions of obstetric patients to the ICU are rare events, there is a paucity of data regarding the best approach to mechanical ventilation in pregnancy. The most appropriate current management approach is to apply the best-practice principles used in the nonobstetric population www.clinicalobgyn.com

Goals of Respiratory Support

Target 95% <45 mm Hg 6-8 mm/kg IBW >7.30 <35 cm H2O

Acute Respiratory Failure However, when faced with a time-limited respiratory compromise, it may be appropriate to use noninvasive positive pressure ventilation (NIPPV) when supplemental oxygen has not improved oxygenation. The ideal candidate should meet at least the following criteria: adequate respiratory drive, ability to control ones own airway, ability to tolerate tight-fighting mask, hemodynamic stability, and not be at high risk for aspiration.

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MECHANICAL VENTILATION VIA ENDOTRACHEAL TUBE

Most obstetric patients in respiratory failure will require mechanical ventilation via endotracheal intubation. The choice of an initial ventilatory rate, tidal volume, oxygen percentage, and the need for positive end expiratory pressure (PEEP), should be balanced against the potential inducement of barotrauma from an unequal distribution of compliant alveoli or from bronchoconstriction. It should be noted as well that any positive pressure method will potentially lead to a worsening of hemodynamic performance secondary to increased intrathoracic pressure and decreases in preload. In practice, tidal volume can be delivered using either volume-regulated or pressure-regulated modes. Volume control modes guarantee tidal volume even in the presence of fluctuating airway resistance and compliance and reducing the rate of lung atelectasis. However, this can lead to a higher work of breathing for the patient and carries an increased risk of trauma to the lung. Pressure control ventilation uses inspiratory pressure as a control variable and is associated with improved ventilation-perfusion matching. Although this is less likely to cause trauma to the lung, it can make it harder to achieve desired constant minute ventilation. Current ventilator technology allows for an extremely wide combination of these

forms of mechanical ventilation. Table 4 reviews some of the most common modes of mechanical ventilation. Additional modes, such as inverse-ratio ventilation and airway pressure-release ventilation have been created to address some of the limitations of the traditional modes. Regardless of the modality, the goal of reducing barotrauma while providing adequate oxygenation and elimination of CO2 remains paramount. A reasonable starting point for mechanical ventilation may use the following settings:  Respiratory rate 10 to 14 breaths/min  Tidal volume 5 to 8 mL/kg  Minute ventilation less than 115 mL/kg  Extrinsic PEEP only as needed to improve
oxygenation

 FiO2 beginning at 100% and weaning as

tolerated to <50% while maintaining an Oxygen saturation of greater than 94%.

Adjustment of settings can be realized and various modalities can be used to achieve the maternal oxygenation goals. In severe cases, optimal oxygenation cannot be achieved within reasonable lung pressures, and carry a higher risk of barotrauma. In these circumstances, it may become necessary to tolerate a higher level of CO2 retention (permissive hypercapnea). This strategy, however, can interfere with removal of carbon dioxide from the fetal compartment. There are no good human studies on the impact of permissive hypercapnea on the fetus and, therefore, it should be used with caution. In certain conditions, such as, ARDS, PEEP may be a necessary component of mechanical ventilation to improve oxygenation through improvement in V/Q ratio and recruiting of collapsed alveoli. The use of PEEP, however, carries a risk of compromised cardiac output and increased intracranial pressure. High-level PEEP has not been shown to greatly improve long-term outcomes over lowlevel PEEP and was associated with hypotension and hypoxemia.4 www.clinicalobgyn.com

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Traditional Modes of Mechanical Ventilation
Used if patient under Work of breathing done general anesthesia or on entirely by ventilator and neuromuscular blockade no assist is given to respiratory efforts between or in coma set breaths Low work of breathing Minimal rate and tidal volume can be set, but every patient inspiratory effort triggers delivery of a set tidal volume The patient can breathe at a Benefits are theoretical: Decreased incidence of spontaneous rate and respiratory alkalosis, volume without ventilator decreased intrathoracic assistance. The ventilator pressure (which leads to provides additional breads at a preset rate and volume decreased cardiovascular problems) Increased patient comfort, Combines mandatory decreased need for breaths if no inspiratory sedation. Good weaning effort detected in mode synchrony with patienttriggered, pressure limited mechanical breath that is delivered with each patient spontaneous breath

TABLE 4.
Controlled mode

Assist control mode (A/C)

Intermittent mandatory mode (IMV)

Can lead to alkalosis, decreased cardiac output, and barotrauma (if patient attempted exhalation during ventilator driven inflation Increased work of breathing, patient fatigue

Synchronized intermittent mandatory ventilation (SIMV)

May not meet patients ventilatory demands especially if increasing patient need or if prolonged time delay between patient breath and delivery of fresh gas

Adapted with permission from Critical Care Obstetrics. 4th Edition. Wiley-Blackwell, 2003.12 Adapted with permission from Pulmonary Problems in Pregnancy (Respiratory Medicine). New York City: Humana PressSpringer Science, 2009.4

Additional Management Concerns

Fluid homeostatis is one of the primary management goals of the patient in respiratory failure. Achieving a balance between adequate organ perfusion (including placental perfusion, if the patient is still pregnant) and limiting the accumulation of extravascular fluid in the lungs may require invasive hemodynamic monitoring. Pulmonary artery catheter is the most often recommended method of hemodynamic monitoring in this patient population, although newer methods of estimating cardiac output from arterial lines and/or central venous pressure catheters exist. With these arterial pressure-based cardiac output devices, cardiac output can be continuously measured in real time and offer a potentially safer and more readily applicable alternative to insertion of a PA catheter. www.clinicalobgyn.com

Displacement of the uterus by a slight (10 to 15 cm) elevation of the right hip can help to alleviate the supine hypotension and decrease in cardiac preload that may occur from compression of the vena cava. In extreme cases of respiratory failure (ARDS), prone positioning has been applied with combination ventilatory modes to improve oxygenation. There are no outcome data to favor this method over traditional ones in pregnancy; however, there is strong evidence to show that prone positioning improves oxygenation in ARDS in nonobstetric populations.13 To have a proper bed is essential to avoiding abdominal uterine compression and may be a limiting factor. The left or right lateral position may be preferred in the pregnant patient over proning. To optimize maternal comfort and to reduce maternal oxygen consumption,

Acute Respiratory Failure analgesia and/or sedation may be required, especially when using positive pressure ventilation. Nutritional support should begin as soon as possible, preferably within 24 to 48 hours, as the higher metabolic needs of pregnancy lead very quickly to a starvation state. Enteral feedings are preferable and carry a lower risk of catheter contamination that is associated with parenteral nutrition. The risk of aspiration, however, is increased with enteral feeding in the sedated patient.
CARE OF THE FETUS AND DECISION TO DELIVER

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Although maternal status is the first priority, in cases of antepartum respiratory failure, monitoring and care of the fetus, including a plan for delivery, becomes a necessary part of the management plan at one point or another. In the presence of certain conditions, such as abruption, severe preeclampsia or eclampsia, or when maternal cardiac arrest has ensued and successful resuscitation seems unlikely, delivery of the fetus will usually be carried out, regardless of gestational age. In other cases, however, the decision of when to deliver may be made more deliberately. This decision needs to assess (a) the risks to the fetus of prematurity with the risks of continued exposure to a hostile uterine environment; (b) the direct risks to the mother of limiting treatment modalities because of her pregnancy; and (c) risks of delivery, given the maternal stability or the lack of it. Historically, the prevailing thought has been that delivery of the fetus is desirable to improve maternal oxygenation and improve the speed or odds of maternal recovery and/or survival. Studies that have specifically examined whether delivery has improved maternal outcome, however, have not supported this hypothesis and, in fact, may support avoiding delivery for nonobstetric indications. In their retrospective case series Tomlison

et al14 reported the outcomes of 10 women who required intubation for respiratory failure and who delivered while on ventilatory support. Although these women experienced a 28% decrease in fraction of inspired oxygen required, overall respiratory function was not improved. Jenkins et al15 conducted a similar study. Their case series consisted of 51 women. Twenty-four of these women underwent cesarean section, 11 of which were carried out for maternal condition. The mortality rate in this group was 36%. The investigators conclude that cesarean delivery in this population should be minimized, if possible, and carried out mainly for obstetric indications. Deciding on a modality and frequency of fetal monitoring in the critically ill patient should take into account a variety of variables, including gestational age, maternal status, and the ability and/or desire to intervene in the presence of evidence of fetal hypoxia. Fetal heart rate decelerations and loss of variability and the sudden onset of uterine contractions can be an early sign of maternal hypovolemia or deteriorating maternal status and therefore continuous fetal heart rate monitoring of the viable fetus may be useful not only in monitoring fetal status, but maternal status as well.

Summary
The pregnant patient who develops respiratory failure presents significant challenges. Early recognition and initiation of respiratory support are essential components of management to optimize outcomes for both mother and fetus. When possible, identification of the inciting cause of respiratory failure and rapid steps to correct or eliminate the source is vital to the eventual course. Respiratory support with mechanical ventilation is a mainstay. With todays computerized ventilators, ventilation modalities can be www.clinicalobgyn.com

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Obstetrics & Gynecology. 2003;101: 511515. Collop NA, Fau-Sahn SA, Sahn SA. Critical illness in pregnancy. An analysis of 20 patients admitted to a medical intensive care unit. Chest. 1993;102: 15481552. Campbell LA, Fau-Klocke RA, Klocke RA. Update in nonpulmonary critical care: implications for the pregnant patient. Am J Respir Crit Care Med. 2001; 163:10511054. Bernard G, Artigas A, Brigham K, et al. The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med. 1994;149:818824. Cole D, Taylor T, McCullough D, et al. Acute respiratory distress syndrome in pregnancy. Crit Care Med. 2005;333: S269S278. Perry K, Martin R, Blake P, et al. Maternal mortality associated with adult respiratory distress syndrome in pregnancy. South Med. 1998;91:441444. Chen C, Chen C, Wang K, et al. Factors implicated in the outcome of pregnancies complicated by acute respiratory failure. J Reprod Med. 2003;48:641648. Whitty JE. Airway management in critical illness. In: Dildy GA, Belfort MA, Saade GR, et al. eds. Critical Care Obstetrics. 4th ed. Malden, MA: Wiley-Blackwell; 2003. Pelosi P, Brazzi L, Gattinoni L. Prone positioning in acute respiratory distress syndrome. Eur Respir J. 2002;20: 10171028. Tomlison M, Cauthers T, Whitty J. Does delivery improve maternal condition in the respiratory-compromised gravida? Obstet Gynecol. 1998;91:108111. Jenkins T, Trolano N, Graves C, et al. Mechanical ventilation in an obstetric population: characteristics and delivery rates. Am J Obstet Gynecol. 2003;188: 549552.

better tailored to protect the lungs under very challenging circumstances. A coordinated response and management plan by a team that includes obstetricians, intensivists, anesthesiologists, neonatologists, and skilled nursing providers will help to optimize outcomes for these critically ill mothers and their fetuses. With prolonged bedrest, provision of DVT prophylaxis with heparin and/or sequential compression devices, enteral or parenteral nutrition, and GI stress reduction with protonics should be instituted. The timing and method of delivery should be guided by obstetrical indications, where possible, with attention to preserving the in utero status of the premature but viable fetus before 32 to 34 weeks of gestation.

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References
1. Chen CY, Fau-Chen C-P, Chen CP, et al. Factors implicated in the outcome of pregnancies complicated by acute respiratory failure. J Reprod Med. 2003;48:641648. 2. Christiansen L, Collin K. Pregnancy associated deaths: a 15-year retrspective study and overall review of maternal pathophysiology. Am J Foren Med Path. 2006;27:1119. 3. El-Solh A, Grant BJ. A comparison of severity of illness scoring systems for critically ill obstetric patients. Chest. 1996; 110:12991304. 4. Munnur U, Bandi VDP, Gropper M. Airway management and mechanical ventilation in pregnancy. In: Bourjeily G, Montella K, eds. Pulmonary Problems in Pregnancy (Respiratory Medicine). New York City: Humana Press-Springer Science; 2009. 5. Sciscione AC, Ivester T, Largoza M, et al. Acute Pulmonary Edema in Pregnancy. 11.

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