You are on page 1of 20

ACUTE PULMONARY

EDEMA IN PREGNANCY
By: Doc Mo

Acute pulmonary oedema in pregnant


women
uncommon but life-threatening event
Superimposed issues of the
physiological changes of pregnancy
and the presence of the fetus, as well
as the contributory effect of poorly
understood pathophysiology of
pregnancy related disease such as
pre-eclampsia.

Epidemiology of critical care in OB


Top causes of mortality in obstetric patients
admitted to the ICU1
Etiology

N (of 1354)

Percentage

Hypertension

20

21.5

Pulmonary

20

21.5

Cardiac

11

11.8

Hemorrhage

8.6

CNS

8.6

Sepsis/Infection

6.4

Malignancy

6.4

Data summarized from 16 studies


Dildy et al. Critical Care Obstetrics, 4th edition.

Pregnancy physiology
Cardiovascular adaptations:
10% by 7th week

Increased plasma volume


Hemodilution

Plateau at 50% by 32
weeks

Larger increase in
Blood pressure variability (CO
x SVR)
multiples

Increased heart rate

(1570 ml vs. 1960 ml)

Accompanied by RBC
Increased cardiac output (HR
x SV)
mass

SVR variability

Important for fetal growth


(IUGR with lower PV)
Result of contribution
from mother & fetus

Pregnancy physiology
Cardiovascular adaptations:
RBC mass < PV

Increased plasma volume


Hemodilution
Blood pressure variability
Increased heart rate

Better placental
perfusion?
Blood viscocity
Stasis
(CO
x SVR)
Placental thrombosis
Protective during delivery

Increased cardiac output (HR x SV)


SVR variability

Pregnancy physiology
Cardiovascular adaptations:
BP = CO x SVR

Increased plasma volume


Hemodilution
Blood pressure variability
Increased heart rate

Influenced by GA &
position
10% by 7th week
(likely due to
progesterone)

Initial drop is SBP 2


Increased cardiac output (HR
x SV)
SVR

SVR variability

to

(MAP in 1st trimester)


BP decreases until 28
weeks
Points of concern:
Method & Position

Pregnancy physiology
Cardiovascular adaptations:
20% in pregnancy

Increased plasma volume


Hemodilution

Likely 2 to SVR
Some impact from FT4

Blood pressure variability (CO x SVR)


Must always be weary of
Increased heart rate

other causes

Plays important role in


Increased cardiac output (HR
x SV)
certain diagnoses

SVR variability

(i.e. mitral stenosis)

Pregnancy physiology
Cardiovascular adaptations:
CO = HR x SV

Increased plasma volume


Hemodilution

Reflects LV capacity
Increases by 10th week

Blood pressure variability (CO x SVR)


Peaks (30-50%) at 26
Increased heart rate
Increased cardiac output
SVR variability

weeks
(4.5 L/min 6.0 L/min)
2 to HR before 20 weeks
2 to SV after 20 weeks

Pregnancy physiology
Cardiovascular adaptations:
Increased plasma volume
Hemodilution

Measure of impedance to
maternal after load
Decreases in 1st/2nd
trimester
(Nadir by 14-24 weeks)

Blood pressure variability (CO x SVR)


Increased heart rate

Increases in 3rd trimester

Inversely proportional to
Increased cardiac output (HR
x SV)
CO

SVR variability

Pregnancy physiology
Cardiovascular adaptations (during labor):
CO (35%) & HR (7%) during contractions
SupineLateral position=22%CO & 27%SV

CO during contractions:
17% at less than 3 cm
23% at 4-7 cm
35% at 8 cm or more
(Offset by regional anesthesia)

Pregnancy physiology
Cardiovascular adaptations (post partum):
Impacted by blood loss at delivery
Increased CO (59%) & SV (71%) within 1-3 hours

Maximal diuresis on days 2-5


Vaginal
Loss
Hct

500 ml
+5.2%

vs. Cesarean
1000 ml
-5.8%

Pregnancy physiology
Pulmonary adaptations:
Mucosal edema

Upper airways
Mechanics of respiration
Physiologic changes
Acid-base changes

Mucosal vascularity
Rhinitis & Epistaxis

Pregnancy physiology
Pulmonary adaptations:
Upper airways
Mechanics of respiration
Physiologic changes
Acid-base changes

8% thoracic
circumference
5 cm elevation of
diaphragm
Increase
15%
50%
76%

in dyspnea
by 10 weeks
by 19 weeks
by 31 weeks

Pregnancy physiology
Pulmonary adaptations:
FEV1

Upper airways
Mechanics of respiration
Physiologic changes
Acid-base changes

Unchanged

FRC

10-25%

TLC

minimally

Minute Vent20-40%
Alveolar Vent

50-75%

Pregnancy physiology
Pulmonary adaptations:
Upper airways
Mechanics of respiration
Physiologic changes
Acid-base changes

Pregnancy=Compensated
respiratory alkalosis

CO2 diffuses faster than


O2

Decreased PaCO2 (27-34)

Increased bicarb (18-21)

pH between 7.40 and


7.45
PaO2 (101-104)
A-a gradient (14.3)

Pregnancy physiology
Other adaptations:
Genitourinary
Gastrointestinal
Hematologic
Endocrine
Immune

Pulmonary-Pulmonary Edema
Causes:
Hydrostatic
Systolic dysfunction
Diastolic dysfunction
Valvular disease

Permeability
Pneumonia
Septic shock
ARDS

Other (i.e. decreased colloid)


Tocolytic induced
Preeclampsia

Pulmonary-Pulmonary Edema
Treatment (general):
Sit patient upright
Administer oxygen (may use CPAP until diuresis)
Furosemide (aim for 2L diuresis in 3-4 hours)
Morphine (2-5 mg IV)
Treatment (Specific):
Systolic dysfunction (afterload reduction/inotrop/diuretic)
Diastolic dysfunction (anti-HTN)

Management
Acute pulmonary edema requires emergency
management. Furosemide is given in 20 to 40 mg
intravenous doses along with therapy to control
dangerous hypertension.
Ante/post artum? Fetus dead/alive?
cardioactive drugs lower peripheral resistance and
in turn severely diminish uteroplacental circulation.
The cause of cardiogenic failure echocardiography,
Not an indication for emergency cesarean delivery.
Indeed, in most cases, these women are better
served by vaginal delivery.