Explainers

Monitoring a Critically Ill Pregnant Patient


Assessing and monitoring a critically ill patient who is pregnant can be extra challenging because of the physiological changes that occur during pregnancy as well as the priorities of care extending not only to the mother but to the care of the unborn fetus as well (Jevon 2012).

Failure to recognise, manage and treat abnormalities in the patient’s airway, breathing and circulation are the most common causes for cardiorespiratory arrest (Resuscitation Council UK 2006). These deficiencies are also present in the care of pregnant patients and a leading factor in maternal deaths (Grady et al. 2007).

Early recognition and management are therefore very important in improving patient outcomes.

The critically ill pregnant patient must be approached using a systematic ABCDE assessment approach, but modifications will be required. These changes can be made only when the clinical staff has a sound understanding of the physiological changes associated with pregnancy.

Therefore, expert help should be summoned at the earliest opportunity from midwives, emergency teams, obstetricians and paediatric teams to improve the outcome of both mother and fetus (Lewis 2007).

Physiological Changes that Occur During Pregnancy

Pregnancy is associated with physiological changes that assist fetal survival as well as preparation for labour. It is essential to know what the ‘normal’ parameters of change are in order to manage the common medical problems of pregnancy.

Some of the physiological changes include:

Respiratory Changes

  • Increased mucosal oedema may be present in the airways, possibly as a result of increased total body water (Jevon 2012).
  • Increased oxygen consumption due to fetal requirements and the increased work of breathing.
  • Nasal congestion.
  • Increase in respiratory rate and breathlessness.
  • Functional residual capacity is reduced (FRC): this compromises gas exchange and reduces oxygen reserve, meaning that a patient will become hypoxaemic more quickly if breathing becomes compromised (Adam & Osborne 2005).

Changes in Circulation

  • Increase in cardiac output due to the metabolic demands of the fetal-placental unit (Adam & Osborne 2005).
  • Blood pressure in particular diastolic pressure may be lower than usual.
  • Increase in venous pressure as uterine size increases, which may cause gravitational oedema (Hayes & Arulhumaran 2006).

Changes Associated with Disability

  • Cerebral blood flow remains unchanged during pregnancy (Silversides & Coleman 2007).
  • Hyperglycaemia and glycosuria may occur, although this can be related to gestational diabetes (Miller et al. 2008).

Changes Associated with Exposure

  • Increase in the body mass index (BMI) (Silversides & Coleman 2007).
  • Increase in breast size in preparation for lactation.
  • Gastric and intestinal motility is reduced (Hayes & Arulkumaran 2006).

Monitoring the Critically Ill Pregnant Patient

Resuscitation Council UK (2006) recommends that the care of a critically ill pregnant patient must be approached using a systematic ‘ABCDE assessment’. However, the ABCDE approach should be undertaken with consideration of the normal physiological changes associated with pregnancy.

Airway

The airway should be assessed using the ‘look and listen’ approach to inspect for signs of obstruction/abnormalities as outlined in How to Assess a Deteriorating/Critically Ill Patient (ABCDE assessment).

  • In addition, clinical staff should be aware that the changes in respiratory physiology such as nasal congestion may affect voice sounds but if a patient is talking the airway is patent.
  • As with any airway abnormality, help should be summoned immediately from those with advanced airway skills (Jevon 2012 ).

Breathing

Breathing should be assessed as outlined in How To Assess a Deteriorating / Critically Ill Patient (ABCDE Assessment). Clinical staff should also be aware that the patient’s general appearance may be one of anxiety or exhaustion. She may also be unresponsive.

  • Airway and breathing problems must be recognised immediately, and expert advice and help summoned at the earliest opportunity.
  • Respiratory rate, pattern and chest excursion should be recorded. Changes in respiratory rate can be the most important early clinical manifestation of critical illness (Goldhill et al. 1999). However, respiratory rate can be altered in pregnancy and should be reviewed in comparison to previous recordings.
  • Pulse oximetry can aid respiratory assessment; however, this does not provide information on oxygen delivery to the tissues so that the patient may have a normal oxygen saturation yet still be hypoxic (Higgins 2005). Therefore, Arterial blood gases (ABG) analysis should be conducted to provide information about the patient’s respiratory and metabolic function (Allen 2005).
  • Able patients with respiratory compromise should be asked what position eases any distress and assisted accordingly to maximise lung expansion.
  • High concentration oxygen supplementation will be indicated to optimise delivery to the maternal and fetal cells. Follow local policies on oxygen administration.

Circulation

Circulation should be assessed as outlined in How to assess a deteriorating /critically ill patient (ABCDE assessment).

  • Clinical staff should be aware when assessing for circulation that oedema may be present.
  • Insensible fluid loss may increase and certain specific complications of pregnancy such as hyperemesis gravidarum (severe vomiting during pregnancy) may influence hydration state. Thus, the practitioner must be aware that dehydration may be evident despite clinical presentation suggesting otherwise (Jevon 2012).
  • Capillary refill time (CRT) may be normal or increased due to a decrease in vascular resistance and increase in circulating volume.
  • Bleeding during pregnancy is common and so severe blood loss may go unnoticed. Losses should be assessed, and the duration of any bleeding noted.
  • Pulse rate may be higher during pregnancy, however, persistent tachycardia or irregular heart beating are abnormal signs and warrant further investigation and a 12 lead ECG.
  • Blood pressure should be recorded. Normal pregnant values should be available for the particular patient to allow comparison. Any hypertension episodes must be reported to senior specialist staff at the earliest opportunity (Jevon 2012).

Disability

Disability should be assessed using the AVPU assessment as outlined in How To Assess a Deteriorating / Critically Ill Patient (ABCDE Assessment) to provide a rapid assessment of the patient’s level of consciousness.

  • Blood glucose assessment should be undertaken to exclude hypoglycaemia and also to detect any gestational diabetes.
  • Pupillary response to light should be assessed.
  • Confusion may be encephalopathic in origin and should alert the practitioner to liver dysfunction.
  • The cause of any change in conscious level should be explored, and history/charts noted to detect any reversible conditions and expert assistance should be summoned without delay (Jevon 2012).

Exposure

Exposure should be assessed as outlined in How To Assess a Deteriorating / Critically Ill Patient (ABCDE Assessment).

  • Oedema may be noted throughout the body.
  • Lower limbs must be assessed for any indication of thrombosis, redness swelling or localised heat plus any pain/tenderness around the calf area should be noted.
  • The patient should be assessed for signs of bleeding or fluid loss, including concealed or visible losses.
  • Urine analysis should be undertaken to assess for the following:
    1. Presence of blood in the urine indicating genitourinary trauma ( Higgins 2008).
    2. Glycosuria in pregnancy may indicate gestational diabetes (Meltzer 2010). Blood glucose assessment should follow if glycosuria present.
    3. Proteinuria may indicate preeclampsia and should be reported immediately.
    4. The patient should be assessed for signs of liver dysfunction including jaundice, epigastric, right upper quadrant pain and evidence of ascites.

Conclusion

The ABCDE assessment approach is recommended in assessment but requires the practitioner to possess essential knowledge of the physiological changes that occur during pregnancy to ensure that its application meets the needs of the patient. As with any critically ill patient, a multidisciplinary approach and senior assistance are required at the earliest opportunity.

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References

  • Adam, S & Osborne, S 2005, Critical care Nursing: science and practise, 2nd edn, Oxford university press.
  • Allen, K 2005, ‘Four-step method of interpreting arterial blood gas analysis’, Nursing times, vol. 101, no.1, pp. 42, viewed 30 August 2018, https://www.nursingtimes.net/clinical-archive/respiratory/four-step-method-of-interpreting-arterial-blood-gas-analysis/204054.article
  • Goldhill, DR & White, SA 1999, ‘Physiological values and procedures in the 24 h before ICU admission from the ward’, Anaesthesia, vol. 54, pp. 529-34, https://www.ncbi.nlm.nih.gov/pubmed/10403864
  • Grady, KM, Howell, C & Cox, CJ 2007, Managing Obstetric Emergencies and Trauma: The MOET Course Manual, 2nd edn, London: Advanced life support group/RCOG press.
  • Hayes, K & Arulkumaran, S 2006, ‘Chapter 1’, in S Arulkumaram, (ed.), Emergencies in Obstetrics and Gynaecology, Oxford university press, Oxford.
  • Higgins, D & Guest, J 2008, ‘Acute respiratory failure 1: assessing patients’, Nursing Times, vol. 104, no. 36, pp. 24-5, viewed 30 August 2018, https://www.nursingtimes.net/clinical-archive/respiratory/acute-respiratory-failure-1-assessing-patients/1833932.article
  • Higgins, D 2005, ‘Pulse oximetry’, Nursing Times, vol. 101, no. 6, pp. 34-5, viewed 30 August 2018, https://www.nursingtimes.net/clinical-archive/respiratory/pulse-oximetry/203997.article
  • Higgins, D 2008, ‘Specimen collection. Part six: urinalysis’, Nursing Times, vol. 104, no. 18, pp. 26-7.
  • Jevon, P, Ewens, B & Pooni, JS 2012, Monitoring The Critically Ill Patient, 3rd edn, Wiley-Blackwell, Oxford.
  • Lewis, G  2007, Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers Lives: Reviewing Maternal Deaths to Make Motherhood Safer – 2003-2005. The Seventh Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom, CEMACH, London.
  • Meltzer, S 2010, ‘Treatment of Gestational Diabetes’, British Medical Journal, vol. 340, no. 1708, viewed 30 August 2018, https://www.bmj.com/content/340/bmj.c1708
  • Miller, FP, Vandome, AF & McBrewster, J 2008, Gestational Diabetes, VDM Publishing, Mauritius.
  • Resuscitation Council UK 2006, Advanced Life Support, 5th edn, Resuscitation Council UK, London.
  • Silversides, CK & Coleman, J 2007, ‘Physiological Changes in Pregnancy’, in C Oakley & CA Warnes (eds.), Heart Disease in Pregnancy, BMJ Publishing/Blackwell, Oxford.

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