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Critical Care Obstetrics part 29

Critical Care Obstetrics part 29 provides expert clinical guidance throughout on how you can maximize the chances of your patient and her baby surviving trauma. In this stimulating text, internationally recognized experts guide you through the most challenging situations you as an obstetrician are likely to face, enabling you to skillfully:Recognize conditions early-on which might prove life threatening, Implement immediate life-saving treatments in emergency situations, Maximize the survival prospects of both the mother and her fetus | Cardiac Disease however the most hazardous time for these women appears to be the immediate postpartum period. Such patients often enter the postpartum period already operating at maximum cardiac output and cannot accommodate the volume shifts that follow delivery. In a series of patients with severe mitral stenosis Clark and colleagues found that a postpartum rise in wedge pressure of up to 16 mmHg could be expected in the immediate postpartum period Figure 20.4 42 . Because frank pulmonary edema is infrequent with wedge pressures below 28-30mmHg 184 it follows that the optimal predelivery wedge pressure for such patients is approximately 14 mmHg or lower as indicated by pulmonary artery catheterization 107 . Such a preload may be approached by cautious intrapartum diuresis and with careful attention to the maintenance of adequate cardiac output. Active diuresis is not always necessary in patients who enter labor with evidence of only mild fluid overload. In such patients simple fluid restriction and the associated sensible and insensible fluid losses that accompany labor can result in a significant fall in wedge pressure before delivery. Previous recommendations for delivery in patients with cardiac disease have also included the liberal use of midforceps to shorten the second stage of labor. In cases of severe disease cesarean section with general anesthesia also has been advocated as the preferred mode of delivery 108 . If intensive monitoring of intrapartum cardiac patients cannot be carried out in the manner described here such recommendations for elective cesarean delivery may be valid. With the aggressive management scheme presented however our experience suggests that vaginal delivery is safe even in patients with severe disease and pulmonary hypertension. Midforceps deliveries are rarely appropriate in modern obstetrics 109 and should be reserved for standard obstetric indications only. Mitral i nsufficiency Hemodynamically significant mitral .