CURRENT Essentials of Critical Care.pdf

Chapter 20 Pregnancy 289■■■Pulmonary Edema in PregnancyEssentials of Diagnosis• Dyspnea, cough, chest discomfort, frothy sputum, hypoxemia• Bilateral rales; other signs of overt heart failure may be absent• Chest radiograph with interstitial or alveolar infiltrates and perihilarcongestion; unilateral edema possible• Can occur without known predisposing conditions and typicallypresents at time of delivery• Associated conditions: hypertension; undiagnosed heart conditions,especially mitral stenosis; tocolytic agents; fluid overload;peripartum cardiomyopathy• Proposed mechanisms: fluid overload due to increased extracellularvolume during pregnancy; fluid administration duringlabor; increased capillary permeability; decreased plasma oncoticpressure• Echocardiography helpful in evaluating valvular heart diseaseor cardiomyopathyDifferential Diagnosis• Pulmonary embolism • Amniotic fluid embolism• Asthma • Myocardial ischemia• Peripartum cardiomyopathyTreatment• Majority improve dramatically within 24 hours of treatment• Discontinue tocolytic agents• Intravenous loop diuretics• Supplemental oxygen to maintain adequate saturations• Antibiotics should be administered if infection suspected• Continuous fetal heart monitoring until normal maternal pulmonaryfunction restored and hypoxemia has resolved; if fetusaffected, late decelerations and loss of heart rate variability maybe noted• If slow in resolving, suspect structural cardiac abnormalities;echocardiography and pulmonary artery catheter may be helpfulin guiding therapy in these settings■ PearlThe physiologic adaptations to pregnancy, including increased cardiacoutput, decreased systemic vascular resistance, and decreasedcolloid oncotic pressure, predispose to the development of pulmonaryedema.ReferenceSiscione AC et al: Acute pulmonary edema in pregnancy. Obstet Gynecol2003;101:511. [PMID: 12636955]