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Obstentrics_Williams. In 2004, an international consensus efort was launched as the Surviving Sepsis Campaign (Dellinger, 2013). he cornerstone of management is eary goal-directed management, and it stresses prompt recognition of serious bacterial infection and close monitoring of vital signs and urine flow. It remains controversial if institution of this protocol has improved survival rates (ARISE Investigators, 2014; Mouncey, 2015; ProCESS Investigators, 2014). Similar conclusions were reached with sets of early warning systems in obstetrics (Edwards, 2015; Mhyre, 2014). Albright and associates (2017) have validated the Sepsis in Obstetrics Score to identiy the risk ofICU admission for sepsis.


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Obstentrics_Williams. An algorithm for management of sepsis syndrome is shown in 47-6. The three basic steps are performed as simultaneously as possible and include evaluation of the sepsis source and its sequelae, cardiopulmonary function assessment, and immediate management. The most important step in sepsis management is rapid infusion of 2 L and sometimes as many as 4 to 6 L of crystalloid luids to restore renal perfusion in severely afected women (Vincent, 2013). Simultaneously, appropriately chosen broad-spectrum antimicrobials are begun. Because hemoconcentration is caused by the capillary leak, if anemia coexists, then blood is given. Maintaining the hemoglobin concentration at : 9 g/ dL did not have superior outcomes compared with that of :7 g/dL (Holst, 2014). hat said, fetal oxygenation is improved by the higher concentration.


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Obstentrics_Williams. The use of colloid solution such as hetastarch is controversial (Angus, 2013; Ware, 2000). One randomized trial comparing tality rate with the starch solution (Perner, 2012). Another study found equivalent results with 6-percent hydroxyethyl starch compared with normal saline (Myburgh, 2012). Albumin was not found to be superior to crystalloids (Caironi, 2014). Aggressive volume replacement ideally is promptly followed by urinary output of at least 30 and preferably 50 mL/hr, as well as other indicators of improved perfusion. If not, then con sideration is given for vasoactive dtug therapy (Pacheco, 2014). Mortality rates are high when sepsis is further complicated by respiratory or renal failure. With severe sepsis, damage to pul alveolar looding and pulmonary edema. This may occur even with low or normal pulmonary capillary wedge pressures, as with the ARDS discussed on page 918 and depicted in Figure 47-1.


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Obstentrics_Williams. Broad-spectrum antimicrobials are chosen empirically based on the probable source of infection. They are given promptly in maximal doses after appropriate cultures are taken of blood, urine, or exudates not contaminated by normal flora. In severe sepsis, appropriate empirical coverage results in better survival rates (Barochia, 2010; MacArthur, 2004). In obstetrics acute pyelonephritis is usually caused by Enterobacteriaceae, as discussed in Chapter 53 (p. 1028). For pelvic infections, empirical coverage with regimens such as ampicillin plus gentamicin plus clindamycin generally suices (Chap. 37, p. 668). Associated incisional and other soft-tissue infections are increasingly likely to be caused by methicillin-resistant S aureus, thus vancomycin therapy may be added (Klevens, 2007; Rotas, 2007). With a septic abortion, a Gram-stained smear may be helpful in identiying Clostridium species or group A streptococcal organisms. his is also true for deep fascial infections.


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Obstentrics_Williams. Continuing sepsis may prove fatal, and debridement of necrotic tissue or drainage of purulent material is crucial (Nelson, 2015; Pacheco, 2014). In obstetrics, the major causes of sepsis are infected abortion, pyelonephritis, and puerperal pelvic infections, which include metritis and infections of perineal lacerations or of hysterotomy or laparotomy incisions. With a septic abortion, uterine contents must be removed promptly by curettage as described in Chapter 18 (p. 351) . Hysterectomy is seldom indicated unless gangrene has resulted.


Obstentrics_Williams

Obstentrics_Williams. For women with pyelonephritis, continuing sepsis should prompt a search for obstruction caused by calculi or by a perinephric or intrarenal phlegmon or abscess. Renal sonography or "one-shot" pyelography can help diagnose obstruction and calculi. With obstruction, ureteral catheterization, percutaneous nephrostomy, or flank exploration may be lifesaving (Chap. 53, p. 1029). Computed tomography (CT) or magneticresonance imaging aids in identiying a phlegmon or abscess. Puerperal Infections. Most cases of puerperal pelvic sepsis are clinically manifested in the first several days postpartum, and FIGURE 47-6 Algorithm for evaluation and management of sepsis syndrome. Rapid and aggressive implementation is paramount for success. The three steps-Evaluate, Assess, and Manage-are carried out as simultaneously as possible.


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Obstentrics_Williams. intravenous antimicrobial therapy without tissue debridement cases, there is bacteremia and widespread tissue invasion, but with is generally curative. here are at least three exceptions. an intact uterus and abdominal incision. If uterine necrosis can


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Obstentrics_Williams. First, massive uterine myonecrosis can be caused by group A be excluded-usually by CT scanning-then in our experiences, 3-hemolytic streptococcal or clostridial infections (Soper, 2011; as well as in others, hysterectomy may not be necessary (Soper, Sugiyama, 2010; Yamada, 2010). hose with early-onset disease 2011). Still, these infections are highly lethal (Yamada, 2010). present with findings listed in Table 47-6. The mortality rate in As a second exception, necrotizing fasciitis of the episiotomy these women with gangrene s shown in Figure 47-7 is high, and site or of the abdominal surgical incision is a surgical emergency. prompt hysterectomy may be lifesaving (Mabie, 1997; Nathan, As described by Gallup and coworkers (2002), these infections 1993). Group A 3-hemolytic streptococci and clostridial coloare aggressively managed as discussed in Chapter 37 (p. 671). nization or infection also cause toxic-shock syndrome without Sinha and colleagues (2015) described a woman with


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Obstentrics_Williams. and clostridial coloare aggressively managed as discussed in Chapter 37 (p. 671). nization or infection also cause toxic-shock syndrome without Sinha and colleagues (2015) described a woman with Fournier obvious gangrene (Mason, 2012). These are due to either strepgangrene who required radical debridement and colostomy. tococcal toxic-shock-syndrome-like toxin or clostridial exotoxin As a inal exception, persistent or aggressive postpartum that evolved from 5 aureus (Chap. 37, p. 675). In many of these uterine infection with necrosis, uterine incision dehiscence, and severe peritonitis may lead to sepsis (Chap. 37, p. 672). In this regard, women following cesarean delivery who are suspected of having peritonitis should be carefully evaluated for uterine incisional necrosis or bowel perforation. These infections tend to be less aggressive than necrotizing group A streptococcal infections and develop later postpartum. CT imaging of the abdomen and pelvis can frequently disclose these.


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Obstentrics_Williams. These infections tend to be less aggressive than necrotizing group A streptococcal infections and develop later postpartum. CT imaging of the abdomen and pelvis can frequently disclose these. If either is suspected, then prompt surgical exploration is indicated. With incisional necrosis, hysterectomy is usually necessary (Fig. 37-5, p. 673). Finally, peritonitis and sepsis much less commonly may result from a ruptured parametrial, intraabdominal, or ovarian abscess (Chap. 37, p. 671).


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Obstentrics_Williams. As shown in Figure 47-6, a woman with severe sepsis syndrome is supported with continuing crystalloid infusion, blood FIGURE 47-7 A fatal case of group A 3-hemolytic Streptococcus pyogenes puerperal infection following an uncomplicated vaginal delivery at term. The infection caused uterine gangrene and overwhelming sepsis syndrome. Arrows point to overtly "balloonedout" black gangrenous areas of the postpartum uterus at the time of laparotomy for hysterectomy. transusions, and ventilation. In some cases, other measures may be necessary. Vasoactive drugs are not given unless aggressive luid treatment fails to correct hypotension and perfusion abnor malities. First-line vasopressors are norepinephrine, epinephrine, dopamine, dobutamine, or phenylephrine (Vincent, 2013).


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Obstentrics_Williams. he use of corticosteroids remains controversial. Some stud ies, but not all, show a salutary efect of corticosteroid admin istration. It is thought that critical ilness-related corticosteroid sion. hus, corticosteroids may be considered for use in vaso pressor-dependent patients (Angus, 2013; Munford, 2015). Endotoxin stimulates endothelial cells to up regulate tis sue factor and thus procoagulant production (Cunningham, 2015). Consumptive coagulopathy associated with sepsis is dis cussed in Chapter 41 (p. 782). At the same time, it decreases the anticoagulant action of activated protein C. Several agents developed to block coagulation, however, did not improve outcomes. Some include recombinant activated protein C, anti thrombin II, platelet-activating actor antagonist, and tissue ac tor pathway inhibitor (Munford, 2015; Wenzel, 2012).


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Obstentrics_Williams. Depending on deinitions used, 10 to 20 percent of gravidas suffer physical trauma (Jain, 2015; Lucia, 2016). Moreover, injuryrelated deaths are the most commonly identiied nonobstetrical cause of maternal mortality (Brown, 2013a; Horon, 2001). In a California study of4.8 million pregnancies, almost 1 in 350 women were hospitalized for injuries from assaults (El Kady, 2005). From Parkland Hospital, motor vehicle accidents and falls accounted for 85 percent of injuries sustained by 1682 pregnant women (Hawkins, 2007). From the National Violent Death Reporting System, Palladino and colleagues (2011) found 2.0 pregnancyassociated suicides per 100,000 live births. he rate was 2.9 per 100,000 for pregnancy-associated homicides. Notably, intimatepartner violence may be linked to these suicides (Martin, 2007). Finally, injury prevention and education of high-risk patients may help to decrease morbidity (Chisolm, 2017; Lucia, 2016).


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Obstentrics_Williams. According to the CDC, llltlmate-partner violence describes physical, sexual, or psychological harm by a current or former partner or spouse (Breiding, 2015). Such violence afects 1 in 5 women each year. One goal in violence prevention for Healthy People 2010 was the reduction of physical abuse directed at women by male partners. The Pregnancy Risk Assessment Monitoring Systems (PRAMS) report showed some improvement in these areas (Suellentrop, 2006). Even more appalling is that physical violence directed at women continues during pregnancy. Abuse is linked to poverty, poor education, and use of tobacco, alcohol, and illicit drugs (Centers for Disease Control and Prevention, 2008). Unfortunately, abused women tend to remain with their abusers, and the major risk factor for intimate-partner homicide is prior domestic violence (Campbell, 2007). Finally, women seeking pregnancy termination have a higher incidence of intimatepartner violence (Bourassa, 2007).


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Obstentrics_Williams. exposure is high aFor nonpregnant women, doxycycline, 100 mg orally twice daily for 7 days, can be given instead. bpregnancy category C. HIV = human immunodeficiency virus; 1M = intramuscularly. Data from Centers for Disease Control and Prevention, 2015. The woman who is physically abused tends to present late, if at all, for prenatal care. In one study, pregnant women hospitalized in California as a result of assault had signiicantly increased perinatal morbidity rates (El Kady, 2005). Immediate sequelae included uterine rupture, preterm delivery, and maternal and perinatal death. Subsequent outcomes included increased rates of placental abruption, preterm and low-birthweight newborns, and other adverse outcomes. Silverman and associates (2006) reported similar results from PRAMS, which included more than 118,000 pregnancies in 26 states.


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Obstentrics_Williams. Preventatively, the American College of Obstetricians and Gynecologists (2012) recommend universal screening for intimate-partner violence at the initial prenatal visit, during each trimester, and again at the postpartum visit (Chap. 9, p. 162). Others recommend a case-finding approach based on clinical suspicion (Robertson-Blackmore, 2013). According to the National Intimate Partner and Sexual Violence Survey (Black, 2014), an estimated 1.2 million women will be sexually assaulted each year. Satin and coworkers (1992) reviewed more than 5700 female sexual assault victims in Dallas County and reported that 2 percent were pregnant. Associated physical trauma is common (Sugar, 2004). From a forensic standpoint, the evidence collection protocol is not altered (Linden, 2011).


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Obstentrics_Williams. In addition to attention to physical injuries, exposure to sexually transmitted diseases must be considered. The CDC (2015) recommends antimicrobial prophylaxis against gonorrhea, chlamydial infection, bacterial vaginosis, and trichomoniasis (Table 47-7). If the woman is not pregnant, another very important aspect is emergency contraception, as recommended by the American College of Obstetricians and Gynecologists (2016; 2017a) and discussed in Chapter 38 (p. 696). Finally, the importance of psychological counseling for the rape victim and her family cannot be overemphasized. A 30-to 35-percent lifetime risk each for posttraumatic stress disorder, major depression, and suicide contemplation follows sexual assault (Linden, 201r1) .


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Obstentrics_Williams. At least 3 percent of pregnant women are involved in motor vehicle accidents each year in the United States. Using data from PRAMS, Sirin and colleagues (2007) estimated that 92,500 gravidas are injured annually. Motor-vehicle crashes are the most common causes of serious, life-threatening, or fatal blunt FIGURE 47-8 Illustration showing correct use of three-point automobile restraint. The upper belt is above the uterus, and the lower belt fits snugly across the upper thighs and well below the uterus.


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Obstentrics_Williams. trauma during pregnancy (Brown, 2013a; Mendez-Figueroa, 2013,r2016; Vladutiu, 2013). Mattox and Goetzl (2005) report these accidents to be the leading cause of traumatic fetal deaths as well. This was also true from our experiences from Parkland Hospital (Hawkins, 2007). Traic crashes are most frequent in the second trimester (Redel meier, 2014). As with all motor vehicle crashes, alcohol use is often associated. But sadly, as many as half of accidents occur without seat-belt use, and many of these deaths would likely be preventable by the three-point restraints shown in Figure 47 8 (Luley, 2013; Schuster, 2016). Seat belts prevent contact with the steering wheel, and they reduce abdominal impact pressure (Motozawa, 2010).


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Obstentrics_Williams. Original concerns regarding injuries caused by airbag deployment have been somewhat allayed (Luley, 2013; Matsushita, 2014). One study included 30 such women from 20 to 37 weeks' gestation whose airbag deployed in accidents with a median speed of35 mph (Metz, 2006). A third did not use seat belts, and there was one fetal death from the single case of placental abruption. In a retrospective cohort study that included 2207 pregnant women in crashes with airbag deployment, perinatal outcomes were not clinically diferent from 1141 controls without airbags (Schif, 2010). Importantly, 96 percent of both groups used seat belts. Thus, it appears that injuries with airbag deployment are related to the severity of the crash (Mendez-Figueroa, 2016).


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Obstentrics_Williams. Some other common causes of blunt trauma are falls and aggra vated assaults. In the California review reported by El Kady and associates (2005), intentionally inflicted injuries were present in approximately a third of pregnant women who were hospitalized for trauma. Less common are blast or crush injury (Sela, 2008). With blunt trauma, intraabdominal injuries can be serious. Even so, bowel injuries are less frequent because of the protective efect of a large uterus. Still, diaphragmatic, splenic, liver, and kidney damage may also be sustained. Par ticularly worrisome is the specter of amnionic-fluid embolism, which has been reported with even mild trauma (Ellingsen, 2007; Pluymakers, 2007). Retroperitoneal hemorrhage is pos sibly more common than in nonpregnant women (T akehana, 2011).


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Obstentrics_Williams. Orthopedic injuries are also encountered with some regular ity (Desai, 2007). From the Parkland Hospital trauma unit, 6 percent of 1682 pregnant women evaluated had orthope dic injuries. his subset was also at increased risk for placen tal abruption, preterm delivery, and perinatal mortality. In a review of 101 pelvic fractures during pregnancy, there was a 9-percent maternal and 35-percent fetal mortality rate (Leggon, 2002). In another study of pelvic and acetabular fractures dur ing 15 pregnancies, there was one maternal death, and four of 16 fetuses died (Almog, 2007). Finally, head trauma and neu rosurgical care raise unique issues (Qaiser, 2007).


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Obstentrics_Williams. Perinatal death rates increase with the severity of maternal injuries. Fetal death is more likely with direct fetoplacental injury, maternal shock, pelvic fracture, maternal head injury, or hypoxia (Ikossi, 2005; Pearlman, 2008). Motor vehicle accidents caused 82 percent of fetal deaths from trauma. Death was caused by placental injury in half and by uterine rupture in 4 percent (Weiss, 2001).


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Obstentrics_Williams. Although uncommon, fetal skull and brain injuries are more likely if the head is engaged and the maternal pelvis is fractured (Palmer, 1994). Conversely, fetal head injuries, presumably from a contrecoup efect, may be sustained in unengaged vertex or nonvertex presentations. Fetal skull fractures are rare and best seen using CT imaging (Sadro, 2012). One example is Figure 46-8 (p. 908). Other sequelae include intracranial hemorrhage (Gherman, 2014; Green-hompson, 2005). A newborn with paraplegia and contractures associated with a motor vehicle accident sustained several months before birth was described by Weyerts and colleagues (1992). Other injuries have included fetal decapitation or incomplete midabdominal fetal transection at midpregnancy (Rowe, 1996; Weir, 2008).


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Obstentrics_Williams. Catastrophic events that occur with blunt trauma include placental injuries-abruption or placental tears (Fig. 47-9). Placental separation from trauma is likely caused by deformation of the elastic myometrium around the relatively inelastic placenta (Crosby, 1968). his may result from a deceleration injury as the large uterus meets the immovable steering wheel or seat belt. Some degree of abruption complicates 1 to 6 percent of p. 768). Kettel and coworkers (1988) emphasized that traumatic abruption may be occult and unaccompanied by uterine pain, tenderness, or bleeding. In our experiences with 13 such women at Parkland Hospital, 11 had uterine tenderness, but only five had vaginal bleeding. Because traumatic abruption is more likely to be concealed and generate higher intrauterine pressures, associated coagulopathy is more likely than with nontraumatic abruption (Cunningham, 2015). Partial separation may also generate uterine activity, which is described more fully on page 930.


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Obstentrics_Williams. associated coagulopathy is more likely than with nontraumatic abruption (Cunningham, 2015). Partial separation may also generate uterine activity, which is described more fully on page 930. Other features are evidence of fetal compromise such as fetal tachycardia, sinusoidal pattern, late decelerations, acidosis, and fetal death.


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Obstentrics_Williams. FIGURE 47-9 Mechanism of placental tear or "fracture" caused by a deformationreformation injury. Placental abruption is seen as blood collecting in the retroplacental space. Inset. From here, blood can be forced into placental bed venules and enter maternal circulation. Such fetomaternal hemorrhage may be identified with Kleihauer-Betke testing.


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Obstentrics_Williams. If the abdominal force associated with trauma is considerable, then the placenta can be torn or "fractured" (see Fig. 47-9). If so, then life-threatening fetal hemorrhage may be encountered either into the amnionic sac or by fetomaternal hemorrhage (Pritchard, 1991). he tear is linear or stellate and is caused by rapid deformation and reformation (Fig. 47-10). Especially if there is ABO compatibility, fetomaternal hemorrhage is quantified using a Kleihauer-Betke stain of maternal blood. A small amount of fetal-maternal bleeding has been described in up to a third of trauma cases, and in 90 percent of these, the volume is < 15 mL (Goodwin, 1990; Pearlman, 1990). Parenthetically, nontraumatic placental abruption is much less often associated with signifi minor injuries and up to 50 percent of major injuries (Pearlcant fetomaternal hemorrhage because only minimal fetal blood man, 1990; Schif, 2002). Abruption was found to be more enters into the intervillous space. With traumatic


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Obstentrics_Williams. of major injuries (Pearlcant fetomaternal hemorrhage because only minimal fetal blood man, 1990; Schif, 2002). Abruption was found to be more enters into the intervillous space. With traumatic abruption, likely if vehicle speed exceeded 30 mph (Reis, 2000). however, massive fetomaternal hemorrhage may follow. In one Clinical indings with traumatic abruption may be simistudy, the risk of associated uterine contractions and preterm lar to those for spontaneous placental abruption (Chap. 41, labor was a 20-fold if there was evidence for a fetomaternal


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Obstentrics_Williams. FIGURE 47-10 A. Partial placental abruption in which the adherent blood clot has been removed. Note the laceration of the placenta (arrow), which caused fetal death from massive fetomaternal hemorrhage. B. Kleihauer-Betke stain of a peripheral smear of maternal blood. The dark cells that constituted 4.5 percent of red blood cells are fetal in origin, whereas the empty cells are maternal. bleed (Muench, 2004). With severe fetal bleeding, long-term adverse neurological outcomes are frequent (Kadooka, 2014).


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Obstentrics_Williams. Blunt trauma leads to uterine rupture in < 1 percent of severe cases (American College of Obstetricians and Gynecologists, 20 17b). Rupture is more likely in a previously scarred uterus and is usually associated with a direct impact of substantial force. Decelerative forces following a 25-mph collision can generate up to 500 mm Hg of intrauterine pressure in a properly restrained woman (Crosby, 1968). Clinical indings may be identical to those for placental abruption with an intact uterus, and maternal and fetal deterioration are soon inevitable. Pearlman and Cunningham (1996) described uterine fundal "blowout" with fetal decapitation in a 20-week pregnancy following a high-speed collision. Similarly, Weir and colleagues (2008) described supracervical uterine avulsion and fetal transection at 22 weeks. CT scanning may be useful to diagnose uterine rupture with a dead fetus or placental separation (Kopelman, 2013; Manriquez, 2010; Sadro, 2012).


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Obstentrics_Williams. In a study of 321 pregnant women with abdominal trauma, Petrone (2011) reported a 9-percent incidence of penetrating injuries. Of these, 77 percent were gunshot wounds and 23 percent were stab wounds. he incidence of maternal visceral injury with penetrating trauma is only 15 to 40 percent compared with 80 to 90 percent in nonpregnant individuals (Stone, 1999). When the uterus sustains penetrating wounds, the fetus is more likely than the mother to be seriously injured. Indeed, although the fetus sustains injury in two thirds of cases with penetrating uterine injuries, maternal visceral injuries are seen in only 20 percent. Still, their seriousness is underscored in that maternal-fetal mortality rates are signiicantly higher than those seen with blunt abdominal injuries in pregnancy. Specifically, maternal mortality rates were 7 versus 2 percent, and fetal mortality rates were 73 versus 10 percent, respectively . • Management of Trauma


Obstentrics_Williams

Obstentrics_Williams. • Management of Trauma Maternal and fetal outcomes are directly related to the severity of injury. That said, commonly used methods of severity scoring do not take into account significant morbidity and mortality rates related to placental abruption and thus to pregnancy outcomes. In a study of 582 pregnant women hospitalized for injuries, the injury severity score did not accurately predict adverse pregnancy outcomes (Schif, 2005). Importantly, relatively minor injuries were associated with preterm labor and placental abruption. Others have reached similar conclusions (Biester, 1997; Ikossi, 2005). In a study of 317 women at 24 weeks' gestation or more who had "minor trauma," 14 percent had clinically significant urerine contractions requiring extended fetal evaluation past 4 hours (Cahill, 2008).


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Obstentrics_Williams. With few exceptions, treatment priorities in injured pregnant women are multidisciplinary (Barraco, 2010; Mendez-Figueroa, 2016). Primary goals are evaluation and stabilization of maternal injuries. Attention to fetal assessment during the acute evaluation (merican College of Obstetricians and Gynecologists, 2017b; Brown, 2009). Basic rules of resuscitation include ventilation, arrest of hemorrhage, and treatment of hypovolemia with crys talloid and blood products. After midpregnancy, the large uterus is positioned of the great vessels to diminish its efect on vessel compression and cardiac output (Nelson, 2015).


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Obstentrics_Williams. Following emergency resuscitation, evaluation is continued for fractures, internal injuries, bleeding sites, and placental, uterine, and fetal trauma. Radiography is not proscribed, but special attention is given each indication. Not surprisingly, one report observed that pregnant trauma victims had less radiation exposure than nonpregnant controls (Ylagan, 2008). Some advocate screening abdominal sonography followed by CT scanning for positive sonographic findings (Brown, 2005; Saphier, 2014). Procedures used include the FAST scan ocused 4ssessment with �onography or t.rauma. his examination is ars-minute, four-to six-view imaging study that evaluates perihepatic, perisplenic, pelvic, and pericardial views (MendezFigueroa, 2016). In general, if fluid is seen in any of these views, then the volume is >500 mL (Fig. 47-11). Importantly, this amount has not been corroborated for pregnancy. In some cases, open peritoneal lavage may be informative (Tsuei, 2006).


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Obstentrics_Williams. Penetrating injuries in most cases must be evaluated using radiography. Because clinical response to peritoneal irritation is blunted during pregnancy, an aggressive approach to exploratory laparotomy is pursued. Whereas exploration is mandatory for abdominal gunshot wounds, some clinicians advocate close observation for selected stab wounds. Diagnostic laparoscopy has also been used (Chap. 46, p. 901). The necessity for cesarean delivery depends on several factors. Laparotomy itself is not an indication for hysterotomy. FIGURE 47-1 1 Fast scan. Upper quadrant scan shows anechoic free fluid (asterisk) between the liver edge (arrow) and kidney (Morison pouch). The patient had 2500 mL of blood in the peritoneal cavity. (Reproduced with permission from Mendez-Figueroa H, Rouse OJ: Trauma in pregnancy. In Yeomans ER, Hoffman BL, Gilstrap, III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili, 2017.)


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Obstentrics_Williams. Some considerations include gestational age, fetal condition, extent of uterine injury, and whether the large uterus hinders adequate management of other intraabdominal injuries (Tsuei, 2006).


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Obstentrics_Williams. Because fetal well-being may relect the status of the mother, fetal monitoring is another "vital sign" that helps evaluate the extent of maternal injuries. Even if the mother is stable, electronic monitoring may suggest placental abruption. In a study by Pearlman and coworkers (1990), no woman had an abruption if uterine contractions were less often than every 10 minutes within the 4 hours after trauma was sustained. lmost 20 percent ofwomen who had contractions more frequently than every 10 minutes in the irst 4 hours had an associated placental abruption. In these cases, abnormal tracings were common and included fetal tachycardia and late decelerations. Conversely, no adverse outcomes were reported in women who had normal monitor tracings (Connolly, 1997). Importantly, if tocolytics are used for these contractions, they may obfuscate findings, and we do not recommend them.


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Obstentrics_Williams. Because placental abruption usually develops early following trauma, fetal monitoring is begun as soon as the mother is stable. The ideal duration ofposttrauma monitoring is not precisely known. From data cited above, observation for 4 hours is reasonable with a normal tracing and no other sentinel indings such as contractions, uterine tenderness, or bleeding. Certainly, monitoring should be continued as long as there are uterine contractions, nonreassuring fetal heart patterns, vaginal bleeding, uterine tenderness or irritability, serious maternal injury, or ruptured membranes (American College ofObstetricians and Gynecologists, 2017b). In rare cases, placental abruption has developed days after trauma (Higgins, 1984).


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Obstentrics_Williams. It is unclear whether routine use of the Kleihauer-Betke or an equivalent test in pregnant trauma victims might modiy adverse outcomes associated with fetal anemia, cardiac arrhythmias, and death (Pak, 1998). In a retrospective review of 125 pregnant women with blunt injuries, the Kleihauer-Betke test was judged to be of little value during acute trauma management (Towery, 1993). Others have reached similar conclusions, although a positive test with fetal cells of0.1 percent was predictive of uterine contractions or preterm labor (Connolly, 1997; Muench, 2003, 2004). For the woman who is D-negative, administration ofanti-D immunoglobulin should be considered. his may be omitted if a test for fetal bleeding is negative. Even with anti-D immunoglobulin, alloimmunization may still develop if the fetalmaternal hemorrhage exceeds 15 mL of fetal cells (Chap. 15, p.r306).


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Obstentrics_Williams. For the pregnant trauma patient, confirmation of current tetanus immunization status is pertinent. When indicated, a dose oftetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) is preferred for its neonatal pertussis immunity beneits (Chap. 9, p. 171). Fetal* Maternal... FIGURE 47-1 2 Maternal and fetal mortality rates by burn severity in nearly 400 women. (Data from Akhtar, 1994; Amy, 1985; Mabrouk, 1977; Maghsoudi, 2006; Parikh, 2015; Rayburn, 1984; Rode, 1990.)


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Obstentrics_Williams. Treatment ofthe burned gravida is similar to that for nonpregnant patients (Mendez-Figueroa, 2016). With treatment, it is generally agreed that pregnancy does not alter maternal outcome from thermal injury compared with that of nonpregnant women ofsimilar age. As perhaps expected, maternal and fetal survival parallels the percentage of burned surface area (Parikh, 2015). Karimi and colleagues (2009) reported higher mortality rates for both with suicidal attempts and with inhalational injuries. The composite mortality rate for nearly 400 women from seven studies increased in a linear fashion as the percent of burned body surface area increased 47-12). For 20-, 40-, and 60-percent burns, the maternal mortality rates were approximately 4, 30, and 93 percent, respectively. he corresponding fetal mortality rates were 20, 48, and 96 percent, respectively. With severe burns, the woman usually enters labor spontaneously within a few days to a week and often delivers a stillborn. Contributory


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Obstentrics_Williams. mortality rates were 20, 48, and 96 percent, respectively. With severe burns, the woman usually enters labor spontaneously within a few days to a week and often delivers a stillborn. Contributory factors are hypovolemia, pulmonary injury, septicemia, and the intensely catabolic state (Radosevich, 2013).


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Obstentrics_Williams. Following serious abdominal burns, skin contractures that develop may be painful during a subsequent pregnancy and may even require surgical decompression and split-skin autografts (Mitsukawa, 2015; Radosevich, 2013). Loss or distortion of nipples may cause problems in breastfeeding. Mitsukawa and associates (2015) reported that contracture release was indicated with scars spanning more thanr>75 percent of the total abdominal area. Alternatively, normal abdominal tissue expansion due to pregnancy appears to be an excellent source for obtaining skin grafts postpartum to correct scar deformities at other body sites (Del Frari, 2004).


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Obstentrics_Williams. Earlier case reports suggested a high fetal mortality rate with electric shock (Fatovich, 1993). In a prospective cohort study, however, Einarson and coworkers (1997) showed similar perinatal outcomes in 31 injured women compared with those of noninjured controls. They concluded that traditional 110volt North American electrical current likely is less dangerous than the 220-volt currents available in Europe. A woman with been related to a mild electrical shock at 22 weeks was described (Sozen, 2004). Another woman with brain death from cardiac arrest was reported (Sparic, 2014). Thermal burns with electro cution may be extensive. The pathophysiological efects of lightning injuries can be devastating. Garda Gutierrez and coworkers (2005) reviewed a 50-percent stillbirth rate.


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Obstentrics_Williams. According to estimates from the Nationwide Inpatient Sample, cardiac arrest complicates approximately 1 in 12,000 delivery admissions (Mhyre, 2014) . The most common underlying causes were hemorrhage, heart failure, amnionic-Buid embolism, and sepsis. General topics regarding planning and equipment have been reviewed by the American College of Obstetricians and Gynecologists (20 17b) and the Society for Obstetric Anesthesia and Perinatology (Lipman, 2014). Special considerations for cardiopulmonary resuscitation (CPR) conducted in the second half of pregnancy are outlined in the American Heart Association 2010 guidelines (Jeejeebhoy, 2015). he committee acknowledges the following as standards for critically ill gravidas: (1) relieve possible vena caval compression by left lateral uterine displacement, (2) administer 100-percent oxygen, (3) establish intravenous access above the diaphragm, (4) assess for hypotension that warrants therapy, which is defined as systolic blood pressure <


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Obstentrics_Williams. displacement, (2) administer 100-percent oxygen, (3) establish intravenous access above the diaphragm, (4) assess for hypotension that warrants therapy, which is defined as systolic blood pressure < 100 mm Hg or < 80 percent of baseline, and (5) review possible causes of critical illness and treat conditions as early as possible.


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Obstentrics_Williams. he position of the heart for external compressions is not diferent from that in nonpregnant women (Holmes, 2015). In nonpregnant women, external chest compression results in a cardiac output approximately 30 percent of normal. In late pregnancy, this may be even less with compressions because of uterine aortocaval compression (Clark, 1997; Nelson, 2015). Thus, it is paramount to accompany other resuscitative eforts with uterine displacement. This can be accomplished by tilting the operating table laterally, by placing a wedge under the patient's right hip, or by pushing the uterus to the left manually (Rees, 1988; Rose, 2015). If no equipment is available, an individual may kneel on the Boor with the maternal back on his or her thighs to form a "human wedge" (Whitty, 2002).


Obstentrics_Williams

Obstentrics_Williams. During maternal resuscitation, because of pregnancy-induced hindrances on CPR eforts, emergent perimortem cesarean delivey for fetal salvage and improved maternal resuscitation may be considered. Some have stated that cesarean delivery is indicated within 4 to 5 minutes of beginning CPR if the fetus is viable (Drukker, 2014). In women delivered by perimortem cesarean, neurologically intact neonatal survival and the cardiac arrest-todelivery interval are inversely related (Katz, 2012). Speciically, of newborns delivered within 5 minutes of arrest, 98 percent are neurologically intact; within 6 to 15 minutes, 83 percent are intact; within 16 to 25 minutes, 33 percent are intact; and within 26 to 35 minutes, only 25 percent are intact (Clark, 1997). This, coupled with some evidence that delivery may also enhance maternal resuscitation, has led the American College of Obstetricians and Gynecologists (2017b) to recommend consideration for cesarean delivery to begin within 4 minutes of


Obstentrics_Williams

Obstentrics_Williams. delivery may also enhance maternal resuscitation, has led the American College of Obstetricians and Gynecologists (2017b) to recommend consideration for cesarean delivery to begin within 4 minutes of cardiac arrest in these cases.


Obstentrics_Williams

Obstentrics_Williams. his serious and sometimes contentious issue is far from evi dence based. To wit, Katz and associates (2005) reviewed 38 perimortem cesarean deliveries with a "large selection bias." of maternal cardiac arrest improves maternal and fetal outcomes.


Obstentrics_Williams

Obstentrics_Williams. Even so, as emphasized by Clark (1997) and Rose (2015) and their coworkers, and in our experiences, these goals rarely can be met in actual practice. For example, most cases of cardiac arrest occur in uncontrolled circumstances, and thus, the time to CPR initiation alone would require the irst 5 minutes. hus "crash" cesarean delivery would supersede resuscitative eforts, would necessarily be done without appropriate anesthesia or surgical equipment, and more likely than not, would lead to maternal death. Moreover, the distinction between a peri mortem versus postmortem cesarean operation is imperative (Katz, 2012; Rose, 2015). Last, in the balance, any choice may favor survival of the mother over the fetus, or vice versa, and thus there are immediate unresolvable ethical concerns. Katz (2012) has provided a scholarly review of peri mortem cesarean delivery.


Obstentrics_Williams

Obstentrics_Williams. Occasionally, a pregnant woman with a supposedly healthy intact fetus will be kept on somatic support to await fetal viability or maturity. This is discussed in Chapter 60 (p. 1168). According to their review, Brown and coworkers (2013b) reported that clinically significant envenomations in pregnant women are from snakes, spiders, scorpions, jellyish, and hymenoptera such as bees, wasps, hornets, and ants. Adverse outcomes are related to maternal efects. These investigators conclude that limited evidence supports the use of a venomspeciic approach that includes symptomatic care, antivenom administration when appropriate, anaphylaxis treatment, and fetal assessment. One management scheme for North American snakebites was provided by Lei and associates (2015).


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Obstentrics_Williams. Mouncey PR, Osbon TM, Power GS, et al: Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 3 2(14):1301,t2015 Muench M, Baschat A, Kush M, et al: Maternal fetal hemorrhage of greater than or equal to 0.t1 percent predicts preterm labor in blunt maternal trauma. Am J Obstet GynecoIt189:S119, 2003 Muench MV, Baschat A, Reddy UM, et a1: K1eihauer-Betke testing is important in all cases of maternal trauma. J Trauma 57: 1 094, 2004 Munford RS: Severe sepsis and septic shock. In Kasper DL, Fauci AS, Hauser SL, et al: Harrison's Principles of Internal Medicine, 19th ed. New York, McGraw-Hill, 2015, p 1751 Myburgh JA, Finfer S, Bellomo R, et a1: Hydroxyethyl starch or saline for luid resuscitation in intensive ca.re. N Engl J Med (20):1901,t2012 Nair M, Kurinczukt]J, Brocklehurst P, et al: Factors associated with maternal death from direct pregnancy complications: a UK national case-control study. BJOG 122(5):653,t2015


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Obstentrics_Williams. Nair M, Kurinczukt]J, Brocklehurst P, et al: Factors associated with maternal death from direct pregnancy complications: a UK national case-control study. BJOG 122(5):653,t2015 Nair P, Davies AR, Beca J, et al: Extracorporeal membrane oxygenation for severe ARDS in pregnant and postpartum women during the 2009 H1N1 pandemic. Intensive Care Med 37(4):648,t201t1 Nasraway SA, Cohen IL, Dennis RC, et al: Guidelines on admission and discharge for adult intermediate care units. Crit Care Med 26(3):607, 1998 Nathan L, Peters MT, Ahmed AM, et al: he return of Iife-threateningtpuerperal sepsis caused by group A streptococci. Am J Obstet Gynecol 169:571, 1993 National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network: Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury. N Engl J Med 354:2213,t2006 National Institutes of Health: Critical Care Medicine Consensus Conference. JAMA 250:798, 1983


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Obstentrics_Williams. National Institutes of Health: Critical Care Medicine Consensus Conference. JAMA 250:798, 1983 Nelson DB, Stewart RD, Matulevicius SA, et al: he efects of maternal position and habitus on maternal cardiovascular parameters as measured by cardiac magnetic resonance. Am J Perinatol 32: 1318, 2015 O'Dwyer SL, Gupta M, Anthony J: Pulmonary edema in pregnancy and the puerperium: a cohort study of 53 cases. J Perinat Med 43:675, 2015 Ognibene FP, Parker MM, Natanson C, et al: Depressed left ventricular performance. Response to volume infusion in patients with sepsis and septic shock. Chest 93:903, 1988 Pacheco LD, Saade GR, Hankins GD: Severe sepsis during pregnancy. Clin Obstet Gynecol 57(4):827, 2014 Pak LL, Reece A, Chan L: Is adverse pregnancy outcome predictable after blunt abdominal trauma? Am J Obstet Gynecol 9:1140, 1998 Palladino CL, Singh V, Campbell J, et al: Homicide and suicide during the perinatal period. Obstet Gynecol 118(5): 1056,t2011


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Obstentrics_Williams. Palladino CL, Singh V, Campbell J, et al: Homicide and suicide during the perinatal period. Obstet Gynecol 118(5): 1056,t2011 Palmer JD, Sparrow OC: Extradural haematoma following intrauterine trauma. Injury 1, 1994 Pandharipande PP, Girad TD, Jackson A, et al: Long-term cognitive impairment after critical illness. N Engl J Med 369: 1306, 20t13 Parikh P, Sunesara I, Lutz E, et al: Burns during pregnancy: implications for maternal-perinatal providers and guidelines for practice. Obstet Gynecol Surv 70:633, 2015 Pathan N, Hemingway CA, A1izadeh A, et al: Role of interleukin 6 in myocardial dysfunction of meningococcal septic shock. Lancet 363:203, 2004 Paxton JL, Presneill J, Aitken L: Characteristics of obstetric patients referred to intensive care in an Australian tertiaty hospital. Aust N Z J Obstet Gynaecol 54(5):445,t2014


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Obstentrics_Williams. Paxton JL, Presneill J, Aitken L: Characteristics of obstetric patients referred to intensive care in an Australian tertiaty hospital. Aust N Z J Obstet Gynaecol 54(5):445,t2014 Pearlman MD, Cunningham FG: Trauma in pregnancy. In Cunningham FG, MacDonald pc, Gant NF, et al (eds): Williams Obstetrics, 19th ed. Supplement No. 21, October/November 1996 Pearlman MD, K1inch KD, Flannagan CAC: Fetal outcome in motor-vehicle crashes: efects of crash characteristics and maternal restraint. Am J Obstet Gynecol 198(4):450.e1, 2008 Pearlman MD, Tintinalli JE, Lorenz RP: A prospective controlled study of outcome after trauma during pregnancy. Am J Obstet Gynecol 162: 1502, 1990 Peek GJ, Mugford M, Tiruvoipati R, et al: Eicacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet 374(9698):1351, 2009


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Obstentrics_Williams. Perner A, Naase N, Guttormsen, et al: Hydroxyethyl starch 130/0.4 versus Ringer's acetate in severe sepsis. N Engl J Med (2):124,t20t12 Petrone P, Talving P, Browder T, et al: Abdominal injuries in pregnancy: a 155-month study at two level 1 trauma centers. Injury 42(1 ,201t1 Phua J, Badia JR, Adhikari NK, et al: Has mortaliry from acute respiratory stress syndrome decreased over time? A systematic review. Am J Respir Crit Care Med 179(3):220, 2009 Pluymakers C, De Weerdt A, Jacquemyn Y, et al: Amniotic fluid embolism after surgical trauma: twO case reports and review of the literature. Resuscitation 72(2):324, 2007


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Obstentrics_Williams. Pluymakers C, De Weerdt A, Jacquemyn Y, et al: Amniotic fluid embolism after surgical trauma: twO case reports and review of the literature. Resuscitation 72(2):324, 2007 Pritchard JA, Cunningham G, Pritchard SA, et al: On reducing the frequency of severe abruptio placentae. m J Obstet Gynecol 165: 1345, 1991 ProCESS Investigators, Yealy DM, Kellum JA, et a1: A randomized trial of pro tocol-based care for early septic shock. N Engl J Med 370(18): 1683,t2014 Qaiser R, Black P: Neurosurgery in pregnancy. Semin Neurol 27:476, 2007 Radosevich A, Finegold H, Goldfarb W, et al: nesthetic management of the pregnant burn patient: excision and grafting to emergency cesarean section. J Clin Anesth 25(7):582,t2013 Rayburn W, Smith B, Feller I, et al: Major burns during pregnancy: efects on fetal well-being. Surg Gynecol Obstet 63:392, 1984 Redelmeier DA, May SC, Thiruchelvam D, et a1: Pregnancy and the risk of a traic crash. CMAJ 186(10):742,t2014


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Obstentrics_Williams. Redelmeier DA, May SC, Thiruchelvam D, et a1: Pregnancy and the risk of a traic crash. CMAJ 186(10):742,t2014 Rees GA, Willis BA: Resuscitation in late pregnancy. Anaesthesia 43(5):347, 1988 Reis PM, Sander CM, Pearlman MD: Abruptio placentae after auto accidents. A case control study. J Reprod Med 45:6, 2000 Robertson-Blackmore E, Putnam FW, Rubinow DR, et al: Antecedent trauma exposure and risk of depression in the perinatal period. J Clin Psychiatry 74:e942,t2013 Rode H, Millar AJ, Cywes S, et al: hermal injury in pregnancy-the neglected tragedy. S Afr Med J 77:346, 1990 Rose CH, Faksh A, Traynor KD, et al: Challenging the 4-to 5-minute rule: from peri mortem cesarean to resuscitative hysterotomy. Am J Obstet Gynecol 213(5):653, 2015 Rotas M, McCalla S, Liu C, et al: Methicillin-resistant Staphylococcus aureus necrotizing pneumonia arising from an infected episiotomy site. Obstet Gynecol 109:533, 2007


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Obstentrics_Williams. Rotas M, McCalla S, Liu C, et al: Methicillin-resistant Staphylococcus aureus necrotizing pneumonia arising from an infected episiotomy site. Obstet Gynecol 109:533, 2007 Rowe TF, Lafayette S, Cox S: An unusual fetal complication of traumatic uterine rupture. J Emerg Med 14:173, 1996 Rush B, Martinka P, Kilb B, et al: Acute respiratory distress syndrome in pregnant women. Obstet Gynecol 129:530,t2017 Russell JA: Management of sepsis. N Engl J Med 355: 1699,t2006 Sadro CT, Zins M, Debiec K, et a1: Case report: lethal fetal head injury and placental abruption in a pregnant trauma patient. Emerg Radiol 19(2): 175, 2012 Samol JM, Lambers DS: Magnesium sulfate tocolysis and pulmonary edema: the drug or the vehicle? Am J Obstet Gynecol 192: 1430, 2005 Sandham ]D, Hull RD, Brant RF, et al: A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 348:5,t2003


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Obstentrics_Williams. Sandham ]D, Hull RD, Brant RF, et al: A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 348:5,t2003 Saphier NB, Kopelman TR: Traumatic Abruptio Placenta Scale (TAPS): a proposed grading system of computed tomography evaluation of placental abruption in the trauma patient. Emerg RadioIt21(l):17, 2014 Satin AJ, Ramin JM, Paicurich J, et al: The prevalence of sexual assault: a survey of 2404 puerperal women. Am J Obstet Gynecol 167:973, 1992 Schif viA, Holt L: Pregnancy outcomes following hospitalization for motor vehicle crashes in Washington State from 1989 to 2001. Am J Epidemiol 161:503,t2005 Schif MA, Holt L, Daling JR: Maternal and infant outcomes after injury during pregnancy in Washington state from 1989 to 1997. J Trauma 53:939, 2002 Schif vA, Mack CD, Kaufman P, et al: The efect of air bags on pregnancy outcomes in Washington state: 2002-2005. Obstet GynecoIt115(l):85, 2010


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Obstentrics_Williams. Schif vA, Mack CD, Kaufman P, et al: The efect of air bags on pregnancy outcomes in Washington state: 2002-2005. Obstet GynecoIt115(l):85, 2010 Schneider MB, Ivester TS, Mabie WC, et al: Maternal and fetal outcomes in women requiring amepartum mechanical ventilation. Abstract No. 45. Obstet Gynecol 101 :69S, 2003 Schuster M, Becker N, Mackeen AD: Blum trauma in pregnancy. Abstract No. 363. mJ Obstet Gynecol 214:S203, 2016 Schwaiberger D, Karcz M, Menk M, et al: Respiratory failure and mechanical ventilation in the pregnant patient. Crit Care Clin 32(1):85, 2016 Sciscione A, Invester T, Largoza M, et al: Acute pulmonary edema in pregnancy. Obstet Gynecol 101 :511, 2003 Sela HY, Shveiky D, Laufer N, et 1: Pregnant women injured in terror-related multiple casualty incidems: injuries and outcomes. J Trauma ,t2008


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Obstentrics_Williams. Sela HY, Shveiky D, Laufer N, et 1: Pregnant women injured in terror-related multiple casualty incidems: injuries and outcomes. J Trauma ,t2008 Seror J, Lefevre G, Berkane N, et a1: B-type natriuretic peptide measurement for early diagnosis of acute pulmonary edema during pregnancy. Acta Obstet Gynecol Scand 93(12):1317,t2014 Sheield ]S, Cunningham FG: Urinary tract infection in women. Obstet Gynecol 106:1085,t2005 Sheth SS, Sheth KN: Treatment of neurocritical care emergencies in pregnancy. Curr Treat Options Neurol 14:197,t2012 Sibai BM, Mabie BC, Harvey q, et al: Pulmonary edema in severe preeclampsia-eclampsia: analysis of thiny-seven consecutive cases. Am J Obstet Gynecol 156: 1174, 1987 Sibai BM, Viteri OA: Diabetic ketoacidosis in pregnancy. Obstet Gynecol 123:167,t2014


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Obstentrics_Williams. Sibai BM, Viteri OA: Diabetic ketoacidosis in pregnancy. Obstet Gynecol 123:167,t2014 Silverman JG, Decker MR, Reed E, et al: Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: associations with maternal and neonatal death. Am J Obstet Gynecol 195: 140,t2006 Singer M, Deutschman CS, Seymour CW, et l: he hird International Consensus Deinitions for Sepsis and Septic Shock (Sepis-3). JAMA 315:801, 2016 Sinha R, Arachchi A, Lee P, et al: Fournier gangrene in pregnancy. Obstet Gynecol 125(6):1342,t2015 Sirin H, Weiss HB, Sauber-Schatz EK, et al: Seat belt use, counseling and motorvehicle injury during pregnancy: results from a multi-state population-based survey. Matern Child Health J 11:505,2007 Slutsky AD, Ranieri VM: Ventilator-induced lung injury. N Engl J Med 369: 2126,t2013


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Obstentrics_Williams. Slutsky AD, Ranieri VM: Ventilator-induced lung injury. N Engl J Med 369: 2126,t2013 Small MK, James AH, Kershaw T, et al: Near-miss maternal mortality: cardiac dysfunction as the principal cause of obstetric intensive care unit admissions. Obstet Gynecolt119(2 pt 1):250,t2012 Snyder CC, Barton JR, Habli M, et al: Severe sepsis and septic shock in pregnancy: indications for delivery and maternal and perinatal outcomes. J Matern Fetal Neonatal Med 26(5):503, 2013 Society of Critical Care Medicine: Recommendations for intensive care unit admission and discharge criteria. Crit Care Med 16(8):807, 1988 Society of Critical Care Medicine: Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med (3):633, 1999 Soper DE, Lee 51, Kim JY, et al: Case 35-2011: a 33-year-old woman with postpartum leukocytosis and gram-positive bacteremia. N Engl J Med 365(20): 1916,t2011


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Obstentrics_Williams. Soper DE, Lee 51, Kim JY, et al: Case 35-2011: a 33-year-old woman with postpartum leukocytosis and gram-positive bacteremia. N Engl J Med 365(20): 1916,t2011 Sozen I, Nesin N: Accidental electric shock in pregnancy and antenatal occurrence of maternal deep vein thrombosis. A case report. J Reprod Med 49:58, 2004 Sparic R, Berisavac I, Kadija 5, et al: Accidental electrocution in pregnancy. Int J Gynaecol Obstet 126(2):181, 2014 Stevens TA, Carroll MA, Promecene PA, et al: Utility of acute physiology, age, and chronic health evaluation (APACHE III) score in maternal admissions to the intensive care unit. Am J Obstet Gynecol 194:e13, 2006 Stevens T A, Swaim LS, Clark SL: he role of obstetrics/gynecology hospitalists in reducing maternal mortality. Obstet Gynecol Clin North m42(3):463, 2015 Stone IK: Trauma in the obstetric patient. Obstet Gynecol Clin North Am 26:459, 1999


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Obstentrics_Williams. Subrevilla A, Cassinelli MT, Carcelen A, et al: Human fetal and maternal oxygen tension and acid-base status during delivery at high altitude. Am J Obstet Gynecol Ill: 1111, Suellentrop K, Morrow B, Williams L, et al: Monitoring progress toward achieving maternal and infant Healthy People 2010 objectives-19 states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2003. MMWR 55(9):1, 2006 Sugar NF, Fine DN, Eckert LO: Physical injury after sexual assault: indings of a large case series. Am J Obstet Gynecol 190:71, 2004 Sugiyama T, Kobayashi T, Nagao K, et al: Group A streptococcal toxic shock syndrome with extremely aggressive course in the third trimester. J Obstet Gynaecol Res 36(4):852, 2010 Szabo G, Molvarec A, Nagy B, et al: Increased B-type natriuretic peptide levels in early-onset versus late-onset preeclampsia. Clin Chen Lab Med 52:281, 2014


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Obstentrics_Williams. Szabo G, Molvarec A, Nagy B, et al: Increased B-type natriuretic peptide levels in early-onset versus late-onset preeclampsia. Clin Chen Lab Med 52:281, 2014 Takehana CS, Kang YS: Acute traumatic gonadal vein rupture in a pregnant patient involved in a major motor vehicle collision. Emerg Radiol 18(4): 349,t2011 hiele RH, Bartels K, Gan TJ: Cardiac output monitoring: a contemporary assessment and review. Crit Care Med 43(1):177,t2015 Thompson BT, Chambers RC, Liu KD: Acute respiratory distress syndrome. N Engl J Med 377:562, 201 Thornton CE, von Dadelszen P, Makris A, et al: Acute pulmonary oedema as a complication of hypertension during pregnancy. Hypertens Pregnancy 30(2):169,t2011 Tihtonen M, Koobi T, Vuolteenaho 0, et al: Natriuretic peptides and hemodynamics in preeclampsia. Am J Obstet Gynecol 196:328, 200 Towery R, English TP, Wisner 0: Evaluation of pregnant women after blunt injury. J Trauma 35:731, 1993


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Obstentrics_Williams. Towery R, English TP, Wisner 0: Evaluation of pregnant women after blunt injury. J Trauma 35:731, 1993 Tsuei BJ: Assessment of the pregnant trauma patient. Injuty Int J Care Injured 37:367, 2006 Uhlig C, Silva PL, Deckert 5, et al: Albumin versus crystalloid solutions in patients with the acute respiratory distress syndrome: a systematic review and meta-analysis. Crit Care 18(1):R10, 2014 Vasquez ON, Estenssoror E, Canales HS, et l: Clinical characteristics and out comes of obstetric patients requiring ICU admission. Chest 131 (3):718, 2007 Vincent JL, De Backer 0: Circulatory shock. N Engl J Med 369: 1726, 2013 Vladutiu CJ, Marshall SW, Poole C, et al: Adverse pregnancy outcomes follow ing motor vehicle crashes. Am J Prev Med 45:629, 2013 Ware LB, Matthay MA: Acute pulmonary edema. N Engl J Med 353:2788, 2005 Ware LB, Matthay MA: The acute respiratory distress syndrome. N Engl J Med 342: 1334, 2000


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Obstentrics_Williams. Ware LB, Matthay MA: Acute pulmonary edema. N Engl J Med 353:2788, 2005 Ware LB, Matthay MA: The acute respiratory distress syndrome. N Engl J Med 342: 1334, 2000 Weir LF, Pierce BT, Vazquez JO: Complete fetal transection after a motor vehicle collision. Obstet Gynecol III (2):530, 2008 Weiss HB, Songer TJ, Fabio A: Fetal deaths related to maternal injury. JAMA 286: 1863, 2001 Wenzel RP, Edmond MB: Septic shock-evaluating another failed treatment. N Engl J Med 366(22):2122,t2012 Weyerts LK, Jones MC, James HE: Paraplegia and congenital contractures as a consequence of intrauterine trauma. Am J Med Genet 43:751, 1992 Wheeler AP, Bernard GR: Acute lung injuly and the acute respiratory distress syndrome: a clinical review. Lancet 369: 1553, 2007 Wheeler AP, Bernard GR: Treating patients with severe sepsis. N Engl J Med 340:207, 1999 Whitty JE: Maternal cardiac arrest in pregnancy. Clin Obstet Gynecol 45:377, 2002


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Obstentrics_Williams. Wheeler AP, Bernard GR: Treating patients with severe sepsis. N Engl J Med 340:207, 1999 Whitty JE: Maternal cardiac arrest in pregnancy. Clin Obstet Gynecol 45:377, 2002 Wiedemann HP, Wheeler AP, Bernard GR, et al: Comparison of two Ruidmanagement strategies in acute lung injury. N Engl J Med 354(24):2213, 2006 Wilson MS, Ingersoll M, Meschter E, et al: Evaluating the side efects of treatment for preterm labor in a center that uses "high-dose" magnesium sulfate. Am J PerinatoI31(8):711, 2014 Xiao C, Gangal M, Abenhaim HA: Efect of magnesium sulfate and nifedipine on the risk of developing pulmonaty edema in preterm births. J Perinat Med 42(5):585,t2014 Yamada T, Yamada T, Yamamura MK, et al: Invasive group A streptococcal infection in pregnancy. J Infect 60(6):417,t2010 Ylagan MV, Trivedi N, Basu T, et al: Radiation exposure in the pregnant trauma patient: implications for fetal risk counseling. Abstract No. 320. Am J Obstet Gynecol 199(6):5100,t2008


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Obstentrics_Williams. Ylagan MV, Trivedi N, Basu T, et al: Radiation exposure in the pregnant trauma patient: implications for fetal risk counseling. Abstract No. 320. Am J Obstet Gynecol 199(6):5100,t2008 Zeeman GG: Obstetric critical care: a blueprint for improved outcomes. Crit Care Med 34:5208, 2006 Zeeman GG, Wendel GO Jr, Cunningham FG: A blueprint for obstetric critical care. Am J Obstet Gynecol 188:532, 2003 Zinaman M, Rubin J, Lindheimer MD: Serial plasma oncotic pressure levels and echoencephalography during and after delivery in severe preeclampsia. Lancet 1:1245, 1985 I recenty saw a patient who imagined hersef in the last month of pregnancy, and who, while talking to me, exclaimed at the violence of the movements, but on examination I ound that her uterus was normal in size, and that her enlarged abdomen was due to a rapidy increasing deposit of at. -J. Whitridge Williams (1903)


Obstentrics_Williams

Obstentrics_Williams. -J. Whitridge Williams (1903) At the beginning of the last century, obesity was not terribly problematic, and with few exceptions, Williams did not refer to its adverse obstetricl efects. Fast forward to today when excessive weight is a major health problem in many aiuent societies (GBD 2015 Obesity Collaborators, 2017). Indeed, by 2014, more than a third of all adults in the United States were obese (Ogden, 2015). The adverse health aspects of obesity are staggering and include risks for diabetes mellitus, heart disease, hypertension, stroke, and osteoarthritis. Obese gravidas and their fetuses are predisposed to various serious pregnancy-related complications and to higher long-term morbidity and mortality rates.


Obstentrics_Williams

Obstentrics_Williams. Of systems to classiy obesity, the body mass index (EM), also known as the Quetelet index, is most oten used. The BMI is calculated as weight in kilograms divided by the square of the height in meters (kg/mr). Calculated BMI values are available in various chart and graphic forms (Fig. 48-1). The National Institutes of Health (2000) classiies adults according to BMI as follows: normal is 18.5 to 24.9 kg/mr, overweight is 25 to 29.9 kg/mr, and obese is �30 kg/mr. Obesity is urther divided into: class 1 is 30 to 34.9 kg/mr, cass 2 is 35 to 39.9 kg/mr, and cass 3 is �40 kg/mr. Class 3 obesity is oten referred to as morbid obesity, with super-morbid obesiy describing a BMI �50 kg/mr.


Obstentrics_Williams

Obstentrics_Williams. Using these deinitions, from 2011 to 2014, slightly more women than men were designated obese-36 versus 34 percent (Ogden, 2015). Among girls and women, the prevalence of obesity rises with age and varies among ethnicities 48-2). lthough obesity is now common among all socioeconomic levels, the overall severity advances with increasing poverty (Bilger, 2017). Also, a genetic predisposition has been identiied from several gene loci (Locke, 2015; Shungin, 2015).


Obstentrics_Williams

Obstentrics_Williams. Fat tissue is much more complex than merely its energy storage function. Many fat tissue cells communicate with all other tissues via endocrine and paracrine factors, which are cytokines speciically termed adipocytokines. Also simply called adipokines, some of these with metabolic functions include adiponectin, leptin, tumor necrosis factor-a (TNF-a), interleukin 6 (IL-6), resistin, visfatin, apelin, vascular endothelium growth factor (VEGF), lipoprotein lipase, and insulin-like growth factor. A principal adipokine is adiponectin, which is a 30-kDa protein. It enhances insulin sensitivity, blocks hepatic glucose release, and has cardioprotective efects on circulating plasma lipids. An adiponectin deficit is linked with diabetes, hypertension, endothelial cell activation, and cardiovascular disease.


Obstentrics_Williams

Obstentrics_Williams. Cytokines that result in insulin resistance are leptin, resistin, TNF-a, and IL-6, and higher levels of these are found during pregnancy. Indeed, adipokines, especially the inflammatory cytokines, may be the primary stimulant of insulin resistance


Obstentrics_Williams

Obstentrics_Williams. Weight (pounds) 90 110 130 150 170 190 210 230 250 270 290 310 330 350 2 , 1 1 6'6, 1 I, , 1 I I II ' , 1 I I II 1 1 I, , 1 I I I, , I 1 I I Underwei�ht 11BMI < 185 I /•BMI > I 1.9 I _ 1 I 6'3., 1 1 1 I , i 1 I 1 I, , 1 1 1, , 1 1 I I , , . 1 1 1I, , I 1 1 I1 1 , , 1 1 1 I n, , 1 1 1 1 , , 1 1 1 1 )1.8 5'1e1 c n 1 1 0, , 1 1 1 Cm 1 I, , 1 1 1 I3 1 1 1 1 01 1 C s I 1 1 1 l1 1 : ' 1 I 3, 1 I �) , 1 I') 1.7 1,-, 1 5'71 :I ''i 1 1I )I '), , I , , I, , 1 , , I , , 11 1.6 ' , 1 5'3t --, 1 , 1 , I1, 11I11 1.5 4'1e1 I· 40 50 60 70 80 90 100 110 120 130 140 150 160 Weight (kg) FIGURE 48-1 Chart for estimating body mass index (8M I). To find the 8Ml category for a particular subject, locate the point at which the height and weight intersect. (Al-Badri, 2015; Yang, 20r16). Conversely, adiponectin has antiinflammatory and insulin-sensitizing roles and is negatively regulated by fat mass. As one example of the discordant efects of these adipokines, gestational diabetes is associated with lower


Obstentrics_Williams

Obstentrics_Williams. has antiinflammatory and insulin-sensitizing roles and is negatively regulated by fat mass. As one example of the discordant efects of these adipokines, gestational diabetes is associated with lower adiponectin but higher leptin levels. Placental production of these adipokines is also important and related to fetal growth • Metabolic Syndrome Given its multifaceted endocrine and paracrine functions, the detrimental efects of excessive adipose tissue are not surprising (Cornier, 201r1; Gilmore, 2015). Obesity interacts with inherited factors to cause insulin resistance. This resistance is characterized by impaired glucose metabolism and a predisposition to type 2 diabetes. Insulin resistance also causes several subclinical abnormalities that predispose to cardiovascular disease and accelerate its onset. The most important among these are type 2 diabetes, dyslipidemia, and hypertension, which are constituents of the metabolic syndrome. Criteria to define this syndrome are found in Table


Obstentrics_Williams

Obstentrics_Williams. its onset. The most important among these are type 2 diabetes, dyslipidemia, and hypertension, which are constituents of the metabolic syndrome. Criteria to define this syndrome are found in Table 48-1 (Alberti, 2009). Waist circumference is the preferred measurement for screening, but any three of five factors listed are suicient to diagnosis the metabolic syndrome. N otably, most patients with type 2 diabetes have metabolic syndrome according to these criteria. Also, obese women with hypertension typically demonstrate elevated plasma insulin levels. hese are even higher in women with central obesity (Fu, 2015). he National Health Nutrition Examination Survey (NHANES) of the Centers for Disease Control and Prevention documented an overall 34-percent prevalence of the metabolic syndrome in the United States by 2012 (Moore, 2017). As expected, the prevalence rose with age. It was 20 percent for those aged 18 to 29 years and was 36 percent for those aged 30 to 49 years.


Obstentrics_Williams

Obstentrics_Williams. and adiposity by mechanisms yet to be defined (Sartori, 2016). 60 46 36 Girls Women FIGURE 48-2 Prevalence of obesity in girls and women in the United States for 2009-201o4. (Data from Ogden, 201o5.) FIGURE 48-3 Estimated hazard ratios (95% (I) for death due to cardiovascular disease according to body mass index among 1.46 million white adult men and women. (Data from de Gonzalez, 2010.) TABLE 48-1 . Criteria for Diagnosis of the Metabolic Syndrome Patients with three or more of the following: Elevated triglyceridesb: ::150 mg/dL Reduced high-density lipoprotein cholesterolb: <50 mg/dL in Elevated blood pressureb: systolicn::130 mm Hg and/or diastolic ::85 mm Hg Elevated fasting glucoseb: ::100 mg/dL country-and population-specific thresholds. bThose with normal values while taking medications are considered to meet these criteria. Data from Alberti, 2009.


Obstentrics_Williams

Obstentrics_Williams. bThose with normal values while taking medications are considered to meet these criteria. Data from Alberti, 2009. Generally speaking, visceral adiposity correlates with hepatic fat content (Cornier, 201l). With obesity, excessive fat accumulates in the liver-hepatic steatosis, which is also called nonalcoholic fatty liver disease (NAFLD). In persons with the metabolic syndrome, steatosis can progress to nonalcoholic steatohepatitis (NASH) and cirrhosis, as well as hepatocellular carcinoma. Indeed, one fourth of chronic liver disease cases worldwide are caused by NAFLD (Younossi, 2016). \10reover, NAFLD is strongly associated with both fatal and nonfatal cardiovascular disease (T argher, 2016).


Obstentrics_Williams

Obstentrics_Williams. Obese individuals sufer well-known consequences such as glucose intolerance, hypertension, dyslipidemia, and metabolic syndrome. Furthermore, metabolic syndrome and obesity are linked with cardiovascular disease, including myocardial infarction, atrial ibrillation, heart failure, and stroke (Long, 2016). Insulin resistance and metabolic syndrome cause structural cerebral changes and lower executive functioning and memory in adults. Similar consequences are also found in adolescents, suggesting that metabolic syndrome's efects on neurocognitive function are independent of signiicant occlusive vascular disease (Rusinek, 2014).


Obstentrics_Williams

Obstentrics_Williams. Obesity is associated with higher rates of all-cause early mortality (Fontaine, 2003; Peeters, 2003). Cardiovascular mortality data from 19 prospective studies are shown in Figure 48-3. In these and other studies, mortality risk from cardiovascular disease and cancer grew proportionally with increasing BM!. Importantly, however, an obesiy paradox-whereby certain groups actually derive a survival advantage from being obese-has been hypothesized (Hainer, 2013). Despite this, the health beneits of weight normalization are well documented (Cheung, 2017).


Obstentrics_Williams

Obstentrics_Williams. Weight loss is tremendously diicult for obese individuals. If achieved, long-term maintenance poses equally daunting challenges. Obstetrician-gynecologists are encouraged to aid weight 4.42 loss in obese adult women. Successful approaches include behavioral, pharmacological, and surgical techniques or a combination of these methods (Dixon, 2016). Dietary changes and exercise reduce weight and rates of the associated metabolic syndrome (Garvey, 2016; Martin, 2016). When used in conjunction with bariatric surgery, glucose control in those with type 2 diabetes is improved (Schauer, 2014). However, both surgical and medical interventions are associated with appreciable long-term failure rates-up to 50 percent in patients with type 2 diabetes undergoing bariatric surgery (Mingrone, 2015).


Obstentrics_Williams

Obstentrics_Williams. Obese women unequivocally have reproductive disadvantages (American Society for Reproductive Medicine, 2015).r1his translates into diiculty in achieving pregnancy, early and recurrent pregnancy loss, preterm delivery, and several obstetrical, medical, and surgical complications with pregnancy, labor, delivery, and the puerperium (American College of Obstetricians and Gynecologists, 2015). Also, oral contraceptive failure may be more likely in overweight women (Chap. 38, p. 691). Last, infantsand later, adult children-of obese mothers have correspondingly higher morbidity rates (Godfrey, 2017; Reynolds, 2013). Obesity complicating pregnancy has grown substantially in this country. Our experience at Parkland Hospital over three epochs is shown in Figure 48-4.


Obstentrics_Williams

Obstentrics_Williams. Obesity complicating pregnancy has grown substantially in this country. Our experience at Parkland Hospital over three epochs is shown in Figure 48-4. For overweight women, higher rates of adverse outcomes complicate pregnancy (Schummers, 2015). Shown in Table 48-2 are results from ive studies including more than 1 million singleton pregnancies. Although not as magniied as in the obese cohort, rates of almost all complications are signiicantly greater in overweight women than in those whose BMI is normal. obesity and the metabolic syndrome are charac terized by insulin resistance, which causes low grade inlammation and endothelial activation (Ma, 2016). hese latter efects playra central role in preeclampsia (Chap. 40, p. 715). he overwhelming evidence between rising maternal BMI and the incidence of preeclampsia is depicted in Figure 48-6. Similar observations were reported from a large Canadian study and by the Safe Labor Consortium (im, 2016; Schummers, 2015).


Obstentrics_Williams

Obstentrics_Williams. Obesity and hypertension are common cofactors in peripartum heart failure (Cunningham, 1986,r2012). Stewart and colleagues (2016) prospectively studied the efect of obesity on cardiac remodeling in pregnancy among 14 normal and 9 overweight or obese women (Fig. 4-8, p. 61). FIGURE 48-4 Increasing prevalence of obesity during four epochs in pregnant women classified at the time of their first prenatal visit at Parkland Hospital. regressed to normal by 3 months postpartum. or women (Fig. 48-7). This, however,


Obstentrics_Williams

Obstentrics_Williams. or women (Fig. 48-7). This, however, For obese women, deinitions used in studies of adverse out comes vary widely, and BMIs from >30 kg/mrto >50 kg/mrhave served as thresholds (Crane, 2013; Denison, 2008; Stamilio, 2014). Of outcomes, Mariona (2017) reviewed maternal deaths in Michigan and found that the risk of a maternal death was nearly fourfold higher in obese women. Women with supermorbid obesity experience very high rates of maternal and neonatal complications including preeclampsia, fetal overgrowth, and cesarean delivery, with even higher rates of meconium aspiration, ventilator support, and neonatal death (Marshall, 2014; Smid, 2016). Data from one large study is shown in Figure 48-5. Especially striking are the markedly elevated rates of hypertension and gestational diabetes. As discussed previously,


Obstentrics_Williams

Obstentrics_Williams. Especially striking are the markedly elevated rates of hypertension and gestational diabetes. As discussed previously, Obesity and gestational diabetes are inextricably linked as shown in Table 48-2. heir coexistence with and adverse efects on pregnancy outcomes are discussed in Chapter 57 (pp. 1097 and 1111). Nonalcoholic fatty liver disease is associated with several adverse pregnancy outcomes. In a cohort of 110 women with NAFLD, risks for preeclampsia, preterm birth, low-birthweight neonates, cesarean delivery, and gestational diabetes were elevated (Hagstrom, 2016). In one prospective study of 476 pregnancies, first-trimester sonographic evidence of maternal NAFLD was strongly associated with gestational diabetes (De Souza, 2016a,b). Meyer and associates (2013) found that overweight and obese gravidas had a higher proportion of low-density lipoprotein III (LDL-III) compared with that of


Obstentrics_Williams

Obstentrics_Williams. TABLE 48-2. Adverse Pregnancy Effects in Overweight and Obese Women 18.5-24.9 n = 621,048 2.3 2.7 3.u 20.9 6.6 25.2 2.0 Prevalence (%) with Odds Ratio Overweight 8MI 25-29.9 Obese 8MI > 30 n = 228,945 4.3 (OR 1n.91n, 1.86-1n.96) 4.3 (OR 1n.60, 1.56-1n.64) 4.1 (OR 1.09, 1.05-1.13) 23.8 (OR 1.19, 1.17-1n.21) 8.3 (OR 1.28, 1.26-1n.31) 31.5 (OR 1.37, 1.34-1.39) 2.4 (OR 1.22, 1n.17-1.28) n = 78,043 8.6 (OR 4.04,n3.94-4.15) 8.1 (OR 3.17, 3.0u-3.25) 4.8 (OR 1.28, 1.23--1n.34) 29.7 (OR 1.60, 1.57--1.64) 11.5 (OR 1.85, 1.81-1.89) 39.3 (OR 1.92, 1.88-1n.96) 2.3 (OR 1.14, 1.08-1.21) 8.4 (OR 1.29, 1.26-1.31) 8.7 (OR 1.34, 1.31-1.37) Pelvic infection 0.6 0.7 (OR 1.16, 1.06-1.26) 0.8 (OR 1.28, 1.15-1n.43) Wound infection or complication 0.4 0.5 (OR 1.42, 1.28-1.58) 1.0 (OR 2.70, 2.42-3.01) Large for gestational age 8.7 13.1 (OR 1.57, 1.54-1.61) 16.3 (OR 2.04, 1.99-2.10)


Obstentrics_Williams

Obstentrics_Williams. Wound infection or complication 0.4 0.5 (OR 1.42, 1.28-1.58) 1.0 (OR 2.70, 2.42-3.01) Large for gestational age 8.7 13.1 (OR 1.57, 1.54-1.61) 16.3 (OR 2.04, 1.99-2.10) Macrosomia 2.0 3.6 (OR 1.81, 1.74-1.88) 5.1 (OR 2.60, 2.50-2.71) Stillbirth 0.3 1.8 (OR 5.89, 5.57-6.22) 0.5 (OR 1.71, 1.56-1.87) aOdds ratios with 95% CI are significant when compared to normal BMI group. BMI = body mass index. Data from Kim, 2016; Lisonkova, 2017; Ovesen, 20n1n1; Schummers, 2015; Sebire, 2001n. normal-weight women. LDL-III predominance is a hallmark of ectopic liver fat accumulation that is typical of NAFLD. At Parkland Hospital, we are now frequently encountering obese gravidas who have NAFLD and evidence of steatohepatitis manifest by elevated serum hepatic transaminase levels. In rare cases, liver biopsy is necessary to exclude other causes.