Page 753 - ACCCN's Critical Care Nursing

730 S P E C I A LT Y P R A C T I C E I N C R I T I C A L C A R E

estimated gestation may be obtained from the woman (or hospitalisation rate. Anecdotally, it is rare for a
friend/relative) or may require blood tests/physical well woman of childbearing age to be admitted to ICU
examination/ultrasound. 160 If the woman is obviously with community-acquired pneumonia; women living in
pregnant, a rough estimate of gestation can be made by disabled support accommodation and pregnant women
measuring the height of the fundus from the symphysis are the exception. Varicella pneumonia is also more pro-
pubis. The height in cm equates to the number of weeks’ minent in the pregnant population. It would appear from
gestation, e.g. 22 cm = 22 weeks’ gestation. The presence studies on pregnant admissions to ICU and maternal
of fetal movement is a quick assessment of fetal wellbeing death reports that severe community-acquired pneu-
and if the woman is conscious and over 18–20 weeks’ monia in previously well women is a persisting concern
gestation, she should be able to communicate if she feels in the pregnant population.
fetal movements. The physiological adaptations of preg- It is not fully understood why pregnant women may be
nancy may initially mask serious injury, with vital signs vulnerable to severe pneumonia though the adaptations
and patient symptoms not reflective of the underlying to the mechanics of breathing and changes in the immune
injuries. 163 A pregnant woman’s condition can rapidly response may be contributing factors. 164 Additionally, it
deteriorate.
has been postulated that pregnant women are amongst
Use of Imaging in Pregnancy small children more often and may have an increased
likelihood of exposure to infective agents. Regardless, the
All radiological investigations and imaging that are clini- treatment and management of pneumonia in pregnancy
cally indicated by the maternal condition should be is no different to pneumonia in non-pregnant women:
attended to without delay over concerns for the fetus. 163 identify causative organism and administer appropriate
When possible and appropriate, use of a pelvic/abdominal antibiotics/antiviral agents as indicated, maintain oxy-
lead shield may be used to protect the developing embryo/ genation and prevent complications (see Chapter 14).
fetus. If a chest tube is necessary for a haemothorax, care Assessment of fetal wellbeing and awareness of the
should be taken to position the catheter 1–2 spaces changed respiratory parameters in pregnancy are the
higher than normal due to the raised diaphragm. obvious additional requirements.
Obstetric Assessment in Trauma Pregnancy and Influenza
If the woman’s gestation is estimated to be 22–24 weeks The WHO has recommended that all pregnant women
or more, then a CTG should be conducted to assess fetal receive the seasonal influenza vaccination since 2006, in
wellbeing (see section on fetal assessment). If there has recognition of the known increased risk that influenza
been any likelihood of blunt trauma to the abdomen poses during pregnancy and because vaccination during
(i.e. by the steering wheel or seatbelt position), then pregnancy is safe and confers immunity to the newborn
a continuous four-hour duration CTG should be done for the first few vulnerable months. In developing coun-
to identify any fetal distress resulting from a potential tries, this policy has the potential to save the lives of many
placental abruption. An abdominal ultrasound is com- women and in particular, their babies. In developed
monly done to assess fetal wellbeing and to identify any countries, maternal death caused by seasonal influenza is
trauma to the fetus. Ultrasound is also useful in detecting rare. However, the pandemic influenza, H1N1 09 (referred
free peri toneal fluid, maternal haemorrhage and may to as ‘swine flu’), which swept across the world in 2009,
assist in the diagnosis of placental abruption. 163 The pos- demonstrated how vulnerable pregnant women are to
sibility of uterine rupture should also be considered even influenza and emphasised the importance of influenza
though it is rare (<1% of pregnant trauma patients). 163 vaccination to prevent severe disease.
Also remember that the bladder becomes an abdominal
organ after 12 weeks’ gestation and is more prone to The H1N1 2009 flu epidemic killed seven pregnant/
traumatic injury. postpartum women in Australia and New Zealand in
three months. 165 Over 60 women were admitted to ICU
Potential for Perimortem Caesarean Section and a number of their babies died (see the Research

If the woman is ≥20 weeks’ gestation, perimortem caesar- vignette at the end of the chapter for more details on this
ean section should be considered early if the woman study). Women in the second half of pregnancy were over
requires resuscitation. Effective CPR is virtually impo s- 13 times more likely to be admitted to ICU with H1N1
sible after midpregnancy and the likelihood for fetal influenza than non-pregnant women of child-bearing
survival is low. age. Pregnant and postpartum women admitted to ICU
with H1N1 influenza were particularly unwell, with 14%
PNEUMONIA of women requiring ECMO. 166

Pneumonia in pregnancy is one of the more common Interestingly, the severe impact of the pandemic influenza
reasons why a pregnant woman may be admitted to ICU. on pregnant women seen during the H1N1 2009 epi-
Although studies have shown that pregnant women are demic is not dissimilar to that seen during the Spanish
not more likely to contract pneumonia than non-pregnant influenza epidemic of 1918 (also caused by H1N1 influ-
women, the severity of pneumonia experienced by women enza A) and the influenza epidemic of 1957. Each of
in these studies has not been well examined. 164 It is not these influenza epidemics has demonstrated an increased
known whether the ICU admission rate for pneumonia likelihood of maternal death from influenza and poor
is higher in the pregnant population as opposed to the maternal and neonatal outcomes.