Page 762 - ACCCN's Critical Care Nursing

Pregnancy and Postpartum Considerations 739

Case study
Carly is a 38-year-old woman who is having her second child. that the woman receives warmed fluids, catering to the obste-
Her first child was born by caesarean section 20 months ago. Carly trician’s needs, obtaining blood products and coordinating every-
has placenta praevia and has been booked for an elective repeat thing that is happening.
caesarean section at 38 weeks’ gestation at a tertiary obstetric hos-
pital. A spinal anaesthesia is established and the baby is born Support staff arrive and the hysterectomy is done with a cystos-
without complication, with Carly’s husband John present at the copy and bladder repair needed due to invasive placental tissue.
birth. However, Carly begins to bleed profusely and the obstetri- The bleeding is finally controlled though Carly is still ‘oozing’ from
cian soon identifies that the placenta is adherent to the uterus and any damaged tissue. Two drains are inserted and the wound is
he is having trouble removing the placenta. Carly has lost 1000 mL closed. Carly has had a documented acute blood loss of over
of blood very quickly and the anaesthetist increases the Hart- 7000 mL. She has received a total of 16 units of red blood cells, five
mann’s infusion and administers a litre of normal saline rapidly. He units of platelets, four units of fresh frozen plasma and four units
sends off an urgent blood crossmatch request and tells the operat- of cryoprecipitate, additional to approximately 9000 mL of crystal-
ing team they will need to convert Carly to a general anaesthesia. loids and colloids. As the wound was being sutured, an ICU bed
John is escorted out of the operating theatre and told that there was organised and arrangements made to transfer Carly to the
has been a bit of a complication and someone will be with him ICU at the general hospital, 2 km away. Carly was in theatre for
shortly. The blood loss continues at a rapid rate and the obstetri- 3.5 hours.
cian is having great difficulty trying to control the bleeding. Some
of the placental tissue has grown into the uterine wall and cannot Carly is admitted to ICU intubated and ventilated with vital signs
be separated. Total blood loss at this time is estimated to be of BP 100/55, HR 110, and her temperature is 35.1°C. Her ICU stay
4000 mL. The haematology department is called to find out where is relatively uncomplicated. Carly was warmed, filled with normal
the requested blood is, and to order fresh frozen plasma, platelets saline and given two more units of red blood cells for an Hb of
and cryoprecipitate. More normal saline is administered along with 79 g/L. She continued to have small ongoing ooze from her
1000 mL of haemaccel. Carly’s haemodynamic status is deteriorat- abdominal wound and into the two drains. As Carly was stabilised
ing. Her BP is 85/50 on the blood pressure cuff. The anaesthetist and it was clear that she would not need to return to theatre, her
would like continuous blood pressure monitoring but hasn’t had sedation was reduced and her ventilation support weaned. Her
time to put an arterial line in. He pages for another anaesthetist to urine output was initially low; this was treated with two small doses
come in to theatre to help. With the ongoing uncontrolled blood of IV frusemide with a good response. Carly was extubated over-
loss, a decision is made to proceed to hysterectomy. The obstetri- night and continued to progress well, though she was very tired
cian asks if a gynaeoncologist is available to come and assist with and her pain management needed addressing. She was transferred
the surgery. The theatre nursing staff are very busy trying to ensure back to the tertiary obstetric hospital the following day.

Research vignette
The ANZIC Influenza Investigators and Australasian Maternity Out- Results
comes Surveillance System. Critical illness due to 2009 A/H1N1 64 pregnant or postpartum women admitted to an intensive
influenza in pregnant and postpartum women: population based care unit had confirmed 2009 H1N1 influenza. Compared
cohort study. British Medical Journal 2010; 340: c1279. with non-pregnant women of childbearing age, pregnant or
Abstract postpartum women with 2009 H1N1 influenza were at increased
risk of admission to an intensive care unit (relative risk 7.4, 95%
Objective confidence interval 5.5 to 10.0). This risk was 13-fold greater
To describe the epidemiology of 2009 A/H1N1 influenza in critically (13.2, 9.6 to 18.3) for women at 20 or more weeks’ gestation.
ill pregnant women.
At the time of admission to an intensive care unit, 22 women
Design (34%) were post partum and two had miscarried. 14 women
Population based cohort study. (22%) gave birth during their stay in intensive care and 26 (41%)
were discharged from an intensive care unit with ongoing
Setting pregnancy. All subsequently delivered. 44 women (69%) were
All intensive care units in Australia and New Zealand.
mechanically ventilated. Of these, nine (14%) were treated with
Participants extracorporeal membrane oxygenation. Seven women (11%) died.
All women with 2009 H1N1 influenza who were pregnant or Of 60 births after 20 weeks’ gestation, four were stillbirths and
recently post partum and admitted to an intensive care unit in three were infant deaths. 22 (39%) of the liveborn babies were
Australia or New Zealand between 1 June and 31 August 2009. preterm and 32 (57%) were admitted to a neonatal intensive
care unit. Of 20 babies tested, two were positive for the 2009
Main outcome measures H1N1 virus.
Maternal and neonatal mortality and morbidity.