Okay, and now I'm going to welcome you to my section of this hour-long presentation. I'll introduce myself on the next slide. So my name is Nicole King. I'm a critical care anesthesiologist at the University of Cincinnati, and I work specifically with high-risk obstetrical patients, including high-risk cardiac obstetrical patients, in taking care of these patients, both in the ICU and in the operating room and on labor and delivery. So we're going to be talking about the approach to the pregnant patient in physiological distress, including COVID-19. As you can see here, I have no financial disclosures, and the opinions are my own, and I'm not here representing any specific organization or institution other than to tell you that I am employed by the University of Cincinnati. So the global objective of the lecture today is really to understand the management approach for the pregnant patient with respiratory failure, shock, and the interplay of COVID-19, understanding that this is only an hour-long lecture, and there are three of us who are giving different segments. So we will be running through these slides at a very quick pace, and this is just a broad strokes overview of respiratory failure, shock, and COVID-19, though I try to not focus as much on COVID in all of the slides. It is unfortunately something that has caused many of us to take care of more pregnant patients and more critically ill pregnant patients over the last 24 months. So the first step in anything is don't run when you hear that there's a pregnant patient either in your ICU or there is a critically ill pregnant patient in the hospital in which you're working. I feel there's no one better equipped in the hospital to intervene when a pregnant patient is in distress. I also think that every single critical care trained professional needs to accept that pregnancy is here to stay, and the average pregnant patient's getting older, more complicated, and more at risk of needing our specialized intervention. And this was true before COVID, though I think COVID has now highlighted and shown us how often these patients can become critically ill and how important those of us who are intensivists are to the care of these high-risk patients. So the second step to think about after not running is that if the patient is in imminent distress, you have to think of the patient and the fetus as one. Thinking of them as two separate entities is impossible when somebody is in acute distress. You already know what to do. You know how to do it. You use ACLS or your other training, displace the uterus to the left if possible, and call for help, especially if in need of a perimortem cesarean. That is not at all any of our jobs. That's the job of the obstetrician. Our focus is on keeping mom as safe as possible in order to save both mom and fetus during this time of distress. I do think that in order to make this less frightening and less stressful for all of us who work in the ICU settings, we do need to provide training and education on the physiological changes of pregnancy to trainings. And I'm also biased to think that more of us should consider spending time with those anesthesiologists who provide obstetrical care, mainly because we become very facile understanding the physiological changes of pregnancy and also the various things that can happen both in the peripartum and postpartum periods. I think that including all of these changes and potential complications in our standard ICU curriculum, we can become more comfortable with this patient population. One of the specific things that we need to remember when we're taking care of these patients is if the patient is not in acute distress and you don't need to activate a code or a rapid or an ACLS event, but the patient is merely moving into a higher level of care where there is critical care physicians as well as high-risk obstetrical physicians and potentially even anesthesia providers coming together to make a decision on how best to take care of both the patient and the patient's fetus. Understanding that at this point in time, you will be forced to make multiple decisions, not only for mom and baby, but also that we'll have to take into consideration ethical and legal implications of whichever state you actually live in. And you have to understand that and talk to the maternal fetal medicine doctors in your institution to understand what is considered pre-viable, periviable, or viable in terms of resuscitation of the infant, as well as what the options are for the pregnancy in terms of termination or continuing the pregnancy based on how sick the mother is at the time of her presentation to the ICU or to the critical care environment. The critical care physician and the maternal fetal medicine experts should work in concert to provide the best possible outcome for both the patient and the fetus. And we also need to have clear conversations with both the patient, if possible, and the family members before making any ongoing care decisions, especially this is important prior to intubation and the mom needing to be put to sleep because after that time, these decisions can become much more complicated if we don't know what her wishes were. So we're going to kind of just dive into very simple, quick overview of why pregnancy is such a different presentation than your average critically ill patient. Pregnant patients are already burning fuel and critical illness only exacerbates this burn rate. So we meet the majority of our patients in the second and third trimester. The third trimester at baseline is a catabolic state, which compounds the known catabolic state of the septic patient. For all intents and purposes, when you're thinking of the patient and the fetus as one, the fetus itself is both a glucose and oxygen sink, which means it's pulling oxygen and glucose continuously from the patient and then providing waste back to the patient, especially in patients who have either COVID or other respiratory distress or ARDS type symptoms, you are going to exacerbate the already profound hypoxia and hypercapnia that you encounter in these patients by also having a fetus who is both extracting oxygen and producing carbon dioxide that then the mother is forced to breathe off or you to breathe off or perfuse off with ECMO. So we need to understand how COVID-19 affects placental perfusion and the resulting fetal outcomes, which is the one way where COVID-19 has significantly changed the way we take care of pregnant patients because of the differences between other ARDS type diseases and COVID-19 specifically. So both of these physiological facts should be considered when determining both the timing and the mode of delivery, especially if the pregnant patient is declining or failing to improve. This is when you have to have the conversation. You cannot wait because the risk of the patient and the fetus both declining can happen very quickly in these patients who have a lot of reserve because they're younger, but also kind of live on the brink of disaster, especially once ill. So though it seems a little crazy that in a critical care medicine lecture, I'm going to talk about the placenta as much as I am in the next couple of slides, I think it's important to remember that the placenta itself is the connection between the patient that's sitting in front of you and the fetus that they are carrying. So most of these patients we will meet, as I previously said, in the second or third trimesters. We especially need to pay attention to the big swings and fluid shifts and metabolic needs that are placed on the mother by the fetus at approximately 27 weeks. This is going to lead to a jump up in the physiological stress placed on the pregnant patient and we also understand that there will be a large change in the distribution of fluid in the pregnant patient and if somebody has a pre-existing cardiac condition, this is the time in pregnancy where we become very concerned of will the pregnancy be able to continue or will continuing pregnancy jeopardize the lives of one or both patients. This is when we need to be prepared to have a specific and detailed birth plan with the associated family and multidisciplinary meetings. In the end, the bottom line is the pregnant patient may need to have the oxygen and glucose sink delivered while the fetus may need to be delivered before their potential destruction of their life source, which is the placenta. So it works both ways. We understand that by having this situation where both the fetus is dependent on the placenta for both their glucose and their oxygen, the mother or the patient is also at the same time unable to really augment their oxygen and carbon dioxide metabolism, their glucose metabolism appropriately in order to improve their critical care outcomes without the fetus being delivered because the fetus itself is going to continue to take what it needs in order to continue to grow. And it's up to the critical care team along with the maternal fetal medicine team and the patient and the patient's family to decide if and when either or needs to happen. We either need to deliver if we're in the periviable or viable timeframe or potentially termination if we're previable, which is why these conversations are so important prior to the patient needing sedation or intubation. So as I said, we would be talking through a few different points about the placenta and the reason why it's so important is because of all of the literature that's coming out and it's coming out on a regular basis every few weeks and definitely at least an article a month talking about the COVID-19 placenta. So in these placentas, they're similar to those found in the placentas of patients with preeclampsia, which is a disease of the placenta. We know this, specifically the spiral arteries. The problem is that this decreased perfusion, which is caused by the inadequate placentation for the fetus and it causes growth restrictions and can also cause other significant abnormalities while the fetus is still in the uterus. So the problem is the results of all of this are still actively being studied and we're not going to ever know exactly what's happening to these fetuses until they're delivered and we have long-term studies post-delivery. But what we do know is that as of right now, COVID-19 does increase the risk of stillbirth. This study, which was just done, and if you look at the statistics initially, you think, well, those are very small numbers. But if you think about it from the perspective of a patient and a pregnancy, to increase the rate of stillbirth from 0.59% to 2.7% for those patients who had COVID-19, you're talking about significant increase in the risk of stillbirth for those patients who have had COVID-19. And this is not necessarily associated with the severity of the disease process, and many of these things are controlled for other confounding factors. And this alone is enough for us to be concerned, in addition to the fact that we have no idea what the decrease in perfusion and oxygen delivery to the fetus when in utero can cause long-term. And not only that, we're increasing the risk to the patient themselves, because any time there is stillbirth or other associated morbidity and mortality associated with pregnancy and with delivery of a pre-viable infant, we are again entering into an environment where we have more complications of a critical care illness that we don't necessarily see with other respiratory diseases. Only because we don't see as many changes in the placentas themselves in other respiratory viruses. So circling back to the pregnant patient, supportive care and sepsis treatment look very similar to the non-pregnant patient. The only difference may be in the actual dosing of steroids, if you're looking for lung maturity. Otherwise, steroids as indicated for COVID treatment based on literature and based on your hospital or institution's protocols. We of course want to limit fluids in the preeclampsic patient, because they have a higher risk of pulmonary edema, understanding that COVID-19 itself can cause similar pathological changes in the placenta as preeclampsia. So we need to be very careful with fluid administration in these patients. Another thing that many people probably don't know, just at baseline, unless they have studied pregnancy and or anesthesia in pregnancy, a normal CO2 in pregnancy is 32 to 34. And we really need to understand that so that we do not hyperventilate and lead to hypocapnia in these patients, because it's one of the only things that can cause placental vasoconstriction. Otherwise, there's no auto-regulation of the placental vessels, which is why blood pressure management is very important in these patients. If a patient comes in and they have longstanding hypertension or preeclampsia, you do not want to allow the blood pressure to fall precipitously below their baseline, even though they're quote-unquote young and healthy at baseline, because this can affect the perfusion and the oxygen and glucose delivery to the fetus itself. So if indicated, ECMO is a safe and effective option for respiratory support while pregnant prior to and during COVID. Obviously, many of us have taken care of ECMO patients who are pregnant prior to the COVID pandemic. The second thing is to call an ECMO center early. And you also need to establish what mode of delivery everybody in the institution is comfortable with. A delivery via vaginal delivery or cesarean sections have both been reported in the literature, and they can both be done safely. And this needs to be a multidisciplinary discussion between the family and the multiple different specialties taking care of these patients in order to increase the optimal outcome for both the patient and the fetus. All right. While talking about the actual delivery of these patients, we also need to understand the large increase in cardiac output that happens in all patients, regardless of preexisting conditions or current physiological changes, that can occur around the time of labor. And these values only increase in the immediate postpartum period and are actually significantly above non-pregnant measurements. And this increase in stroke volume, as well as in heart rate, it can increase increases and maintains the increased cardiac output. The problem is with this increased volume of autotransfusion, which is half a liter to a liter of blood, is that you obviously are going to have large physiological effects on the maternal cardiac function, depending if she has preexisting conditions. So the physiological effects will be noted approximately 10 minutes after delivery. So don't be confused if the patient appears to be completely stable immediately after delivery. You still need to be on high alert for the next 10 to 30 minutes as the autotransfusion happens and the cardiac abnormalities or kind of preexisting conditions become more strained. You need to be ready with inotropes and or diuretics based on the baseline pulmonary or cardiac parameters. And we'll have a further discussion about this in an upcoming lecture. So in conclusion, very quickly, we went through kind of the physiological effects of sepsis and respiratory failure and including the effects of COVID-19 specifically. I believe the sickest and scariest potential patients in the hospital are pregnant patients. And for me, understanding basic physiological changes of pregnancy should be a part of critical care training so that we all have an increased level of comfort. Those of us who study anesthesia before we become intensivists already have a strong background in the physiological changes of pregnancy, but I don't think that they are often taught as commonly in other ICU specialties. And as our pregnant patient population ages and becomes more complex, we will be exposed to these patients more commonly. Obviously understanding that congenital heart patients are not having babies, this is going to change everything and is again something we'll discuss in a following lecture. The long lasting morbidity and mortality associated with COVID on both the patient and the fetus are not fully known at this point. Do not assume that hypoxia isn't without profound effects on the fetus. We already know that the placenta and the fetus conserve energy, but at what expense? We also have no idea at what level of hypoxia do we induce labor or do we induce any significant effects to the fetus itself. And then due to the limited reserve, these patients will decline faster. We have to move quickly to a higher level of care and we always need to talk with the patients and their families about their wishes prior to intubation or sedation if possible to optimize outcomes for both the patient and the fetus and increase the amount of communication that we have between the multidisciplinary team in order to best offset the potential negative effects of sepsis, respiratory failure, and COVID on our pregnant patients. And here are my references. I want to thank everyone for coming to this lecture and I hope that there is an opportunity for questions and discussions in the future.

pregnant patients

physiological distress

COVID-19

critical care professionals

interconnectedness