Acute respiratory failure during pregnancy and the peripartum period
- Peter F Clardy, MD
Peter F Clardy, MD
- Assistant Professor of Medicine
- Harvard Medical School
- Christine C Reardon, MD
Christine C Reardon, MD
- Associate Professor of Medicine
- Boston University School of Medicine
- Section Editors
- Scott Manaker, MD, PhD
Scott Manaker, MD, PhD
- Section Editor — Critical Care
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Charles J Lockwood, MD, MHCM
Charles J Lockwood, MD, MHCM
- Section Editor — Obstetrics
- Senior Vice President, USF Health
- Dean, Morsani College of Medicine
- Professor, Obstetrics and Gynecology
- University of South Florida
- David L Hepner, MD
David L Hepner, MD
- Section Editor — Obstetric Anesthesia
- Associate Professor of Anaesthesia
- Harvard Medical School
Fewer than 2 percent of women require admission to an intensive care unit (ICU) during pregnancy or the peripartum period, defined as the last month of gestation or the first few weeks following delivery [1-4]. Among those who are admitted to an ICU, the most common indications are postpartum hemorrhage and hypertensive disorders. Acute respiratory failure is a rare complication of pregnancy.
The clinical presentation, differential diagnosis, most common causes, and management of acute respiratory failure during pregnancy and the peripartum period are reviewed here. Other critical illnesses associated with pregnancy are described separately. (See "Critical illness during pregnancy and the peripartum period".)
Patients with acute respiratory failure during pregnancy or the peripartum period generally present with respiratory distress [5-7]. They are typically dyspneic and unable to speak in complete sentences. Confusion, somnolence, agitation, diaphoresis, and/or cyanosis are common.
Most patients are breathing rapidly (tachypnea) and shallowly (small tidal volumes), while using their accessory muscles of respiration. Ausculatory findings vary according to the cause of the acute respiratory failure, but may include crackles, rhonchi, and/or wheezes. Consolidation may be evident, as indicated by bronchophony, egophony, or whisper pectoriloquy.
Initial management is the same regardless of the cause of the acute respiratory failure. Supplemental oxygen should be administered. The preferred method of administering the oxygen depends upon the severity of the hypoxemia. For patients with mild hypoxemia, administration via nasal cannula may be sufficient. More severe hypoxemia generally requires administration via a facemask or a nonrebreather mask. Oxygenation should be monitored continuously by pulse oximetry. A reasonable goal for pregnant patients is to maintain the oxyhemoglobin saturation ≥95 percent to optimize the fetal oxygen content. Adequate fetal oxygenation requires a maternal arterial oxygen tension (PaO2) >70 mmHg, which corresponds to an oxyhemoglobin saturation of 95 percent .
- Leung NY, Lau AC, Chan KK, Yan WW. Clinical characteristics and outcomes of obstetric patients admitted to the Intensive Care Unit: a 10-year retrospective review. Hong Kong Med J 2010; 16:18.
- Vasquez DN, Estenssoro E, Canales HS, et al. Clinical characteristics and outcomes of obstetric patients requiring ICU admission. Chest 2007; 131:718.
- Pollock W, Rose L, Dennis CL. Pregnant and postpartum admissions to the intensive care unit: a systematic review. Intensive Care Med 2010; 36:1465.
- Zwart JJ, Dupuis JR, Richters A, et al. Obstetric intensive care unit admission: a 2-year nationwide population-based cohort study. Intensive Care Med 2010; 36:256.
- Madan I, Puri I, Jain NJ, et al. Characteristics of obstetric intensive care unit admissions in New Jersey. J Matern Fetal Neonatal Med 2009; 22:785.
- Muench MV, Baschat AA, Malinow AM, Mighty HE. Analysis of disease in the obstetric intensive care unit at a university referral center: a 24-month review of prospective data. J Reprod Med 2008; 53:914.
- Wanderer JP, Leffert LR, Mhyre JM, et al. Epidemiology of obstetric-related ICU admissions in Maryland: 1999-2008*. Crit Care Med 2013; 41:1844.
- Cole DE, Taylor TL, McCullough DM, et al. Acute respiratory distress syndrome in pregnancy. Crit Care Med 2005; 33:S269.
- Meschia G. Placental respiratory gas exchange and fetal oxygenation. In: Maternal-Fetal Medicine, Creasy RK, Resnik R (Eds), WB Saunders, Philadelphia 1999. p.260.
- Mighty HE. Acute respiratory failure in pregnancy. Clin Obstet Gynecol 2010; 53:360.
- Sciscione AC, Ivester T, Largoza M, et al. Acute pulmonary edema in pregnancy. Obstet Gynecol 2003; 101:511.
- Ogunyemi D. Risk factors for acute pulmonary edema in preterm delivery. Eur J Obstet Gynecol Reprod Biol 2007; 133:143.
- Hatjis CG, Swain M. Systemic tocolysis for premature labor is associated with an increased incidence of pulmonary edema in the presence of maternal infection. Am J Obstet Gynecol 1988; 159:723.
- Lamont RF. The pathophysiology of pulmonary oedema with the use of beta-agonists. BJOG 2000; 107:439.
- Pisani RJ, Rosenow EC 3rd. Pulmonary edema associated with tocolytic therapy. Ann Intern Med 1989; 110:714.
- Samol JM, Lambers DS. Magnesium sulfate tocolysis and pulmonary edema: the drug or the vehicle? Am J Obstet Gynecol 2005; 192:1430.
- Wilson MS, Ingersoll M, Meschter E, et al. Evaluating the side effects of treatment for preterm labor in a center that uses "high-dose" magnesium sulfate. Am J Perinatol 2014; 31:711.
- Kutuk MS, Ozgun MT, Uludag S, et al. Acute pulmonary failure due to pulmonary edema during tocolytic therapy with nifedipine. Arch Gynecol Obstet 2013; 288:953.
- Vaast P, Dubreucq-Fossaert S, Houfflin-Debarge V, et al. Acute pulmonary oedema during nicardipine therapy for premature labour; Report of five cases. Eur J Obstet Gynecol Reprod Biol 2004; 113:98.
- Abbas OM, Nassar AH, Kanj NA, Usta IM. Acute pulmonary edema during tocolytic therapy with nifedipine. Am J Obstet Gynecol 2006; 195:e3.
- Kuklina EV, Callaghan WM. Cardiomyopathy and other myocardial disorders among hospitalizations for pregnancy in the United States: 2004-2006. Obstet Gynecol 2010; 115:93.
- Tidswell M. Peripartum cardiomyopathy. Crit Care Clin 2004; 20:777.
- Sibai BM, Mabie BC, Harvey CJ, Gonzalez AR. Pulmonary edema in severe preeclampsia-eclampsia: analysis of thirty-seven consecutive cases. Am J Obstet Gynecol 1987; 156:1174.
- Dennis AT, Solnordal CB. Acute pulmonary oedema in pregnant women. Anaesthesia 2012; 67:646.
- Benedetti TJ, Kates R, Williams V. Hemodynamic observations in severe preeclampsia complicated by pulmonary edema. Am J Obstet Gynecol 1985; 152:330.
- Bauer ST, Cleary KL. Cardiopulmonary complications of pre-eclampsia. Semin Perinatol 2009; 33:158.
- Sheffield JS, Cunningham FG. Community-acquired pneumonia in pregnancy. Obstet Gynecol 2009; 114:915.
- Graves CR. Pneumonia in pregnancy. Clin Obstet Gynecol 2010; 53:329.
- Lapinsky SE. H1N1 novel influenza A in pregnant and immunocompromised patients. Crit Care Med 2010; 38:e52.
- Brito V, Niederman MS. Pneumonia complicating pregnancy. Clin Chest Med 2011; 32:121.
- Wack EE, Ampel NM, Galgiani JN, Bronnimann DA. Coccidioidomycosis during pregnancy. An analysis of ten cases among 47,120 pregnancies. Chest 1988; 94:376.
- Harger JH, Ernest JM, Thurnau GR, et al. Risk factors and outcome of varicella-zoster virus pneumonia in pregnant women. J Infect Dis 2002; 185:422.
- CDC: Updated Interim Recommendations for Obstetric Health Providers Related to Use of Antiviral Medications in the Treatment and Prevention of Influenza for the 2009-2010 Season. www.cdc.gov (Accessed on January 18, 2012).
- Duarte AG. ARDS in pregnancy. Clin Obstet Gynecol 2014; 57:862.
- Kwon HL, Belanger K, Bracken MB. Effect of pregnancy and stage of pregnancy on asthma severity: a systematic review. Am J Obstet Gynecol 2004; 190:1201.
- Schatz M, Dombrowski MP, Wise R, et al. Asthma morbidity during pregnancy can be predicted by severity classification. J Allergy Clin Immunol 2003; 112:283.
- Murphy VE, Gibson P, Talbot PI, Clifton VL. Severe asthma exacerbations during pregnancy. Obstet Gynecol 2005; 106:1046.
- Stenius-Aarniala BS, Hedman J, Teramo KA. Acute asthma during pregnancy. Thorax 1996; 51:411.
- Enriquez R, Griffin MR, Carroll KN, et al. Effect of maternal asthma and asthma control on pregnancy and perinatal outcomes. J Allergy Clin Immunol 2007; 120:625.
- Källén B, Rydhstroem H, Aberg A. Asthma during pregnancy--a population based study. Eur J Epidemiol 2000; 16:167.
- Murphy VE, Namazy JA, Powell H, et al. A meta-analysis of adverse perinatal outcomes in women with asthma. BJOG 2011; 118:1314.
- National Asthma Education and Prevention Program. Managing asthma during pregnancy: Recommendations for pharmacological treatment, Update 2004. Bethesda MD, National Institutes of Health, National Heart, Lung and Blood Institute, 2004, Publication 04-5246.
- National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol 2007; 120:S94.
- Silverman RA, Osborn H, Runge J, et al. IV magnesium sulfate in the treatment of acute severe asthma: a multicenter randomized controlled trial. Chest 2002; 122:489.
- Johnston RG, Noseworthy TW, Friesen EG, et al. Isoflurane therapy for status asthmaticus in children and adults. Chest 1990; 97:698.
- Hanania NA, Belfort MA. Acute asthma in pregnancy. Crit Care Med 2005; 33:S319.
- Lo JO, Boltax J, Metz TD. Cesarean delivery for life-threatening status asthmaticus. Obstet Gynecol 2013; 121:422.
- Brown HL, Hiett AK. Deep vein thrombosis and pulmonary embolism in pregnancy: diagnosis, complications, and management. Clin Obstet Gynecol 2010; 53:345.
- Bates SM, Greer IA, Pabinger I, et al. Venous thromboembolism, thrombophilia, antithrombotic therapy, and pregnancy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:844S.
- Bates SM, Greer IA, Middeldorp S, et al. VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e691S.
- Bandi VD, Munnur U, Matthay MA. Acute lung injury and acute respiratory distress syndrome in pregnancy. Crit Care Clin 2004; 20:577.
- Kostash MA, Mensink F. Lethal air embolism during cesarean delivery for placenta previa. Anesthesiology 2002; 96:753.
- CLINICAL PRESENTATION
- INITIAL MANAGEMENT
- DIFFERENTIAL DIAGNOSIS
- Pulmonary edema
- - Tocolytics
- - Cardiogenic
- - Preeclampsia or eclampsia
- Asthma exacerbation
- - Management
- Pulmonary embolism
- Amniotic fluid embolism
- Air embolism
- ONGOING MANAGEMENT
- Directed therapy
- Supportive care
- SUMMARY AND RECOMMENDATIONS