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Keywords: critical care; high-risk pregnancy; intensive care; maternal morbidity; maternal mvortality; risk prediction; severity of illness EN critical care high-risk pregnancy intensive care maternal morbidity maternal mvortality risk prediction severity of illness 765 766 2 04/21/20 20200501 NES 200501 Maternal mortality represents a catastrophic end to pregnancy, with marked heterogeneity in frequency occurring across the world. In this issue of I Critical Care Medicine i , the Intensive Care National Audit and Research Centre (ICNARC) have used their large Case Mix Program database (CMPDB) from United Kingdom, Wales, and Northern Ireland to develop a risk prediction model for the pregnant patient by Simpson et al ([5]). Mortality of pregnant ICU patients in the CMPDB was 1.7%, lower than the systematic review which reported a mortality in pregnant ICU patients of 3.4% in developed countries and 14% in developing countries ([2]). [Extracted from the article]

Objectives: To provide an up-to-date review of the literature on the assessment and management of pulmonary and cardiac conditions that may affect women during pregnancy and the postpartum period.Design: A review of the current literature was performed.Results: Pregnancy may be complicated by a variety of pregnancy-specific and other cardiopulmonary complications. Management requires knowledge of the cardiopulmonary physiologic changes occurring in pregnancy, the pregnancy-specific conditions that may occur, and the effect of a fetus on maternal care.Conclusions: Admission of the pregnant or postpartum woman to the intensive care unit is uncommon but may require specialized knowledge for successful management. [ABSTRACT FROM AUTHOR]

The author reflects on the study which investigates the risk of lung injury during pregnancy in a rabbit model. He describes the two-hit mechanism as demonstrated in the study which involves the induction of hemorrhagic shock followed by resuscitation. He stresses that acute respiratory distress syndrome (ARDS) occurred 10 times more frequently in pregnat women compared to the general population.

The article focuses on pregnancy-related admissions to the intensive care unit (ICU) with emphasis on the quality of care given to fetuses of critically ill mothers. It cites an overview of the study conducted by several researchers and their utilization of analysis tools and associated materials in identifying risk factors, behavior mechanisms and other conditions related to efficient health care delivery. It also discusses the investigations conducted to construe interventions in these cases.

Purpose of Review: Two recent viral epidemics producing pneumonitis (severe acute respiratory syndrome and pandemic influenza A H1N1) have highlighted the potential for viral infections to cause respiratory failure with a significant risk of mortality. This review describes these epidemics and other causes of epidemic viral pneumonia., Recent Findings: The recent literature highlights the rapidity with which these emerging viral infections can be characterized and how management strategies, including supportive care, antiviral therapy and infection control precautions, can be rapidly shared and implemented., Summary: The severe acute respiratory syndrome outbreak was too short to allow management protocols to be tested in a research environment. The current 2009 influenza A (H1N1) pandemic is fortunately not associated with as high a mortality rate as the avian influenza A (H5N1), another potential pandemic candidate virus. Prior pandemic planning as well as research planning has allowed a rapid response to this outbreak, with a significant amount of literature generated in a few months. Other common seasonal viruses, such as respiratory syncytial virus and parainfluenza, as well as previously poorly recognized viruses such as hantavirus, have the ability to cause significant respiratory morbidity and mortality.

Objective: To describe the increased risk of severe disease and the appropriate management of patients at high risk such as pregnant women and immunosuppressed patients who acquire novel influenza A (H1N1)., Design: Review of the literature regarding influenza A in these patient groups, and review of published and unpublished data with regard to novel influenza A (H1N1)., Main Results: Pregnant women are at increased risk for severe pneumonitis and respiratory failure from influenza infection, particularly during pandemics, including the current pandemic. Fetal morbidity is significant, usually resulting from maternal fever and severe hypoxemia. Early antiviral therapy using oseltamivir may be beneficial, and intensive care unit support should target adequate oxygenation at all times. Immunosuppressed patients are at increased risk for influenza, as well as at risk for more severe or prolonged infection. Patients after hematopoietic stem cell transplantation, after lung transplantation, and those receiving chemotherapy for leukemia are at highest risk, whereas the risk for human immunodeficiency virus-infected individuals appears relatively low. Treatment with antiviral therapy may be beneficial, even after the usual cut-off of 48 hrs after symptom onset., Conclusions: Optimal management of these patients is preventive by influenza vaccination, but the neuraminidase inhibitor antiviral agents provide effective treatment.

Objective: To prospectively evaluate the oxygenation effect of inhaled nitric oxide (INO) delivered during high-frequency oscillatory ventilation in adult patients with the acute respiratory distress syndrome and oxygenation failure. DESIGN Prospective, clinical study., Setting: Intensive care unit of a university teaching hospital., Patients: A total of 23 adults (14 women, 9 men, 44.9 +/- 17.5 yrs, Acute Physiology and Chronic Health Evaluation II score of 28.6 +/- 7.1) with acute respiratory distress syndrome (lung injury score, 3.5 +/- 0.4) with Fio2 of > or = 0.6 and mean airway pressure of >or=28 cm H2O., Interventions: INO was initiated at a dose of 5 ppm, and subsequently titrated according to a protocol, to determine the dose (5, 10, or 20 ppm) resulting in the greatest increase in Pao2/Fio2. Blood gas measurements were obtained 10-15 mins after initiation or any increase in INO dosage to assess the effect on Pao2/Fio2., Measurements and Main Results: Arterial blood gases and ventilator settings were recorded at four time points: during conventional ventilation just before initiating high-frequency oscillatory ventilation, during high-frequency oscillatory ventilation just before initiating INO, after 30 mins on the optimal dose of INO, and 8-12 hrs after starting INO. Oxygenation index ([Fio2 x mean airway pressure x 100]/Pao2) and Pao2/Fio2 ratios were calculated at the same time intervals. At 30 mins after INO initiation, 83% of patients had a significant increase in blood oxygen tension, defined as > or = 20% increase in Pao2/Fio2. The mean change in Pao2/Fio2 at 30 mins was 38%. In these 19 patients, Pao2/Fio2 was highest at 20 ppm in four patients, at 10 ppm in eight patients, and at 5 ppm in seven patients. Compared with baseline measurements, Pao2/Fio2 improved significantly at both 30 mins (112 +/- 59 vs. 75 +/- 32, p=.01) and 8-12 hrs after INO initiation (146 +/- 52 vs. 75 +/- 32, p<.0001). In addition, oxygenation index was reduced at 8-12 hrs compared with baseline measurements (26 +/- 13 vs. 40 +/- 17, p=.08)., Conclusions: INO delivered at doses of 5 to 20 ppm during high-frequency oscillatory ventilation increases Pao2/Fio2 and may be a safe and effective rescue therapy for patients with severe oxygenation failure.