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The pregnant patient normally has increased cardiac output and minute ventilation by the third trimester. Despite this increase, however, these patients have little cardiopulmonary reserve should they become critically-ill.
Remember the mnemonic T.O.L.D.D. for simple tips that should be done for the pregnant patient who presents critically-ill or with the potential for critical illness:
- Tilt: The supine-hypotension syndrome occurs after the 20th week of pregnancy as the gravid uterus compresses the IVC and aorta, reducing cardiac output by up to 30%. Placing a 30-degree right hip-wedge under the patient will relieve this obstruction.
- Oxygen: the growing uterus pushes up on the base of the lungs reducing the functional residual capacity meaning there is less oxygen reserve and rapid oxygen desaturations. Supplemental oxygen may increase the patient's reserve.
- Lines: The circulatory system reserve is reduced, so early and large bore venous access is important. Remember that lines should be placed above the diaphragm because the enlarging uterus compresses pelvic veins, reducing venous return to the heart.
- Dates: Rapidly determine the gestational age of the fetus as 24 weeks is a critical date to remember (e.g., increased risk of supine-hypotension syndrome, fetal viability, etc.)
- Delivery: Call labor and delivery early on, not only for the consultation, but also for the fetal monitoring that this service provides.
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