The critically ill parturient: Subarachnoid hemorrhage, mitral stenosis, and postpartum hemorrhage

Although the care of the pregnant women with significant co-existing illness is one of the greatest challenges faced by anesthesiologists, an excellent outcome can be expected in the majority of patients. Such an outcome will depend, however, on a thorough understanding of the underlying pathophysiology of the illness, as well as its interaction with the physiologic alterations of normal pregnancy. The effects of maternal therapeutic interventions of fetal well-being must also be considered if neonatal outcome is to be optimal. Although the three disorders discussed are quite different, there are certain principles that recur when considering their management. First, the decision to perform corrective surgery remote from term should primarily be based on maternal considerations. Nevertheless, fetal outcome can be excellent if maternal interventions, such as cardiopulmonary bypass, are tempered by an understanding of their effects on the fetus. Second, obstetric management should be governed by obstetric concerns; in most cases, maternal outcome is not improved by cesarean section, and surgical delivery should be performed for obstetric indications only. Third, there is a large and growing role for invasive radiologic procedures in the management of several disorders seen during pregnancy. Finally, and most importantly, while certain therapeutic interventions may at first seem to have the potential to cause fetal harm, one must also consider the negative effects on the fetus if that intervention is withheld and maternal outcome suffers as a result.