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to measure cerebral blood flow during C/S under slowly induced extensive cutaneous vascular malformations, venous varicosities,
epidural anesthesia.147 However, the value of transcranial Doppler and focal abnormalities of the deep venous system. In addition,
in this setting is uncertain. An arterial catheter is recommended for there is underlying soft-tissue and bony hypertrophy that can give
continuous BP monitoring during labor and delivery.148 rise to arm and leg asymmetry and facial asymmetry. The latter
may give rise to temporomandibular joint dysfunction.160 Other
orthopedic manifestations of KTWS include limb-length discre-
Kawasaki disease (mucocutaneous lymph
pancies, digital anomalies, ulcerations, spine and hip abnormal-
node syndrome)
ities, and Charcot osteoarthropathy.161
Kawasaki disease (KD) is an acute febrile illness of children under Klippel-Trenaunay-Weber syndrome can be diagnosed in utero
using routine prenatal ultrasound.162,163 Women with KTWS can
the age of four years. Most investigators agree that an infectious



69
1 Cardiovascular and respiratory disorders


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Summary
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This chapter has dealt with uncommon vascular disorders that have
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70
Chapter 3


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1 Cardiovascular and respiratory disorders


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74
RESPIRATORY DISORDERS IN PREGNANCY
4
John Philip and Shiv K. Sharma




Adult respiratory distress syndrome Worsening hypoxemia impairs O2 delivery to tissues causing
multisystem organ dysfunction, typically acute renal failure, dis-
Epidemiology
seminated intravascular coagulopathy, and hepatic failure.
Adult respiratory distress syndrome (ARDS) is a severe form of Multisystem organ failure is the main cause of death.
acute respiratory failure that can develop following a systemic or
pulmonary insult. Adult respiratory distress syndrome is not Diagnosis
unique to adults, and in children is known as ˜˜acute respiratory
The clinical spectrum of ARDS is wide. In 1994, the American“
distress syndrome™™. The incidence of ARDS in pregnancy is vari-
European consensus conference on ARDS8 issued the following
ably reported as 1 in 3000 to 1 in 6000 deliveries1 with mortality as
definition that has been widely adopted by clinicians and
high as 44%.1,2,3,4
researchers. ARDS is characterized by: (1) bilateral radiographic
pulmonary infiltrates; (2) PaO2 to FiO2 ratio of 200 or less regard-
Etiology
less of the level of positive end-expiratory pressure (PEEP); (3) no
clinical evidence of heart failure (if measured, a pulmonary capil-
Several disorders can cause ARDS in pregnancy (see Table 4.1).
lary wedge pressure (PCWP) of 18 mmHg or less).
Sepsis, secondary to pyelonephritis, chorioamnionitis, or endo-
metritis, is a common cause of ARDS in pregnancy.1,2,5 Other
causes include obstetric hemorrhage, severe preeclampsia, and Medical management
aspiration.1,2,5 There may be a combination of sepsis, shock, and
The management of ARDS in pregnancy does not differ signifi-
fluid overload, the latter of which can be exacerbated by tocolytic
cantly from that in nonpregnant patients. The main objectives in
therapy.
managing ARDS are to treat the underlying cause, optimize tissue
O2 delivery, and manage the acute lung injury while limiting
Pathophysiology
further lung injury.
General principles of management include provision of res-
Following the initial insult, a number of inflammatory mediators
piratory support to ensure adequate oxygenation; support of CO
such as tumor necrosis factor and interleukins 1, 6, and 8 are
with fluids and inotropes to promote O2 delivery; correction of
released. Neutrophils are activated to release other mediators
anemia to facilitate O2 delivery; and administration of sedatives,
such as reactive oxygen (O2) species and proteases. These medi-
analgesics, and antipyretics to reduce O2 consumption. Sepsis is
ators produce widespread microvascular and alveolar epithelial

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