critical care of the obstetric patient shannon carroll, m.d. suresh agarwal, m.d

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Critical Care of the Obstetric Patient

Shannon Carroll, M.D.

Suresh Agarwal, M.D.

www.peainthepodcast.com

Aspects of Critical Care Specific to Obstetric Patients

• Anatomic Changes in Pregnancy

• Physiologic/Pathologic Changes in Pregnancy

– Hemodynamic

– Endocrinologic

– Pulmonary

• Postpartum Hemorrhage

• Trauma in the Pregnant Patient

Anatomic Changes in Pregnancy

ajnoffthecharts.wordpress.com/2009/11/03

Anatomic Changes in Pregnancy

focosi.altervista.org/uterinelevels.jpg

Physiologic/Pathologic Changes in Pregnancy

• Cardiovascular Changes

• Endocrinologic Changes

• Pulmonary Changes

empracticenews.files.wordpress.com/2008/06/0708-emp-table-2.png

Cardiovascular Changes

• Increase Cardiac Output

– Up to 50% by 24th week of gestation

– CO plateaus from 24th week until term

– Further increased during labor and delivery

– “Autotransfusion Effect”

– Increased Preload after fetus and placenta delivery

www.ljmu.ac.uk/sportandexercisesciences/RISES/Health/82521.htm


• Increased Cardiac Output

– Increased Contractility

– Early in Pregnancy: Increased Blood Volume

– Later in Pregnancy: Increased Heart Rate

• 15 – 20 beats faster

www.biomaterials.org/SIGS/Cardiovascular/Heart.htm

• Cardiac Output and Stroke Volume

• Supine Position

– Aortocaval Compression

– Decreased Preload

– “Supine Hypotensive Syndrome” of Pregnancy

– Left Lateral Recumbent Position after 20th week

Body Positioning

media.photobucket.com/image/left%20and%20ivc%20and%20gravid/JHWalker/shs1.jpg

Body Positioning

• Cardiac Resuscitation

– Left Lateral Recumbent Position

Or

– Left Manual Displacement of the Uterus

www.the-pillow.com.au/more/lucky-7-body-pillow-more.php


• LV End-Diastolic Volume is Increased

• Filling Pressures Unchanged

– Decreased systemic and pulmonary vascular resistance

• Blood Volume

– 30 – 50% Increase by Full Term

• Red Blood Cell Mass

– 15 – 20% Increase by Full Term

• -> “Physiologic Anemia” of Pregnancy


nursingcrib.com/pregnancy-complications/


• Up to 35% Blood Volume Loss before Tachycardia and Hypotension occur

• Increased Blood Flow

– Breasts


www.med.yale.edu/intmed/cardio/imaging/anatomy/breast_anatomy/graphics/

breast_anatomy.gif



– Breasts

– Uterus

embryology.med.unsw.edu.au/notes/images/urogen/uterine_blood_supply.jpg



– Breasts

– Uterus

– Kidneys

• ↑ Renal Blood Flow by 25 – 50%

• ↑ Glomerular Filtration Rate up to 50%

• ↓ BUN and Plasma Creatinine

www.physicscentral.org/explore/action/images/scans-img8.jpg


• Diastolic Blood Pressure Decreased

– ↓ by 10% in 2nd Trimester

– Due to ↓ Systemic Vascular Resistance

– Returns to Baseline by Full Term


• Blood Vessel Remodeling

• Coagulation System Changes

– Most Clotting Factors Increased

– Hypercoagulable

www.answers.com/topic/factor-xii

http://en.wikipedia.org/wiki/File:Coagulation_full.svg


• Heart Remodeling

– Enlargement of All 4 Chambers

• Susceptible to Supraventricularand Atrial Arrhythmias

myhealth.ucsd.edu/library/healthguide/en-us/support/topic.asp?hwid=zm2767


• “Normal” Changes in Heart Sounds

– Systolic Ejection Murmur

– Third Heart Sound

• Potentially Pathologic Changes in Heart Sounds

– Diastolic Murmurs

– Pansystolic Murmurs

– Late Systolic Murmurs

www.ed4nurses.com/heartsnd.aspx


• Cardiac Disease

– Mild to Moderate: Pregnancy Usually Well-Tolerated

– Pulmonary Hypertension and Right-to-Left Shunts: up to 50% Mortality with Pregnancy

Hypertension In Pregnancy

• Definition:

– increase of at least 30 mmHg in the SBP and

– Increase of at least 15 mmHg in the DBP

– Above baseline

Hypertension In Pregnancy

• Monitoring

• Etiology

• Preeclampsia

• Treatment

• Management During Labor and Delivery

Blood Pressure Monitoring

• Sustained Hypertension

– At least 2 separate occasions

• Position

– Upper arm in the sitting position, or

– Lower arm in the lateral recumbent position

Etiology of Hypertension in Pregnancy

• Predisposing factors

– Family history

– Personal history of Diabetes mellitus

– Vascular or Renal Disorders

– Primigravid state

– Multiple gestational pregnancies

Preeclampsia

• Pregnancy induced

• Multisystem

• Onset is after 32nd week of gestation

• Symptom triad:

– Peripheral edema

– Systemic hypertension

– Significant proteinuria (> 0.3g in 24hr urine)nursingcrib.com/pregnancy-complications/

http://nursingcrib.com/wp-content/uploads/preeclampsia.jpg

Preeclampsia

• US Incidence = 7%

• Diastolic hypertension is usually more prominent than systolic hypertension

• Evaluate patient for underlying or coexisting disease processes

• Familial cases

• May present as late as 7 days postpartum

• Postpartum preeclampsia often associated with the HELLP syndrome

Preeclampsia and the HELLP Syndrome

• Some or all of the following:

– (H) microangiopathic hemolytic anemia

– (EL) elevated liver enzymes

– (LP) low platelets

– May be present without significant blood pressure elevations

Preeclampsia

• Increased risk with significant elevation in blood pressure in the second trimester

– 1/3 of patients with MAP > 90 in the second trimester will develop it

– < 2% of patients with MAP < 90 in the second trimester will develop it

Treatment of Hypertension In Pregnancy

• Uterine Blood Flow and BP Management

– Increases or shows no change with BP control

• Avoid Overly Aggressive BP Management

– Affects maternal hemodynamics

– Compromises uterine blood flow

• Initial Agents

– po α-methyldopa

– po labetalol

• IV Agents

– Labetalol

– Hydralazine

– Sodium Nitroprusside

BP Management During L&D

• Antihypertensive agents

• Judicious use of IV fluids

• Postpartum monitoring for high risk patients

• Preeclampsia

– Hypertension resolves spontaneosly within a few weeks

• Trace amounts of all antihypertensive agents are found in breast milk

– No adverse affects on infants have been identified

Endocrinologic Changes

• Hypothalamus

• Pituitary Gland

• Adrenal Glands

www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1093.jpg


• Increased ACTH and Cortisol Levels in Pregnancy

– Cushing’s Syndrome may be exacerbated by pregnancy

– Acute Adrenal Crisis may be precipitated by labor and delivery

www.beliefnet.com/healthandhealing/getcontent.aspx?cid=179661

Waterhouse-Friderichsen syndrome

• Massive adrenal hemorrhage

– Usually bilateral

– Meningococcemia

– Hypotension/Shock

– DIC with purpura

– Rapidly progressive adrenocortical insufficiency

• Most common etiology = Neisseria meningitidis

• Prevention: Vaccine against meningococcus

www.livestrong.com/ls_images/disease/1000-1999/1814-2938.jpg


• Onset: fever, rigors, vomiting, and headache

• Rash quickly develops

– first macular

– progresses to petechiae and purpura; dusky gray color

• Hypotension/Septic shock

• Usually no Meningitis

• Adrenal Insufficiency (hypoglycemia, hyponatremia, hyperkalemia)

• DIC

• Acidosis

• ARF

• Meningococci

– from blood or CSF

– smears of cutaneous lesions

library.med.utah.edu/WebPath/jpeg4/ENDO004.jpg


• Treatment:

– Medical emergency

– Ceftriaxone

– Hydrocortisone for hypoadrenal shock

library.med.utah.edu/WebPath/jpeg4/ENDO006.jpg


• Prolactin Levels Increased

– Preparation for lactation

– Pituitary Adenomas

• May increase in size

• May become symptomatic

www.biologie.uni-freiburg.de/data/bio1/varga/projects.htm


• Thyroid Hormones Increased

– Thyroxine-Binding Globulin Increased

– Free Levels Unchanged

– No Associated Complications if Iodine Consumption is Adequate

www.pyroenergen.com/articles08/thyroid-gland-hormones.htm


• Transient Diabetes Insipidus

– Due to Vasopressin Resistance

www.medscape.com/viewarticle/558561_3


• Fluctuations in Insulin and Glucose Levels

• Increased Insulin Secretion

• Increased Insulin Resistance

• Gestational Diabetes Mellitus

– Obese women with insulin resistance

– Women with minimal pancreatic reserve

nursingcrib.com/pregnancy-complications/

http://nursingcrib.com/wp-content/uploads/gestationaldiabetes.jpg


• Increased Maternal Lipid Metabolism

Pulmonary Complications in the Obstetric Patient

• Normal Pulmonary Physiology in Pregnancy

• Asthma

• Pulmonary Edema

• Acute Respiratory Distress Syndrome

• Embolism

saltyandsweet.wordpress.com/2008/05/12/various-gunky-topics

http://saltyandsweet.files.wordpress.com/2008/05/heart-and-lungs.jpg


• Normal Pulmonary Physiology in Pregnancy

– Tidal volume is increased

– Functional residual capacity is decreased

• Normal ABG = compensated respiratory alkalosis

• Respiratory distress may progress more rapidly due to pregnancy medical-dictionary.thefreedictionary.com/

functional+residual+capacity


• Asthma in Pregnancy

– Monitoring: Peak flow meter (no change in FEV1)

– PaCO2 > 35 mmHg in a pregnant patient with asthma may signify respiratory distress

– Treatment principles are the same for pregnant and non-pregnant patients

wellness.blogs.time.com/2009/10/09/women-with-asthma-keep-up-your-treatment-during-pregnancy


• Acute Respiratory Distress Syndrome in Pregnancy

– Need for mechanical ventilation does not mandate delivery

– Therapeutic drugs NOT contraindicated in pregnancy:

• Sedatives

• Hypnotics

• Non-depolaring paralytics

http://www.rtjournalonline.com/images.htm


• Embolism in Pregnancy

– Hypercoagulable state

– Radiographic studies if indicated by respiratory distress

– Warfarin contraindicated in 1st trimester

– Amniotic fluid embolism • 1/80,000 pregnancies

• significant maternal morbidity/mortality

www.oxygentimerelease.com/B/Bonnie/p23.htm

Postpartum Hemorrhage

• Definition

• Epidemiology

• Pathophysiology

• Diagnosis

• Treatment

• Surgical Therapy

• Prognosis


• Definition: excessive and life-threatening bleeding

• Normal blood loss:

– Vaginal birth < 500 mL

– Cesarean section = 800 – 1000 mL

• after 20 weeks gestation

• at time of delivery of baby or placenta

• Primary PPH: within 24 hours of delivery

• Secondary PPH: between 24 hours and 12 weeks of delivery


• Epidemiology leading world-wide cause of maternal death (> 100,000 deaths per year)

• one of three leading causes of maternal death in the US (with embolism and hypertensive disorders)

www.thedoctorstv.com/main/show_synopsis/207?section=synopsis

Pathophysiology

• Uterine Blood Flow at Term

– 10% of maternal cardiac output

– Approximately 600 to 1200 mL/min

• Myometrial Contraction

– Placental separation

– Hemostasis

– Myometrial fibers contract (compression) and retract (occlusion)

– Increase in Circulating Clotting Factors


www.bodyworlds.com/en/media/picture_database/preview.html?id=12


Pathophysiology

• Causes of excessive hemorrhage

– Uterine Atony

– Lacerations

– Placental Anomalies

– Trauma

library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.html


• Diagnosis/Workup:

– often obvious, w/ external bleeding

– if occult:

• Ultrasonography

– Clot

– Hematoma

– retained placental fragments

www.3bscientific.co.th/obgyn/placenta-w10604,p_895_0_0_0_3376_image_full.html

• Oxytocic drugs Treatment for Postpartum Hemorrhage

– First line = Oxytocin (Pitocin)

– Methylergonovine (Methergine)

– Carboprost tromethamine (Hemabate)

• Uterine packing

• Balloon occlusion catheters

• Arteriography with selective arterial embolization

www.cookmedical.com/wh/features/bakri_en_US/

index_bakri.html

Treatment for Postpartum Hemorrhage

http://www.cookmedical.com/wh/features/bakri_en_US/img/bakri_lg.jpg

www.obfocus.com/high-risk/bleeding/hemorrhagepa.htm

Surgical Therapy for Postpartum Hemorrhage

• Temporizing measure: occlusion of aorta by manual pressure with fist just cephalad to the umbilicus

• Manual examination of the uterus w/ evacuation of retained placenta

Surgical Therapy for Postpartum Hemorrhage

• Hematomas of lower genital tract: incise and drain

• Hematomas of broad ligament and retroperitoneum: monitor unless expanding

• Visible lacerations: repaired & oversewn

• Ligation of uterine, ovarian, internal iliac arteries

– Supply 90% of uterine blood flow

• Definitive treatment for PPH = Hysterectomy

• Uterine rupture mandates Hysterectomy


• Complications

– DIC

– Dilutional Coagulopathy -when > 80% of blood volume replaced

– Hemorrhagic Shock

– Renal failure

– Liver failure

– ARDS

– Sheehan’s Syndrome

– Avascular necrosis of pituitary gland

– Permenant hypopituitarism

• Prognosis -- Dependent on prompt diagnosis and treatment

www.ohiohealth.com/bodymayo.cfm

Trauma in the Obstetric Patient

• Relevant Fetal Physiology

• Assessment and Resuscitation

• Blunt Trauma

• Penetrating Trauma

• Specific Complications of Trauma in the Pregnant Patient


• “Save the mother, save the fetus”


• Trauma

– #1 cause of nonobstetric death in pregnant patients

– #1 traumatic cause of fetal demise with maternal survival is placental abruption

• Maternal injuries associated with fetal demise

– Pelvic fracture = fetal skull fracture and intracranial injury

– 80% of patients with hemorrhagic shock experience fetal demise


• Screen all female patients of child-bearing age for β-human chorionic gonadotropin

www.babydoll.ws/content/uploads/2008/05/a-baby-in-the-making-3.jpg

Specific Complications of Trauma in the Pregnant Patient

• Fetomaternal Hemorrhage

– Fetal blood crosses into maternal circulation

– About 1 in 4 pregnant trauma patients

– To quantify: Kleihauer-Betke test

• Complications

– Maternal Rh sensitization

– Neonatal anemia

– Fetal cardiac arrhythmias

– Fetal exsanguination

• Treatment

– Rho(D) immune globulin for Rh negative mothers


• Abruptio Placentae

– Most frequent cause of fetal death with maternal survival in trauma

– Occurs even with minor trauma

– Risk increases with gestational age

• Presentation

– Abdominal pain

– Vaginal bleeding

– Premature rupture of membranes

– Uterine tenderness or rigidity

– Expanding fundal height

– Maternal shock

– Fetal distress

• Treatment = Delivery


• Amniotic Fluid Embolism

www.wadsworth.org/chemheme/heme/microscope/pix/schistocyte_nw.jpg


– Leakage of amniotic fluid with fetal elements into the maternal circulation

– Incidence: 1/8,000 to 1/80,000

– Most common cause of peripartum deaths

• Presenting symptoms:

– 1st through 3rd trimester

– Seizures or seizure-like activity

– Cardiopulmonary collapse

• Progress to develop a consumptive coagulopathy


ipodsuite.com/search/?cx=016304524648153656041%3Atn7nrxq7qf4&c

of=FORID%3A11&ie=UTF-8&q=amniotic%20fluid#946



– Consumptive Coagulopathy

• Decreased Fibrinogen (<100mg/dL)

• Increased Fibrin Split Products

• Decreased Platelets

• Increased PT and aPTT



– Diagnosis

• Diagnosis of exclusion

• Fetal elements in maternal venous blood

– Not always present/identified



– Prognosis: dismal

• <15% survive neurologically intact



– Treatment• Supportive

– CPR with L lateral displacement of uterus

– Intubation, Mechanical Ventilation with FiO2=100%

– Volume resuscitation

– Pressor support early; 1st –line = Epinephrine

– Emergent C-section if fetus not yet delivered

– ? Corticosteroids

• Treat DIC

– Red blood cells, Platelets, FFP, and Cryoprecipitate


– Treatment:

• Delivery of the fetus

• Platelets + Clotting factors (including fibrinogen)


• Premature Labor

– Common

– Usually self-limited

– May require tocolytics

– Tocolytics are contraindicated in patients with placental abruption

i.ehow.com/images/GlobalPhoto/Articles/5378889/351878-main_Full.jpg


• Uterine Rupture

– Direct trauma to the uterus

– Almost all result in fetal death

– Often associated with maternal death

– Abdominal pain + peritoneal signs

library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.jpg


• Fetal Demise

– Labor usually ensues within 48 hours

– Induction or C-section indicated if labor does not begin

– Monitor for DIC


• Cesarean Section

– Fetal indications:

• Fetal distress

• Placental abruption

• Uterine rupture

• Fetal malposition with premature labor

– Maternal indications:

• Inability to control other injuries due to pregnancy

• DIC www.jeffersonhospital.org/obgyn/fibroid_images/39weeks-2.jpg

• Cardiac Arrest

– Manually displace the uterus to the left

– Consider left thoracotomy and cardiac massage + emergency C-section

• Continue CPR until delivery

• Delivery may allow maternal resuscitation

• C-section is indicated if:

– delivery within 5 to 15 minutes of maternal cardiac arrest

– Fetal vital signs persist


www.ehow.com/how_5511869_heal-having-emergency-cesarean-section.html


• Maternal Head Trauma

– Pregnant patients diagnosed with brain death have been supported until a viable fetus could be safely delivered

– Essential Consults:

• Obstetricians

• Ethicists

jeffreyleow.files.wordpress.com/2009/03/the_hand_of_hope_.jpg

Medications Commonly Used in Pregnancy

Critical Care of Gynecologic Patients

• Necrotizing fasciitis

• Risk factors

– DM

– Atherosclerosis

– Long-term NSAID use

– Glucocorticoids

– Immune Deficiency

• Causative organisms

– Streptococcus pyogenes (group A Strep)

– Staphylococcus aureus

– Polymicrobial

media.jaapa.com/images/2009/04/07/fournierCME1107figs23_49370.jpg


• Necrotizing fasciitis

• Indications for Surgical resection

– Areas of necrosis (purple discoloration early)

– Anesthetic areas

• Treatment

– Systemic support

– Systemic antibiotics

– Radical Excision

• Histology:

– Vascular occlusion/thrombosis

– Leukocyte infiltration

– Necrosis


• Uterine Perforation

• Potential Etiologies:

– Endometrial biopsy

– IUD Placement

– Dilation and Curettage

– Surgical Termination of Pregnancy

– Hysteroscopy

• Risk factors

– Pregnancy or Infection (Uterus is edematous)

– Postmenopausal (Uterus is fibrotic)


• Uterine Perforation

• If suspected:

– Blunt instrument/No negative pressure applied

• Conservative management

• Monitor for bleeding

– Sharp instrument/Negative pressure applied

• Exploratory laparoscopy/laparotomy

• Close inspection of nearby structures for damage


• Adnexal Torsion

• Risk factors

– Long ligaments (Infundibulopelvic, Uteroovarian)

– Adnexal Mass

– Absence of Uterine attachments

• Pain

– Unilateral

– Intermittent

• Treatment

– Reduction with fixation to Psoas muscle

– Resection if necrotic or postmenopausal


• Salpingo-oophoritis/Tubo-Ovarian Abscesses

• Risk Factors

– IUD use

– History of PID

• Diagnosis

– Radiographic (Transvaginal Ultrasound)

• Treatment

– Antibiotics

– Interventional Radiology

– Surgical• Bilateral Salpingo-oopherectomy

• Transvaginal Colpotomy Drainage

2.bp.blogspot.com/_fBQVVpFhTQs/SsTC-TdKK3I/AAAAAAAAAy8/JeB-86DE8qc/s320/tuboovarian-abscess.jpg

Critical Care of the Obstetric Patient

• Complex patients

• Medical, Surgical, Trauma, Postpartum

• Physiologic Alterations

• Altered response to potential injuries/illness

• Management of specific injuries/processes

travel.ciao.co.uk/Body_Worlds_4_Manchester__Review_5753139

References

• Fink MB, Abraham E, Vincent JL, Kochanek PM. Textbook of Critical Care , Fifth Edition. Elsevier, 2005

• Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Upchurch GR. Greenfield’s Surgery: Scientific Principles & Practice, Fourth Edition. Lippincott Williams & Wilkins, 2006

Image Sources

• ajnoffthecharts.wordpress.com/2009/11/03/

• anatomyforme.blogspot.com/2008/05/pathways-of

• 2.bp.blogspot.com/_fBQVVpFhTQs/SsTC-TdKK3I/AAAAAAAAAy8/JeB-86DE8qc/s320/tuboovarian-abscess.jpg

• embryology.med.unsw.edu.au/notes/images/urogen/uterine_blood_supply.jpg

• empracticenews.files.wordpress.com/2008/06/0708-emp-table-2.png

• focosi.altervista.org/uterinelevels.jpg

• i.ehow.com/images/GlobalPhoto/Articles/5378889/351878-main_Full.jpg

• jeffreyleow.files.wordpress.com/2009/03/the_hand_of_hope_.jpg

• library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.html

• library.med.utah.edu/kw/human_reprod/mml/hrob_oh_5.jpg

Image Sources

• library.med.utah.edu/WebPath/jpeg4/ENDO004.jpg

• library.med.utah.edu/WebPath/jpeg4/ENDO006.jpg

• media.jaapa.com/images/2009/04/07/fournierCME1107figs23_49370.jpg

• media.photobucket.com/image/left%20and%20ivc%20and%20gravid/JHWalker/shs1.jpg

• medical-dictionary.thefreedictionary.com/functional+residual+capacity

• myhealth.ucsd.edu/library/healthguide/en-us/support/topic.asp?hwid=zm2767

• nursingcrib.com/pregnancy-complications

• saltyandsweet.wordpress.com/2008/05/12/various-gunky-topics/

• travel.ciao.co.uk/Body_Worlds_4_Manchester__Review_5753139

• wellness.blogs.time.com/2009/10/09/women-with-asthma-keep-up-your-treatment-

Image Sources

• www.babydoll.ws/content/uploads/2008/05/a-baby-in-the-making-3.jpg• www.beliefnet.com/healthandhealing/getcontent.aspx?cid=179661• www.biologie.uni-freiburg.de/data/bio1/varga/projects.htm• www.biomaterials.org/SIGS/Cardiovascular/Heart.htm • www.bodyworlds.com/en/media/picture_database/preview.html?id=12• www.3bscientific.co.th/obgyn/placenta-w10604,p_895_0_0_0_3376_image_full.html• www.cookmedical.com/wh/features/bakri_en_US/index_bakri.html • www.thedoctorstv.com/main/show_synopsis/207?section=synopsis• www.ed4nurses.com/heartsnd.aspx• www.ehow.com/how_5511869_heal-having-emergency-cesarean-section.html• www.jeffersonhospital.org/obgyn/fibroid_images/39weeks-2.jpg• www.ljmu.ac.uk/sportandexercisesciences/RISES/Health/82521.htm

Image Sources

• www.livestrong.com/ls_images/disease/1000-1999/1814-2938.jpg• www.medscape.com/viewarticle/558561_3• www.med.yale.edu/intmed/cardio/imaging/anatomy/breast_anatomy/graphics/

breast_anatomy.gif• www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1093.jpg• www.obfocus.com/high-risk/bleeding/hemorrhagepa.htm• www.ohiohealth.com/bodymayo.cfm?id=6&action=thumbnail&image=/images/

image_popup/ww5rn89.jpg• www.oxygentimerelease.com/B/Bonnie/p23.htm• www.peainthepodcast.com• www.physicscentral.org/explore/action/images/scans-img8.jpg• www.the-pillow.com.au/more/lucky-7-body-pillow-more.php• www.pyroenergen.com/articles08/thyroid-gland-hormones.htm• www.rtjournalonline.com/images.htm• www.sonosite.com/news/2008/10/advanced-new-la-county-usc-trauma-center-

redefines-resuscitation-through-integrating-mounted-point-of-care-ultrasound/

critical care of the obstetric patient shannon carroll, m.d. suresh agarwal, m.d

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