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Critical Care Obstetrics
Critical Care Obstetrics

Sixth Edition

Editor‐in‐Chief
Jeffrey P. Phelan
President and Director of Clinical Research, Childbirth Injury Prevention Foundation, Glendora, CA;
San Gabriel Valley Perinatal Medical Group, Inc., West Covina, CA; and Former Director of Quality Assurance,
Department of Obstetrics and Gynecology, Citrus Valley Medical Center,
West Covina, CA, USA

Editors
Luis D. Pacheco
Professor of Departments of Obstetrics, Gynecology, and Anesthesiology,
Divisions of Maternal Fetal Medicine and Surgical Critical Care, The University of Texas Medical Branch,
Galveston, TX, USA

Michael R. Foley
Professor and Chair, Department of Obstetrics and Gynecology,
University of Arizona College of Medicine Phoenix,
Phoenix, AZ, USA

George R. Saade
Professor of Obstetrics & Gynecology, and Cell Biology, Chief of Obstetrics and Maternal Fetal Medicine,
University of Texas Medical Branch,
Galveston, TX, USA

Gary A. Dildy
Professor of Obstetrics & Gynecology, Baylor College of Medicine,
Houston, TX, USA

Michael A. Belfort
Professor of Obstetrics and Gynecology, Division of Maternal Fetal Medicine,
Baylor College of Medicine,
Houston, TX, USA
This sixth edition first published 2019
© 2019 by John Wiley & Sons Ltd

Edition History [John Wiley and Sons 5e, 2011]

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material
from this title is available at http://www.wiley.com/go/permissions.

The right of Jeffrey P. Phelan, Luis D. Pacheco, Michael R. Foley, George R. Saade, Gary A. Dildy, and Michael A. Belfort to be identified as the
authors of editorial in this work has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication Data

Names: Phelan, Jeffrey P., editor.
Title: Critical care obstetrics / editor-in-chief, Jeffrey P. Phelan ; editors, Luis D. Pacheco, Michael R. Foley, George R. Saade,
Gary A. Dildy, Michael A. Belfort.
Other titles: Critical care obstetrics (Clark)
Description: 6th edition. | Hoboken, NJ, USA : Wiley-Blackwell, [2019] | Includes bibliographical references and index. |
Identifiers: LCCN 2018016215 (print) | LCCN 2018017095 (ebook) | ISBN 9781119129394 (Adobe PDF) | ISBN 9781119129387 (ePub) |
ISBN 9781119129370 (hardback)
Subjects: | MESH: Pregnancy Complications | Critical Care–methods
Classification: LCC RG571 (ebook) | LCC RG571 (print) | NLM WQ 240 | DDC 618.3/028–dc23
LC record available at https://lccn.loc.gov/2018016215
Cover design: Wiley
Cover image: © Petri Oeschger/Getty Images; © Mikael Damkier/Shutterstock; © Dan Alto/Shutterstock

Set in 10/12pt Warnock by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
 v

Contents

List of Contributors ix
Foreword to the Sixth Edition xvii

Part One Basic Critical Care Clinical and Surgical Principles 1

1 Epidemiology of Critical Illness in Pregnancy 3

Cande V. Ananth and John C. Smulian

2 Organizing an Obstetrical Critical Care Unit: Care without Walls 17

Julie Scott and Michael R. Foley

3 Critical Care Obstetric Nursing 27

Nan H. Troiano and Suzanne McMurtry Baird

4 Pregnancy‐Induced Physiologic Alterations 41

Errol R. Norwitz and Julian N. Robinson

5 Maternal Blood Gas Physiology 69

Aaron B. Caughey

6 Fluid and Electrolyte Balance 87

William E. Scorza, Sharon Maynard, and Anthony Scardella

7 Interventional Radiology in Pregnancy 115

Sheena A. Pimpalwar and Michael A. Belfort

8 Fetal Considerations in the Critically Ill Gravida 123

Jeffrey P. Phelan

9 Fetal Effects of Drugs Commonly Used in Critical Care 151

Sarah Gloria Običan and Jerome Yankowitz

10 Maternal‐Fetal Oxygenation 175

Alfred D. Fleming and Marsha Henn

11 Cardiopulmonary Resuscitation (CPR) in Pregnancy 183

Terri‐Ann Bennett and Carolyn M. Zelop

12 Neonatal Resuscitation 193

Jay P. Goldsmith and Gilbert I. Martin
vi Contents

13 Ventilator Management in Critical Illness 215

Luis D. Pacheco and Antonio Saad

14 Vascular Access 249

Gayle Olson and Aristides P. Koutrouvelis

15 Nutritional Support 265

Bill Tang, Michael J. Tang, and Jeffrey P. Phelan

16 Dialysis in Pregnancy 273

Evan I. Fisher, Shad H. Deering, and James D. Oliver III

17 Cardiopulmonary Bypass 285

Alexis L. McQuitty

18 Noninvasive Monitoring in Critical Care 303

Amir Shamshirsaz and Michael A. Belfort

19 Obstetric Analgesia and Anesthesia 315

M. James Lozada, Rovnat Babazade, and Rakesh B. Vadhera

20 Critical Care Drills in Obstetrics 331

Monica A. Lutgendorf and Shad H. Deering

21 Maternal‐Fetal Transport in the High‐Risk Pregnancy 347

Albert P. Sarno, Joshua A. Makhoul, and John C. Smulian

Part Two Acute Emergencies 359

22 Seizures and Status Epilepticus 361

Michael W. Varner

23 Acute Spinal Cord Injury 369

Lisa R. Wenzel, Angela Vrooman, and Hunter A. Hammill

24 Severe Acute Asthma 391

Dharani K. Narendra and Nicola A. Hanania

25 Acute Respiratory Distress Syndrome in Pregnancy 403

Dharani K. Narendra, David Muigai, and Kalpalatha K. Guntupalli

26 Cardiogenic Pulmonary Edema 419

Wayne J. Franklin and William C. Mabie

27 The Acute Abdomen during Pregnancy 429

Ibrahim A. Hammad and Howard T. Sharp

28 Acute Pancreatitis 441

Anna S. Leung and Jeffrey P. Phelan

29 Acute Renal Injury 457

Kristen L. Elmezzi, Caroline C. Marrs, C. Luke Dixon, Shad H. Deering, and Giuseppe Chiossi
 Contents vii

30 Acute Fatty Liver of Pregnancy 471

Ibrahim A. Hammad and T. Flint Porter

31 Disseminated Intravascular Coagulation 479

Nazli Hossain and Michael J. Paidas

32 Endocrine Emergencies 487

Mary Catherine Tolcher, Heather S. Hoff, and Kjersti Marie Aagaard

33 Acute Psychiatric Conditions in Pregnancy 501

Lucy J. Puryear

34 Diabetic Ketoacidosis 519

Mark A. Curran

Part Three Shock in Pregnancy 533

35 Hypovolemic Shock 535

Jerasimos Ballas and Scott Roberts

36 Blood Component Therapy and Massive Transfusion 547

Shiu‐Ki Rocky Hui, Kjersti Marie Aagaard, and Jun Teruya

37 Etiology and Management of Hemorrhage 569

Irene A. Stafford, Michael A. Belfort, and Gary A. Dildy

38 Septic Shock 599

Sonya S. Abdel‐Razeq and Errol R. Norwitz

39 Cardiogenic Shock 631

Scott Roberts and Martha W.F. Rac

40 Anaphylactic Shock in Pregnancy 641

Raymond O. Powrie

41 Amniotic Fluid Embolism 653

Gary A. Dildy, Michael A. Belfort, and Steven L. Clark

Part Four Medical and Surgical Management 671

42 Pregnancy‐Related Stroke 673

Jamil ElFarra and James N. Martin, Jr.

43 Cardiac Disease and Pregnancy 699

Wayne J. Franklin, Roxann Rokey, Michael R. Foley,
and Michael A. Belfort

44 Anesthetic Considerations in the Critically Ill Gravida with Cardiac Disease 731
Shobana Murugan, Lisa Mouzi Wofford, Sandeep Markan, and Yi Deng

45 Thromboembolic Disease 755

Martha Pritchett Mims
viii Contents

46 Pulmonary Hypertension in Pregnancy 775

Mohammed F. Zaidan and Alexander G. Duarte

47 Sickle Cell Disease and Pregnancy 791

Iberia Romina Sosa and Mark M. Udden

48 Thrombotic Thrombocytopenic Purpura, Hemolytic‐Uremic Syndrome, and HELLP 803

Kelty R. Baker

49 The Placenta as a Critical Care Issue 821

Karin A. Fox, Martha W.F. Rac, Alireza A. Shamshirsaz,
and Michael A. Belfort

50 Complications of Preeclampsia 837

Mary Catherine Tolcher, Hector Mendez‐Figueroa, and Kjersti Marie Aagaard

51 Systemic Lupus Erythematosus and Antiphospholipid Syndrome 873

Fawzi Saoud and Maged M. Costantine

52 Trauma in Pregnancy 891

Robert Rossi, Alfredo F. Gei, and James W. Van Hook

53 Thermal and Electrical Injury 919

Cornelia R. Graves

54 Overdose, Poisoning, and Envenomation during Pregnancy 927

Alfredo F. Gei, Victor R. Suarez, and James W. Van Hook

55 The Organ Transplant Patient in the Obstetric Critical Care Setting 985
Calla Holmgren and James R. Scott

56 Fetal Surgery Procedures and Associated Maternal Complications 997

Alireza A. Shamshirsaz, Venkata Bandi, David Muigai, R. H. Ball,
and Michael A. Belfort

57 Cancer in the Pregnant Patient 1005

Kristin Bixel, Kenneth H. Kim, and David M. O’Malley

58 Mass Casualties and the Obstetrical Patient 1023

Lisa M. Foglia and Peter E. Nielsen

59 Biological, Chemical, and Radiological Exposures in Pregnancy 1027

Lisa M. Foglia and Peter E. Nielsen

Part Five Ethical and Legal Considerations 1037

60 Ethics in the Obstetric Critical Care Setting 1039

Fidelma B. Rigby

61 Medical‐Legal Considerations in Critical Care Obstetrics 1063

Jeffrey P. Phelan

Index 1085
 ix

List of Contributors

Kjersti Marie Aagaard, MD, PhD, FACOG Baylor College of Medicine

Henry and Emma Meyer Chair in Obstetrics & Gynecology Ben Taub Hospital
Professor & Vice Chair of Research Texas Children’s Pavilion for Women
Department of Obstetrics and Gynecology Houston, TX, USA
Division of Maternal‐Fetal Medicine
Baylor College of Medicine and Texas Children’s Hospital Venkata Bandi, MD
Houston, TX, USA Baylor College of Medicine
Houston, TX, USA
Sonya S. Abdel‐Razeq, MD
Assistant Professor
Obstetrics, Gynecology, and Reproductive Sciences Michael A. Belfort, MBBCH, MD, PhD
Yale University Professor, Department of Obstetrics and
New Haven, CT, USA Gynecology
Division of Maternal Fetal-Medicine,
Cande V. Ananth, PhD, MPH Baylor College of Medicine
Department of Obstetrics and Gynecology Houston, TX, USA
College of Physicians and Surgeons
Department of Epidemiology
Terri‐Ann Bennett, MD
Joseph L. Mailman School of Public Health
Columbia University Division of Maternal‐Fetal Medicine
New York, NY, USA Department of Obstetrics and Gynecology
New York University Langone Medical Center
Rovnat Babazade, MD New York, NY, USA
Department of Anesthesiology
The University of Texas Medical Branch Kristin Bixel, MD
Galveston, TX, USA Division of Gynecologic Oncology
Department of Obstetrics and Gynecology
Suzanne McMurtry Baird, DNP, RN
James Cancer Hospital and Solove Research Institute
Owner and Nursing Director, Clinical Concepts
The Ohio State University
in Obstetrics, Inc.
Columbus, OH, USA
Brentwood, TN, USA; Labor and Delivery,
Vanderbilt University Medical Center,
Nashville, TN, USA Aaron B. Caughey, MD, PhD
Professor and Chair, Department of Obstetrics &
Kelty R. Baker, MD, PA Gynecology;
Houston Methodist Hospital Women’s Health Research & Policy
Houston, TX, USA Oregon Health & Science University
Portland, OR, USA
R.H. Ball, BM, BCh
Baylor College of Medicine
Giuseppe Chiossi, MD
Houston, TX, USA
Department of Obstetrics & Gynaecology
Jerasimos Ballas, MD, MPH Division of Maternal and fetal Medicine
Assistant Professor, Department of Obstetrics The University of Texas Medical Branch
and Gynecology Galveston, TX, USA
x List of Contributors

Steven L. Clark, MD Evan I. Fisher, MD, Major, USAF MC, Nephrologist wPAFB
Department of Obstetrics and Gynecology Nephrology Service
Baylor College of Medicine Department of Medicine
Houston, TX, USA Walter Reed National Military Medical Center
Uniformed Services University of the Health Sciences
Maged M. Costantine, MD Bethesda, MD, USA
Associate Professor, Division of Maternal
Fetal Medicine
Alfred D. Fleming, MD
The University of Texas Medical Branch
Chairman, Department of Obstetrics and Gynecology
Galveston, TX, USA
Director, Maternal‐Fetal Medicine
Saint Luke’s Regional Medical Center
Mark A. Curran, MD
Sioux City, IA, USA
San Gabriel Valley Perinatal Medical Group, Inc.
West Covina, CA, USA
Lisa M. Foglia, MD, FACOG, Col. USARMY
Shad H. Deering, MD Associate Professor, Uniformed Services University
Professor and Chair, Department of Obstetrics and of the Health Sciences, Medical Education and Research
Gynecology DIO;
Uniformed Services University of the Health Sciences Director
Bethesda, MD, USA Womack Army Medical Center, Fayetteville, NC, USA

Yi Deng, MD
Michael R. Foley, MD
Assistant Professor, Cardiac Anesthesia and
Professor and Chair, Department of Obstetrics
Critical Care
and Gynecology
Ben Taub General Hospital
University of Arizona College of Medicine Phoenix
Baylor College of Medicine
Phoenix, AZ, USA
Houston, TX, USA

Gary A. Dildy, MD Karin A. Fox, MD, MEd, FACOG

Professor Assistant Professor, Associate Fellowship Director,
Department of Obstetrics and Gynecology and Co‐Chief
Baylor College of Medicine Maternal‐Fetal Surgery Section
Houston, TX, USA Division of Maternal‐Fetal Medicine
Department of Obstetrics and Gynecology
C. Luke Dixon, MD Baylor College of Medicine;
Department of Obstetrics and Gynecology The Pavilion for Women
Division of Maternal and Fetal Medicine Texas Children’s Hospital
The University of Texas Medical Branch Houston, TX, USA
Galveston, TX, USA
Wayne J. Franklin, MD
Alexander G. Duarte, MD
Head, Department of Adult Medicine
Professor, Division of Pulmonary, Critical Care
Director, Adult Congenital Heart Disease Program
and Sleep Medicine
Texas Children’s Hospital
The University of Texas Medical Branch
Associate Professor of Medicine and Pediatrics
Galveston, TX, USA
Associate Professor of Obstetrics and
Jamil ElFarra, MD, FACOG Gynecology
Attending Physician, Maternal Fetal Medicine Baylor College of Medicine
Norton Healthcare Houston, TX, USA
Louisville, KY, USA
Alfredo F. Gei, MD, PA
Kristen L. Elmezzi, DO Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine
Uniformed Services University of the Health Sciences The Methodist Hospital
Bethesda, MD, USA Houston, TX, USA
 List of Contributors xi

Jay P. Goldsmith, MD Calla Holmgren, MD

Clinical Professor of Pediatrics, Division of Assistant Professor, Maternal Fetal Medicine
Neonatal Medicine Intermountain Healthcare and The University of Utah
Tulane University; Health Sciences
Department of Pediatrics Murray, UT, USA
Ochsner Medical Institutions
New Orleans, LA, USA Nazli Hossain, FCPS
Professor, Department of Obstetrics and Gynecology
Cornelia R. Graves, MD Unit III, Dow University of Health Sciences
Medical Director, Tennessee Maternal Fetal Medicine; Karachi, Pakistan
Director of Perinatal Services, St. Thomas Health;
Clinical Professor Vanderbilt University; Shiu‐Ki Rocky Hui, MD
Adjunct Professor, Meharry Medical College Assistant Professor, Departments of Pathology &
Professor, University of Tennessee Immunology, Pediatrics and Medicine
Nashville, TN, USA Baylor College of Medicine
Houston, TX, USA
Kalpalatha K. Guntupalli, MD
Division of Pulmonary, Critical Care and Sleep Kenneth H. Kim, MD
Medicine Division of Gynecologic Oncology
Department of Medicine Department of Obstetrics and Gynecology
Baylor College of Medicine University of Alabama–Birmingham
Houston, TX, USA Birmingham, AL, USA

Hunter A. Hammill, MD Aristides P. Koutrouvelis, MD

Obstetric and Gynecology Attending Physician Medical Director, Surgical Intensive Care Unit
TIRR Memorial Hermann Hospital Department of Anesthesiology
Colonel 228th CSH The University of Texas Medical Branch
US ARMY retired Galveston, TX, USA
Houston, TX, USA
Anna S. Leung, MD
Ibrahim A. Hammad, MD
Medical Director of Maternal‐Fetal Medicine
Fellow, Maternal‐Fetal Medicine
Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
Citrus Valley Medical Center
University of Utah and Intermountain Healthcare
San Gabriel Valley Perinatal Medical Group, Inc.
Salt Lake City, UT, USA
West Covina, CA, USA
Nicola A. Hanania, MD, MS
Associate Professor, Division of Pulmonary, Critical M. James Lozada, DO
Care and Sleep Medicine, Department of Medicine Assistant Professor, Division of Obstetrical
Baylor College of Medicine Anesthesiology
Houston, TX, USA Department of Anesthesiology
Vanderbilt University Medical Center
Marsha Henn, MSN, BSN, RNC‐MNN Nashville, TN, USA
Nurse Scientist, Clinical Practice Expert – Obstetrics
Office of Research and Evidence Based Practice Monica A. Lutgendorf, MD, FACOG
Saint Luke’s Regional Medical Center Division Head, Maternal-Fetal Medicine
Sioux City, IA, USA Naval Medical Center
San Diego, CA, USA
Heather S. Hoff, MD
Department of Obstetrics and Gynecology William C. Mabie, MD
Division of Reproductive Endocrinology and Greenville Health System
Infertility University Medical Group
University of North Carolina University of South Carolina
Chapel Hill, NC, USA Greenville, SC, USA
xii List of Contributors

Joshua A. Makhoul, MD Lisa Mouzi Wofford, MD

Department of Obstetrics and Gynecology Assistant Professor
Lehigh Valley Health Network Division of Trauma and Regional Anesthesia
Allentown, PA, USA Ben Taub General Hospital
Baylor College of Medicine
Sandeep Markan, MD, FCCP Houston, TX, USA
Associate Professor and Section Chief
David Muigai, MD
Cardiac Anesthesia and Critical Care
Assistant Professor
Ben Taub General Hospital
Division of Pulmonary, Critical Care and Sleep Medicine
Baylor College of Medicine
Department of Medicine
Houston, TX, USA
Baylor College of Medicine
Houston, TX, USA
Caroline C. Marrs, MD
Department of Obstetrics and Gynecology Shobana Murugan, MD
Division of Maternal and Fetal Medicine Associate Professor, Texas Children’s Hospital
The University of Texas Medical Branch Pavilion for Women
Galveston, TX, USA US Anesthesia Partners
Houston, Texas, USA
Gilbert I. Martin, MD
Director Emeritus, Neonatal Intensive Care Unit Dharani K. Narendra, MD
Citrus Valley Medical Center – Queen of the Valley Campus Assistant Professor, Division of Pulmonary, Critical
West Covina, CA Care and Sleep Medicine
Professor of Pediatrics Department of Medicine
Loma Linda University Medical Center Baylor College of Medicine
Loma Linda, CA, USA Houston, TX, USA

James N. Martin Jr., MD Peter E. Nielsen, MD, FACOG, COL, US Army, Retired
Department of Obstetrics and Gynecology Professor and Vice Chair
Division of Maternal‐Fetal Medicine Department of Obstetrics and Gynecology
University of Mississippi Medical Center Baylor College of Medicine;
Jackson, MS, USA The Children’s Hospital of San Antonio
San Antonio, TX, USA
Sharon Maynard, MD
Division of Nephrology Errol R. Norwitz, MD, PhD, MBA
Department of Medicine Louis E. Phaneuf Professor of Obstetrics & Gynecology
Lehigh Valley Health Network Tufts University School of Medicine
Allentown, PA, USA Chair, Department of Obstetrics & Gynecology
Chief Scientific Officer, Tufts Medical Center
Alexis L. McQuitty, MD
Tufts University
Associate Professor, Cardiothoracic Anesthesiology Boston, MA, USA
Department of Anesthesiology
The University of Texas Medical Branch Sarah Gloria Običan, MD
Shriners Burn Hospital Assistant Professor, Division of Maternal‐Fetal
Galveston, TX, USA Medicine
Department of Obstetrics and Gynecology
Hector Mendez‐Figueroa, MD Morsani College of Medicine
Maternal‐Fetal Medicine University of South Florida
University of Texas Medical School Tampa, FL, USA
Houston, TX, USA
James D. Oliver III, MD, Col. USARMY
Martha Pritchett Mims, MD, PhD Chief, Nephrology Service, Department of Medicine
Professor of Medicine Walter Reed National Military Medical Center
Section Chief, Hematology/Oncology Director & Associate Professor, Nephrology Division
Baylor College of Medicine Uniformed Services University of the Health Sciences
Houston, TX, USA Bethesda, MD, USA
 List of Contributors xiii

Gayle Olson, MD Raymond O. Powrie, MD

Department of Obstetrics and Gynecology Professor of Medicine and Obstetrics & Gynaecology
Division of Maternal‐Fetal Medicine Interim President, Kent Hospital, Warwick, RI;
The University of Texas Medical Branch CNE Executive Chief of Medicine
Galveston, TX, USA SVP for Population Health
Chief of Medicine
David M. O’Malley, MD Women & Infants Hospital of Rhode Island | A Care
Division of Gynecologic Oncology New England Hospital
Department of Obstetrics and Gynecology Providence, RI, USA
James Cancer Hospital and Solove Research
Institute Lucy J. Puryear, MD
The Ohio State University Maureen Hackett Endowed Chair in Reproductive
Columbus, OH, USA Psychiatry
Associate Professor of Obstetrics and
Luis D. Pacheco, MD
Gynecology
Professor, Departments of Obstetrics
Meninger Department of Psychiatry
Gynecology, and Anesthesiology
Baylor College of Medicine;
Divisions of Maternal Fetal Medicine and Surgical
Medical Director
Critical Care, The University of Texas Medical Branch
The Women’s Place
Galveston, TX, USA
Center for Reproductive Psychiatry
Michael J. Paidas, MD The Pavilion for Women
Professor and Vice Chair, Obstetrics Texas Children’s Hospital
Program Director, Maternal Fetal Medicine Houston, TX, USA
Fellowship
Yale Women and Children’s Center for Blood Disorders Martha W.F. Rac, MD
and Preeclampsia Advancement Assistant Professor, Division of Maternal‐Fetal Medicine
Co-Director, National Hemophilia Foundation – Baxter Baylor College of Medicine
Clinical Training Fellowship Program at Yale Houston, TX, USA
Yale University
New Haven, CT, USA Fidelma B. Rigby, MD
Department of Obstetrics and Gynecology
Jeffrey P. Phelan, MD, JD MFM Division
President and Director of Clinical Research MCV Campus of Virginia Commonwealth
Childbirth Injury Prevention Foundation University
Glendora, CA; Richmond, VA, USA
San Gabriel Valley Perinatal Medical Group, Inc.
West Covina, CA; Scott Roberts, MD, MSc
Former Director of Quality Assurance Medical Director, High-Risk Obstetrical Unit
Department of Obstetrics and Gynecology Parkland Hospital, Department of Obstetrics
Citrus Valley Medical Center and Gynecology
West Covina, CA, USA University of Texas Southwestern Medical Center
Dallas, TX, USA
Sheena A. Pimpalwar, MD, MBBS, FRCR
Assistant Professor, Baylor College of Medicine Julian N. Robinson, MD
Texas Children’s Hospital Harvard Medical School
Houston, TX, USA Division of Maternal-Fetal Medicine
Department of Obstetrics, Gynecology and
T. Flint Porter, MD, MPH Reproductive Biology
Professor and Fellowship Program Director Brigham and Women’s Hospital
Maternal‐Fetal Medicine Boston, MA, USA
University of Utah Health Sciences;
Chief, Maternal‐Fetal Medicine Roxann Rokey, MD
Intermountain Medical Center and LDS Hospital Department of Cardiology
Intermountain Healthcare Marshfield Clinic
Salt Lake City, UT, USA Marshfield, WI, USA
xiv List of Contributors

Robert Rossi, MD Julie Scott, MD

Department of Obstetrics and Gynecology Associate Professor, Maternal Fetal Medicine
Division of Maternal‐Fetal Medicine Department of Obstetrics and Gynecology
University of Cincinnati College of Medicine University of Colorado
Cincinnati, OH, USA Aurora, CO, USA

Antonio Saad, MD Alireza A. Shamshirsaz, MD., FACOG

Maternal‐Fetal Medicine Associate Professor, Fetal surgeon/Maternal Fetal
Department of Obstetrics and Gynecology Medicine
The University of Texas Medical Branch Chief, Division of Fetal Therapy and Surgery
Galveston, TX, USA Director, Fetal Surgery Fellowship
Co-Chief, Maternal-Fetal Surgery Section
George R. Saade, MD
Department of Obstetrics and Gynecology/Department
Professor, Obstetrics and Gynecology, and Cell
of Surgery, Baylor College of Medicine
Biology
Texas Children’s Fetal Center, Texas Children’s
Chief of Obstetrics and Maternal Fetal Medicine
Hospital
The University of Texas Medical Branch
Houston, TX, USA
Galveston, TX, USA

Fawzi Saoud, MD Amir Shamshirsaz, MD

Division of Maternal-Fetal Medicine Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine
The University of Texas Medical Branch Baylor College of Medicine
Galveston, TX, USA Texas Children’s Hospital
Houston, TX, USA
Albert P. Sarno Jr., MD, MPH
Director, Fetal Cardiology Howard T. Sharp, MD
Division of Maternal‐Fetal Medicine Professor and Vice Chair
Vice-Chairman, Dept of Obstetrics & Gynaecology Department of Obstetrics and Gynecology
Lehigh Valley Health Network Clinical Activities and Quality
Allentown, PA; University of Utah Health Sciences Center
Professor, Department of Obstetrics and Gynecology Salt Lake City, UT, USA
Morsani College of Medicine
University of South Florida John C. Smulian, MD, MPH
Tampa, FL, USA Division of Maternal‐Fetal Medicine
Lehigh Valley Health Network
Anthony Scardella, MD
Allentown, PA;
Professor and Chief
Department of Obstetrics and Gynecology
Division of Pulmonary and Critical Care Medicine
Morsani College of Medicine
Vice Chair for Clinical Affairs
University of South Florida
Department of Medicine
Tampa, FL, USA
Rutgers Robert Wood Johnson Medical School
New Brunswick, NJ, USA
Iberia Romina Sosa, MD, PhD
William E. Scorza, MD Hematology Oncology Section
Division of Maternal‐Fetal Medicine Department of Medicine
Department of Obstetrics Baylor College of Medicine
Lehigh Valley Hospital Houston, TX, USA
Allentown, PA, USA
Irene A. Stafford, MD
James R. Scott, MD Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology Division of Maternal‐Fetal Medicine
University of Iowa Carver College of Medicine Baylor College of Medicine, Texas Children’s Hospital
Iowa City, IA, USA Houston, TX, USA
 List of Contributors xv

Victor R. Suarez, MD James W. Van Hook, MD

Attending physician Department of Obstetrics and Gynecology
Maternal‐Fetal Medicine Division of Maternal‐Fetal Medicine
Advocate Christ Medical Center University of Toledo College of Medicine and Life
Chicago, IL, USA Sciences, Toledo, OH, USA

Bill Tang, MD, PharmD Michael W. Varner, MD

Department of Obstetrics & Gynecology Professor
Citrus Valley Medical Center Department of Obstetrics and Gynecology
West Covina, CA, USA University of Utah Health Sciences Center
Salt Lake City, UT, USA
Michael J. Tang, BA
School of Medicine Angela Vrooman, DO
Universidad Autonoma de Guadalajara Assistant Professor, Department of Physical Medicine
Guadalajara, Mexico and Rehabilitation
University of Texas Health Science Center;
Jun Teruya, MD, DSc, FCAP
Spinal Cord Injury Staff Physician
Departments of Pathology & Immunology
Audie L. Murphy VA Medical Center, San Antonio
Vice Chairman for Education
TX, USA
Professor of Pediatrics and Medicine
Director, Transfusion Medicine/Blood Banking
Lisa R. Wenzel, MD
Fellowship Program
Assistant Professor, Baylor College of Medicine;
Baylor College of Medicine; Chief, Division of
TIRR‐Memorial Hermann Hospital
Transfusion Medicine & Coagulation
Houston, TX, USA
Texas Children’s Hospital
Houston TX, USA
Jerome Yankowitz, MD
James M. Ingram Professor and Chair
Mary Catherine Tolcher, MD, MS
Department of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
Morsani College of Medicine
Division of Maternal-Fetal Medicine
University of South Florida
Baylor College of Medicine
Tampa, FL, USA
Houston, TX, USA

Nan H. Troiano, MsN, RN‐OB, NE-BC, C-EFM Mohammed F. Zaidan, MD

Consultant, Perinatal nursing and high‐risk and Pulmonary and Critical Care Medicine Fellow
critical care obstetrics Arley, AL, USA; Sibley Johns Division of Pulmonary, Critical Care and Sleep
Hopkins Medicine, Women & Infants Clinical Service Medicine
Departments, Washington, DC, USA The University of Texas Medical Branch
Galveston, TX, USA
Mark M. Udden, MD
Hematology Oncology Section Carolyn M. Zelop, MD
Department of Medicine Clinical Professor, Department of Obstetrics and
Baylor College of Medicine Gynecology
Houston, TX, USA New York University School of Medicine
New York, NY;
Rakesh B. Vadhera, MD Maternal‐Fetal Medicine Program
Director of Obstetric Anesthesia, Departments of The Valley Hospital
Anesthesiology, The University of Texas Medical Ridgewood, NJ, USA
Branch, Galveston, TX, USA
 xvii

­Foreword to the Sixth Edition

This is a story about a book, this book – Critical Care had, on what he should consider doing as his fellowship
Obstetrics. Strange as it may seem, this book has a project. As my recollection best serves me, the newly
bicoastal beginning and arose almost simultaneously on published Phelan–Yurth article (published in 1982)
both coasts without the future editors having any idea served as an impetus to explore the new frontier of criti-
that they were going to start a book – let alone be editors cal care obstetrics. Soon thereafter, Dr. Clark took the
of a book that would continue to be published over bull by the horns and catapulted us into the new dimen-
30 years and is now in its sixth edition. The bicoastal sion of critical care obstetrics.
beginnings were triggered by the introduction of two Sometime later, Dr. Clark, a fellow at the time, came
articles on invasive hemodynamic monitoring in preec- into my office and quickly shut the door. Almost simulta-
lampsia: Benedetti and Cotton [1] at the Los Angeles neously, he said,
County/University of Southern California (LAC/USC) “Jeff, I am going to make you famous! You and I are
Medical Center on the west coast, and Phelan and Yurth going to do a book called Critical Care Obstetrics.”
[2] at the Naval Regional Medical Center in the old build- While I was admittedly impressed by his bravado, my
ing on the east coast. In retrospect, the pulmonary artery response was less than enthusiastic and laced with seri-
catheter became the Aladdin’s lamp of Critical Care ous doubts. I said simply, “Who would buy a book from
Obstetrics. Once the Genie appeared, terms such as left us?” After all, Dr. Clark was a first‐year fellow and I was
ventricular stroke work index, pulmonary artery pres- just a junior faculty member.
sure, hyperdynamic ventricular function, and pulmonary Much to my amazement, a whole lot of folks would buy
capillary wedge pressure became commonplace in the this book and have kept on buying each new edition.
obstetrical community. Never did I imagine in 1987 that, now more than 30
Interestingly enough, the origins of Critical Care years later, I would be in a rice field in Shijyonawate (just
Obstetrics had its genesis at the then‐epicenter of north of Osaka), Japan, watching the annual rice harvest
fetal assessment: LAC/USC Medical Center. There, the and editing the sixth edition of Critical Care Obstetrics.
schools of fetal monitoring, obstetrical ultrasonogra- As the sun slowly set in the west, the harvester contin-
phy, and fetal echocardiography were united under one ued up and down the rows of rice, separating the rice
umbrella. But something was missing. There, a void from its stalks and projecting the rice into collection
needed to be filled: maternal critical care. But that was bags. The rice harvesting, much like critical care obstet-
about to change. rics, has changed dramatically over the past 30 years.
As the story goes, it was a quiet Sunday afternoon in More than 30 years after that eventful day with Dr. Clark
the year 1981. I was working as an OB/GYN hospitalist, and five editions later, life and this book, Critical Care
as it is known today, at Hollywood Presbyterian Hospital Obstetrics, have taught us how much “time flies when
in Hollywood, California, with a then‐resident, Steven we are alive.”
L. Clark, MD, whom I was about to meet. A code blue While working on the sixth edition, there were also
was called in another unit of the hospital. As I ran to that many stories within the book’s five prior editions. One
area to attempt CPR on a nonpregnant stranger, an OB story struck me hard personally. In my first edition, there
resident named Steve Clark was also running to the was an inscription written 30 years ago to my Father.
same code. By the time we had arrived at the code, the Then, I wrote the following:
gentleman had already been resuscitated by the code “To my Dad, Thanks for being my Father & teaching
blue team. me that hard work and perseverance pays off, Love
Several months later, Dr. Clark and I had a discussion, always, your Son, Jeff 1987.”
similar to other conversations that faculty and fellows Sadly, my Father died a few weeks later.
Other documents randomly have
different content
Presently, above the impossibly blue sea loomed a bit of land, a tiny,
gray-green, barren cay, rimmed with ragged, weather-beaten rocks
in whose coves and hollows coral beaches gleamed, white as the
beating surf, beyond the turquoise water. Leaning upon the
schooner’s rail, I gazed idly and curiously at the little isle, the one
break upon the shimmering sea, a lonely spot whose only signs of
life were the circling sea-birds hovering over it in clouds.

I turned to the fellow at the wheel—a giant of a man, black as ebony

and muscled like a Hercules, [9]naked to the waist, his dungaree
trousers rolled to his knees and supported by a wisp of scarlet sash,
his huge flat feet wide-spread, and a flapping jipijapa hat upon his
huge head. His lusterless eyes, bloodshot from constant diving (for
he was a sponger by profession), and the huge hoops in his ears,
gave him a fierce, wild look, and, glancing at him, one might well
have imagined him a member of a pirate crew, a corsair steering
toward some doomed prize.

“Sam,” I asked, “what’s that island over there to port?”

The big negro slowly turned his head and gazed at the speck of rock
and sand.

“Tha’ ’s Dead Man’s Chest, Chief,” he replied in the soft drawl of the
Bahaman.

Dead Man’s Chest! Instantly, at his words, the song made famous by
Stevenson flashed through my mind: “Fifteen men on the Dead
Man’s Chest—Yo-ho-ho, and a bottle of rum!”

Dead Man’s Chest! The little cay at once took on a new interest. Now
I could almost picture them yonder,—those shipwrecked men, fifteen
of them,—gaunt, fierce-visaged, unshorn; sprawled on the sand in
the scanty shade of the twisted sea-grape trees above the surf.
Marooned, cast away, but reckless daredevils to the last; gambling in
the [10]face of death, tossing a gleaming golden doubloon in their
final game of chance—the stake, their lives against that one bottle of
rum! And then drink and the devil would have done for them as for
the rest, and only their whitening bones over which the sea-birds
fought and screamed would remain to tell their grim tale.

Dead Man’s Chest! What more fitting than that this bit of ocean-girt
land should have been the first of the isles made famous by the
buccaneers to greet my eyes, and what more appropriate than that I
should have sighted it from the deck of a real pirate craft! Fortunate
indeed had I been when her owners delivered the Vigilant into my
hands for my cruise, and I pondered, as we sped past wave-beaten
Dead Man’s Chest, on the story the Vigilant might tell could she but
speak. Then my thoughts were brought back to the present as Sam
spoke:

“The’ says as how the’ ’s plenty o’ tr’asure yonder, on Dead Man’s

Chest,” he remarked, “but Ah can’ say as how true ’tis, Chief. Plenty
folks has s’arched for it, but Ah can’ say as the’ ’s foun’ it. I ’spec’
the’ ’s tr’asure a plenty on th’ cays here ’bout. The’ says as how th’
pirates was num’rous roun’ here.”

“Yes, it was a great place for pirates,” I replied. [11]“You know these
islands well, Sam. Have you ever run across any old guns or forts or
wrecks on any of them? By the way, what’s your last name?”

Sam grinned.

“Ah got a right funny name, Chief,” he responded. “Ah don’ ’spec’
you ever hear it. It’s Lithgow, Chief.”

Lithgow! What a name to conjure with, in the old buccaneer days!

Red Lithgow, the bold, unprincipled pirate chieftain who hailed from
Louisiana and met death at the end of a rope from his own yard-
arm! Perchance—nay, in all probability—some of the old rascal’s
blood still flowed in Sam’s veins; for all through the islands one finds
lineal descendants (though they may be brown, black, or yellow) of
the buccaneers, whose progeny was legion.

But Sam was again speaking, replying to my first question and

telling me that hidden among the brush and weeds on St. John, St.
Martin, and others of the Virgins, were numerous old walls, ruins,
and cannon which, rumor had it, were relics of the pirates who once
made the islands their stronghold.

My itinerary included all of these in turn, and so the Vigilant’s course

remained unaltered and [12]with the wind humming through the taut
rigging and filling the great straining sails, we rushed on toward St.
Thomas, looming like a cloud upon the horizon far ahead.

And now, as the schooner races onward toward the quaint port of
Charlotte Amalie, a word about the crew that manned the Vigilant;
for Sam was not by any means the only or the most important
personage besides myself. A mixed lot they were, but most valuable
factors in my cruise and an entertaining lot as well. Originally they
were all Virgin Islanders, save Sam, the Bahaman pilot and
“captain,” and Joseph, the long-legged, solemn-faced cook, who,
notwithstanding his ebony skin and kinky head, dubbed all of his
race “stupid niggers,” who found everything not to his liking “pure
corruption,” and who proudly boasted of being a Turks Island boy.

With the Chesterfieldian manners of a duke, painstakingly perfect

English, and the dignity of a Spanish grandee, Joseph looked down
upon the “stupid niggers” of the crew as from an impregnable
height, and fraternized with Sam only, the others being merely
tolerated. A right good cook and a faithful boy was Joe, and a never-
ending source of amusement because of his assumption of a sort of
guardianship over me. [13]

But ere the cruise was over he and Sam and one other were the only
remaining members of my original crew. Never did the Vigilant’s
mud-hook seek bottom in the limpid waters of some lovely isle that
one or more of my sailors did not desert. Not that they had aught of
which to complain, or found their duties on the ship irksome, but
good American dollars in their pockets, a rich green shore, and
chocolate-colored sirens were temptations beyond the black man’s
power to resist. Yet never were we short-handed. For every man
who left, a score clamored to be taken on, and had the Vigilant been
on a pirating adventure I could have filled her to the hatches with as
varicolored and vari-charactered a crew as ever swarmed over the
bulwarks of a stricken prize.

To the West Indians, every American is a millionaire and a

philanthropist, and in their eyes, apparently, he is morally bound to
carry each, all, and sundry to that dreamed-of-land the States, the
Mecca of every inhabitant of the islands. Wherever the Vigilant
folded her white wings and came to rest, we were besieged by a
small army of black, brown, yellow, and every intermediate shade,
all begging to be allowed to accompany us. For the West Indian is a
restless soul, never content unless on the move and caring not a jot
where day or [14]night may find him, albeit he is intensely patriotic,
and thinks his island preferable to all others and his people the salt
of the earth.

Thus it came about that, what with deserters and new-comers, the
crew was a sort of kaleidoscopic aggregation, shifting from yellow to
brown, from black to tan, from soft-voiced, slurring-tongued “patois
men” to h-dropping ’Badians and brogue-speaking Montserratans.
And a happy family they were at that—good-naturedly chaffing one
another, having long-winded arguments over the respective merits of
their various island homes, using preposterous, meaningless words
of their own invention. And all and each making life miserable for the
hapless natives of that “right little, tight little island” designated on
the maps as Barbados, affectionately dubbed “Little England” by its
sons and daughters, and also known as “Bimshire Land,” 2 whose
natives seem for some strange reason ever to be the butt and the
jest of the other [15]islanders, and who are the pariahs of their race,
if we are to believe their fellow negroes of the Caribbees.

Never did my men tire of taunting some poor ’Badian with the
doggerel verse

A ha’penny loaf an’ a bit o’ salt fish,

Da’ ’s wha’ de ’Badian call’ a dish.
A bottle o’ soda divided ’twix’ t’ree,
Da’ ’s wha’ de ’Badian call’ a spree.

If the ’Badians happened to be in the minority, they bore it as best

they might or retorted that “You men awnt civ’lized. You don’ know
better’n to wear alpargats to a charch of a Sunday,” a response
which usually brought on a loud cracking of tough skulls, as, like
enraged goats, the men butted one another’s wool-covered craniums
—a contest in which the ’Badian always emerged victorious. For to
accuse an islander of wearing alpargatas (the sandal-like footgear
brought from Venezuela) to church, is an insult not lightly to be
suffered. Indeed, if ever there was a being who outshone Solomon
in all his glory, it is the West Indian negro on the Sabbath; and his
highest ambition is, in order to draw greater attention to his
gorgeous raiment, to possess a pair of brilliant, pumpkin-colored
shoes which, to quote his own [16]words, “goes queek, queek when
Ah walks in de charch.”
As might be expected, in the constant change and interchange of
multicolored flotsam and jetsam, we picked up many a strange and
interesting, not to say downright weird, character.

There, for example, was Trouble. He appeared one glorious golden

morn as we lay at anchor off St. John, like Aphrodite rising from the
sea, his scanty garments dripping with brine; for, being both boatless
and penniless, he had used nature’s gifts to win his way from shore
to ship like the amphibious creature he proved to be. But, aside from
the unexpected manner of his appearance, nothing could have
resembled the goddess of the sea less. In fact, he was
unquestionably the ugliest and most repulsive representative of the
genus Homo and the species Sapiens that I have ever gazed upon—
bony and big, with gorilla-like arms and a face so broad and
forehead so low that his head appeared to have been forced out of
shape by hydraulic pressure, while his natural absence of human-like
features had been enhanced by some accident which had deprived
him of even the semblance of a nose. There, above his immense
mouth, were two huge round holes which, when he grinned,—as he
constantly [17]did,—stretched into slits that seemed ever on the point
of meeting his ears and literally severing his black face into upper
and lower hemispheres.

Like a prize bull-pup, he was so extravagantly ugly that he actually

was fascinating, and not until he spoke could I take my eyes from
him. And his first words were almost as astounding and unexpected
as his appearance:

“Ah’m beggin’ o’ yo’ pawdon, Boss, for mah audacity an’ assumption
o’ de manner o’ mah absence o’ dignification for precip’tately
discommodin’ yo’, but Ah’d like for to propoun’ de interrogation ef yo’
can absorbinate mah sarvices for a member o’ de crew, sir, for to
circumnavigate de islan’s, sir.”
Was I dreaming, or had the climate affected my brain? I literally
gasped.

But the next instant I had recovered myself, for I knew that this
noseless apparition with his wide mouth filled with long words could
have originated in but one locality in all the islands, Antigua, whose
dusky inhabitants seem to pride themselves upon the amplitude of
the words they can command, regardless of their meaning or
aptness.

“What’s your name, and what can you do?” I [18]asked, more as a
formality than anything else, for I never dreamed of taking this
creature on.

The noseless negro scratched his head and wiggled his bare toes.

“Ah was christened wi’ de cognomen o’ Henry Francis William Nelson

Wellington Shand, sir,” he replied; and then, as an afterthought, “but
Ah’m most usually designated by de name o’ Trouble, sir.”

“Trouble!” I exclaimed.

“Yaas, sir,” responded the grinning negro, instantly. “Thank yo’ sir, for
mekkin’ acceptance o’ mah sarvices, sir. Ah’ll endeavor for to conduc’
mahself wif circumspection an’ implicitness. Ah’s a sailor, sir, an’
Ah’m not expandulatin’ buncomb when Ah takes upon mahself de
assumptiveness o’ de assertion, sir.”

I was speechless,—so astounded at the man’s “assumptiveness” that

he had been hired that I could not find words to inform him of his
mistake,—and by the time I recovered from my astonishment he had
disappeared in the forecastle.

Sam stood by, chuckling to himself.

“Ah ’spec’s he may be a good sailor, Chief,” he vouchsafed. “An’ we’re
in need o’ two han’s, Chief.”

“All right, Sam,” I replied. “I suppose he [19]doesn’t need a nose to

run aloft or tail onto a rope.”

And so Trouble came unto us, but if ever a man belied his name it
was “Henry Francis William Nelson Wellington Shand, sir,” for Trouble
was a very treasure of a hand. He was as much at home in the
water as on land or deck, and when, later, our anchor fouled one
day, in fifteen fathoms, Trouble made nothing of diving down and
releasing the fluke from its lodgment under a mass of coral and rock,
while the height of his enjoyment was to challenge Sam to dive
overboard and kill a big shark in a single-handed duel beneath the
sea. And Sam, though a diver by profession, who had killed many a
man-eater with a blow of his long, keen-bladed knife, freely
admitted Trouble’s amphibious superiority.

Aloft he was a very monkey; he was ever scouring decks or polishing

brass; he was as good-natured as he was ugly, and even dignified
Joseph unbent and passed many a half-hour chinning with this weird
waif of the sea. As for the other members of the crew, after one or
two tests and trials they abandoned all attempts to out-talk or out-
argue him, for his ready flow of multisyllabled words left them
floundering in a vocabulary totally inadequate to cope with Trouble’s
“expandulations” [20]and “supercil’ous methodictions.” On one
occasion I overheard a bit of argument between our Antiguan find
and a recent addition to the crew—for the older members invariably
egged on new recruits to argue with Trouble.

I do not know what the argument had been about nor what the new
man had said, but as he was a French mulatto from Dominica,—or,
as the other islanders have it, a “patois man,”—I presume he had
been referring in no complimentary terms to Henry Francis et
cetera’s native heath.

“Yo’ worthless specimen o’ misguided humanity yo’!” exclaimed

Trouble. “Yo’ insignificant an’ fragment’ry yaller element! For
wherefo’ yo’ have de audacity to let yo’ imagination direc’ yo’ to dat
assumption? Who yo’ t’ink yo’ addressin’ in dat highfalutin’,
presumptious, dictatious manner? Ah desire yo’ to distinc’ly an’
def’nitely absorbinate de eminen’ly interestin’ an’ important
info’mation Ah’s propoundin’, an’ if yo’ declinates to precip’tately
reconsider de sentiments yo’ jus’ expressed an’ at once an’
immediately an’ hereby and in witness whereof retrac’ yo’
asservations once, forever, an’ henceforth, der’ ’s boun’ for to occur
a casulty an’ a deceased patois nigger, an’ de gentleman is goin’ for
to be compulsified for to discommode hisself to acquire another
incumbent for [21]to fill de work what yo’ lack o’ intellec’ don’ fit yo’
for.”

Needless to say, in the face of this dire threat—which to the fear-

stricken recipient savored of an incantation by a witch doctor or
“obeah man”—the French islander promptly and “precip’tately”
reconsidered and retracted whatever it was that had inadvertently
brought on Trouble’s outburst.

To the last day of the voyage Trouble was with us in name if not in
spirit, and never did I regret that he had hired himself, so to speak.

Aside from him and Sam and Joe, the only fixture was a red-haired,
freckle-faced Montserratan boy whom I could not resist employing
on account of his rich brogue and who served as cabin-boy,
laundryman, and clown, and with the ready wit of his wild Irish
ancestors kept us all in good humor throughout the cruise. [22]
 According to the most reliable records, the Vigilant was built in Baltimore in the
1
latter part of the eighteenth century. Originally named the Nonesuch, she was
intended for a privateer, but, the Revolution being virtually over before she was
launched, she was sold and won an unsavory reputation as a pirate. She later
turned privateer, during the War of 1812, and afterward engaged in the slave-
trade until England’s anti-slavery crusade made this work too dangerous. She was
then sold again, and became a notorious smuggler. Still later she changed hands
once more, and under her new owner, a Danish West Indian merchant, resumed
privateering with letters of marque from the Danish Government. In 1825 the
Vigilant became a man-of-war. A Spanish privateer had been harassing the Danish
shipping, and, all available Danish warships being too large to follow through the
shallow channels where she sought refuge, the Vigilant was chartered and a
company of soldiers [7]concealed upon her. As she cruised within sight of the
privateer the latter swept down upon her, thinking her a helpless merchantman,
only to be surprised and completely overwhelmed by the hidden troops. After this
episode the old schooner became a peaceful mail-packet among the Virgin Islands.
She has been repeatedly sunk and raised again. In the hurricane of 1876 she went
on a reef off Christiansted, St. Croix, and again, in 1916, a hurricane sent her to
the bottom in almost the same spot. Her rig originally was that of a topsail
schooner, but this was later changed to that of a fore-and-aft schooner with gaff
topsails. Probably very little besides the keel and timbers of the original craft
remains, as she has been repaired from time to time during her long career. ↑
The origin of the colloquial name of “Bimshire Land” for Barbados and of “Bims”
2
for its natives appears to puzzle many people. One writer in a well-known
magazine went so far as to suggest that it was a corruption of “bam”! In reality it
was applied to the island owing to the fact that Robert Bims (who was one of the
earliest colonizers of St. Kitts), hearing of Barbados, went there with a party of
settlers and took possession. Half-humorously and half-sarcastically (for it was
generally believed the island was worthless) it was referred to as “Bim’s Shire,” a
nickname which has always stuck. ↑
[Contents]
CHAPTER II
 ST. THOMAS AND ITS PAST
St. Thomas is very beautiful when seen from a distance, with its
gray-green mountains rising above the sea, mottled with soft
mauves of shadow and dazzling silvery sunlight—a mass of
opalescent tints, as though the hills were carven from a giant pearl
shell. And as the harbor opens to view, and the little town of
Charlotte Amalie is seen spreading fanwise up its three hillsides in
triangles of soft buff, creamy white, and red, it seems a bit of the
Mediterranean detached and transplanted here in the Caribbean.

But it must be confessed that the enchantment is mainly loaned by

distance, for St. Thomas is a barren, arid island. Charlotte Amalie—
shut in by the hills—is unbearably hot; there is but one level street,
and while steep lanes, often ascending in stairways, lend
picturesqueness to the place, they are most discouraging
thoroughfares on a sweltering tropical day. Moreover, St. Thomas,
having ever been a world’s mart, a free port depending entirely upon
commerce, has not the foreign, fascinating [23]atmosphere we find in
many of the islands.

Its people, a marvelous potpourri of nationalities, of necessity have

become remarkable linguists, with a smattering of virtually every
civilized tongue, but they are neither picturesque nor interesting.

On such a cruise as ours, however, this Virgin Island possession of

Uncle Sam’s could not well be passed by, although, truth to tell, its
piratical associations are somewhat meager and of questionable
authenticity.

I had seen this famed source of bay-rum under both Danish and
American rule, in rain and in shine, in war and in peace; in
prosperity with a forest of masts in its snug harbor, and, again,
devastated by hurricanes, its shores strewn with tangled wrecks of
countless vessels. But never before had St. Thomas appeared to me
just as it did when, passing Sail Rock in the lee of the land, we
entered the harbor and dropped the Vigilant’s anchor before
Charlotte Amalie.

I was looking at it now from a new point of view. I was blind to the
great coaling-piers, to the gaunt dry-dock, to the fact that gray-
painted cruisers and big liners rode upon the glassy surface of the
harbor, that the Stars and Stripes flew from the mastheads and
flagstaffs, that motor-cars scurried along [24]the waterfront street. I
was trying to visualize St. Thomas as it had been two centuries and
more before, when ships with lateen yards, high poops, and wall-
sided hulls pierced with cannon ports had swung to anchor before
the town; when roistering crowds of fierce-whiskered, besashed sea-
rovers with cutlasses at their belts and bandanas on their heads had
swaggered through the steep and crooked streets; when the little
pink “Christian’s” fort beside the quay had been looked upon as a
real fortification, and the Danes had not been above receiving the
corsairs with open arms.

It is not a difficult matter to imagine Charlotte Amalie’s streets filled

with buccaneers, for after a few encounters with boatmen, beggars,
guides, and gamins the average visitor will be convinced that the
pirates still haunt the place in spirit if not in body. Maybe the
freebooters’ traits have been passed down in their blood that flows
to some extent in the veins of a large proportion of the Virgin
Islanders; but, however that may be, the present inhabitants of St.
Thomas know little and care less about piratical history or relics.

And an investigation of the contents of the shops in Charlotte Amalie

will lead one to think that much of the buccaneers’ loot still remains
in stock after a lapse of two centuries or more. Such juxtaposition
[25]of odds and ends from all quarters of the world, it would be hard
to duplicate in any other port upon the planet.

Predominant, and everywhere in evidence, are the two items

inseparably associated with St. Thomas,—jipijapa hats and bay-rum,
—although I understand that since my last visit to the island the
Volstead law has shown its effects even on bay-rum. But formerly—
at any rate, until its acquisition by Uncle Samuel—St. Thomas was
more famous for its bay-rum than for anything else; bay-rum and St.
Thomas were synonymous around the world. Charlotte Amalie
reeked of bay-rum: every ragged negro one met upon the streets
besought one to purchase it, and from mysterious pockets or other
receptacles produced a bottle or two; every shop was filled with it,
and the bumboats that flocked about every incoming and departing
ship were laden with it. And, strangely enough, very little bay-rum is
or was made in St. Thomas. To be sure, it was adulterated, bottled,
and labeled there, but the oil itself, the distilled extract of the
aromatic bay-tree, was largely produced in St. John. Not one person
in a million has ever heard of St. John, perhaps the most charming
island of the Virgins, and yet it is really the home of the bay-rum
which made St. Thomas [26]famous. Such are fate and the effects of
publicity; and as the St. Johnians ultimately reaped a goodly portion
of the profits, I do not suppose they ever complained.

If the visitor to St. Thomas could not be cajoled or nagged into

purchasing bay-rum, then the islanders at once pressed upon him
their next most famous commodity, the jipijapa or Panama hats.
Somehow the visiting public was imbued with the idea that Panama
hats could be purchased more cheaply in St. Thomas than
elsewhere, and despite the fact that very few of the St. Thomas
head-coverings ever saw the Isthmus of Panama, and still fewer ever
were made in far-off Ecuador (the home of the bona-fide Panama),
tourists, seamen, and other visitors to St. Thomas invariably stocked
up. It made no difference, apparently, whether the hats were made
in the neighboring Virgins or in Porto Rico; as long as they were
bought in St. Thomas the purchasers reasoned that they must be
genuine and cheap. Even the braided paper affairs made by the
Japanese were often passed off on the unsuspecting and gullible
tourists as real Panamas—whatever that may mean. Of course, St.
Thomas being formerly under Danish rule and a free port, many
articles which were subject to high duties in the United States were
to be had in [27]the island at bargain prices, but Monte Cristi Panama
hats were not among them.

In the good old days before our country and all its colonies became
Saharas, St. Thomas was noted up and down and roundabout the
islands for its liquid refreshments. Not only was there the justly
famed St. Croix rum, but countless other beverages were procurable
there, brought from every liquor-producing country on the globe, in
addition to several native concoctions that were not to be laughed
at, especially after a few glasses with the jovial Danes on a holiday.
Oddly enough, inhabitants of tropical lands, especially the West
Indies, consume incredible quantities of alcoholic drinks and seem to
thrive upon them. Indeed, it is a source of pride among the islanders
that their native islets consume more alcohol per capita than any
other lands, and there is always a keen rivalry between Barbados,
Bermuda, and Demerara in this respect. But I had never heard that
St. Thomas strove for first honors and when, on one occasion, I
inquired of a huge blond-bearded St. Thomas Dane why this was so,
he informed me in all seriousness that as the St. Thomas people
consumed more than all the others combined, it was beneath them
even to mention the question. Surely it must make the old
buccaneers squirm in their graves [28]to think of St. Thomas, of all
places, being dry, dry as old Dead Man’s Chest with its one bottle of
rum to fifteen men, at least on the surface, though I know there is
many a cask, bottle, and keg stored safely away in private stocks for
the proper drinking of a skoal when occasion arises.

But to return to the shops of Charlotte Amalie and their strange and
motley contents. Here, with the bay-rum, jipijapa hats, and dried
corals and starfish, are French perfumes, picture post-cards, and
seed necklaces. Miscellaneous hardware, groceries, tinned goods,
cloth, and bric-à-brac are inextricably mixed. A salesman searches
among piles of cordage and bundles of rowlocks to find a pair of
shoes or a package of patent medicine, for every shop in Charlotte
Amalie, save the drug stores, is a little of everything with nothing in
its place. I remember seeing a pair of very old-fashioned skates
dangling rusty and forlorn outside a shop one blistering December
day. Curious to know how such things happened to be in the island,
or to whom the proprietor expected to sell them I entered and
inquired. Imagine my amusement and surprise when I was solemnly
informed that they had been there for years, that no one knew
exactly what they were used for, but, in the words of the chocolate-
colored shopkeeper: [29]

“I am aware that they are significant of the holiday season, and so I

hang them outside regularly each year as an indication to passers-by
that my Christmas stock of merchandise is on sale.” Truly, an original
method of advertising!

In another shop a pair of strange slipper-like objects, unlike anything

I had ever seen, were displayed. The owner of the shop, without
appearing to think it at all curious, told me they were from Lapland,
and, perhaps with a faint hope of making a sale, thereupon
rummaged among his stock of countless years’ standing and proudly
produced a pair of moth-eaten Eskimo boots! Had he brought forth a
full suit of armor or the skeleton of a buccaneer, I could scarcely
have been more astonished. But after all, when we come to think of
it, it is not so remarkable, for both Greenland and St. Thomas were
Danish colonies, and no doubt some far-cruising Dane brought the
reindeer-skin foot-coverings here on one of his trading voyages. We
may laugh at the Dane for not realizing that such things were hardly
suitable for everyday wear in the Virgin Islands, but is his mistake
any more ridiculous than that of our own countryman who shipped a
cargo of warming-pans to St. Kitts, or our own United States Senator
who, when about to start on a mission to Porto Rico, [30]asked a
friend if the people there had means of heating their houses in
winter?

Far more interesting than the shops, however, and a spot which
every visitor who is interested in maritime matters should see, is the
“ships’ graveyard” at Krum Bay, near the harbor entrance.

Here, for countless years, have been towed the disabled, storm-
beaten ships condemned as unworthy of repair, and here they have
found their last port, their final resting-place. Stripped of rigging and
other fittings, they have been burned for the copper they contained;
but though they are lost forever, though history makes no mention
of them, though their very names have long since been forgotten,
yet they still live on, perpetuated in their figure-heads which have
been saved and, while sadly neglected, are prized as relics.

There is something pathetic, almost tragic, in these dumb and

lifeless figures lying there exposed to the elements, their once-gay
paint and gilt tarnished, faded, and flaked off by storm and wind and
sun. They seem almost like tombstones, as indeed they are—
monuments to dead and gone ships that once proudly plowed the
seven seas and the five broad oceans. Only carven effigies, perhaps,
but all that remain to tell of stately hulls and towering pyramids of
canvas, of lofty trucks and [31]clipper bows, of craft that, disabled,
maimed, battered, and wrecked, have left their bones here in St.
Thomas at Krum Bay.

Looking at these reminders of a bygone day, one can visualize the

ships of which they formed a part, can almost identify the craft
beneath whose soaring bowsprits these figures once gazed forth
across the tumbling, foam-flecked brine. Here, leaning against a
cocoanut palm, is a Roman legionary, his short sword broken at the
hilt as though in some hard-fought battle, his shield dented and
bruised, and his wooden face seamed and scarred. Faded, weather-
beaten, and forlorn, he is still a martial figure. He has fought more
battles, has seen victory in more hard-won fights than ever soldier of
Cæsar,—battles against the elements, struggles between lashing,
storm-flung waves and puny man,—and while in the end the sea
was victorious, yet we know that the stern-visaged warrior fought a
good fight and bore the brunt of battle always in the foremost rank,
ever there with threatening falchion at the bows. Massive, heroic he
is, and we feel sure that in years gone he looked proudly, defiantly
upon the sea from some ship of war or privateer with grinning ports
along her sides.

Close by, coquettishly peeping from behind a pile of junk, is a very

different figure, a female [32]form with doll-like, simpering face, long,
flowing hair, and clinging draperies. Upon her cheeks are still
patches of pink, as though she had but freshly rouged; her skirts
and low-cut bodice still are gaudy with red and yellow, and we can
see that once her wooden tresses were of raven hue. Looking at her,
we can reconstruct the ship she graced, we can see the bluff-bowed,
wallowing, honest merchantman, and we feel sure, could we but
look upon the stern, we should see, painted across her counter,
“Polly” or “Betsy” or perchance even “Mary Ann.”
Near this lady, with her fixed wooden smile that has withstood the
tempests of centuries, a sailor lad in glazed hat lurches drunkenly,
propped up by an iron post just as his living counterpart no doubt
was supported many a time after a glorious night ashore. Now his
eyes are fixed in an unwinking stare upon raven-haired Polly, while
behind him, with outflung arm, one shapely foot spurning a carven
shield, poises a Victory. A masterpiece she, albeit her wings are
sadly clipped and disrespectful insects have pitted her classic
features with their borings until she looks as though she had
suffered from smallpox. But the finely chiseled draperies, the
perfectly proportioned, softly rounded limbs speak eloquently of
beauty long since faded, of expert craftsmanship. All [33]who love
ships must pause before her in reverence, for once she flew
gracefully at the sharp prow of some famous clipper-ship, a
grayhound of the sea, a fabric such as never will be seen again,—the
very acme of Yankee shipbuilding skill. A craft with sky-piercing
masts, vast tapering yards, and acres of billowing canvas, the clipper
was the queen of transatlantic liners, and proudly she flaunted the
Stars and Stripes for all the world to see.

And something of an epitome of St. Thomas’s history and St.

Thomas’s trade is this graveyard of the ships. As each old sailing-
craft was towed to its funeral pyre at Krum Bay the island took a
step nearer its doom, for with the passing of the old West India
trade, with the discarding of crossed yards and square sails, St.
Thomas’s greatness departed. Never again will her harbor be filled
with a forest of masts flying the flags of every maritime nation.

Perchance under the United States Government she may be more

stable than heretofore: she may suffer less from lack of cash and a
mother country’s interest. Coaling-docks and grimy colliers will
attract a certain number of hideous tramps and spotless liners to her
harbor; tourists may spend a few hours and a few dollars in quaint
Charlotte Amalie, [34]but never again will this port be world-famed as
of yore.

But even so,—even though the island’s romantic past is little more
than tradition, with the old days gone forever; even with the
omnipresent marines and Fords upon the streets and the American
flag flying over the old pink fort,—St. Thomas is still a charming
resort with its three hills rising like pyramids of multicolored, red-
roofed buildings, its gray-green mountains over all, its blue sky and
bluer waters and its brown, black, and yellow good-natured, care-
free inhabitants, who, though the blood of pirate chieftain or old
Viking may run in their veins, one and all proudly proclaim
themselves “Americans.”

Of all things in St. Thomas, the most cherished, even sacred, to the
natives, and invariably the first to be pointed out to the visitor, is the
famous “Blackbeard’s Castle” at the apex of the hillside town of
Charlotte Amalie.

Perhaps old Blackbeard never dwelt in the tower that bears his
name, any more than Bluebeard of the inquisitive wives built or
occupied the neighboring structure which bears his name. Indeed,
there is no denying that Blackbeard’s Castle bears a striking
resemblance to an old stone windmill tower. But the skeptics who
have pointed this out and have [35]scoffed at the beloved legend of
the St. Thomians have overlooked the fact that even if the tower
was originally only an unromantic cane-mill, there is no valid reason
why Teach should not have made use of it. Dutch windmills were
built, used, and abandoned years before the famous pirate saw the
light of day, and a cylindrical tower of massive stone, whether
designed for a windmill or otherwise, was an ideal structure for a
freebooter’s dwelling and fortress, and was admirably adapted to
defensive tactics.
In fact, between the two, I would far rather have been within that
tower on the hill than in the squat pink fort, in case of attack in the
days when muzzle-loading guns and round shot were in vogue, and
the fact that Blackbeard’s Castle bears a family likeness to a windmill
proves or disproves nothing. Everywhere in the West Indies one
finds Spanish, French, Dutch, and even English towers built for forts
and as much like that upon this St. Thomas hilltop as peas in the
same pod. Right on the splendid Malecon in Havana there is one;
several are scattered about Puerto Plata, Macoris, and other towns in
Santo Domingo. They may be seen in a more or less ruined state all
up and down the Antilles and the Main, and yet no one has the
temerity to suggest that they were once windmills! [36]Why, then,
should any one try to destroy this almost sacred tradition of St.
Thomas? Why try to rob the islanders of that one reminder of the
buccaneers? No, let us not be doubting Thomases, but rather be
thankful that this old-time haven of the pirates still retains at least
one landmark that links it with the past.

And there is no reason why Blackbeard should not have dwelt in St.
Thomas in those days of his prosperity. All the Virgin Isles—Danish,
Dutch, and British—were safe refuges for the pirates, retreats
wherein they could lie in peace, where they could refit and careen
their craft, could secure supplies, could exchange their loot for gold
and silver currency, and could gamble and carouse to their hearts’
content.

Very canny were the thrifty islanders in thus opening their doors to
the freebooters. It protected them from attack, and it insured a lively
trade. And they well knew that whatever they paid in good pieces of
eight and golden onzas for plundered goods would eventually return
to their own pockets over bars and gaming-tables, for the pirates
were free spenders and money ever burned holes in their pockets.
So we may feel sure that St. Thomas has sheltered many a pirate
ship and many a famous or infamous buccaneer, [37]especially in the
great harp-shaped bay to the west of Charlotte Amalie, and
separated from the harbor by a rocky peninsula. Here the pirates
were wont to lie in wait for unsuspecting merchantmen bound
through the Virgin Passage between the island and neighboring
Porto Rico, until, to save their faces, the Danish authorities were
compelled to request their welcome but disreputable guests to
confine themselves to more peaceful pursuits while in Danish waters
or else betake themselves elsewhere. [38]
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