Common Obstetric Problems in ICU

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Dr CT ChungSeptember 2010 Physiological changes in Pregnancy Common causes of ICU admission for ObstetricPatients in PYNEH.
Post partum haemorrhage Pregnancy related hypertension Aminotic fluid embolism Cardiac failure in Pregnancy Key aspects in General Intensive Care.
Human Swine Influenza infection in obstetric patients Physiological Changes in Aim Expand maternal blood volumne and support placentalblood flow and fetal growth Cardiovascular.
Cardiac output increases by 40 50 by 10 weeks due to a largeincrease in stroke volume and a smaller increase in heart rate Marked reduction in total peripheral resistance systemicvasodilatation Decreased BP diastolic systolic return topre pregnancy level by 3rd trimester.
Aortocaval compression decreased preload and increasedafterload supine hypotension syndrome Emergencies in Obstetrics and GynaecologyBy Linsey Stevens Anthony Kenney Contributor Physiological Changes in.
Haematological Increase in Plasma volume Increase in Red cell volume Dilutional reduction in Hb concentration Neutrophilia 10 15 reduction in platelet count.
Hypercoagulable state Respiratory Increase in RR and Increaase in Tidal Volume Increase in minute volume Mild respiratory alkalosis.
Decreased diaphragmatic mobility in late pregnancy Physiological Changes in Increase in glomerular filtration rate Decrease in urea creatine concentration Mild reduction in sodium level.
Net gain in fluid balance mineralocorticoid effect GERD Constipation Increase in ALP decrease in ALT and albumin Physiological Changes in Oral cavity mucosal edema hyperaemic difficult airway.
Increase gastric acidity cardiac sphincter relax decrease inoesophageal and gastric motility Aspiration risk Ligament laxity and pelvic discomfort Anxiety and depression All these physiological changes of pregnancy are.
important in interpretation of clinical information andprovision of care Obstetrics Patients in ICU Total 50 Obstetrics patients were admitted to theIntensive Care Unit of Pamela Youde Nethersole.
Eastern Hospital from January 1998 to December 0 65 of total ICU admissions 50 7692 0 13 of all deliveries 50 37505 Leung YW Lau CW Chan KC Yan WW Clinical characteristics and outcomes of obstetric patients.
admitted to the Intensive Care Unit a 10 year retrospectivereview Hong Kong Med J 2010 16 18 25 Hong Kong Med J 2010 16 18 25 Hong Kong Med J 2010 16 18 25 Post partum Haemorrhage PPH .
Obstetrical emergency Can follow vaginal or cesarean delivery Major cause of maternal morbidity and one of thetop three causes of maternal mortality Cochrane Database Syst Rev 2003 1 CD003249 .
Commonest cause of ICU admission for obstetricspatient 38 Hong Kong Med J 2010 16 18 25 PPH Definition Genital Tract Bleeding after delivery of 500 mLafter vaginal birth or 1000 mL after cesarean.
Estimated blood loss is highly subjective and under estimation likely Am J Obstet Gynecol 1976 Nov 15 126 6 671 7 Am J Obstet Gynecol 1999 180 S69 Am J Obstet Gynecol 2008 Nov 199 5 519 e1 7 .
PPH Definition Excessive bleeding that makes the patientsymptomatic and or results in signs of hypovolemiaBlood loss percent mL Blood pressure mm Hg Signs and symptomsPalpitations .
10 to 15 500 to 1000 Normal lightheadedness tachycardiaWeakness sweating 15 to 25 1000 to 1500 Slightly lowtachycardia.
Restlessness confusion 25 to 35 1500 to 2000 70 to 80pallor oliguriaLethargy air hunger 35 to 45 2000 to 3000 50 to 70.
anuria collapse Best Pract Res Clin Obstet Gynaecol 2000 14 1 PPH Definition Primary PPH within 24 hours after delivery.
early PPH Secondary PPH 24 hours to 12 weeks after delivery late PPH PPH Causes 4 Ts .
Tone Uterine Atony Trauma Cervix Vagina Perineum Anus Rectum Tissue Retained Placenta Thrombin Underlying or acquired coagulopathy Emergencies in Obstetrics and Gynaecology.
By Linsey Stevens Anthony Kenney Contributor Initial management Large bore intravenous IV access IV fluid replacement 3 mL of crystalloid solution per mL of estimated blood loss.
Pack cell transfusion consider after 1 to 2 L of blood loss Supplemental oxygen Give one unit for each 4 to 6 units of pack cells to reducedilutional and citrate related coagulopathy .
Platelets if the platelet count falls below 50 000 L Johns Hopkins Manual of Gynecology and Obstetrics Treatment for specific causes Uterine Atony.
Bimanual massage of the uterus Uterine contractile agents Oxytocin methylergonovine andprostaglandins Laceration of lower genital tract Surgical repair.
Vaginal Packing Retained product of conception Blunt curettage with ultrasonographic guidance Coagulopathy FFP Cryoprecipitate Platelet transfusion.
Uterine Arterial Embolization Ensure patient stable enough for transfer Fertility saving procdure that can successfullyreduce bleeding Surgical Therapy.
Exploratory laparotomy Compressive sutures B Lynch technique Bilateral uterine artery ligation using the O Leary s Ligation of the anterior division of the internal iliac hypogastric artery.
Hysterectomy B Lynch technique Recombinant Factor VIIa NovoSeven Developed in 1999.
Approved indication Treatment of bleeding episodes inhaemophilia A or B patients exhibiting inhibitors tofactors VIII or IX congenital factor VII deficiency oracquired haemophilia Off label use for haemostasis in obstetric and or.
gynaecological haemorrhage Franchini et al recommended a bolus dose of 60 to 90 g kg and a repeated injection within 30 minutes if therewas no clinical improvement A critical review on the use of recombinant factor VIIa in life threatening.
obstetric postpartum hemorrhage Semin Thromb Hemost 2008 34 104 12 In PY ICU Arterial embolisation 13 65 5 38 failed 2 underwent hysterectomy.
2 rFVIIa 1 rFVIIa hysterctomy Hysterectomy 7 35 Vs 85 in a previous HK study Critical care in obstetricalpatients an eight year review Chin Med J Engl 1997 110 936 41 .
Off label use of rFVIIa NovoSeven 3 15 Pregnancy relatedhypertension Pregnancy relatedhypertension.
Second most common obstetric cause of ICUadmission 7 50 14 Chronic Hypertension hypertension diagnosed before pregnancy before 20weeks gestation or elevated BP that is first diagnosed.
during pregnancy and persists after 42 dayspostpartum Pre eclampsia onset of elevated BP and proteinuria after 20 weeks gestation in a patient known previously to be.
normotensive Pregnancy relatedhypertension Mild Pre eclampsia BP of 140 90 mm Hg or higher.
Proteinuria greater than 300 mg in a 24 hour urine collection or ascore of 1 measured on two occasions at least 6 hours but no more than 7days apart Severe Pre eclampsia.
BP during bed rest of 160 mm Hg systolic or 110 mm Hg diastolic Proteinuria greater than 5 g in a 24 hour collection Accompanied by any one of the following Oliguria Cerebral orvisual disturbances Pulmonary edema Epigastric or right upperquadrant pain associated with impaired liver function .
Thrombocytopenia Evidence of microangiopathic hemolytic Pregnancy relatedhypertension HELLP syndrome Thrombocytopenia 100.
Hemolysis Elevated liver function test Eclampsia generally defined as pre eclampsia accompaniedby convulsions and or unexplained coma .
may develop in the absence of hypertension 16 or proteinuria 14 Severe pre eclampsia HELLP Syndrome Mother s safety.
34 weeks gestation or later Delivery is the optimal treatment Cesarean section is not indicated in every case With a cervical condition favorable to the initiation oflabor with oxytocin can deliver vaginally.
Close monitoring of maternal and fetal condition withcareful attention to intake and output Severe pre eclampsia HELLP Syndrome Before 34 weeks gestation.
Antenatal steroid therapy Aggressive antihypertensive therapy Consider termination of pregnancy if 24 weeks gestation and Other measures Bed rest.
Seizure prophylaxis Close monitoring of Vital signs Fluid status CBP L RFT Daily 24 hour urine protein Daily fetal surveillance including fetal movement counts and NSTor biophysical profile.
Seizure prophylaxis Recommended during labor and for 24 hours postpartum forall patients with pre eclampsia Magnesium Sulfate MgSO4 Loading dose is 6 g IV administered over 15 to 20 minutes.
Maintenance dosage is 2 g hr IV and may be titrated to higher The therapeutic magnesium level is 4 to 6 mEq L Phenytoin Dilantin MgSO4 was shown to be superior to phenytoin in preventingseizures in a recent trial However individualization of.
phenytoin dosage as recommended here was not followed inthat trial N Engl J Med 1995 333 4 201 205 Antihypertensive therapy Indicated for antepartum intrapartum and postpartum patients.
with a diastolic BP of 105 mm Hg or higher IV Hydralazine hydrochloride begin with a 5 mg bolus and repeated every 20 minutes Aim SBP 140 150 DBP 90 100 IV Labetalol hydrochloride.
alternative therapy for women who cannot be given or have notresponded to hydralazine contraindicated if maternal heart block of greater than first degree Other antihypertensive nifedipine methydopa diltiazem Fluid Management.
Hypovolemic because of loss of fluid into theinterstitial spaces due to low serum oncotic pressureand increased capillary permeability Increased risk for pulmonary edema IV fluids should be restricted to 84 to 125 mL hr.
Renal replacement therapy continuous veno venous haemofiltration CVVH Eclampsia Control of Seizures Magnesium sulfate or phenytoin .
Status epilepticus Control of the Airway and Ventilation Treatment of Hypertension Delivery of the Fetus Amniotic fluid embolism.
Amniotic fluid embolism Rare complication that has high morbidity andmortality 18 33 3 patients in PY ICU 1998 to 2007 Clinical Features .
occurs acutely during labor and delivery or immediatelyat postpartum Classic hypoxia hypotension with shock altered mentalstatus and disseminated intravascular coagulation Other seizure activity agitation and evidence of fetal.
Amniotic fluid embolism Diagnosis clinical diagnosis of exclusion made when a woman acutely and dramaticallypresents with profound shock and cardiovascular.
collapse during or immediately after labor differential diagnosis pulmonary embolism hemorrhage anaphylaxis sepsis and myocardialinfarction Definitive diagnosis postmortem autopsy.
Amniotic fluid embolism Management Earty diagnosis Aggressive supportive management and intensiveperi partum monitoring.
Intubation Good IV access Volume support inotropic agents and pressors Packed red blood cells and FFP Immediate delivery Caesarean Section Cardiac Failure in.
Cardiac Failure in Pregnancy Not uncomman condition in ICU obstetric patients Complication of pregnancy related hypertension Peripartum cardiomyopathy Amniotic fluid embolism.
Pre existing cardiac diseases Cardiac Failure in Pregnancy Management Preload Diuretics.
Afterload Vasodilators not in cardiogenic shock IPPV with PEEP With good sedation patient ventilator synchrony Decrease both preload and afterload.
Improve PaO2 and SaO2 Transfer blood supply from respiratory muscle to other vital Cardiac Failure in PregnancyIncrease in ITP Decrease in VR LVEDV Preload .
Key aspects in GeneralIntensive Care FAST HUG Key aspects in General Intensive Care FAST HUG .
Feeding Analgesia Sedation Thromboembolic prophylaxis Head of bed elevation.
Stress Ulcer Prevention Glucose control FAST HUG Does not cover all aspects of patient care May not be applicable to every patient.
Just serve as a checklist Oral feeding If not NG tube feeding If not Parenteral feeding A number of clinical trials indicated the benefits ofproviding nutrition support particularly enteral.
feedings to critically ill patients Important outcomes such as rates of infection lengths of stay and costs can be decreased by thePlatelets if the platelet count falls below 50,000/µL [ Johns Hopkins Manual of Gynecology and Obstetrics ] Treatment for specific causes Uterine Atony Bimanual massage of the uterus Uterine contractile agents (Oxytocin, methylergonovine and prostaglandins) Laceration of lower genital tract Surgical repair Vaginal Packing Retained product of ...

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