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Common Obstetric Problems in ICU

Common Obstetric Problems in ICU. Dr. CT Chung September 2010. Content. Physiological changes in Pregnancy Common causes of ICU admission for Obstetric Patients in PYNEH Post-partum haemorrhage Pregnancy related hypertension Aminotic fluid embolism Cardiac failure in Pregnancy

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Common Obstetric Problems in ICU

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  1. Common Obstetric Problems in ICU Dr. CT Chung September 2010

  2. Content Physiological changes in Pregnancy Common causes of ICU admission for Obstetric Patients 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

  3. Physiological Changes in Pregnancy • Aim: Expand maternal blood volumne and support placental blood flow and fetal growth • Cardiovascular • Cardiac output increases by 40-50% by 10 weeks due to a large increase in stroke volume and a smaller increase in heart rate • Marked reduction in total peripheral resistance (systemic vasodilatation)  Decreased BP (diastolic > systolic)  return to pre-pregnancy level by 3rd trimester • Aortocaval compression decreased preload and increased afterload (supine hypotension syndrome) [ Emergencies in Obstetrics and Gynaecology By: Linsey Stevens Anthony Kenney(Contributor) ]

  4. Physiological Changes in Pregnancy • 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

  5. Physiological Changes in Pregnancy • Renal • Increase in glomerular filtration rate • Decrease in urea, creatine concentration • Mild reduction in sodium level • Net gain in fluid balance (mineralocorticoid effect) • GI • GERD, Constipation • Increase in ALP, decrease in ALT and albumin

  6. Physiological Changes in Pregnancy • Others • Oral cavity mucosal edema, hyperaemic  difficult airway • Increase gastric acidity, cardiac sphincter relax, decrease in oesophageal 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 and provision of care

  7. Obstetrics Patients in ICU • Total 50 Obstetrics patients were admitted to the Intensive Care Unit of Pamela Youde Nethersole Eastern Hospital from January 1998 to December 2007 • 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 retrospective review. Hong Kong Med J 2010;16:18-25

  8. Hong Kong Med J 2010;16:18-25

  9. Hong Kong Med J 2010;16:18-25

  10. Post-partum Haemorrhage

  11. Post-partum Haemorrhage (PPH) • Obstetrical emergency • Can follow vaginal or cesarean delivery • Major cause of maternal morbidity, and one of the top three causes of maternal mortality • Commonest cause of ICU admission for obstetrics patient (38%) [ Cochrane Database Syst Rev 2003;(1):CD003249 ] [ Hong Kong Med J 2010;16:18-25 ]

  12. PPH: Definition • Genital Tract Bleeding, after delivery, of ≥500 mL after vaginal birth or ≥1000 mL after cesarean delivery • 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. ]

  13. PPH: Definition • Excessive bleeding that makes the patient symptomatic and/or results in signs of hypovolemia [ Best Pract Res Clin Obstet Gynaecol 2000; 14:1. ]

  14. PPH: Definition • Primary PPH: • within 24 hours after delivery • early PPH • Secondary PPH • 24 hours to 12 weeks after delivery • late PPH

  15. 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) ]

  16. 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 • FFP • Give one unit for each 4 to 6 units of pack cells to reduce dilutional and citrate-related coagulopathy. • Platelets • if the platelet count falls below 50,000/µL [ Johns Hopkins Manual of Gynecology and Obstetrics ]

  17. 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 conception • Blunt curettage with ultrasonographic guidance • Coagulopathy • FFP, Cryoprecipitate, Platelet transfusion

  18. Uterine Arterial Embolization • Ensure patient stable enough for transfer • Fertility saving procdure that can successfully reduce bleeding

  19. Surgical Therapy • Exploratory laparotomy • Compressive sutures (B-Lynch technique) • Bilateral uterine artery ligation using the O'Leary's technique • Ligation of the anterior division of the internal iliac (hypogastric) artery • Hysterectomy

  20. B-Lynch technique

  21. Recombinant Factor VIIa (NovoSeven) • Developed in 1999 • Approved indication: Treatment of bleeding episodes in haemophilia A or B, patients exhibiting inhibitors to factors VIII or IX, congenital factor VII deficiency, or acquired haemophilia • ‘Off-label’ use for haemostasis in obstetric and/or gynaecological haemorrhage • Franchini et al recommended a bolus dose of 60 to 90 μg/kg, and a repeated injection within 30 minutes if there was 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 ]

  22. 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 obstetrical patients: an eight-year review. Chin Med J (Engl) 1997;110:936-41 ] • ‘Off-label’ use of rFVIIa (NovoSeven) 3 (15%)

  23. Pregnancy-related hypertension

  24. Pregnancy-related hypertension • Second most common obstetric cause of ICU admission 7/50 (14%) • Chronic Hypertension: • hypertension diagnosed before pregnancy, before 20 weeks' gestation, or elevated BP that is first diagnosed during pregnancy and persists after 42 days postpartum. • Pre-eclampsia: • onset of elevated BP and proteinuria after 20 weeks' gestation in a patient known previously to be normotensive.

  25. Pregnancy-related hypertension • Mild Pre-eclampsia • BP of 140/90 mm Hg or higher • Proteinuria greater than 300 mg in a 24-hour urine collection or a score of 1+ • measured on two occasions at least 6 hours but no more than 7 days 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 or visual disturbances, Pulmonary edema, Epigastric or right upper quadrant pain associated with impaired liver function, Thrombocytopenia, Evidence of microangiopathic hemolytic anemia

  26. Pregnancy-related hypertension • HELLP syndrome • Thrombocytopenia<100 • Hemolysis • Elevated liver function test • Eclampsia • generally defined as pre-eclampsia accompanied by convulsions and/or unexplained coma. • may develop in the absence of hypertension (16%) or proteinuria (14%)

  27. 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 of labor with oxytocin, can deliver vaginally • Close monitoring of maternal and fetal condition with careful attention to intake and output.

  28. Severe pre-eclampsia / HELLP Syndrome • Before 34 weeks' gestation • Antenatal steroid therapy • Aggressive antihypertensive therapy • Consider termination of pregnancy if 24 weeks' gestation and earlier • 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 NST or biophysical profile

  29. Seizure prophylaxis • Recommended during labor and for 24 hours postpartum for all 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 doses • The therapeutic magnesium level is 4 to 6 mEq/L. • Phenytoin (Dilantin) • MgSO4 was shown to be superior to phenytoin in preventing seizures in a recent trial. However, individualization of phenytoin dosage, as recommended here, was not followed in that trial [ N Engl J Med 1995;333 (4):201–205 ]

  30. 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 not responded to hydralazine. • contraindicated if maternal heart block of greater than first degree • Other antihypertensive: nifedipine, methydopa, diltiazem

  31. Fluid Management • Hypovolemic because of loss of fluid into the interstitial spaces due to low serum oncotic pressure and 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)

  32. Eclampsia • Control of Seizures • Magnesium sulfate, or phenytoin. • Status epilepticus • Control of the Airway and Ventilation • Treatment of Hypertension • Delivery of the Fetus

  33. Amniotic fluid embolism

  34. Amniotic fluid embolism • Rare complication that has high morbidity and mortality (18-33%) • 3 patients in PY ICU (1998 to 2007) • Clinical Features. • occurs acutely during labor and delivery or immediately at postpartum • Classic: hypoxia, hypotension with shock, altered mental status, and disseminated intravascular coagulation. • Other: seizure activity, agitation, and evidence of fetal distress

  35. Amniotic fluid embolism • Diagnosis • clinical diagnosis of exclusion • made when a woman acutely and dramatically presents with profound shock and cardiovascular collapse during or immediately after labor • differential diagnosis: pulmonary embolism, hemorrhage, anaphylaxis, sepsis, and myocardial infarction • Definitive diagnosis: postmortem autopsy

  36. Amniotic fluid embolism • Management • Earty diagnosis • Aggressive supportive management and intensive peri-partum monitoring • Intubation; Good IV access • Volume support, inotropic agents, and pressors • Packed red blood cells and FFP • Immediate delivery (Caesarean Section)

  37. Cardiac Failure in Pregnancy

  38. Cardiac Failure in Pregnancy • Not uncomman condition in ICU obstetric patients • Complication of pregnancy related hypertension • Peripartum cardiomyopathy • Amniotic fluid embolism • Sepsis • Pre-existing cardiac diseases

  39. 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 organs

  40. Cardiac Failure in Pregnancy Increase in ITP  Decrease in VR (LVEDV = Preload)

  41. Key aspects in General Intensive Care “FAST HUG”

  42. Key aspects in General Intensive Care“FAST HUG” • Feeding • Analgesia • Sedation • Thromboembolic prophylaxis • Head-of-bed elevation • Stress Ulcer Prevention • Glucose control

  43. “FAST HUG” • Does not cover all aspects of patient care • May not be applicable to every patient • Just serve as a checklist

  44. Feeding • Oral feeding? If not, NG tube feeding? If not, Parenteral feeding ? • A number ofclinical trials indicated the benefits of providing nutritionsupport, particularly enteral feedings, to critically ill patients. • Important outcomes such as rates of infection, lengths of stay,and costs can be decreased by the early initiation of enteralfeedings [ Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29:2264–2270 ] [ Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials. BMJ. 2001;323:773–776. ]

  45. Feeding • Usualy not a problem in obstetric patients • Fasting period is usully limited • Calorie • 25 to 35 kCal/kg/Day • Nitrogen / Protein • 1 – 1.5g/kg/day

  46. Analgesia • Patient should not suffer pain • Excessive analgesia shoulder be avoided • Morphine, Pethidine, Panadols, NSAIDs • Continuous IV / epidural infusion or repeated small boluses or nerve block

  47. Sedation • Patient should not experience discomfort • Especially important in patients with heart failure and high intracranial pressure • Excessive sedation should be avoided • Increase venous thromvosis • Decrease GI motility • Hypotension • Prolonged mechanical ventilation • Prolonged length of stay in ICU • Increase cost

  48. Effects of sedative drugs * Minimal effect.• Only at low doses.

  49. Thrombo-embolic prophylaxis • Pregnancy and puerperium is risk factor for Thrombo-embolism • Means • TED stocking • Sequential compression device • Heparin – UFH, LMWH • Early mobilization

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