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Program Information. Critical Care of the Obstetric Patient. Shannon Carroll, M.D. Suresh Agarwal, M.D. www.peainthepodcast.com. Aspects of Critical Care Specific to Obstetric Patients. Anatomic Changes in Pregnancy Physiologic/Pathologic Changes in Pregnancy Hemodynamic Endocrinologic

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Program Information

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  1. Program Information

  2. Critical Care of the Obstetric Patient Shannon Carroll, M.D. Suresh Agarwal, M.D. www.peainthepodcast.com

  3. Aspects of Critical Care Specific to Obstetric Patients • Anatomic Changes in Pregnancy • Physiologic/Pathologic Changes in Pregnancy • Hemodynamic • Endocrinologic • Pulmonary • Postpartum Hemorrhage • Trauma in the Pregnant Patient

  4. Anatomic Changes in Pregnancy ajnoffthecharts.wordpress.com/2009/11/03

  5. Anatomic Changes in Pregnancy focosi.altervista.org/uterinelevels.jpg

  6. Physiologic/Pathologic Changes in Pregnancy • Cardiovascular Changes • Endocrinologic Changes • Pulmonary Changes empracticenews.files.wordpress.com/2008/06/0708-emp-table-2.png

  7. Cardiovascular Changes • Increase Cardiac Output • Up to 50% by 24th week of gestation • CO plateaus from 24th week until term • Further increased during labor and delivery • “Autotransfusion Effect” • Increased Preload after fetus and placenta delivery www.ljmu.ac.uk/sportandexercisesciences/RISES/Health/82521.htm

  8. Cardiovascular Changes • Increased Cardiac Output • Increased Contractility • Early in Pregnancy: Increased Blood Volume • Later in Pregnancy: Increased Heart Rate • 15 – 20 beats faster www.biomaterials.org/SIGS/Cardiovascular/Heart.htm

  9. Body Positioning • Cardiac Output and Stroke Volume • Supine Position • Aortocaval Compression • Decreased Preload • “Supine Hypotensive Syndrome” of Pregnancy • Left Lateral Recumbent Position after 20th week media.photobucket.com/image/left%20and%20ivc%20and%20gravid/JHWalker/shs1.jpg

  10. Body Positioning • Cardiac Resuscitation • Left Lateral Recumbent Position Or • Left Manual Displacement of the Uterus www.the-pillow.com.au/more/lucky-7-body-pillow-more.php

  11. Cardiovascular Changes • LV End-Diastolic Volume is Increased • Filling Pressures Unchanged • Decreased systemic and pulmonary vascular resistance

  12. Cardiovascular Changes • Blood Volume • 30 – 50% Increase by Full Term • Red Blood Cell Mass • 15 – 20% Increase by Full Term • -> “Physiologic Anemia” of Pregnancy nursingcrib.com/pregnancy-complications/

  13. Cardiovascular Changes • Up to 35% Blood Volume Loss before Tachycardia and Hypotension occur

  14. Cardiovascular Changes • Increased Blood Flow • Breasts www.med.yale.edu/intmed/cardio/imaging/anatomy/breast_anatomy/graphics/breast_anatomy.gif

  15. Cardiovascular Changes • Increased Blood Flow • Breasts • Uterus embryology.med.unsw.edu.au/notes/images/urogen/uterine_blood_supply.jpg

  16. Cardiovascular Changes • Increased Blood Flow • Breasts • Uterus • Kidneys • ↑ Renal Blood Flow by 25 – 50% • ↑ Glomerular Filtration Rate up to 50% • ↓ BUN and Plasma Creatinine www.physicscentral.org/explore/action/images/scans-img8.jpg

  17. Cardiovascular Changes • Diastolic Blood Pressure Decreased • ↓ by 10% in 2nd Trimester • Due to ↓ Systemic Vascular Resistance • Returns to Baseline by Full Term

  18. Cardiovascular Changes • Blood Vessel Remodeling • Coagulation System Changes • Most Clotting Factors Increased • Hypercoagulable www.answers.com/topic/factor-xii

  19. Cardiovascular Changes • Heart Remodeling • Enlargement of All 4 Chambers • Susceptible to Supraventricularand Atrial Arrhythmias myhealth.ucsd.edu/library/healthguide/en-us/support/topic.asp?hwid=zm2767

  20. Cardiovascular Changes • “Normal” Changes in Heart Sounds • Systolic Ejection Murmur • Third Heart Sound • Potentially Pathologic Changes in Heart Sounds • Diastolic Murmurs • Pansystolic Murmurs • Late Systolic Murmurs www.ed4nurses.com/heartsnd.aspx

  21. Cardiovascular Changes • Cardiac Disease • Mild to Moderate: Pregnancy Usually Well-Tolerated • Pulmonary Hypertension and Right-to-Left Shunts: up to 50% Mortality with Pregnancy

  22. Hypertension In Pregnancy • Definition: • increase of at least 30 mmHg in the SBP and • Increase of at least 15 mmHg in the DBP • Above baseline

  23. Hypertension In Pregnancy • Monitoring • Etiology • Preeclampsia • Treatment • Management During Labor and Delivery

  24. Blood Pressure Monitoring • Sustained Hypertension • At least 2 separate occasions • Position • Upper arm in the sitting position, or • Lower arm in the lateral recumbent position

  25. Etiology of Hypertension in Pregnancy • Predisposing factors • Family history • Personal history of Diabetes mellitus • Vascular or Renal Disorders • Primigravid state • Multiple gestational pregnancies

  26. Preeclampsia • Pregnancy induced • Multisystem • Onset is after 32nd week of gestation • Symptom triad: • Peripheral edema • Systemic hypertension • Significant proteinuria (> 0.3g in 24hr urine) nursingcrib.com/pregnancy-complications/

  27. Preeclampsia • US Incidence = 7% • Diastolic hypertension is usually more prominent than systolic hypertension • Evaluate patient for underlying or coexisting disease processes • Familial cases • May present as late as 7 days postpartum • Postpartum preeclampsia often associated with the HELLP syndrome

  28. Preeclampsia and the HELLP Syndrome • Some or all of the following: • (H) microangiopathic hemolytic anemia • (EL) elevated liver enzymes • (LP) low platelets • May be present without significant blood pressure elevations

  29. Preeclampsia • Increased risk with significant elevation in blood pressure in the second trimester • 1/3 of patients with MAP > 90 in the second trimester will develop it • < 2% of patients with MAP < 90 in the second trimester will develop it

  30. Treatment of Hypertension In Pregnancy • UterineBloodFlowandBPManagement • IncreasesorshowsnochangewithBPcontrol • AvoidOverlyAggressiveBPManagement • Affectsmaternalhemodynamics • Compromisesuterinebloodflow • InitialAgents • poα-methyldopa • polabetalol • IVAgents • Labetalol • Hydralazine • SodiumNitroprusside

  31. BP Management During L&D • Antihypertensive agents • Judicious use of IV fluids • Postpartum monitoring for high risk patients • Preeclampsia • Hypertension resolves spontaneosly within a few weeks • Trace amounts of all antihypertensive agents are found in breast milk • No adverse affects on infants have been identified

  32. Endocrinologic Changes • Hypothalamus • Pituitary Gland • Adrenal Glands www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/1093.jpg

  33. Endocrinologic Changes • Increased ACTH and Cortisol Levels in Pregnancy • Cushing’s Syndrome may be exacerbated by pregnancy • Acute Adrenal Crisis may be precipitated by labor and delivery www.beliefnet.com/healthandhealing/getcontent.aspx?cid=179661

  34. Waterhouse-Friderichsen syndrome • Massive adrenal hemorrhage • Usually bilateral • Meningococcemia • Hypotension/Shock • DIC with purpura • Rapidly progressive adrenocortical insufficiency • Most common etiology = Neisseria meningitidis • Prevention: Vaccine against meningococcus www.livestrong.com/ls_images/disease/1000-1999/1814-2938.jpg

  35. Waterhouse-Friderichsen syndrome • Onset: fever, rigors, vomiting, and headache • Rash quickly develops • first macular • progresses to petechiae and purpura; dusky gray color • Hypotension/Septic shock • Usually no Meningitis • Adrenal Insufficiency (hypoglycemia, hyponatremia, hyperkalemia) • DIC • Acidosis • ARF • Meningococci • from blood or CSF • smears of cutaneous lesions library.med.utah.edu/WebPath/jpeg4/ENDO004.jpg

  36. Waterhouse-Friderichsen syndrome • Treatment: • Medical emergency • Ceftriaxone • Hydrocortisone for hypoadrenal shock library.med.utah.edu/WebPath/jpeg4/ENDO006.jpg

  37. Endocrinologic Changes • Prolactin Levels Increased • Preparation for lactation • Pituitary Adenomas • May increase in size • May become symptomatic www.biologie.uni-freiburg.de/data/bio1/varga/projects.htm

  38. Endocrinologic Changes • Thyroid Hormones Increased • Thyroxine-Binding Globulin Increased • Free Levels Unchanged • No Associated Complications if Iodine Consumption is Adequate www.pyroenergen.com/articles08/thyroid-gland-hormones.htm

  39. Endocrinologic Changes • Transient Diabetes Insipidus • Due to Vasopressin Resistance www.medscape.com/viewarticle/558561_3

  40. Endocrinologic Changes • Fluctuations in Insulin and Glucose Levels • Increased Insulin Secretion • Increased Insulin Resistance • Gestational Diabetes Mellitus • Obese women with insulin resistance • Women with minimal pancreatic reserve nursingcrib.com/pregnancy-complications/

  41. Endocrinologic Changes • Increased Maternal Lipid Metabolism

  42. Pulmonary Complications in the Obstetric Patient • Normal Pulmonary Physiology in Pregnancy • Asthma • Pulmonary Edema • Acute Respiratory Distress Syndrome • Embolism saltyandsweet.wordpress.com/2008/05/12/various-gunky-topics

  43. Pulmonary Complications in the Obstetric Patient • Normal Pulmonary Physiology in Pregnancy • Tidal volume is increased • Functional residual capacity is decreased • Normal ABG = compensated respiratory alkalosis • Respiratory distress may progress more rapidly due to pregnancy medical-dictionary.thefreedictionary.com/functional+residual+capacity

  44. Pulmonary Complications in the Obstetric Patient • Asthma in Pregnancy • Monitoring: Peak flow meter (no change in FEV1) • PaCO2 > 35 mmHg in a pregnant patient with asthma may signify respiratory distress • Treatment principles are the same for pregnant and non-pregnant patients wellness.blogs.time.com/2009/10/09/women-with-asthma-keep-up-your-treatment-during-pregnancy

  45. Pulmonary Complications in the Obstetric Patient • Acute Respiratory Distress Syndrome in Pregnancy • Need for mechanical ventilation does not mandate delivery • Therapeutic drugs NOT contraindicated in pregnancy: • Sedatives • Hypnotics • Non-depolaring paralytics http://www.rtjournalonline.com/images.htm

  46. Pulmonary Complications in the Obstetric Patient • Embolism in Pregnancy • Hypercoagulable state • Radiographic studies if indicated by respiratory distress • Warfarin contraindicated in 1st trimester • Amniotic fluid embolism • 1/80,000 pregnancies • significant maternal morbidity/mortality www.oxygentimerelease.com/B/Bonnie/p23.htm

  47. Postpartum Hemorrhage • Definition • Epidemiology • Pathophysiology • Diagnosis • Treatment • Surgical Therapy • Prognosis

  48. Postpartum Hemorrhage • Definition: excessive and life-threatening bleeding • Normal blood loss: • Vaginal birth < 500 mL • Cesarean section = 800 – 1000 mL • after 20 weeks gestation • at time of delivery of baby or placenta • Primary PPH: within 24 hours of delivery • Secondary PPH: between 24 hours and 12 weeks of delivery

  49. Postpartum Hemorrhage • Epidemiology leading world-wide cause of maternal death (> 100,000 deaths per year) • one of three leading causes of maternal death in the US (with embolism and hypertensive disorders) www.thedoctorstv.com/main/show_synopsis/207?section=synopsis

  50. Postpartum Hemorrhage Pathophysiology • Uterine Blood Flow at Term • 10% of maternal cardiac output • Approximately 600 to 1200 mL/min • Myometrial Contraction • Placental separation • Hemostasis • Myometrial fibers contract (compression) and retract (occlusion) • Increase in Circulating Clotting Factors www.bodyworlds.com/en/media/picture_database/preview.html?id=12

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