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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 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 Key aspects in General Intensive Care Human Swine Influenza infection in obstetric patients
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) ]
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
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
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
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
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 ]
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. ]
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. ]
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 • 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 ]
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
Uterine Arterial Embolization • Ensure patient stable enough for transfer • Fertility saving procdure that can successfully reduce bleeding
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
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 ]
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%)
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.
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
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%)
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.
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
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 ]
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
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)
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 • 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
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
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)
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
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
Cardiac Failure in Pregnancy Increase in ITP Decrease in VR (LVEDV = Preload)
Key aspects in General Intensive 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
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. ]
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
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
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
Effects of sedative drugs * Minimal effect.• Only at low doses.
Thrombo-embolic prophylaxis • Pregnancy and puerperium is risk factor for Thrombo-embolism • Means • TED stocking • Sequential compression device • Heparin – UFH, LMWH • Early mobilization