1、Dr.Kolli S.Chalam,MD;PDCC.HOD ANESTHESIOLOGY&CRITICAL CARE MEDICINESRI SATHYA SAI INSTITUTE OF HIGHER MEDICAL SCIENCESWHITEFIELD,BANGALORE.pWHEN TO INTERVENE:CONSULT!pPrevalence of obstetric pts in ICU 100-900 per 100,000 gestationspMaternal mortality:55-920 per 100,000 gestations in developing coun
2、tries-Germain SJ&Nelson-Piercy C.Obstetric admissions to intensive care or obstetric high dependency units in a London tertiary/teaching hospital.Journal of Obstetrics and Gynaecology 2019;26:S37S38.Critical illnesses in pregnancy and 6 weeks postpartumpObstetric hemorrhagepPlacental abruption/Place
3、nta previapPreeclampsia,EclampsiapHELLP syndromepChorioamnionitis/Puerperal sepsispAcute fatty liver of pregnancypAmniotic fluid embolismpPelvic thrombophlebitispPeri partum cardiomyopathyA.Conditions unique to pregnancy:account for B.50-80%admissions to ICU:Critical illnesses in pregnancy and 6 wee
4、ks postpartumInfectionsnFalciparum MalarianViral Hepatitis EnVaricella pneumonianH1N1 InfectionpRenal acute renal failure pHematologicnDIC;Venous thrombosispEndocrine:DM,sheehans syndromepNeurologic intra cranial hemorrhage(ICH)pRespiratory -Pulmonary embolism -Venous air mbolism -Mendelson syndrome
5、Critical illnesses in pregnancy and 6 weeks postpartum.Conditions unrelated to pregnancypTrauma,BurnspDiabetic ketoacidosispCytomegalovirus infectionpHIVpCommunity acquired pneumoniapARDSpBronchial asthmapDrug abuseCardiovascularnValvular diseasenEisenmengers syndromencyanotic congenital heart disea
6、sencoarctation of aortanPrimary pulmonary hypertensionpRenal:-Glomerulonephritis,-Chronic renal insufficiencypHematologic-sickle cell disease,anemiapLiver -CirrhosisCritical illnesses in pregnancy and 6 weeks postpartumpEndocrine,Diabetes mellitus,prolactinomapReumatologic:Scleroderma,polymyositispR
7、espiratory:cystic fibrosis,lung transplantpNeurologicnEpilepsynIntracranial tumorsnMasthenia gravisnmultiple sclerosis.Critical illnesses in pregnancy and 6 weeks postpartumRespiratory:Airway Management in Critical IllnessRespiratory:Airway Management in Critical IllnesspCauses include:ARDS,venous a
8、ir embolism,p Beta-adrenergic tocolytic therapy,p Asthma,thromboembolic disease,p Pneumothorax,and pneumomediastinum pARDS complicating pregnancy pare sepsis,pneumonia,aspiration of gastric contents,and amniotic fluid embolism.Treatment of Respiratory Failure,ARDSp Control of Hemorrhage SURGICALpBlo
9、od universal donor O neg PRBC.pFFP=10-15 ml/kgpPlatelet transfusion 50,000.pCryoprecipitate if fibrinogen con.7.2,PTT,PT 1.25 times control levels,Platelet count 100,000/mm3,fibrinogen 100 mg/dL.Complications of Pre-eclampsia/EclampsiapRefractory hypertension,p Pulmonary edema,or cardiovascular deco
10、mpensation.pOliguria,acute renal failure in severe cases.pHELLP syndrome in 2-12%casespRupture of the subcapsular liver hematomapPul.Aspiration due to eclamptic seizurepHypertensive encephalopathy,or cerebral edema.pDIC,multiorgan failure in severe cases pEffective management plan for delivery and p
11、ostpartum care.pPyelonephritis,pChorioamnionitispSeptic abortionpPP endometritis,pPelvic thrombophlebitis.qNo single definition q Early Goal directed therapy&tenets of SSCqRole of steroids,APCqEarly antibiotic use&aggressive source control qIntensive insulin therapy p32 yr old Iraqi womenp2nd PO pyr
12、exiapDistension Abd,resp distresspWound dehiscence NF with L puspARDS on 5th daypARF 7th day CVVHFpVentilated,prone position,PCTpDischarged from ICU 3rd week after successful recovery Cr=serum creatinine;UO=urine output;GFR=glomerular filtration rate;ESKD=end stage kidney disease.Risk of Renal Failu
13、re,Injury to Kidney,Failure of Kidney Function,Loss of Kidney Function,End-Stage Renal Failure Criteria:GFR criteria Cr 1.5X baseline Or GFR 25%Urine output criteriaUO 50%UO 75%or Cr 4.0mg/dlUO 80%parturients experience cardiopulmonary arrest.vCoagulopathy resembling DIC Rx.MV with 100%oxygen,Inotro
14、pic support as guided by CVP/PA monitoring,correction of coagulopathyMaternal heart disease Apprx 1.6%of all e.g.:mitral,aortic valve diseases,TOF;Coarctation of the aorta 2nd trimester,:-in blood volume in labor and delivery,cardiac output due to cardiovascular sympathetic stimulation fr.Pain decom
15、pensation immediately postpartum,due to large in venous return after delivery of the placenta no invasive monitoring in the absence of cardiac symptomsPeri-partum Cardiomyopathy late in pregnancy&6wks PPpDue myocarditis/autoimmuneppreload optimization;afterload reduction&improvement of myocardial co
16、ntractility prequire anticoagulation pCollaboration among the obstetrician,cardiologist,and criticalist pCardiac transplantation If supportive measures fail*Ray p,Murphy G J et al.Recognition and management of maternal cardiac disease in pregnancy.British Journal of Anaesthesia 2019 93(3):428-439 AN
17、TIPHOSPHOLIPID SYNDROMEvPresence of two autoantibodies,lupus anticoagulant and anticardiolipin antibody vAssociated with thrombotic events,both arterial and venous vImproved fetal survival if Rx with low-dose aspirin,high-dose corticosteroids,heparin.vEg:Young radiologist with IUD Acute Fatty Liver
18、of Pregnancyq3rd trimester 1 in 11,000 pregnancies,q maternal mortality 0%to 18%;fetal mortality 47%.qS/S:rt upper quadrant pain,nausea,vomiting,proteinuria,edema,mild hypertension,jaundice,coagulapathy,encephalopathy,hypoglycemia,NH3qHELLP(vs)AFLP basing on histopathology,with microvesicular fatty
19、infiltration qSupportive therapy:Vit K,Glucose,lactulose,coagulopathy correction,and airway protection in comaTRAUMA and PREGANACY-INCIDENCEp The Leading cause of non-obst.mortality-46%p Trauma during pregnancy-7%p Causes of Trauma nMVA 54.6%nDomestic abuse&Assault 22.3%nFalls21.8%nPenetrating injur
20、y1.3%p 20 wks p 200 successful cases reported in literaturep 20 minutes,fetal survival unlikelyp 4 Minute Rule:Maternal CPR for 4 minutes,Infant should be delivered by the 5th minute.p7%of women of reproductive age p5 factors size of burn,depth of burn,part of body burned,concurrent injuries,&past m
21、edical historypCritical,40%TBSA burntp Inhalation of CO in a closed firep Freely crosses the placenta pProduce fetal cardiac edema.q Oxygenation,ventilation with 100%O2q Electrical burns,fetal mortality-73%q Maintenance of a normal intravascular vol,q Avoidance of hypoxia,prevention of inf q correct
22、ion of electrolyte imbalance q Debridement&cleaning of Burned areasq Povidine-iodine influences fetal ThyroidqSilver sulphadizine cause kernicterusRequire prompt and excellent CPR with some modifications in basic and advanced cardiovascular lifePrimary ABCD Survey pAirway&Breathing:no modificationsC
23、irculation:wedge under the womans right side Defibrillationp No modifications in dose or pad position.,shocks transfer no significant current to the fetus.p Remove any fetal or uterine monitors before shock delivery._Circulation.2019;112:IV-150-IV-153.)2019 American Heart Association._Circulation.20
24、19;112:IV-150-IV-153.)2019 American Heart Association.Secondary ABCD Survey Airway A Insert an advanced airway early in resuscitation to reduce the risk of regurgitation&aspiration.Airway edema,small diameter ETT,Effective preo-O2 Rapid sequence intubation,deep sedation to minimize hypotension.Breat
25、hing avoid esophageal device to confirmCirculation Follow standard ACLS recommendations Do not use femoral veins D/D:Decisions Decide whether to perform emergency hysterotomy.Identify and treat reversible causes of the arrest.vsmall but important group of patients vUnique problems and need specialized attention vconfounded by physiologic changes in pregnancy.vbetter outcomes vapproach requires good communication and collaboration between the obstetrician and intensivist
