Nhi Nguyen is an Intensivist from Nepean Hopsital, with a particular interest in feto-maternal health. She gave this lecture on the Registrar day at the Bedside Critical Care conference 2012 (#BCC3). Go to www.intensivecarenetwork.com for more details.
2. +
Admission to Intensive Care
Happen to be pregnant
Related to Pregnancy
3. +
Obstetric Considerations in
Non-Obstetric Related Admissions
Two Patients
What’s good for the mum is generally good for the baby
Do necessary imaging (With shielding as required esp in 1st
trimester, lower dose contrast for CTPA)
Physiologically – pregnant state until 6 weeks postpartum
Hyperdynamic
Hypercoagulable
Leaky/Peripheral Oedema
4. +
Obstetric Considerations in
Non-Obstetric Related Admissions
Surveillance of baby
On admission
Foetal Heart
Growth Scan
Viability >26 weeks
>30 weeks generally good outcome
Decision regarding delivery – multidisciplinary
Maternal vs Foetal
5. +
Obstetric Considerations in
Non-Obstetric Related Admissions
H1N1
Higher incidence in pregnant women
Asthma and smoking risk factors
Obesity
First time maternal indications for delivery of foetus reported
Acute illnesses, babies delivered all normal size for gestation
ECMO series – largest case series described in the literature
6. +
Obstetric Related Problems
Amniotic Fluid Embolism
Peripartum Cardiomyopathy
Postpartum Haemorrhage
Hypertensive Disorders of Pregnancy
7. +
Amniotic Fluid Embolism
Catastrophic
Mortality reported as high as 85%
Resuscitation and Supportive management
DIC, ARDS commonly ensues
Neurological sequelae common in survivors
8. +
Peripartum Cardiomyopathy
Often presents third trimester
Needs to be considered when a patient presents with
symptoms of breathlessness
Particularly important around delivery time
Autotransfusion of blood from placental bed at delivery
Movement of extravascular fluid back into the intravascular
space in few days post delivery
9. +
Postpartum Haemorrhage
Increasing numbers
Repeat caesarean sections
Surgical management
Balloon Tamponage
Peripartum hysterectomy
Supportive
Increasing reports of use of Factor VII
10. +
Hypertensive Disorders of
Pregnancy
Spectrum of Disease
Chronic Hypertension
Superimposed Gestational Hypertension
Preeclampsia
HELLP
Eclampsia
Acute Fatty Liver of Pregnancy
11. +
Preclampsia
After 20 weeks
Hypertension, Proteinuria, organ dysfunction (renal
failure, thrombocytopenia, abnormal LFTs)
Mild, Moderate, Severe
Disorder of pregnancy, abnormal placentation
Timely delivery
12. +
MAGPIE TRIAL
10,000 women randomised to receive Magnesium sulphate vs
placebo
33 countries
Primary outcome
- eclampsia
- neonatal death
Reduction (half the risk) of eclampsia in magnesium group
Best result in income poor countries
Safe for baby
13. +
Magnesium and Preeclampsia
Lowers risk of seizures
24 hr infusion following 4g loading dose
Post delivery of baby
Toxicity is rare
14. +
Eclampsia
50% present postpartum
Magnesium sulphate loading and then infusion
Little evidence for other anticonvulsant agents
BP control
Labetalol
Hydrallazine
clonidine
15. +
aemolysis levated iver
Enzymes and ow latelets
Within the spectrum of Preeclampsia
Often RUQ pain with liver capsule distension
Fragmentation on blood film may lag behind clinical
Rate of fall of platelet count
Timely delivery
Controversial – FFP
16. +
Take home messages
Clinical signs often difficult to attribute to disease
BE SUSPICIOUS and VIGILANT
Well paradigm
Maternal mortality and morbidity is rare in Australia
Intensive Care Team best equipped to manage