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CRITICALCAREOBSTETRICSDr.KolliS.Chalam,MD;PDCC.HODANESTHESIOLOGY&CRITICALCAREMEDICINESRISATHYASAIINSTITUTEOFHIGHERMEDICALSCIENCESWHITEFIELD,BANGALORE.CRITICALCAREOBSTETRICSDr.Kol1OrganizingaCriticalCareObstetricUnitWHENTOINTERVENE:CONSULT!!!PrevalenceofobstetricptsinICU100-900per100,000gestationsMaternalmortality:55-920per100,000gestationsindevelopingcountriesOrganizingaCriticalCareObs2EpidemiologyofCriticalIllnessandOutcomesinPregnancy
------------------------------------------------------------------------------------------------------GermainSJ&Nelson-PiercyC.ObstetricadmissionstointensivecareorobstetrichighdependencyunitsinaLondontertiary/teachinghospital.JournalofObstetricsandGynaecology2019;26:S37–S38.NumberofdeliveriesTransferstoICUICUadmissionrateper1000deliveriesMaternaldeathsMaternaldeathstoICUtransferratiocountryStudyperiodReference614351262.111:126Australia1978-1989Stephensetal493492334.781:29USA1991-2019Gilbertetal159896830.5231:28Canada1988-2019Baskett&O’Connell13333282.121:14England2019-2019Germain&PiercyetalEpidemiologyofCriticalIllne3Criticalillnessesinpregnancyand6weeks’postpartumObstetrichemorrhagePlacentalabruption/PlacentapreviaPreeclampsia,EclampsiaHELLPsyndromeChorioamnionitis/PuerperalsepsisAcutefattyliverofpregnancyAmnioticfluidembolismPelvicthrombophlebitisPeripartumcardiomyopathyConditionsuniquetopregnancy:accountfor50-80%admissionstoICU:Criticalillnessesinpregnanc4Criticalillnessesinpregnancyand6weeks’postpartumInfectionsFalciparumMalariaViralHepatitisEVaricellapneumoniaH1N1InfectionRenal–acuterenalfailureHematologicDIC;VenousthrombosisEndocrine:DM,sheehan’ssyndromeNeurologic–intracranialhemorrhage(ICH)Respiratory-Pulmonaryembolism-Venousairmbolism-MendelsonsyndromeB.ConditionswithsusceptibilityinpregnancyCriticalillnessesinpregnanc5Criticalillnessesinpregnancyand6weeks’postpartumC.ConditionsunrelatedtopregnancyTrauma,BurnsDiabeticketoacidosisCytomegalovirusinfectionHIVCommunityacquiredpneumoniaARDSBronchialasthmaDrugabuseCriticalillnessesinpregnanc6CardiovascularValvulardiseaseEisenmenger’ssyndromecyanoticcongenitalheartdiseasecoarctationofaortaPrimarypulmonaryhypertensionRenal:
-Glomerulonephritis,-ChronicrenalinsufficiencyHematologic-sicklecelldisease,anemiaLiver-CirrhosisCriticalillnessesinpregnancyand6weeks’postpartumD
Pre-existingconditionsthatmayworsenduringpregnancy:CardiovascularCriticalillness7Endocrine,Diabetesmellitus,prolactinomaReumatologic:Scleroderma,polymyositisRespiratory:cysticfibrosis,lungtransplantNeurologicEpilepsyIntracranialtumorsMastheniagravismultiplesclerosis.Accountfor20-50%ofadmissionstoICUCriticalillnessesinpregnancyand6weeks’postpartumEndocrine,Diabetesmellitus,8Respiratory:AirwayManagementinCriticalIllnesskeypointsinairwayintubationofpregnantwomenFetalwell-beingdependsonmaternalwell-beingAssessairwayeveninurgentintubationsAvoidaspiration:elevateheadofbed,cricoidpressure,sodcitrate,smallerETTinsizeNeedofLowerdoseofsedatives/anestheticsPre-oxygenationRespiratory:AirwayManagement9Respiratory:AirwayManagementinCriticalIllness↑riskofaspirationbymanualventilationFasteroccurrenceofHypoxiaandhypercapniainresponsetoapneaLeftlateraldecubitustorelieveIVCobstructionReadyavailabilityofDifficultintubationcartIntubationbythemostexperiencedCXRtoconfirmETTplacementRespiratory:AirwayManagement10AcuteRespiratoryFailure,
ARDSCausesinclude:ARDS,venousairembolism,Beta-adrenergictocolytictherapy,Asthma,thromboembolicdisease,Pneumothorax,andpneumomediastinum
ARDScomplicatingpregnancyaresepsis,pneumonia,aspirationofgastriccontents,andamnioticfluidembolism.AcuteRespiratoryFailure,
AR11TreatmentprinciplesTreatprimaryproblemPhysiologicalsupport(lungs&otherorgans)AvoidcomplicationsDifferentmethodsofventilatorysupport-NoninvasivePositive-PressureVentilation-Lung-ProtectiveConventionalVentilationAdvancedoptions:Aairwaypressure-releaseventilation(APRV)HFOVlungrecruitmentmaneuvers(LRMs)PronepositioningTreatmentofRespiratoryFailure,ARDSTreatmentprinciplesTreatment12ControlofHemorrhage~SURGICALBlood~universaldonorOnegPRBC.FFP=10-15ml/kgPlatelettransfusion<50,000.Cryoprecipitateiffibrinogencon.<100mg/dLrFVIIa~90-100microg/kgpromptcorrectionofhypothermia,acidosis,coagulopathyObstetrichemorrhage
Resuscitationendpoints:Euthermia,pH>7.2,PTT,PT>1.25timescontrollevels,Plateletcount>100,000/mm3,fibrinogen>100mg/dL.ControlofHemorrhage~SURGI13ComplicationsofPre-eclampsia/EclampsiaRefractoryhypertension,Pulmonaryedema,orcardiovasculardecompensation.Oliguria,acuterenalfailureinseverecases.HELLPsyndromein2-12%casesRuptureofthesubcapsularliverhematomaPul.AspirationduetoeclampticseizureHypertensiveencephalopathy,orcerebraledema.DIC,multiorganfailureinseverecasesEffectivemanagementplanfordeliveryandpostpartumcare.ComplicationsofPre-eclampsia14SepsisandsepticshockCauses:Pyelonephritis,ChorioamnionitisSepticabortionPPendometritis,Pelvicthrombophlebitis.Nosingledefinition
EarlyGoaldirectedtherapy&tenetsofSSCRoleofsteroids,APCEarlyantibioticuse&aggressivesourcecontrolIntensiveinsulintherapy
SepsisandsepticshockCauses:15NecrotizingfasciitisafterLSCS32yroldIraqiwomen2ndPOpyrexiaDistensionAbd,respdistressWounddehiscenceNFwith½LpusARDSon5thdayARF7thday~CVVHFVentilated,proneposition,PCTDischargedfromICU3rdweekaftersuccessfulrecoveryNecrotizingfasciitisafterLS16
Cr=serumcreatinine;UO=urineoutput;GFR=glomerularfiltrationrate;ESKD=endstagekidneydisease.RiskofRenalFailure,InjurytoKidney,FailureofKidneyFunction,LossofKidneyFunction,End-StageRenalFailure(RIFLE)Criteria:
GFRcriteria
↑
Cr1.5XbaselineOrGFR↓
>25%UrineoutputcriteriaUO<.5.ml/Kg/hX6hSensitivity/specificity:HighsensitivityINJURY↑Cr2XbaselineOrGFR↓>50%UO<0.5ml/Kg/hX12hHighsensitivityFAILURE↑Cr3XbaselineOrGFR↓>75%orCr>4.0mg/dlUO<0.3ml/Kg/hX24horanuriaX12hrs.HighsensitivityLOSSPersistentARF(lossofkidneyfunctionforatleast4wk)HighspecificityESKDEndstagekidneydisease(completelossofrenalfunctionforatleast3mo)HighspecificityRISK
17Treatmentofunderlyingcauses.Avoidanceofnephrotoxicdrugse.gMgdosingLow-dosedopamine–noteffectiveFurosemide/mannitol(classBdrugs),thiazides(classC)Indicationsfordialysiintravascularvolumeoverload,refractoryhyperkalemiaRestoreRenalperfusiontopreventfurtherischemia↓morbidityandmortalityAgentsinthepipeline–NAC/ANP
RenalfailureandpregnancyTreatmentofunderlyingcauses18ThromboticDiseaseandPregnancyPregnancy--ahypercoagulablestateIncreasedactivityofClottingFactorsDecreasedFibrinolysisVenousHypertensionduetoUterinePressureonIVCIncidenceofDVTof0.1-0.2%ecognition&appropriatetreatmentofPE↓mortalityratesfrom30%to0.7%.ThromboticDiseaseandPregnan19Diagnosticmodalities:compressionUS,V/Qscan,pulmonaryangiography,spiral(CT)ConcernsaboutradiationexposureLowerExtremitySequentialCompressionDevicesHeparinandLowMolecularHeparinokinpregnancyCoumadinCONTRAINDICATEDbecauseofseverefetalmalformations.SupportiveRx.oxygen,mechanicalventilation,hemodynamic,fluidsupport
PEandPregnancyPEandPregnancy20AnaphylactoidSyndromeofPregnancy(AmnioticFluidEmbolus)Rarecatastrophicandlife-threateningcomplicationoccursduetodisruptioninbarrierbetweentheamnioticfluidandmaternalcirculationS/S:dyspnea,arterialhypoxemia,seizures,lossofconsciousness,&hypotension>80%parturientsexperiencecardiopulmonaryarrest.CoagulopathyresemblingDIC
Rx.MVwith100%oxygen,InotropicsupportasguidedbyCVP/PAmonitoring,correctionofcoagulopathyAnaphylactoidSyndromeofPreg21Maternal
heartdisease
Apprx~1.6%ofalle.g.:mitral,aorticvalvediseases,TOF;Coarctationoftheaorta
2ndtrimester,:-in↑bloodvolumeinlaboranddelivery,↑cardiacoutputduetocardiovascular
sympatheticstimulationfr.Pain
decompensationimmediatelypostpartum,duetolarge↑invenousreturnafterdeliveryoftheplacentanoinvasivemonitoringintheabsenceofcardiacsymptomsMaternal
heartdiseaseApp22Peri-partumCardiomyopathyLVFlateinpregnancy&6wksPPDuemyocarditis/autoimmunepreloadoptimization;afterloadreduction&improvementofmyocardialcontractilityrequireanticoagulationCollaborationamongtheobstetrician,cardiologist,andcriticalistCardiactransplantationIfsupportivemeasuresfail*
Rayp,Murphy
GJetal.Recognitionandmanagementofmaternalcardiacdiseaseinpregnancy.BritishJournalofAnaesthesia201993(3):428-439
Peri-partumCardiomyopathyLVF23ANTIPHOSPHOLIPIDSYNDROMEPresenceoftwoautoantibodies,lupusanticoagulantandanticardiolipinantibodyAssociatedwiththromboticevents,botharterialandvenousImprovedfetalsurvivalifRxwithlow-doseaspirin,high-dosecorticosteroids,heparin.Eg:YoungradiologistwithIUDANTIPHOSPHOLIPIDSYNDROMEPrese24AcuteFattyLiverofPregnancy3rdtrimester~1in11,000pregnancies,maternalmortality~0%to18%;fetalmortality~47%.S/S:rtupperquadrantpain,nausea,vomiting,proteinuria,edema,mildhypertension,jaundice,coagulapathy,encephalopathy,hypoglycemia,↑NH3HELLP(vs)AFLPbasingonhistopathology,withmicrovesicularfattyinfiltrationSupportivetherapy:VitK,Glucose,lactulose,coagulopathycorrection,andairwayprotectionincomaAcuteFattyLiverofPregnancy25TRAUMAandPREGANACY-INCIDENCETheLeadingcauseofnon-obst.mortality-46%Traumaduringpregnancy-7%CausesofTraumaMVA 54.6%Domesticabuse&Assault 22.3%Falls 21.8%Penetratinginjury 1.3%<1%oftraumaadmissionsarepregnantPretermLaborin11.4%&P.Abruptionin1.58%--------------------------------------------------------------------------------------------------------------------------------------*
ConnollyA,KatzVL,BashKL,etal:Traumaandpregnancy.AmJPerinatol14:331-336,2019
TRAUMAandPREGANACY-INCIDENC26TRAUMAaNdPREGANACY
ATLSProtocolAirwayAssess&controlPreoxygenateandsellick’smaneuverbeforeintubationBreathingAssessandmanagePlaceCTin4thintercostalspaceCirculationAssessmaternalcirculation(+SHOCK)IVaccessTilttoleftif>20wksTRAUMAaNdPREGANACY
ATLSPro27TRAUMAINPREGNANCY
RememberWhatisBestfortheMotherisBestfortheFetus!TRAUMAINPREGNANCY
RememberW28GoalsofTreatmentoftheSeverelyInjuredPregnantPatientGoal1Goal2
SAVETHEMOTHER;
SavetheFetusifpossible
GoalsofTreatmentoftheSeve29~200successfulcasesreportedinliterature<23weeksgestationsurvivalchance~0%MaternalCPR>20minutes,fetalsurvivalunlikely
PerimortemCesareanSection
4MinuteRule:MaternalCPRfor4
minutes,Infantshouldbedeliveredbythe5thminute.~200successfulcasesreporte30
Burnsandburninjuries7%ofwomenofreproductiveage5factors~
sizeofburn,depthofburn,partofbodyburned,concurrentinjuries,&pastmedicalhistoryCritical,>40%TBSAburntInhalationofCOinaclosedfireFreelycrossestheplacenta
Producefetalcardiacedema.Burnsandburninjuries7%of31
Burnsandburninjuries
Oxygenation,ventilationwith100%O2
Electricalburns,fetalmortality-73%Maintenanceofanormalintravascularvol,Avoidanceofhypoxia,preventionofinfcorrectionofelectrolyteimbalance
Debridement&cleaningofBurnedareasPovidine-iodineinfluencesfetalThyroidSilversulphadizine~causekernicterusBurnsandburninjuriesOxyge32CPRINPREGNANCYRequirepromptandexcellentCPRwithsomemodificationsinbasicandadvancedcardiovascularlifePrimaryABCDSurveyAirway&Breathing:nomodificationsCirculation:wedgeunderthewoman’srightsideDefibrillationNomodificationsindoseorpadposition.,shockstransfernosignificantcurrenttothefetus.Removeanyfetaloruterinemonitorsbeforeshockdelivery.___________________________________________________________Circulation.2019;112:IV-150-IV-153.)©2019AmericanHeartAssociation.CPRINPREGNANCYRequireprompt33CPRINPREGNANCY
_________________________________________________________Circulation.2019;112:IV-150-IV-153.)©2019AmericanHeartAssociation.SecondaryABCDSurveyAirway●AInsertanadvancedairwayearlyinresuscitationtoreducetheriskofregurgitation&aspiration.●Airwayedema,smalldiameterETT,Effectivepreo-O2●Rapidsequenceintubation,deepsedationtominimizehypotension.Breathing–avoidesophagealdevicetoconfirmCirculation●FollowstandardACLSrecommendationsDonotusefemoralveinsD/D:DecisionsDecidewhethertoperformemergencyhysterotomy.●Identifyandtreatreversiblecausesofthearrest.CPRINPREGNANCY_____________34PredictingMaternalMortalityinICUPatientsICUsmallbutimportantgroupofpatientsUniqueproblemsandneedspecializedattentionconfoundedbyphysiologicchangesinpregnancy.betteroutcomes
approachrequiresgoodcommunicationandcollaborationbetweentheobstetricianandintensivist
PredictingMaternalMortality35ThankyouThankyou36CRITICAL-CARE-OBSTETRICS---SRI-SATHYA-SAI-INSTITUTE-…：危重病妇产科赛巴巴所…37CRITICALCAREOBSTETRICSDr.KolliS.Chalam,MD;PDCC.HODANESTHESIOLOGY&CRITICALCAREMEDICINESRISATHYASAIINSTITUTEOFHIGHERMEDICALSCIENCESWHITEFIELD,BANGALORE.CRITICALCAREOBSTETRICSDr.Kol38OrganizingaCriticalCareObstetricUnitWHENTOINTERVENE:CONSULT!!!PrevalenceofobstetricptsinICU100-900per100,000gestationsMaternalmortality:55-920per100,000gestationsindevelopingcountriesOrganizingaCriticalCareObs39EpidemiologyofCriticalIllnessandOutcomesinPregnancy
------------------------------------------------------------------------------------------------------GermainSJ&Nelson-PiercyC.ObstetricadmissionstointensivecareorobstetrichighdependencyunitsinaLondontertiary/teachinghospital.JournalofObstetricsandGynaecology2019;26:S37–S38.NumberofdeliveriesTransferstoICUICUadmissionrateper1000deliveriesMaternaldeathsMaternaldeathstoICUtransferratiocountryStudyperiodReference614351262.111:126Australia1978-1989Stephensetal493492334.781:29USA1991-2019Gilbertetal159896830.5231:28Canada1988-2019Baskett&O’Connell13333282.121:14England2019-2019Germain&PiercyetalEpidemiologyofCriticalIllne40Criticalillnessesinpregnancyand6weeks’postpartumObstetrichemorrhagePlacentalabruption/PlacentapreviaPreeclampsia,EclampsiaHELLPsyndromeChorioamnionitis/PuerperalsepsisAcutefattyliverofpregnancyAmnioticfluidembolismPelvicthrombophlebitisPeripartumcardiomyopathyConditionsuniquetopregnancy:accountfor50-80%admissionstoICU:Criticalillnessesinpregnanc41Criticalillnessesinpregnancyand6weeks’postpartumInfectionsFalciparumMalariaViralHepatitisEVaricellapneumoniaH1N1InfectionRenal–acuterenalfailureHematologicDIC;VenousthrombosisEndocrine:DM,sheehan’ssyndromeNeurologic–intracranialhemorrhage(ICH)Respiratory-Pulmonaryembolism-Venousairmbolism-MendelsonsyndromeB.ConditionswithsusceptibilityinpregnancyCriticalillnessesinpregnanc42Criticalillnessesinpregnancyand6weeks’postpartumC.ConditionsunrelatedtopregnancyTrauma,BurnsDiabeticketoacidosisCytomegalovirusinfectionHIVCommunityacquiredpneumoniaARDSBronchialasthmaDrugabuseCriticalillnessesinpregnanc43CardiovascularValvulardiseaseEisenmenger’ssyndromecyanoticcongenitalheartdiseasecoarctationofaortaPrimarypulmonaryhypertensionRenal:
-Glomerulonephritis,-ChronicrenalinsufficiencyHematologic-sicklecelldisease,anemiaLiver-CirrhosisCriticalillnessesinpregnancyand6weeks’postpartumD
Pre-existingconditionsthatmayworsenduringpregnancy:CardiovascularCriticalillness44Endocrine,Diabetesmellitus,prolactinomaReumatologic:Scleroderma,polymyositisRespiratory:cysticfibrosis,lungtransplantNeurologicEpilepsyIntracranialtumorsMastheniagravismultiplesclerosis.Accountfor20-50%ofadmissionstoICUCriticalillnessesinpregnancyand6weeks’postpartumEndocrine,Diabetesmellitus,45Respiratory:AirwayManagementinCriticalIllnesskeypointsinairwayintubationofpregnantwomenFetalwell-beingdependsonmaternalwell-beingAssessairwayeveninurgentintubationsAvoidaspiration:elevateheadofbed,cricoidpressure,sodcitrate,smallerETTinsizeNeedofLowerdoseofsedatives/anestheticsPre-oxygenationRespiratory:AirwayManagement46Respiratory:AirwayManagementinCriticalIllness↑riskofaspirationbymanualventilationFasteroccurrenceofHypoxiaandhypercapniainresponsetoapneaLeftlateraldecubitustorelieveIVCobstructionReadyavailabilityofDifficultintubationcartIntubationbythemostexperiencedCXRtoconfirmETTplacementRespiratory:AirwayManagement47AcuteRespiratoryFailure,
ARDSCausesinclude:ARDS,venousairembolism,Beta-adrenergictocolytictherapy,Asthma,thromboembolicdisease,Pneumothorax,andpneumomediastinum
ARDScomplicatingpregnancyaresepsis,pneumonia,aspirationofgastriccontents,andamnioticfluidembolism.AcuteRespiratoryFailure,
AR48TreatmentprinciplesTreatprimaryproblemPhysiologicalsupport(lungs&otherorgans)AvoidcomplicationsDifferentmethodsofventilatorysupport-NoninvasivePositive-PressureVentilation-Lung-ProtectiveConventionalVentilationAdvancedoptions:Aairwaypressure-releaseventilation(APRV)HFOVlungrecruitmentmaneuvers(LRMs)PronepositioningTreatmentofRespiratoryFailure,ARDSTreatmentprinciplesTreatment49ControlofHemorrhage~SURGICALBlood~universaldonorOnegPRBC.FFP=10-15ml/kgPlatelettransfusion<50,000.Cryoprecipitateiffibrinogencon.<100mg/dLrFVIIa~90-100microg/kgpromptcorrectionofhypothermia,acidosis,coagulopathyObstetrichemorrhage
Resuscitationendpoints:Euthermia,pH>7.2,PTT,PT>1.25timescontrollevels,Plateletcount>100,000/mm3,fibrinogen>100mg/dL.ControlofHemorrhage~SURGI50ComplicationsofPre-eclampsia/EclampsiaRefractoryhypertension,Pulmonaryedema,orcardiovasculardecompensation.Oliguria,acuterenalfailureinseverecases.HELLPsyndromein2-12%casesRuptureofthesubcapsularliverhematomaPul.AspirationduetoeclampticseizureHypertensiveencephalopathy,orcerebraledema.DIC,multiorganfailureinseverecasesEffectivemanagementplanfordeliveryandpostpartumcare.ComplicationsofPre-eclampsia51SepsisandsepticshockCauses:Pyelonephritis,ChorioamnionitisSepticabortionPPendometritis,Pelvicthrombophlebitis.Nosingledefinition
EarlyGoaldirectedtherapy&tenetsofSSCRoleofsteroids,APCEarlyantibioticuse&aggressivesourcecontrolIntensiveinsulintherapy
SepsisandsepticshockCauses:52NecrotizingfasciitisafterLSCS32yroldIraqiwomen2ndPOpyrexiaDistensionAbd,respdistressWounddehiscenceNFwith½LpusARDSon5thdayARF7thday~CVVHFVentilated,proneposition,PCTDischargedfromICU3rdweekaftersuccessfulrecoveryNecrotizingfasciitisafterLS53
Cr=serumcreatinine;UO=urineoutput;GFR=glomerularfiltrationrate;ESKD=endstagekidneydisease.RiskofRenalFailure,InjurytoKidney,FailureofKidneyFunction,LossofKidneyFunction,End-StageRenalFailure(RIFLE)Criteria:
GFRcriteria
↑
Cr1.5XbaselineOrGFR↓
>25%UrineoutputcriteriaUO<.5.ml/Kg/hX6hSensitivity/specificity:HighsensitivityINJURY↑Cr2XbaselineOrGFR↓>50%UO<0.5ml/Kg/hX12hHighsensitivityFAILURE↑Cr3XbaselineOrGFR↓>75%orCr>4.0mg/dlUO<0.3ml/Kg/hX24horanuriaX12hrs.HighsensitivityLOSSPersistentARF(lossofkidneyfunctionforatleast4wk)HighspecificityESKDEndstagekidneydisease(completelossofrenalfunctionforatleast3mo)HighspecificityRISK
54Treatmentofunderlyingcauses.Avoidanceofnephrotoxicdrugse.gMgdosingLow-dosedopamine–noteffectiveFurosemide/mannitol(classBdrugs),thiazides(classC)Indicationsfordialysiintravascularvolumeoverload,refractoryhyperkalemiaRestoreRenalperfusiontopreventfurtherischemia↓morbidityandmortalityAgentsinthepipeline–NAC/ANP
RenalfailureandpregnancyTreatmentofunderlyingcauses55ThromboticDiseaseandPregnancyPregnancy--ahypercoagulablestateIncreasedactivityofClottingFactorsDecreasedFibrinolysisVenousHypertensionduetoUterinePressureonIVCIncidenceofDVTof0.1-0.2%ecognition&appropriatetreatmentofPE↓mortalityratesfrom30%to0.7%.ThromboticDiseaseandPregnan56Diagnosticmodalities:compressionUS,V/Qscan,pulmonaryangiography,spiral(CT)ConcernsaboutradiationexposureLowerExtremitySequentialCompressionDevicesHeparinandLowMolecularHeparinokinpregnancyCoumadinCONTRAINDICATEDbecauseofseverefetalmalformations.SupportiveRx.oxygen,mechanicalventilation,hemodynamic,fluidsupport
PEandPregnancyPEandPregnancy57AnaphylactoidSyndromeofPregnancy(AmnioticFluidEmbolus)Rarecatastrophicandlife-threateningcomplicationoccursduetodisruptioninbarrierbetweentheamnioticfluidandmaternalcirculationS/S:dyspnea,arterialhypoxemia,seizures,lossofconsciousness,&hypotension>80%parturientsexperiencecardiopulmonaryarrest.CoagulopathyresemblingDIC
Rx.MVwith100%oxygen,InotropicsupportasguidedbyCVP/PAmonitoring,correctionofcoagulopathyAnaphylactoidSyndromeofPreg58Maternal
heartdisease
Apprx~1.6%ofalle.g.:mitral,aorticvalvediseases,TOF;Coarctationoftheaorta
2ndtrimester,:-in↑bloodvolumeinlaboranddelivery,↑cardiacoutputduetocardiovascular
sympatheticstimulationfr.Pain
decompensationimmediatelypostpartum,duetolarge↑invenousreturnafterdeliveryoftheplacentanoinvasivemonitoringintheabsenceofcardiacsymptomsMaternal
heartdiseaseApp59Peri-partumCardiomyopathyLVFlateinpregnancy&6wksPPDuemyocarditis/autoimmunepreloadoptimization;afterloadreduction&improvementofmyocardialcontractilityrequireanticoagulationCollaborationamongtheobstetrician,cardiologist,andcriticalistCardiactransplantationIfsupportivemeasuresfail*
Rayp,Murphy
GJetal.Recognitionandmanagementofmaternalcardiacdiseaseinpregnancy.BritishJournalofAnaesthesia201993(3):428-439
Peri-partumCardiomyopathyLVF60ANTIPHOSPHOLIPIDSYNDROMEPresenceoftwoautoantibodies,lupusanticoagulantandanticardiolipinantibodyAssociatedwiththromboticevents,botharterialandvenousImprovedfetalsurvivalifRxwithlow-doseaspirin,high-dosecorticosteroids,heparin.Eg:YoungradiologistwithIUDANTIPHOSPHOLIPIDSYNDROMEPrese61AcuteFattyLiverofPregnancy3rdtrimester~1in11,000pregnancies,maternalmortality~0%to18%;fetalmortality~47%.S/S:rtupperquadrantpain,nausea,vomiting,proteinuria,edema,mildhypertension,jaundice,coagulapathy,encephalopathy,hypoglycemia,↑NH3HELLP(vs)AFLPbasingonhistopathology,withmicrovesicularfattyinfiltrationSupportivetherapy:VitK,Glucose,lactulose,coagulopathycorrection,andairwayprotectionincomaAcuteFattyLiverofPregnancy62TRAUMAandPREGANACY-INCIDENCETheLeadingcauseofnon-obst.mortality-46%Traumaduringpregnancy-7%CausesofTraumaMVA 54.6%Domesticabuse&Assault 22.3%Falls 21.8%Penetratinginjury 1.3%<1%oftraumaadmissionsarepregnantPretermLaborin11.4%&P.Abruptionin1.58%--------------------------------------------------------------------------------------------------------------------------------------*
ConnollyA,KatzVL,BashKL,etal:Traumaandpregnancy.AmJPerinatol14:331-336,2019
TRAUMAandPREGANACY-INCIDENC63TRAUMAaNdPREGANACY
ATLSProtocolAirwayAssess&controlPreoxygenateandsellick’smaneuverbeforeintubationBreathingAssessandmanagePlaceCTin4thintercostalspaceCirculationAssessmaternalcirculation(+SHOCK)IVaccessTilttoleftif>20wksTRAUMAaNdPREGANACY
ATLSPro64TRAUMAINPREGNANCY
RememberWhatisBestfortheMotherisBestfortheFetus!TRAUMAINPREGNANCY
RememberW65GoalsofTreatmentoftheSeverelyI
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