Nhi Nguyen on Critically Ill Obstetrics

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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.

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Nhi Nguyen on Critically Ill Obstetrics

  1. 1. + Critically Ill Obstetrics Nhi Nguyen Nepean Hospital
  2. 2. + Admission to Intensive Care  Happen to be pregnant  Related to Pregnancy
  3. 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. 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. 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. 6. + Obstetric Related Problems  Amniotic Fluid Embolism  Peripartum Cardiomyopathy  Postpartum Haemorrhage  Hypertensive Disorders of Pregnancy
  7. 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. 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. 9. + Postpartum Haemorrhage  Increasing numbers  Repeat caesarean sections  Surgical management  Balloon Tamponage  Peripartum hysterectomy  Supportive  Increasing reports of use of Factor VII
  10. 10. + Hypertensive Disorders of Pregnancy  Spectrum of Disease  Chronic Hypertension  Superimposed Gestational Hypertension  Preeclampsia  HELLP  Eclampsia  Acute Fatty Liver of Pregnancy
  11. 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. 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. 13. + Magnesium and Preeclampsia  Lowers risk of seizures  24 hr infusion following 4g loading dose  Post delivery of baby  Toxicity is rare
  14. 14. + Eclampsia  50% present postpartum  Magnesium sulphate loading and then infusion  Little evidence for other anticonvulsant agents  BP control  Labetalol  Hydrallazine  clonidine
  15. 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. 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
  17. 17. + Questions? Nhi Nguyen

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