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1.Introduction to maternal intensive care.pptx
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- 2. Introduction Epidemiology OBSTETRIC CRITICAL CARE BASIC PRINCIPLES FOR OBSTETRIC EMERGENCIES Transfer to critical care setting Role of the Obstetrician–Gynecologist Resuscitative hysterotomy SUPPORTIVE CARE Recommendations and Conclusions Items to be discussed
- 3. ICU receives obstetricpatients with medical & surgical emergencies as well as specific obstetric complications Proportion of obstetric patients in most ICUs is low Relative inexperience in management & team-work between ICU team & obstetrician. Introduction
- 4. Approximately (0.7–13.5) obstetricpatients per 1,000 deliveries are admitted to ICU Most common indications are postpartum hemorrhage and hypertensive disorders Most of these (63–92%) are postpartum admissions not require major lifesaving interventions but rather more intensive monitoring than can be provided Epidemiology
- 5. median length ofstay was 2.0 days for women admitted antepartum and 1.1 day for those admitted postpartum The maternal death rate after ICU admission differs significantly between high- and low-income countries (median 3.3% versus 14.0%) Epidemiology
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- 7. Hypertensive disorders Obstetric hemorrhage Sepsis Thromboembolic and PE Trauma Respiratory conditions Cardiovascular disorders DKA Gastrointestinal disorders overdose or poisoning neurologic disorders Leading causes of ICU admission
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- 9. Clinically unstable (hypotensive or hypoxemic) At high risk of deterioration Need specialized ICU care such as mechanical ventilation Laboratory work • arterial blood gas • serum lactate The Quick Sequential Organ Failure Assessment can also be used to stratify risk in patients who have infection Patients require • level 2 care (monitoring and simple interventions) Factors contribute to the decision to move a pregnant patient to ICU
- 10. Maternal Early WarningCriteria From the National Partnership for Maternal Safety
- 11. Physiological changes inpregnancy modify: • Presentation of the problem • Normal physiological variables • Response to treatment Both mother & fetus are affected by the pathology & subsequent treatment. Mother’s welfare always takes precedence over fetal concerns Fetal survival dependent on optimal management
- 17. If apregnancy is complicated by a critical illness or condition, the woman should be cared for at a hospital with obstetric services, an adult ICU, advanced neonatal care services, and appropriate hospital services such as a blood bank. It is important not to discourage ICU admission; rather, encouraged to use critical care services when appropriate
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- 19. Hypertensive Emergency (1st LineTherapy)
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- 21. Pre-transport evaluation ofthe woman and her fetus must be performed, and maternal status must be stabilized before transport when transport is unsafe or impossible, or when imminent delivery is anticipated, arrangements can be made for postpartum rather than antepartum maternal transport If there is a high probability that intubation and mechanical ventilation will be needed during transport, it should be accomplished before departure Transfer Between Hospitals
- 22. During transport : •continuous cardiac rhythm and pulse oximetry monitoring • regular assessment of vital signs • Venous access must be established before transport • Left uterine displacement should be routine obstetrician–gynecologists at the receiving hospital give an opinion about medical interventions before arrival, or prepare for interventions needed Transfer Between Hospitals
- 23. communication betweenthe obstetrician–gynecologist and critical care services is crucial. In some cases (eg, planned cesarean hysterectomy possible to request an ICU bed in advance (planned) involve critical care staff early in the transfer process During transport, the team must be able to assess BP, heart rate, and oxygenation status. For a critically ill patient , the team also should have a cardiac monitor with defibrillator, airway management equipment, oxygen, and basic resuscitation medications. At least two health care professionals should accompany the patient during transport Transfer Within the Hospital
- 24. obstetrician–gynecologist’s rolewill depend on: • patient status (antepartum or postpartum) • ICU model and type According to ICU model , his role is • open model >>>>>> 1ry physician • closed model >>>>>> only to be consulted • semi-open model >>>>>> MDT patient care decisions made collaboratively multidisciplinary care team. Decisions also should involve the patient, her family, or both. Role of the Obstetrician–Gynecologist
- 25. Role of theObstetrician–Gynecologist Regardless of the type of ICU weighing the risks and benefits of interventions such as medication administration and diagnostic Imaging fetal monitoring delivery planning when indicated. Daily rounds, frequent communication with the ICU team rapid response to calls for consultation are all important evaluation of vaginal or surgical site bleeding obstetric sources of infection, therapies (such as magnesium for eclampsia prophylaxis),
- 26. Role of theObstetrician–Gynecologist Regardless of the type of ICU The underpinning principles are that the woman’s interests are paramount, and optimal fetal status is generally predicated on optimizing the maternal condition as much as possible. Medical interventions and diagnostic imaging may be modified to an extent but when indicated for maternal health should not be withheld purely for fetal concerns. It is important not to discourage ICU admission; rather, encouraged to use critical care services when appropriate
- 27. Maternal stabilization isthe first priority Once woman is stable, determine GA to plan of care, immediate decision-making. Drugs that cross the placenta may have fetal effects Known adverse effects on the woman and the fetus must be carefully monitored, and risk–benefit ratios assessed Neither necessary medications nor diagnostic imaging should be withheld from a pregnant woman because Special considerations in care of a pregnant woman in a critical care setting
- 28. Administration ofsteroids for fetal benefit Indicated delivery should not be delayed for administration of steroids in the late preterm period Fetal monitoring In postpartum period, obstetricians should evaluate vaginal or surgical site bleeding, therapies, surgical issues Provision of lactation support and a breast pump special considerations in care of a pregnant woman in a critical care setting
- 29. SUPPORTIVE CARE Definedas interventions that sustain life and prevent complications, but do not treat the cause of the critical illness Mechanical ventilation Sedation Vasopressors hemodynamic monitoring
- 30. Normal physiology,pregnancy maintain respiratory alkalosis (PaCO2 32 mmHg and arterial pH 7.4 to 7.47) due to respiratory stimulation by progesterone Mechanical ventilation is similar for pregnant and non- pregnant women The major pregnancy-specific considerations are related PaCO2. Target PaCO2 should be 30 to 32 mmHg PaCO2 values <30 mmHg or >40 mmHg to be avoided A reasonable goal is a maternal PaO2 above 65 mmHg Mechanical ventilation
- 31. Intubation andmechanical ventilation are undertaken when hypoxemia is profound and cannot be corrected by noninvasive means, or when ventilation is failing Airway management in pregnancy can be challenging Increased airway edema and increased breast size make positioning and direct laryngeal visualization more difficult. The risk of failed intubation in obstetrics is eight times higher than in the general population Once the decision to intubate is made, the patient should be preoxygenated and suction should be available; the most qualified personavailable should intubate. Mechanical Ventilation
- 32. Interventions otherthan vasopressors should be used initially to manage hypotension, including the IV fluids and left lateral decubitus position. If Hypotension persists initiate vasopressor, since sustained hypotension decreases uterine blood flow. For pregnant women, suggest norepinephrine as the initial agent, rather than ephedrine, epinephrine or dopamine (Grade 2C). If refractory shock , suggest the use of phenylephrine Vasopressors
- 33. Most drugsused for analgesia, sedation, and paralysis cross the placenta >>>>>> Possible adverse effects Consultation with an obstetrician and a pharmacist A neonatologist should be present at delivery because may respiratory depression in the newborn Analgesia: Any opioid is acceptable. However, NSAIDs should be avoided during late pregnancy Sedation: * Midazolam is superior to lorazepam * Propofol classified as a pregnancy category B agent. Sedation
- 34. All patients shouldundergo conventional ICU monitoring. Invasive hemodynamic monitoring especially when hypoxemic respiratory failure (pulmonary edema) accompanied by hypotension and/or renal failure. Using a central venous catheter to measure the central venous pressure, rather than a pulmonary artery catheter Hemodynamic monitoring
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