Basic approach to an unconscious patient and management

1. Approach to an
Unconscious Obstetric
Patient
Presenter: Dr B. Mwanza
Moderator: Dr Sasa

2. Content
 Consciousness
 Level consciousness
 Unconsciousness
 Causes of Coma
 Critical care in Obstetrics
 Responding to an emergency
 Organizing a Critical Care Unit
 Admission Criteria
 Fetal Care in ICU

3. Consciousness
 Consciousness consists of awareness of ones surrounding and responsiveness to
external stimulation and inner need.
 A normal level of consciousness (wakefulness) depends on activation of the
cerebral hemispheres and by neurons located in the brainstem reticular
activating system (RAS)
 Both components and the connections between them must be preserved for
consciousness to be maintained
 LEVEL OF CONSCIOUSNESS
 Obtundation: Responds to verbal stimuli although slow and inappropriate
 Stupor: The subject can be aroused only by vigorous and repeated noxious
stimuli
 Coma: Unarousable and unresponsive

4. Unconsciousness/ Coma
 Coma is a state of unconsciousness in which a person cannot be awakened,
fails to respond normally to painful stimuli, light or sound and lacks a normal
wake sleep cycle and does not initiate voluntary actions.
 Clinically a coma is defined as a glasgow coma scale score of <8 lasting >6hrs
 A person in a state of coma is described as comatose

5. Causes of coma
 VASCULAR
 Hemorrhage: epidural, subdural,
subarachnoid, intraperychymal
 Stroke: large hemispheric ischaemic
stoke
 Anoxic briain injury (cardiac arrest)
 INFECTION
 Encephalitis
 Meningitis
 Severe systemic infections: malaria,
typhoid fever, pneumonia, septicemia
 Traumatic Brain Injuries
 Blunt or Penetrating head injuries
 Metabolic imbalances
 DKA
 HHS
 Electrolyte imbalance
 Addisonian crisis
 Hashimoto encephalopathy
 Neoplastic + SOL
 Tumors
 Tuberculoma
 Nuerocysticercosis

6. Con’t
 Drugs and Toxins
 Alcohol
 Barbituates
 Sedatives
 Opiates
 Lead
 Carbon monoxide
 Degenerative Disease
 Wernicke – Korsakoff Syndrome

7. Critical care in Obstetrics
 Pregnant women with multisystem pathology need special care with improved
technology and expertise of critical care obstetrics.
 A multidisciplinary approach much be employed to provide adequate health
care to the patient.
 Women need ICU admission, when they need cardiovascular, or pulmonary
support following multiorgan pathology or trauma.
 It is the responsibility of the skilled provider (physician) to make sure that all
staff at the health post know how to respond to an emergency.
 A health care provider should be able to identify a woman with danger signs
of pregnancy or in advanced labor, appropriately offer treatment and or call
for the skilled provider.
 The skilled provider and staff should work together to plan for a way to
respond to emergencies.
 Resuscitation, Appropriate management or timely referral.

8. Responding To An Emergency
 The skilled provider should perform a rapid initial assessment to determine
what is needed for immediate stabilization, management, and referral.
 SHOUT FOR HELP.
 Position the woman lying down on her left side with her feet elevated.
 perform a Rapid Initial Assessment (RIA) to determine the woman’s degree of
illness and assess her need for emergency care/stabilization
 ATLS protocols
 Airway
 Breathing
 Circulation
 Disability
 Exposure

9. Organization of a Critical Care Unit
 Critical care unit involves multidisciplinary approach
 The team members involve physicians, anesthetists, cardiologists,
pulmonologists, intensivists, respiratory therapists, pharmacists and nurses.
 Obstetric critical care unit involves obstetricians, obstetric nurses and
neonatologists
 There are three levels of adult critical care (ACOG)
 Level 1: Highest level of care: Severely ill patients are managed with the
involvement of multidisciplinary team members.
 Level 2: Intermediate care or high dependency care units (HDU): This is the
post ICU step down unit. These are within the labor ward.
 Care is provided by experienced obstetricians, midwives and nurses.
 Level 3: Other intensive care units: For patients requiring long-term
ventilator support

10. ICU Admission Criteria
 Criteria for admitting a patient to ICU should be based on organ failure and
need for organ support or in anticipation of deterioration in the medical
condition.
 Altered level of consciousness of recent onset
 Hemodynamic instability (e.g., clinical features of shock, arrythmias)
 Need for respiratory support (e.g. escalating oxygen requirement, de–novo
respiratory failure requiring non-invasive ventilation, invasive mechanical
ventilation, etc.)
 Patients with severe acute (or acute–on–chronic) illness requiring intensive
monitoring and/or organ support
 Any medical condition or disease with anticipation of deterioration
 Patients who have experienced any major intraoperative complication (e.g.
cardiovascular or respiratory instability)
 Patients who have undergone major surgery with haemodynamic instability or
high risk of developing postoperative complications

11. Common Conditions That May Lead To ICU
Admission
 Hemorrhage
 APH
 PPH
 Nearly 75% of obstetric patients admitted in ICU are postpartum
 Hypertensive disorders
 Severe Preeclampsia
 Eclampsia
 HELLP syndrome

12.  Sepsis syndrome
 Post abortal
 Pregnancy (Chorioamnionitis,pyelonephritis)
 Cardiopulmonary
 Heart disease in pregnancy
 Thromboembolism
 Trauma
 Puerperal sepsis

13. Fetal Care in ICU
 Fetal gestational age assessment is essential to estimate the approximate
fetal survival rate following delivery. Effects of obstetric medications need to
be carefully judged in terms of risks and benefits.
 Drug-related side effects that may arise are: beta agonists (tachycardia),
indomethacin (platelet dysfunction, reduced renal perfusion), beta blockers
(IUGR).
 Antenatal corticosteroids are to be given in the event of preterm delivery (<
34 weeks).
 Maternal drugs (sedatives), acidemia, hypoxia, blood pH, may alter the CTG
tracings.
 However, fetal interest comes second and essential medications should not be
withheld to the pregnant woman. (FDA drug risk categories. A, B, C, D, X)

14. Biophysical Profile
 Biophysical profile is a screening test for utero–placenta insufficiency.
 It evaluates the well being of the fetus using ultrasound and cardialtocograpy
CTG to examine the fetus
 Fetal Biophysical Profile (BPP)—considers several parameters using real time
ultrasonography as a high predictive value.
 8–10: Normal; Less risk of fetal asphyxia
 7-5: Suspect chronic asphyxia
 <4: Strongly suspect asphyxia

16. References
 Dr. Sayed Sujon. DC Dutta’s Textbook of Obstetrics. 8th edition
 Dr. Sheila Nainan. Intensive Care Unit Admission and Discharge Criteria. 2023
 Emergency Obstetric Care. Quick Reference Guide for Frontline
Providers.2003