Dr. Shashwat Jani discusses the challenges of caring for critically ill pregnant women. The assessment, monitoring, and treatment must consider both the mother's physiological adaptations to pregnancy and the well-being of the fetus. Some leading causes of obstetric ICU admission include pre-eclampsia, eclampsia, sepsis, and hemorrhage. Conditions making pregnant women critically ill can be specific to pregnancy, increase susceptibility during pregnancy, involve an underlying medical condition exacerbated by pregnancy, or be unrelated to pregnancy. Interpreting laboratory results in critically ill pregnant patients requires considering normal physiological changes of pregnancy to avoid over- or under-diagnosis. The document then focuses on interpreting various hematological and coagulation laboratory tests

1. Dr. Shashwat Jani.
M. S. ( Obs – Gyn )
Diploma in Advance Laparoscopy.
Consultant Assistant Professor,
Smt. N.H.L. Municipal Medical College.
Sheth V. S. General Hospital , Ahmedabad.
Mobile : +91 99099 44160.
E-mail : drshashwatjani@gmail.com

2. Why it’s challenging ???
Care of the critically ill pregnant women presents a
unique challenge …
…. Because the assessment,
monitoring and the treatment must be
taken into an account with maternal
physiological adaptations to pregnancy
& also the presence of a fetus whose
well-being is linked to the mother.
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3. Leading obstetric causes requiring
Obstetric ICU admission …
Pre-eclampsia & Eclampsia
Sepsis
Haemorrhage.
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4. Conditions which can make
pregnant women critically ill….
These wide range of conditions are mainly
divided in to 4 main groups…
1. Specific to pregnancy
2. Increase susceptibility in pregnancy
3. Underlying medical condition
4. Unrelated to pregnancy
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5. • Specific to pregnancy:
e.g. pre-eclampsia, acute fatty liver, obstetric
haemorrhage, amniotic fluid embolism,
peripartum cardiomyopathy etc.
• Increased susceptibility in pregnancy:
e.g. venous thromboembolism, aspiration
syndromes.
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6. • Underlying medical condition that is
exacerbated by pregnancy:
e.g. congenital heart disease, pulmonary
hypertension, and chronic renal failure.
• Unrelated to pregnancy and coincidently
developed during pregnancy:
e.g. diabetic ketoacidosis, pneumonia, viral
hepatitis and asthma
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7. To confirm the diagnosis of any
condition ...
Clinical examination
Urine Output
Laboratory investigations
Radiologic investigations
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8. In critically ill obstetric pts…
It’s sometimes difficult to know….
 Which Lab. tests are to be done ?
 How to interpret these lab. Reports. ?
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9. Remember
“ During interpretation of
laboratory results in critically ill
obstetric patients, always consider
the normal physiological changes
of pregnancy, otherwise underlying
disease may be over- or under-
diagnosed…!!! “
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10. Common changes in haematological
& biochemical parameters that occur
with pregnancy
&
how they impact on maternal / fetal
resuscitation…!!!
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11. Parameter Non-
pregnant
Term pregnancy Impact on resuscitative care
PaO2
(kPa /
mmHg)
13.3 / 100 13.7 / 103 A rightward shift of the maternal
oxyhaemoglobin dissociation curve is a
compensatory mechanism to improve fetal
oxygenation
PaCO2
(kPa /
mmHg)
5.3 / 40 4 / 30 Maintenance of materno-fetal CO2 gradient
is important for ongoing fetal CO2 excretion
HCO3-
(mmol/L/mEq/L)
24 20 ↓ Buffering capacity, acidosis more likely.
pH 7.40 7.44
Haematocrit (%) 37-39 33-35 ↓ Oxygen carrying capacity
White cell count
(n × 109/l)
4 – 11 6 -16 Interpretation of trends in infection more
difficult
Platelet count (n
× 109/l)
150-400 150-400 Gestational thrombocytopaenia is common,
a level <100 × 109/l
warrants investigation

12. Coagulation
screen
Fibrinogen
levels may
increase up
to 50% at term
PT (Prothrombin time) /aPTT are unchanged
Predominant ↑ in clotting factors and ↓ in
fibrinolytic activity.
Generalised hypercoagulable state
Urea 7.0–21.0
mg/dL
6.7–10.6 mg/dL Seemingly normal renal indices may indicate
renal dysfunction in the parturient
Creatinine 0.7–1.14
mg/dL
0.6–0.8 mg/dL
Liver
function
Tests
Transaminase
levels -
unchanged.
Alkaline
phosphatase
markedly
elevated
Alkaline phosphatase levels increase
throughout pregnancy, initially as a
result of corpus luteal production and
subsequently by the placenta.
Total protein 6.4–8.6 g/dL 4.8–6.4 g/dL Reduction in albumin:globulin ratio, ↑free
fraction of albumin-bound medications
↓ Colloid oncotic pressure

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14. Now ,
let’s see …
Interpretation of some most
commonly used important
laboratory investigations of
Critical obstetric patients…
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19. Indications
 Evaluate the cause of certain symptoms such as
fever, bruising, or weight loss
 Detect anemia
 Determine the severity of blood loss
 Diagnose polycythemia vera
 Diagnose an infection
 Diagnose diseases of the blood, such as leukemia
 Monitor the response to some types of drug or
radiation treatment
 Evaluate abnormal bleeding
 Screen for abnormal values before surgery
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20. A hematocrit may be used to:
• Identify and evaluate the severity of anemia
(low RBCs, low hemoglobin, low hematocrit)
OR Polycythemia (high RBCs, high hemoglobin,
high hematocrit)
• Help make decisions about blood
transfusions or other treatments if anemia is
severe
• Evaluate dehydration & IV Fluid Mx
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21. Normal = 35 – 45 %
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22. f
Obstetric
Indication
< 8 gm
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24. Platelets: Risk of Spontaneous
Hemorrhage
Count Site
> 40,000 Minimal
20-40,000 GI Mucosa
5-20 Skin, Mucus Membranes
< 5 CNS, Lung
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25. Prothrombin Time ( PT )
• Prothrombin time is more sensitive to factor
VII deficiency than factor deficiencies within the
final common pathway.
• The prothrombin time has significant
interlaboratory variability influenced by the
instrument, and more importantly, the reagent
used. In an effort to offset variation in
thromboplastin reagent, and enhance
standardization of PT in patients receiving warfarin,
the World Health Organization (WHO) introduced
the International normalized ratio (INR).
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26. • The INR is intended to standardize PT,
such that a PT generated from one laboratory
would yield an INR value comparable to that
generated from any other laboratory in the
world.
• INR = [Patient PT/Mean PT] ISI
• Prothrombin time is an important
coagulation test because it measures the
presence and activity of five different blood
clotting factors (factors I, II, V, VII, and X).
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28. Normal Findings:
• INR : 0.8 – 1.12
• PT : < 15 seconds
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29. PT increased in
• Warfarin use
• Vitamin K deficiency from malnutrition, biliary obstruction,
malabsorption syndromes, or use of antibiotics
• Liver disease, due to diminished synthesis of clotting factors
• Deficiency or presence of an inhibitor to factors VII, X,
II/prothrombin, V, or fibrinogen
• Disseminated intravascular coagulopathy (DIC)
• Fibrinogen abnormality (eg, hypofibrinogenemia, afibrinogenemia,
dysfibrinogenemia)
• Massive blood transfusion due to dilution of plasma clotting
proteins
• Hypothermia, as it causes inhibition of a series of enzymatic
reactions of the coagulation cascade .
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30. aPTT
To evaluate bleeding abnormalities
To monitor the treatment effects with heparin
• The aPTT is used to evaluate the coagulation factors
XII, XI, IX, VIII, X, V, II (prothrombin), and I
(fibrinogen) as well as prekallikrein (PK) and high
molecular weight kininogen (HK)
• aPTT : 24-35 seconds
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31. Prolonged aPTT may indicate:
• Bleeding disorders
• Use of heparin
• Antiphospholipid antibody (especially lupus
anticoagulant, which paradoxically increases
propensity to thrombosis)
• Coagulation factor deficiency (e.g. hemophilia)
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32. PT Result aPTT Result Common Condition Present
Prolonged Normal Liver disease, decreased vitamin K,
decreased or defective factor VII
Normal Prolonged Hemophilia A or B (decreased or
defective factor VIII or IX) or factor XI
deficiency, von Willebrand disease,
factor XII deficiency, or lupus
anticoagulant present
Prolonged Prolonged Decreased or defective factor I
(fibrinogen), II (prothrombin), V or X,
severe liver disease, disseminated
intravascular coagulation (DIC)
Normal Normal or
slightly prolonged
May indicate normal hemostasis;
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33. Bleeding Time ( B T )
• Done to assess platelet function and the
body’s ability to form a clot.
• < 7 minutes: Normal
• 8-15 minutes: Platelet dysfunction
• More than 15 minutes: Critical; test must be
discontinued and pressure should be applied
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34. Clotting Time ( C T )
This is a useful bed side test
Take 5ml of blood in a glass tube
If a clot forms in 10 mts & remains firm it
is unlikely that the pt has a DIC & also
means that the fibrinogen levels are
normal.
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35. Clot retraction time
• Another bed side test wherein the
clot retracts at the end of 1 hour.
• This means that the platelets are
adequate.
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36. D - dimer
• Used to determine if further testing is necessary to help
diagnose diseases and conditions that cause
hypercoagulability, a tendency to clot inappropriately.
• DVT
• Stroke
• Pulmonary embolus
• DIC
Normal Value
< 0.5 mg / l OR 0 – 200 microgm / ml
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37. Positive D –dimer
• S /o presence of an abnormally high level of fibrin
degradation products.
• It indicates that there may be significant blood clot
(thrombus) formation and breakdown in the body.
• Imp. Conditions Are …
- DIC
- Post Surgical
- Trauma
- Infection
- M.I.
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38. Fibrinogen Level
• To evaluate fibrinogen, a protein that is
essential for blood clot formation.
• When there is an injury and bleeding occurs,
the body forms a blood clot through a series of
steps.
• In one of the last steps, soluble fibrinogen is
converted into insoluble fibrin threads that
crosslink together to form a net that stabilizes
and adheres at the injury site until the area has
healed.
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39. It is advised in …
 Unexplained or prolonged bleeding
 Thrombosis
 An abnormal PT and PTT test result
 Has symptoms of or is undergoing
treatment for DIC or abnormal fibrinolysis
 May have an inherited or
acquired coagulation factor (clotting
protein) deficiency or dysfunction
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40. • Normal Fibrinogen Level
= 300 -600 mg/dl.
• More than 150 mg / dL required for
coagulation.
• Decrease level found in DIC and Acute
Fibrinolysis
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41. FDP
• Normal value : < 10 microgm/dl
Level increses in ….
 DIC
 Post fibrinolytic therapy
 Thromboembolic events
 Pulmonary embolism
 Deep vein thrombosis
 Acute myocardial infarction (first 24-48 h)
 Preeclampsia
 Exercise, anxiety, stress, severe liver disease (mild elevation)
 Acute and chronic renal failure
 Sepsis/shock
 Postoperative states
 Glomerulonephritis
 Extensive tissue damage
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42. CRP
• Used to detect inflammation
• Normal : 0 – 10 mg / L
Elevated in…
• Bacterial infection like Sepsis
• Fungal infection
• PID.
• Chorioamnionitis
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43. Lab . Criteria for HELLP
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46. Other tests which are done
routinely are….
• Blood Sugar
• Urine R – M ( ketones , sugar, proteins ,
leukocytes , RBCs )
• Uric Acid
• Culture Sensitivity
• Serum Ammonia level
& many more ….
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