title: Obstetrics Critical Illness tags: #FFICM #obstetrics notebook: 🌑-FFICM
source: eLfH category: obstetrics
Maternal Collapse / Maternal Critical Care
Overview
Reduced GCS/Unconsciousness due to cardiovascular/resp/neuro cause during pregnancy to 6 weeks post delivery 1
Maternal Collapse Affects 6/1000 births 1
Risk increased by: 1
- Commorbidities
- Maternal Age
- Increased BMI 1
The study into Maternal Complications is called MBRRACE-UK 1
Deaths in pregnancy can be direct (Due to pregnancy) and indirect (pregnant mothers died due to non pregnant reasons) 1
Deaths in pregnancy affect 9 in 100,000 births. For every death there's 70 with severe morbidity 1
Most caused by cardiac, then thrombosis, then neuro. 1
Physiology Changes in Pregnancy
- Airway worsened by weight gain, laryngeal oedema, increased brest tissue
- Increased O2 consumption by 20%
- Increased Minute Ventilation due to increased tidal volumes
- Diaphragmatic Spinting decreases FRC
- Inferior Vena Cava compressed by gravid uterus after 20 weeks when lying flat (decreasing preload by decreasing venous return to heart)
- Cardiac Output increases by 50% and Uterine Blood Flow is 10% of CO at term
- Gastrointestinal motility decreases so more aspiration risk 1
MEWS
Theres a national Scottish MEWS
It has:
- RR
- Sats
- O2 Need
- Temp
- HR
- BP
- Neuro
- Urine
- Looks Unwell 1
Common (Serious) Causes
Mneumonic: BEAU CHOPS
- Bleeding
- Embolism
- Anaesthetic Related
-
Uterine Pathology 1
-
Cardiac Disease
- Hypertensive
- Others (4Hs and 4Ts) - In pregnancy include AFE and Air Embolus in Thrombus, Include Local Anaesthetic and Magnesium Toxicity
- Placental Pathology
- Sepsis 1
Peri-partum
(Pre) Eclampsia
Defn Preeclampsia: Hypertension (Sys > 140 or Dias >90) after 20 weeks with proteinuria, organ dysfunction or fetal growth restriction
Defn Eclampsia: Above plus seizures
Note almost 1/2 of seizures are post par 1
Pathology
Abnormal Placental Development, normally large vessels in placenta become narrow and constricted. Ischaemic placenta releases mediators, causing endothelial dysfunction and vasoconstriction. 1
Can Cause:
- Intracranial haemorrhage
- Cerebral Oedema
- Vasospasm
- Hypertensive Encephalopathy
- HTN
- Cardiac Failure
- Pulm Oedema
- Renal Failure
- Proteinuria
- Subcapsular Haemorrhage
- Hepatic Rupture
- IUGR
- Prematurity
- Abruption
- Fetal Death
- Thrombocytopenia
- DIC
- Haemolysis
- Thrombosis 1
Clinical Features
Hypertension
Headache/Visual Disturbance (due to raised ICP and cerebral oedema)
Subcostal Pain - Due to hepatic capsule pain
Vomiting
Swelling of hands/face/feet 1
Monitoring
BP Fluid Balance U&Es LFTs Urate Coag Foetal Monitoring 1
Management
BP Reduction: Labetalol / Nifedipine / Hydralazine 1
Magnesium if: Fitting / Deliver in Next 24hrs / Features of Severe Pre-Eclampsia 1
- Give magnesium with 4 grams over 5-15mins
- Then maintenance of 1g/hr for 24hrs
- If seize again give 2-4 grams over 5-15 mins
- If seize again for third time focus on BP and consider intubation (be careful not to stimulate with laryngoscopy too much)
- CT Head
- Target magnesium levels 2-4mmol/L
- If arrest give calcium gluconate for presumed magnesium toxicity (10ml 10%) 1
Delivery 1
Steroids if < 37 weeks 1
HELLP
Defn: Haemolysis, Elevated Liver Enzymes, Low Platelets
It's a marker of preeclampsia severity 1
Can be divided into Class I (Platelets < 50 = worst - half die) to III (Platelets 100-150 = least bad but still bad - 1 in 5 die) 1
Management
Need careful monitoring/standard critical care plus:
- Haem guidance on coagulopathy
- BP treatment if hypertensive
- IV magnesium
- (Steroids? - Cochrane says dont work)
- Delivery of fetus and placenta is KEY 1
Amniotic Fluid Embolism
1/5 die!
Significant neuro morbidity in survivors 1
Pathophysiology
Defn: Caused by amniotic fluid/debris into maternal circulation 1
Causes immune mediated life threatening reaction. 1
First Phase: Vasoactive chemicals in response to fetal antigens causes pulm art vasospasm, causing RVF, hyoptension/hypoxaemia. 1
Second Phase: Left ventricular failure and pulmonary oedema 1
Clinical Features/Diagnosis
Can occur in labour/delivery/30 mins post 1
Clinical Triad:
- Hypoxia
- Hypotension
- Coagulopathy
Presenting with hypotension and resp distress. 1
DIC often occurs (causing bleeding/rash) 1
Management
Like any other critically ill cardiovascular collapse
Deliver foetus if not already.
Major Obstetric Haemorrhage Protocol (monitor for PPH) 1
Ante/post Partum Haemorrhage
Causes:
- Placenta Praevia
- Placenta accreta
- Placental abruption
- Ectopic Pregnancy
- Uterine Rupture
- Uterine Inversion
- Primary (within 24hrs) and Secondary (Up to 12 weeks) Postpartum 1
4 Ts:
- Tone (Atony)
- Tissue
- Trama (Instrumental/Operati)
- Thrombin (Coagulopathy) 1
Management
As other cardiovascular collapse bleeding patients. 1
Avoid recombinent factor VII if can, as makes amniotic fluid embolism outcomes worse 1
TXA 1
Delivery 1
Replace Calcium 1
Specific:
Tone - Rub uterus and empty bladder 1
Drugs: TXA, Oxytocin/Syntocinon, Misoprostol/Carboprost, Ergometrine 1
Surgical: Bakri Balloon, Suture, Ligation Blood Vessels, Hysterectomy 1
Ectopic Pregnancy
Sepsis / Septic Abortion
Specific Causes/Risk Factors:
- Previous Pelvic Infection
- Previous Group B Strep Infection
- Invasive Procedures
- PROM
- Group A Strep Infection 1
Common Bugs:
- Group A Strep
- E. Coli
- Mixed organisms
- Coliforms 1
Peripartum Cardiomyopathy
LVSD (EF < 45%) and Heart Failure towards end of pregnancy when no other cause found 1
Manage with sodium restriction, loop diuretic, betablockers,and vasodilation with hydralazine 1
Can also see MI, Valvular Heart Disease (Mitral Stenosis), Aortic Dissection 1
Cerebral Venous Sinous Thrombosis
Increased change in pregnancy as generally pro coagulant 1
General Management
Algorithm in maternal collapse, treat as other collapsed patient, with displaced uterus to be used. 1
If in cardiac arrest follow maternal cardiac arrest algorithm 1
Maternal Cardiac Arrest
I've looked at the maternal cardiac arrest algorithm. It's the same as the normal adult life support with ensuring uterine displacement, consider magnesium, empty uterus if 20 weeks onwards, and more specific reversible causes (THE) 1
T: - Thromboembolic (With Pulmonary and Amniotic Fluid) - Toxic (Consider Local Anaesthetic) - Cardiac Tamponade - Tension Pneumothorax H: - Hypoxia - Hypovolaemia - Hyper/hyopkalaemia - Hypothermia E: - Eclampsia 1
PeriMortem Delivery
Is done with the aim of improving maternal outcome, increasing venous return and cardiac output
- Don't move to theatre, don't need sterile preparations
- Dont need anaesthetic
- Start within 3 minutes 1
Foetal Assessment in Critically Unwell Pregnant
- Fetal Heart Rate Doppler
- Cardiotocograph (CTG)
- Ultrasound of Foetas (HR, Movements, Blood Flow)