Obstetric critical care Flashcards
What percentage of Critical Care admissions are permpartum?
Around 1%
What is the commonest cause of pregnant women to ICU in the UK?
During pregnancy - respiratory deterioration
Post partum - haemorrhage
Overall is still haemorrhage
Where is it appropriate to care for peripartum patients?
Maternity ward/delivery suite - level 1
Enhanced maternal care (EMC) areas - can be maternity ward if staff and facilities available - level 1 and 2
Critical care - level 2 & 3
What are the causes of maternal death and what is the commonest cause of maternal death?
Direct causes:
- haemorrhage
- sepsis
- Pulmonary embolus
- psychiatric - post natal depression/psychosis
- neurological causes e.g. eclampsia
- HELLP, acute fatty liver of pregnancy
- amniotic fluid embolus
Indirect causes:
- cardiac - failure, dysrhythmias
- asthma
- pneumonia
- renal failure
Most common based on the data in the MBRRACE report is cardiac.
Intention to focus on SUDEP.
What specific aspects of care to obstetric patients should be included when obstetric patients are admitted to critical care?
MDT approach
- consultant obstetrician
- consultant obstetric anaesthetist
- consultant intensivist
- midwife
- neonatologist
Family
- mum and baby time
- partner support
- parental/other family support
Why might the demand for pregnant patients needing critical care support increase?
Maternal risk factors:
- more women are having children at an older age
- as we get better at treating chronic disease, more women who have complex care needs or medical comorbidities are becoming pregnant
What national enquiries help guide improving maternal care?
MBRRACE UK: Mothers and Babies: Reducing Risk through Audit and Confidential Enquiries across the UK.
National Maternity Review: Better Births (Part of the Five Year Forward View of maternity care):
- personalised care
- continuity of carer
- safer care
- better mental health care
- multi-professional working
- working across boundaries
- fair payment system
What are the specific features of initial management of a collapsed pregnant patient?
- Understanding that you have two potential patients, but that optimal care of the mother will ensure the best chance of survival of the baby.
- early recognition of need for MDT input, including paediatrics and obstetrics and obstetric anaesthetist. - Use a A-E assessment and stabilisation approach including:
A: Often difficult airway due to:
- anatomical reasons - soft tissue swelling, obesity, enlarged breast tissue
- physiological reasons - reduced FRC decreases safe apnea time, increased risk of aspiration
B: - Maybe difficult to optimally ventilate due diaphragmatic splinting
- Aim for low normal CO2 as foetus cannot correct for acidosis
C: - early recognition relief of aortocaval compression
- consider haemorrhage early on.
- Aim to rule out massive PE as cause
D: - consider eclampsia/pre-eclampsia
E: - early recognition of potential need to deliver foetus
- awareness of additional common pathologies:
a) amniotic fluid embolus
b) bleeding
c) cardiac failure (PE/cardiomyopathy)
d) disorders of liver & sepsis
e) eclampsia
What is amniotic fluid embolism?
A rare, catastrophic obstetric emergency presenting with:
- maternal collapse
- hypoxaemia
- cardiovascular collapse
- coagulopathy
Occurs when amniotic fluid or cells enter the maternal circulation and cause a widespread inflammatory response.
What is the incidence of amniotic fluid embolus?
Around 1 to 10 in 100,000
What is the pathophysiology of amniotic fluid embolus?
Still fairly poorly understood.
Appears to follow a 2 step immune response following reaction to foetal antigens:
- Phase 1: Marked pulmonary artery spasm leading to right heart failure, hypotension and hypoxaemia.
- Phase 2: Left heart failure, pulmonary congestion, hypotension, increased capillary permeability, uterine atony and coagulopathy and haemorrhage.
What are the risk factors for amniotic fluid embolus?
Antenatal risk factors:
- Advanced maternal age
- Multiparity
- Placental pathology
- Polyhydramnios
Obstetric factors:
- Induction of labour
- Operative delivery
- Trauma (cervical lacerations)
What are the principles of management of a patient with amniotic fluid embolus?
Resuscitate using an A-E approach.
Early delivery of foetus (do not delay by going to theatre)
- Low threshold for intubation and ventilation for hypoxaemia and maternal distress.
- Aggressive fluid resuscitation and use of vasopressors
- Left lateral tilt to prevent aorta-caval compression.
- Large bore access and intravenous monitoring.
- Active major haemorrhage protocol - correction of coagulopathy and management of haemorrhage.
- Uterotonics - ergometrine, oxytocin, prostaglandins.
- Consider surgery for haemorrhage control.
What are the differential diagnoses of amniotic fluid embolus?
Obstetric causes:
- Peripartum haemorrhage
- Peripartum cardiomyopathy
- Eclampsia
- Uterine rupture
Non-obstetric causes:
- Anaphylaxis
- Sepsis
- Total spinal anaesthetic
- Pulmonary embolus
