Role of the anaesthetist in obstetric critical care (original) (raw)
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The Management of the Critically Ill Obstetric Patient
Journal of Intensive Care Medicine, 2013
Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial.
The critically ill obstetric patient - Recent concepts
Indian Journal of Anaesthesia, 2010
Obstetric patients admitted to an Intensive Care Unit (ICU) present a challenge to an intensivist because of normal physiological changes associated with pregnancy and puerperium, the specific medical diseases peculiar to pregnancy and the need to take care of both the mother and the foetus. Most common causes of admission to an ICU for obstetric patients are eclampsia, severe preeclampsia, haemorrhage, congenital and valvular heart disease, septic abortions, severe anemia, cardiomyopathy and non-obstetric sepsis. The purpose of this review is to present the recent concepts in critical care management of obstetric patients with special focus mainly on ventilatory strategies, treatment of shock and nutrition. The details regarding management of individual diseases would not be discussed as these would be beyond the purview of this article. In addition, some specific issues of importance while managing such patients would also be highlighted.
Principles of Critical Care in Obstetrics
2016
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Critical care management of the obstetric patient
Canadian Journal of Anaesthesia, 1997
Occasional Review Critical care management of the obstetric patient Purpose: To review a series of critically ill obstetric patients admitted to a general intensive care unit in a Canadian centre, to assess the spectrum of diseases, interventions required and outcome. Methods. A retrospective chart review was performed of obstetric patients admitted to the intensive care unit of an academic hospital with a high-risk obstetric service, during a five-year period. Data obtained included the admission diagnosis, ICU course and outcome. Daily APACHE II and TISS scores were recorded. Results: Sixty-frye obstetric patients, representing 0.26% of deliveries in this hospital, were admitted to the ICU dunng the study period. All had received prenatal care. Admission diagnoses included obstetric (71%) and nonobstetric (29%) complications. The mean APACHE ii score was 6.8-4.2 and mean TISS score was 24 +_ 8, I. Twenty-seven patients (42%) required mechanical ventilation, No maternal mortality occurred and the pennatal mortality rate was I 1%.
Indian Journal of Critical Care Medicine : Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 2020
Introduction Obstetric patients are a special group of patients whose management is challenged by concerns for fetal viability, altered maternal physiology, and diseases specific to pregnancy. Materials and methods A prospective analysis of all obstetric patients admitted to the critical care department was done to assess reasons for transfer to the critical care unit (CCU) and the interventions required for management of these patients. Results Between June 2013 and September 2017, obstetric admission comprised 95 women (5.9%) of the total critical care admissions. There were 77 patients (81.1%) who were discharged from the hospital and 18 patients (18.9%) died. In most of the cases, the primary reasons for shifting the patient to the CCU were severe preeclampsia with pulmonary edema (22.1%), eclampsia (8.4%), acute respiratory distress syndrome (ARDS) (14.7%), and hypovolemic shock in antepartum hemorrhage (APH) and postpartum hemorrhage (PPH) (10.5 and 13.7%, respectively). It wa...
Critical Care of the Obstetric Patient
Annals of Internal Medicine, 1984
The obstetric patient, pregnant or puerperal, is significantly different from the average patient who enters an intensive care unit. These patients have a unique pathophysiology and present specific disorders; in addition, there is the presence of the fetus, an alteration of the pharmacokinetics, diseases that may be aggravated by pregnancy and the scenario of a birth. The pregnant patient undergoes dramatic physiological changes at the cardiovascular, respiratory, renal, endocrinological, and hematological levels, which make her a different patient [1]. Post-partum hemorrhages, pre-eclampsia, acute fatty liver of pregnancy, and post-partum endometrial infections are unique conditions in an obstetric patient. The management challenge of these patients increases with the presence of the fetus. Publications report that there is a prevalence of critical obstetric patients of 100-900/100,000 gestations (0.1-0.9%) [2, 3], but these statistics are usually from medium-and high-resource countries. Statistical data from lowincome countries reach much higher values and often patients do not even manage to be treated in intensive care units. The mortality ratio is also very different between rich and low-income countries, with statistics of 6-24/100,000 live births (LB) in the highest-income countries, and 55-920/100,000 LB in poor countries [4]. It is estimated that 75% of hospitalizations of obstetric patients to intensive care units occur in the puerperium [3], because it is a period susceptible to complications such as pulmonary edema (due to a reduction in oncotic pressure) and a high frequency of hemorrhages, such as uterine atony. In the ICNARC study in UK 2007, 81.5% of patients were reported as recently pregnant (within 42 days of admission to the ICU) [5], either post-partum or post-abortion. There are vulnerable populations where the risk of maternal death is multiplied, such as ethnic minorities, extreme maternal ages, and low socioeconomic status [6].
Aims of obstetric critical care management
Best Practice & Research Clinical Obstetrics & Gynaecology, 2008
The aims of critical care management are broad. Critical illness in pregnancy is especially pertinent as the patient is usually young and previously fit, and management decisions must also consider the fetus. Assessment must consider the normal physiological changes of pregnancy, which may complicate diagnosis of disease and scoring levels of severity. Pregnant women may present with any medical or surgical problem, as well as specific pathologies unique to pregnancy that may be life threatening, including pre-eclampsia and hypertension, thromboembolic disease and massive obstetric haemorrhage. There are also increasing numbers of pregnancies in those with high-risk medical conditions such as cardiac disease. As numbers are small and clinical trials in pregnancy are not practical, management in most cases relies on general intensive care principles extrapolated from the non-pregnant population. This chapter will outline the aims of management in an organ-system-based approach, focusing on important general principles of critical care management with considerations for the pregnant and puerperal patient.
Anaesthetic management of obstetric emergencies
Indian Journal of Anaesthesia
Obstetric emergencies are a challenge both for the obstetrician and the anaesthesiologist. The incidence of caesarean sections as per the National Family Health Survey published in 2015-16 was 17.2%. In 7.6% of cases, the decision to conduct a caesarean section was taken after the onset of labour pains. Caesarean sections are classified depending on the urgency into four categories. The target decision to delivery interval for category 1 caesarean section is less than 30 min. This is used as an audit tool for the efficiency of an obstetric service. The management of these emergencies involves a rapid assessment, with minimal investigations. Although general anaesthesia is considered to have higher morbidity and mortality, category 1 caesarean sections may still warrant this technique. Rapid sequence spinal anaesthesia is replacing general anaesthesia for many of the category 1 indications. In category 2 and 3 caesarean sections, spinal anaesthesia still remains the technique of choice. Failed intubation, failed neuraxial block, extensive neuraxial block, awareness under anaesthesia, thromboembolism, amniotic fluid embolism, haemorrhage and maternal collapse are some of the complications. Haemorrhage is said to be the leading cause of mortality worldwide.
Critical care obstetrics and gynecology
Critical Care Clinics, 2003
The critical care aspects of the gynecologic patient have many similarities to the care of the critically ill, adult patient with respect to physiologic and organ support. The critical care aspects of the pregnant patient, however, are substantially different from that of the nonpregnant patient. In part, this is because treatment considerations that are geared toward optimization and individualization of a single patient in the adult ICU setting must be approached with greater flexibility to consider the needs of each of the individual components of the maternal-fetal unit complex. Pregnant patients in the critical care unit can present with diseases and conditions that are specific to pregnancy, but must also be viewed in the light of specific differences in physiology between the gravid and nongravid patient, as well as the gravid patient and the fetus [1-13]. Maternal -fetal medicine was first recognized as a distinct obstetric subspecialty by the American Board of Obstetrics and Gynecology in 1972 [14] and the need for specialty resource units to care for the obstetric patient soon followed. In the current era of cost containment few hospitals can devote specialized resources to maternal -fetal ICUs. Many critical care practitioners may not have had exposure to the special needs of a pregnant patient during their training or within their practice settings . An issue which further complicates consideration of this topic is that many of the published reviews of this area were written from a purely obstetric viewpoint [17 -19]. This article, which focuses primarily upon the obstetric patient, summarizes for the nonobstetric critical care practitioner the scope of the problem, the physiologic changes in pregnancy, the fetal concerns, the most common clinical illnesses that result in ICU care for the pregnant 0749-0704/03/$ -see front matter D 2003, Elsevier Science (USA). All rights reserved. PII: S 0 7 4 9 -0 7 0 4 ( 0 2 ) 0 0 0 5 9 -3