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You are here: Home / 03. Intensive Care / Obstetric Critical Care Management

Obstetric Critical Care Management

March 12, 2014 by CrashMaster

Review Article (J Intensive Care Med. 2006 Sep-Oct;21(5):278-86)

Vent Stuff

↑ alveolar ventilation (20-40%), ↑ TV, ↑ RR

Compensated hypocarbia (Normal 25-32 and normal bicarb 18-21)

Mechanical ventilation- need to adjust for PaCO2 30-32 (compensated hypercarbia); no studies show harm with permissive hypercarbia

Faster desaturation: ↑ O2 consumption + ↓ function residual capacity + ↑ small airway collapse with exhalation

Meds

Avoid benzos and NSAIDs

First line should be norepi for pressors

Placenta

No auto-regulation of the blood supply, fetal distress may = mom compensated shock

Fetal Monitoring

Uterine Activity

consider monitoring after 20 weeks

Fetal Heart Rate Monitoring

consider after 24 weeks

mom in full lateral tilt, IV fluids, supp. ox

Hematological changes

↑ RBC mass (20%)

↑ Plasma volume (40-50%)

Sepsis

pyelo more common

chorioamnionitis

endometritis

ScvO2 not accurate

Critical Care

 

 

Sedation- avoid benzos and NSAIDS; limited data exists for Propofol or Precedex

Vasopressors- #1 is NE!

Fetal monitoring-

Look for uterine contractility- eval for abruption or premature labor >20 weeks

Start fetal HR monitoring EARLY, is an early warning for maternal distress

Sepsis- UTI/Pyelo are common; post-partum: Endometritis

Maternal trauma- even minor trauma can cause fetal harm, recommend:

4 hrs min of Fetal HR monitoring, longer with: 1) contraction, bleeding, abdominal pain

Steroids early for surfactant formation

Image mom as NEEDED (don’t hold back if its is important)

Put in chest tubes HIGHER than expected

Fetomaternal hemmorhage: 30% of trauma patients

Quant: Kleinhauer-Betke testing (fetal cells in circulation

Give Rho-Gam early

 

Pregnancy Specific Problems:

 

Pre-eclampsia/Eclampsia:

Features: HTN, Hypovolemia, Renal dysfunction

40% of Eclampsia is post-partum

Tx: HTN meds, MgSO4 (watch for AKI)

HELLP:

15% w/o HTN or proteinuria

Features: plts<100, hemolytic anemia, LFT dysfunction, and RUQ pain

Tx all SBP>160 or DBP>110 = ↓ CVA risk

Acute fatty liver of pregnancy:

Features: similar to HELLP but with more significant liver failure

Tx: delivery (though some need transplant)

Amniotic fluid embolism:

Normally immediately following labor (w/in 8 mins)

SIRS + anaphylaxis → severe hypoxemia

20-40% mortality (with severe neurological morbidity)

DIC is a staple of the disease

Cardiomyopathy:

Peripartum (up to 5 months)

LVEF <30%

↑ to trop/BNP = worse outcome

 

 

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Filed Under: 03. Intensive Care, 10. Obstetrics and Gynecology


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