Management of Critical Obstetric Cases

Clinical Input

            There are two patients who delivered in quick succession at your hospital, normally. Both are having PPH. Which of these will you shift to an ICU?

Detection Of The Patient Requiring Critical Care

Important signs of serious injury and illness include

·         Low-blood pressure or weak peripheral pulses,

·         Cold temperature of extremities, and

·         Peripheral cyanosis

·         Warning signs include

·         Reduced urinary output,

·         Dyspnea or hyperpnea,

·         High temperature,

·         Unexplained fatigue,

·         Chest pains, and

·         Tachycardia or palpitations.

·         Subtle changes in mental status

 Clinical Input

I was giving a trial of labour to a previous LSCS scar attempting a VBAC. Labour did not progress and patient’s general condition also worsened. I opened her up and found a bad rupture. First I tried to save the uterus but failed. So I did a hysterectomy. Patient was shifted to the ward. As the surgery was prolonged, there was a big back-log in the outdoor. The ward paramedic staff was providing me with the info on vital parameters. All seem to be going well. Suddenly the patient collapsed. What must have happened?

Reply:

After massive hemorrhage, meticulous monitoring of the patient’s pulse and BP is mandatory.  Recognizing shock in an early stage may be missed otherwise, especially on busy days. Prolonged surgery or surgery following massive hemorrhage will send the patient into shock. After hemorrhagic shock has been tackled, the obstetrician should continue to be vigilant, even after the vital parameters begin to improve, because, such patients may go into systemic inflammatory response and subsequent septic shock.  

Principles of Management Of A Patient Needing Critical Care

Management of a patient in an ICU should be systematic and should include

·         Clinical monitoring,

·         Respiratory support and

·         Cardiovascular support, in addition to

·         Correction of the cause

Clinical Input

I have observed that patients of obstetric hemorrhage admitted to ICU with altered sensorium respond poorly to treatment compared to well-oriented patients. Why so?

Clinical Monitoring:

Mental status

Altered mental status in a post-hemorrhage patient may indicate severe shock with a deficit of more than 40% of blood volume. This may be due to inadequate cerebral perfusion. 

Heart rate

Tachycardia generally alerts one to the possibility of hypovolemia,

But it could also be increased with

·         Cardiac impairment,

·         Infection,

·         Anxiety,

·         Fear,

·         Fever, or

·         Pain and discomfiture. 

Clinical Input

I have observed two paradoxical situations at times:

Inspite of “excessive” bleeding many times the BP just remains fine

Inspite of clinical volume correction, BP doesn’t respond fast enough

Why so?

Clinical Monitoring

Blood pressure:

Inspite of “excessive” bleeding many times the BP just remains fine

·         Severely reduced cardiac output for periods of 40 minutes to 2 hours has been demonstrated before a significant reduction in arterial pressure. 

·         Depends on the reserve and compensatory response

Inspite of clinical volume correction, BP doesn’t respond fast enough

·         On the other hand, if fluids are used to restore blood pressure, the cardiac output and oxygen transport may still need to be corrected even if the blood pressure is normal.

Clinical Input

My Professor during my UG Surgical posting told me that respiration though shown very prominently in films as an important parameter, in clinical practice it is not very helpful in monitoring. I wondered why this great man said so.

Clinical Monitoring

Respiration:

Acute increase in respiratory rate:

·         Pulmonary embolism or pneumothorax.

·         Pulmonary edema, pneumonia, atelectasis, etc in the moribund patient.

·         Abdominal loading, caused by ascites or pregnancy by itself could lead to dyspnea. 

·         Massive hemoperitoneum or collection of pus in the abdomen could also lead to dyspnea.

·         Electrolyte abnormalities, metabolic acidosis and renal failure may also increase respiratory effort. 

Clinical Input

Once while I was about to board my flight on a similar lecture trip, my registrar from labour room OT put in a frantic call to me: “Sir all three Pulse-Ox machines are not working”. We have an LSCS. What should we do?

Electronic monitoring and invasive hemodynamic monitoring Pulseoximetry:

A reading of 95% SpO2 or less could indicate hypoxia and should be investigated. SpO2 reading of 90% or less indicates significant hypoxia and requires immediate action. In severe shock, if the pulse oximeter shows no reading, it may mean that there is not adequate flow in the finger capillaries for the probe to pick up a reading. Pulseoximetry reading may be incorrect in patients with low perfusion, anemia and increased venous pulsations.

Clinical Input

My medicine teacher told something very pithily; Don’t overload a patient. A little hypo will not kill but a small hyper-load can kill! He said to monitor CVP is not that difficult. At the least you can pass a fine gauge tube in the antecubital vein and it will give a reasonably good idea.

Electronic monitoring and invasive hemodynamic monitoring:

Central venous pressure (CVP) monitoring

CVP is the pressure of blood in the thoracic vena cava just before it (blood) enters the heart. Normal values are between 5 to10cm of H2O. It can be measured by inserting a catheter in the subclavian vein.  Measuring CVP alone is useful in detecting extreme cases of hypervolemia, fluid overload or heart failure.  CVP does not accurately reflect left ventricular filling in patients with preeclampsia, pulmonary and cardiac disease.

Electronic Monitoring And Invasive Hemodynamic Monitoring:

Pulmonary Artery Catheterization:

The Swan-Ganz pulmonary artery catheter introduced into the pulmonary artery is used to measure, in addition to the continuous Central Venous Pressure (CVP), the Pulmonary Artery Pressures and Intermittent Capillary Wedge Pressure (PCWP). Drugs and fluids used to optimize ventricular preload can be monitored more accurately if the pulmonary artery pressures are known in these patients, so as to avoid pulmonary edema.

CLINICAL INPUT

Our surgery examiner veteran loved to ask this question: Which bare minimum tests would you like to carry out from the blood of a patient in ICU?

Blood investigations

·         Hemoglobin 

·         Coagulation parameters

·         Electrolyte imbalance

·         Sodium

·         Potassium

·         Calcium

 Respiratory Support In The Critically Ill:

Clinical criteria

·         Apnea or hypopnea

·         Respiratory distress

·         Clinically apparent increasing work of breathing unrelieved by other interventions

·         Need for airway protection 

Laboratory criteria

·         Blood gases

o   PaO2 <55 mm Hg

o   PaCO2 >50 mm Hg and

o   pH <7.32

·         Pulmonary function tests

o   Vital capacity <10 mL/kg

o   Negative inspiratory force <25 cm H2O

o   FEV1 <10 mL/kg

Clinical Input

In the institution where I worked for decades, home delivery and its complications, unsafe abortion practices leading to septic peritonitis and the like used to be a regular feature. The first thing our seniors used to brief us about was handling septic cases. It was a common password as soon as a “septic” patient was admitted: “Lag gayee”

Septic Shock:

Management

o   Any source of infection should be identified and removed.  

o   Hysterectomy is seldom indicated

o   Antibiotics: Choice of antibiotic should be dictated by hospital data.

o   Fluid therapy could be on the same lines as for hemorrhagic shock. 

o   Blood transfusion should be cautiously given as it may be associated with increased mortality. 

o   Patients can tolerate and may even benefit from hemoglobin levels lower than the traditional 10 g/dL

o   If hypotension and organ hypoperfusion do not respond to volume infusion, then ionotropic drugs (to improve cardiac performance) and vasopressor therapy (for hypotension) are indicated.

Newer modalities of therapy

o   Use of steroids in septic shock has been controversial 

o   A meta-analysis showed that hydrocortisone in doses from 200-300mg for 5 days or more reduced duration of shock, systemic inflammation, and mortality without causing harm

o   Vasopressin replacement therapy in doses ranging from 0.01-0.04IU/min improved hemodynamics and decreased catecholamine requirements.  However, vasopressin might induce myocardial, cutaneous, or mesenteric vasoconstriction.

o   Use of polyvalent intravenous immunoglobulins was found to reduce mortality in studies, but high quality trials found no evidence that immunoglobulins were beneficial

Clinical Inputs

One side there is vasoconstriction on the other there is edema. On one side there is hypertension on the other side there is shock. On side everyone seems to know its management, on the other no body knows. That is Hypertensive Crisis in PIH

Pre-Eclamptic Toxemia

In a patient with severe preeclamptic toxemia needing ICU care, one should be alert to prevent eclampsia, prevent end-organ damage and maintaining adequate uteroplacental perfusion.  If urgent lowering of blood pressure is required, intravenous labetalol or intravenous hydralazine or sublingual nifedipine may be used. Pulmonary edema develops most commonly. Most patients respond to 10 mg of frusemide administered intravenously. For patients with oliguria and rising creatinine, treatment with small fluid boluses (250 mL) may improve urine output. Fluids should be given with caution to prevent pulmonary edema. 

 IN CONCLUSION

Critical care of the high risk patient should be done as a team effort with the help of an intensivist, but the obstetrician should be aware of all the treatment and investigative modalities, by which he/she can actively participate in the ICU care of the patient.