OBSTETRIC EMERGENCIES IN THE I.C.U

PROF. DR. SAKINA JAFFERY

MBBS, MCPS, FCPS

CONSULTANT ANAESTHESIOLOGIST & INTENSIVIST.

• ICU receives obstetric patients with medical & surgical emergencies as well as specific obstetric complications.

• Proportion of obstetric patients in most ICUs is low

• Relative inexperience in management & team-work between intensivist & obstetrician.

BASIC PRINCIPLES FOR OBSTETRIC EMERGENCIES.

• Physiological changes in pregnancy modify:• Presentation of the problem• Normal physiological variables• Response to treatment

• Both mother & fetus are affected by the pathology & subsequent treatment.

• Mother’s welfare always takes precedence over fetal concerns ---Fetal survival is usually dependant on optimal maternal management.

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PHYSIOLOGICAL CHANGES IN PREGNANCY

• After 20 weeks aorto-caval compression.• Complicated tracheal intubation due to edematous

tissues, delayed gastric emptying & increased oxygen consumption.

• Prophylaxis for thrombo-embolism with low molecular weight heparin & elastic compression stockings

CARDIO-PULMONARY ARREST

• Cardiac arrest rare in pregnancy (1 in 30000 deliveries)

• Usually associated with particular obstetric complications like amniotic fluid embolism, drug toxicity from Magnesium sulphate & local anesthetics.

• Technique for external cardiac massage: External cardiac massage in non-obstetric patient provides 30%

cardiac output. After 20 weeks reduced further due to veno-caval compression. Relief of aorto-caval compression part of BLS: left lateral tilt --- decreased efficacy of compressions wedge 270 angle allows 80% of maximal force to be

dissipated rescuer’s thigh as wedge.

• Sodium bicarbonate controversial as it leads to fetal acidosis but pH has to be kept above 7.30 to prevent uterine vasoconstriction.

• International Liaison Committee on Resuscitation (ILCOR) “ if there is no response to ALS, peri-mortem caesarean delivery should be made within 5 minutes of arrest”

TRAUMA

• Occurs in 6-7% of all pregnancies.• Hospital admissions only 0.3- 0.4 % of all pregnancies.• 1% of all trauma cases are pregnant.• Maternal deaths associated most commonly with head

injuries & severe hemorrhage.• Fetal deaths associated with placental abruption &

maternal death.• Initial resuscitation should follow normal plan of ABC.• Hypotension may not be present until 35% or more blood

volume is lost.

• Aorto-caval compression release• Rule out pelvic fractures, uterine injury & retro-peritoneal

hemorrhage• Fetal monitoring with cardio-tocographic monitor & USG.• Rh immunoglobulin – within 72 hours.• Radiation hazards:

1st trimester >5 cGy

Chest x-ray < 5 cGy

Pelvic film <1 cGy

Abdomino-pelvic CT scan 5-10 cGy

BURNS

• Increased levels of prostaglandins predispose to pre-term labour.

• Replacement of fluids vis-à-vis increased volumes in pregnancy.

• Inhalational injury- hypoxia & carbon monoxide poisoning• Infections- prophylactic antibiotics controversial• Topical Povodine iodine- affects fetal thyroid functions