Nhi Nguyen is an Intensivist from Nepean Hopsital, with a particular interest in feto-maternal health. She gave this lecture on the Registrar day at the Bedside Critical Care conference 2012 (#BCC3). Go to www.intensivecarenetwork.com for more details.

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Critically Ill Obstetrics
Nhi Nguyen
Nepean Hospital

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Admission to Intensive Care
 Happen to be pregnant
 Related to Pregnancy

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Obstetric Considerations in
Non-Obstetric Related Admissions
 Two Patients
 What’s good for the mum is generally good for the baby
 Do necessary imaging (With shielding as required esp in 1st
trimester, lower dose contrast for CTPA)
 Physiologically – pregnant state until 6 weeks postpartum
 Hyperdynamic
 Hypercoagulable
 Leaky/Peripheral Oedema

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Obstetric Considerations in
Non-Obstetric Related Admissions
 Surveillance of baby
 On admission
 Foetal Heart
 Growth Scan
 Viability >26 weeks
 >30 weeks generally good outcome
 Decision regarding delivery – multidisciplinary
 Maternal vs Foetal

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Obstetric Considerations in
Non-Obstetric Related Admissions
 H1N1
 Higher incidence in pregnant women
 Asthma and smoking risk factors
 Obesity
 First time maternal indications for delivery of foetus reported
 Acute illnesses, babies delivered all normal size for gestation
 ECMO series – largest case series described in the literature

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Obstetric Related Problems
 Amniotic Fluid Embolism
 Peripartum Cardiomyopathy
 Postpartum Haemorrhage
 Hypertensive Disorders of Pregnancy

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Amniotic Fluid Embolism
 Catastrophic
 Mortality reported as high as 85%
 Resuscitation and Supportive management
 DIC, ARDS commonly ensues
 Neurological sequelae common in survivors

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Peripartum Cardiomyopathy
 Often presents third trimester
 Needs to be considered when a patient presents with
symptoms of breathlessness
 Particularly important around delivery time
 Autotransfusion of blood from placental bed at delivery
 Movement of extravascular fluid back into the intravascular
space in few days post delivery

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Postpartum Haemorrhage
 Increasing numbers
 Repeat caesarean sections
 Surgical management
 Balloon Tamponage
 Peripartum hysterectomy
 Supportive
 Increasing reports of use of Factor VII

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Hypertensive Disorders of
Pregnancy
 Spectrum of Disease
 Chronic Hypertension
 Superimposed Gestational Hypertension
 Preeclampsia
 HELLP
 Eclampsia
 Acute Fatty Liver of Pregnancy

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Preclampsia
 After 20 weeks
 Hypertension, Proteinuria, organ dysfunction (renal
failure, thrombocytopenia, abnormal LFTs)
 Mild, Moderate, Severe
 Disorder of pregnancy, abnormal placentation
 Timely delivery

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MAGPIE TRIAL
 10,000 women randomised to receive Magnesium sulphate vs
placebo
 33 countries
 Primary outcome
 - eclampsia
 - neonatal death
 Reduction (half the risk) of eclampsia in magnesium group
 Best result in income poor countries
 Safe for baby

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Magnesium and Preeclampsia
 Lowers risk of seizures
 24 hr infusion following 4g loading dose
 Post delivery of baby
 Toxicity is rare

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Eclampsia
 50% present postpartum
 Magnesium sulphate loading and then infusion
 Little evidence for other anticonvulsant agents
 BP control
 Labetalol
 Hydrallazine
 clonidine

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aemolysis levated iver
Enzymes and ow latelets
 Within the spectrum of Preeclampsia
 Often RUQ pain with liver capsule distension
 Fragmentation on blood film may lag behind clinical
 Rate of fall of platelet count
 Timely delivery
 Controversial – FFP

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Take home messages
 Clinical signs often difficult to attribute to disease
 BE SUSPICIOUS and VIGILANT
 Well paradigm
 Maternal mortality and morbidity is rare in Australia
 Intensive Care Team best equipped to manage

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Questions?
Nhi Nguyen