Lecture 8: High Risk OB in the ICU Flashcards

Question

HELLP Syndrome - accompanies ______ ________ and ________ in approximately ______ to _____ cases - increased risk for developing complications such as (6) - s/sx similar to? - what other 2 symptoms?

Answer 1

Accompanies severe preeclampsia and eclampsia in approximately 10% to 20% of cases Increased risk for developing complications such as renal failure, pulmonary edema, DIC, placental abruption, ARDs, and liver hematoma and rupture Signs and symptoms similar to those of severe preeclampsia, however, hypertension may be absent in 20% of cases Decreased platelets (<100,000/mm3) and elevated liver enzymes.

Answer 2

- Delivery!! regardless of gestational age - Bed rest, frequent BP checks, frequent LFTs, coagulation status, and intensive fetal surveillance - Magnesium sulfate and antihypertensive agents as needed - Monitoring VS, bleeding, pain, and labs - Assess fetal heart rate and S & S of placental abruption- may present with abruption - Worsening pain, vascular collapse, or shock may indicate liver hematoma or rupture - Accurate I & O

Answer 3

1) Overlap of symptoms with HELLP - More likely to have mental status changes - Hypertension may not be present - Abnormal LFTs may not be present - Sign/symptoms do not resolve after delivery 2) Treat with: - Dexamethasone - Plasmaphoresis tip: Plateltes are being destroyed. - Looks like help. Low platelets, hemolytic anemia, micorvascular emboli -Donor plasma is given after

Answer 4

1) Number 1 cause of death in pregnant women in the world - Number 2 in the U.S. 2) Causes: - Miscarriage - Ectopic pregnancy - Abruptio Placentae - Uterine Rupture - Postpartum hemorrhage tip: Miscarriage Ectopic pregnancy – rupture of fallopian tubes. Abruptio Placentae. - can conceal bleeding- 20 weeks, HTN, preeclampsia, trauma, illicit drugs Uterine Rupture – contents are spilled into abdominal contents- 50% fetal rate, 5-15% maternal rate. Postpartum hemorrhage – 24 hours, but also 12 weeks >1000ml with s/s of hypovolemia. – 15% of cardiac output goes to the placenta. ---Bimanual uterine compression massage is performed by placing one hand in the vagina and pushing against the body of the uterus while the other hand compresses the fundus from above through the abdominal wall.

Answer 5

Meds: which ones? Clot evacuation D&C Bimanual compression Bakri balloon Blood and FFP Hysterectomy

Answer 6

1) Obstetric causes: - Abruptio placenta - Preeclampsia-eclampsia - Dead fetus syndrome - Septic abortion - Amniotic fluid embolism tip: What is DIC?: overactive clotting, then the body uses all of its clotting factors and has none left so uncontrolled bleeding. Usually post delivery if it happens.

Answer 7

Identify and treat the underlying condition Evaluate and monitor the coagulation system Prevent further hemorrhage and thrombosis If caused by septic shock, prompt delivery of the fetus and intravenous administration of broad-spectrum antibiotics For abruptio placentae, prompt delivery of the fetus Prevent further bleeding, monitoring coagulation studies, assess for multisystem involvement, altered tissue perfusion, and fluid volume deficits Monitor respiratory status, administer intravenous fluids, assess hemodynamic values, and administer and evaluate antibiotics, blood replacement products, and antipyretics tip: Low platelet, low fibrinogen, prolonged PT, PTT. Give plasma and platelets, blood. stop the bleeding

Answer 8

1) Anaphylactoid syndrome of pregnancy - Previously known as amniotic fluid embolism (AFE) - Rare cause of maternal death - Symptoms: Acute respiratory distress, hypoxia, hypotension from vasodilation and loss of circulatory integrity, shock, coagulopathy, altered mental status, fever - Diagnosis: No specific diagnostic test- meet 4 requirements - Management: Maintaining oxygenation and supporting cardiac function tip: - Acute hypotension or cardiac arrest. - Acute hypoxia. - Coagulopathy or severe hemorrhage in the absence of other explanations. - All of these occurring during labor, cesarean delivery, dilation and evacuation, or within 30 min postpartum with no other explanation of findings. Can happen during labor, delivery, postpartum

Answer 9

1) Cause of 10% of maternal deaths in the United States - Occurs during cesarean birth, uterine rupture, or small tears in the endocervical veins during a vaginal delivery - Amniotic fluid enters the maternal venous circulation, is transported to the pulmonary vasculature, results in pulmonary emboli. 2) Transient pulmonary hypertension and profound hypoxia 3) Predisposing factors: - preeclampsia - multiple gestation - polyhydramnios (excess amniotic fluid) - low insertion of placenta - post term pregnancy - hypertonic contractions during labor - abruptio placentae - uterine rupture - maternal seizures - umbilical cord prolapse 4) Clinical manifestations: sudden onset of dyspnea, cyanosis, and hypotension, decreased pulse ox followed by cardiopulmonary arrest tip: Within 20 minutes of delivery.

Answer 10

Maintaining left ventricular output and adequate airway Intubation and ventilation with 100% oxygen, IV vasopressors and crystalloid fluids, CPR, blood products, and pulmonary artery catheterization Extracorporeal membrane oxygenation (ECMO) in extreme cases Complications: acute pulmonary edema, respiratory distress, DIC, hemorrhage, and multi-system failure ABCs Pulse oximetry Side position or a wedge under right hip (as the uterus is still enlarged) Large-bore IV Assess cardiovascular, pulmonary, hematological, and neurological systems

Answer 11

- Maternal and fetal outcomes related to severity of disease - Peak incidence of asthma exacerbation is at second and early third trimester - Management - Peak flow meter to monitor pulmonary function - Rapid assessment and intervention tip: poorly controlled asthma related to low birth weight and preterm labor/birth. treat and manage the same way as non-pregnant people. People with severe asthma exacerbations will be hospitalized to stabilize and monitor baby

Answer 12

1) Normal pulmonary changes of pregnancy lead to pulmonary decomposition 2) Increased mortality and morbidity for both mother and fetus 3) Management: Ongoing assessment Bronchial drainage and chest physiotherapy Replacement of pancreatic enzymes Supplementation of nutrition

Answer 13

- Results from variety of factors; can be related to asthma, flu, covid - Exacerbations more common in second and third trimesters - Associated with other maternal disease --- Prior respiratory disease, HIV infection, drug/tobacco use, anemia - Physiologic changes of pregnancy decrease ability to clear secretions, increase risk of gastric aspiration - Typically pneumonia has bacterial origin tip: use amox/clav or cephalosporins usually. do not use tetracyclines, fluoroquinolones, or clarithromycin

Answer 14

1) Result from variety of conditions - Pharmacologic agents - Aspiration - Preeclampsia-eclampsia - Massive blood transfusions - Anaphylactoid syndrome of pregnancy - Pulmonary edema - Covid infection 2) Presentation - Pulmonary function rapidly deteriorates over 24 hours - Symptoms: Diffuse or basilar rales Bilateral opacities on chest radiograph** Deteriorating PaO2 with increasing FiO2 demands** No evidence of left sided heart failure** 3) Management of respiratory failure: - Mechanical ventilation - Pharmacologic therapies - consider maternal-fetal risks and benefits: Antibiotics Corticosteroids - inhaled/systemic Leukotriene receptor antagonist Analgesics Beta-mimetic tocolytics for prevention of labor induction Neuromuscular blockade tip: Quinolones are teratogenic so avoid those- Montelukast (Singulair) TOCOLYTICS- Salbutamol, terbutaline (IV) --- indomethacin. if someone is vented or in pulm distress, we do NOT want them to labor. their o2 demands increase dramatically

Answer 15

May be related to physiologic changes in pregnancy Greatest risk is in immediate postpartum period, which is increased if C-section is performed Assessment, management, and complications do not differ from nonpregnancy Differential diagnosis of anaphylactoid syndrome of pregnancy must be made Warfarin and most DOACs are teratogenic, Lovenox is the drug of choice- may require altered dose tip: Asymmetric lower extremity swelling. DOAC: direct acting oral anticoag xaralto and eliquis Lovenox has an air bubble of hydrogen.

Answer 16

1) B2 agonists- albuterol, terbutaline, isoxsuprine, ritodrine Refractory edema 2) Etiology not defined 3) Discontinue tocolytic agent 4) Diuretics may help 5) Mechanical ventilation may be avoided with non-invasive ventilation

Answer 17

1) Accidental injuries occur in 6% to 7% of all pregnancies and are associated with spontaneous abortion, preterm labor, abruptio placentae, and fetal death. 2) Common types of trauma include blunt trauma from motor vehicle crashes (49%), falls and domestic violence (18% to 25%) and penetrating trauma from stab wounds or gunshots (4%). 3) Fetal survival depends on maternal survival. 4) A pregnant woman can lose up to 2,000 mL of blood before becoming hemodynamically unstable.

Answer 18

ABCs NG tube to avoid aspiration Wedge under the right hip increases cardiac output up to 30% - Gets the Uterus off the IVC ACLS Avoid vasopressors if possible, use fluids instead Large bore IV Control bleeding Fluids Assess neurological status. Fetal assessment, including determination of life. Fetal monitoring at least 24 hours after event. Highest risk of abruption is in the first 4 hours Assess: onset of regular contractions, vaginal bleeding, and amniotic rupture

Answer 19

1) Minimal differences from other trauma patients - Women beyond 22 to 24 weeks’ gestation should have at LEAST 4 hours of fetal monitoring - Rh- blood when transfusing 2) Goals - First priority is mother’s survival 3) Emergency C-section - If fetus has reached point of viability and mother is at risk for immediate demise

Answer 20

Seizure frequency increases during pregnancy Goal: keep mother seizure-free and avoid teratogenic effects from anticonvulsant medications If mom has a seizure disorder, should take more folate than people without seizure disorder (1-2mg/day)

Answer 21

1) Causes - Ruptured cerebral aneurysm or arteriovenous malformation - Cocaine use increases risk - vasospasm 2) Management - Same as nonpregnant except cautious use of hypotensive agents

Answer 22

Postpartum exacerbations are common Management during pregnancy same as when not pregnant Mother may need interventions during second stage of labor to meet pushing requirements - Forceps, vacuum-assistance, C-section tip: Acetyl choline receptor dysfunction at nicotinic receptors of muscle at NMJ Does not affect uterine muscles, but the pelvic floor muscles nec to push