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Critical Care in Obstetrics
Jyoti Sinha, Manju Gita Mishra
SECTION A: PHYSIOLOGY AND PATHOPHYSIOLOGY
1:
Critical Care Illness in the Obstetric Patient
Introduction
Conditions Requiring Critical Care
Intensive Care Monitoring
Ventilation for Respiratory Failure in Obstetric Patients
Observations to be made during Mechanical Ventilation
Hypovolemic Shock
Physiology
Pathophysiology
Management
Septic Shock
Pathophysiology
Management
Hypertensive Disorders in Pregnancy
Pathophysiology
Clinical Features
HELLP Syndrome
Management
Fetal Status
Summary
SECTION B: SHOCK AND SYNDROME
2:
Amniotic Fluid Embolism
Incidence
What Causes AFE?
Risk Factors
Clinical Features
Diagnosis
Imaging Studies
Pathophysiology
Histologic Findings
Management
Oxygenation
Circulation
Fetal Management
Coagulopathy and Control of Hemorrhage
Surgical Care
Conclusion
3:
Disseminated Intravascular Coagulation (DIC) in Obstetrics
Introduction
Definition of DIC (Minimal Acceptable Criteria)1
Historical Aspects
Etiology
Predisposing Factors of DIC
Causes of DIC (Table 3.1)
Pathophysiology
Clinical Presentation
Chronic DIC
Acute DIC
Amniotic Fluid Embolism (AFE)
Incidence
Clinical Presentation
Pathophysiology
Risk Factors for AFE4
Diagnosis of DIC
Laboratory Abnormalities in Acute DIC
Laboratory Abnormalities in Chronic DIC
Differential Diagnosis of DIC
Treatment Options for DIC Syndrome13
Manage the DIC
4:
Trauma and Burn Injury in Obstetrics
Introduction
Physiological Changes
Cardiovascular Systems
Respiratory Physiology
Renal Physiology
Coagulation Physiology
Gastrointestinal Physiology
Central Nervous System
Injury to the Mother
Injury to Uterus and Fetus
General Approach to the Trauma Patient
Primary Care
Secondary Care
Diagnostic Imaging
Electrical Injury
Injury due to Burn in Pregnancy
Perimortem Cesarean Section
Conclusion
5:
Systemic Lupus Erythematosus (SLE) and Pregnancy
Introduction
Pathophysiology
Specific Antigen Driven Response
Polyclonal B-cell Activation
Recent Theory7
Effects of SLE on Pregnancy
Effects on the Mother
Effects on the Fetus
Effects of Pregnancy on SLE
Diagnosis
Diagnosis of Antiphospholipid Antibody Syndrome (APAS)
Management of Lupus during Pregnancy
Prepregnancy Counseling
Antenatal Care
Planning of Delivery
Puerperium
Contraception
Conclusion
6:
Thromboembolic Phenomena— Pregnancy
Introduction
Incidence
Coagulation and Fibrinolysis Systems in Pregnancy
Coagulation System during Pregnancy
Venous Thromboembolism
Types of Thromboembolism
Clinical Features
Superficial Thrombophlebitis
Management
Deep Vein Thrombosis
Pulmonary Embolism
Disseminated Intravascular Coagulation in Clinical Conditions
Fetal Risks
Investigations to Diagnose Thromboembolism
Treatment
Acute Phase—Treatment
Alternative Treatment
Chronic Phase—Treatment
Prophylaxis of Thromboembolism
Thromboprophylaxis
Cesarian Section
Conclusion
7:
Sepsis in Obstetrics
Introduction
Historical Perspective
Definition
Recent Understanding of Sepsis and its Pathophysiology
Predisposing Factors
Clinical Aspects of Sepsis
Assessment and Management of Sepsis
Principles of Therapy
Universal Measures
Medication
Definitive Treatment
The Future of Sepsis Management
Conclusion
Acknowledgement
8:
Massive Obstetric Hemorrhage
Introduction
Pathophysiology
Causes of Massive Obstetric Hemorrhage
Management of Massive Obstetric Hemorrhage
Management Protocol
Monitoring
Definitive Obstetrical Management
Abortion
Molar Pregnancy
Investigation
Management of Molar Pregnancy with Massive Hemorrhage
Definitive Surgery
Follow-up
Antepartum Hemorrhage (APH)
Uterotonic Agents
Management of Retained Placenta and Placenta Bit
Uterine Inversion
9:
Ovarian Hyperstimulation Syndrome (OHSS) and Pregnancy
Introduction
OHSS Classification
Pathogenesis of OHSS
Prediction and Prevention of OHSS
Types of OHSS
Distinction between Early and Late OHSS
Effect of OHSS on Pregnancy
Increased Early Pregnancy Loss
Other Effects on Pregnancy
Effect of Pregnancy on OHSS
Severity of OHSS
Management of OHSS in Pregnancy
Medical Management
Surgical Management
Conclusion
10:
Postpartum Collapse
Introduction
Cause of Collapse at or Immediately after Delivery
Circulatory Failure
Respiratory Compromise
Intracranial Pathology
Metabolic Disturbances
Management
Resuscitation
Discussion
Conclusion
11:
Critical Care in Septic Shock
Pathophysiology of Septic Shock
The Role of Macrophages
The Role of Microvascular Endothelial Cells
The Role of Neutrophils
Cytokines in Sepsis
Receptors
Other Inflammatory Barriers
Complement Activation
Apoptosis in Septic Shock
Genetic Predisposition to Sepsis and Septic Shock
The Role of the Gastrointestinal Tract
The Role of the Liver
Myocardial Dysfunction in Septic Shock
Clinical Features
Critical Laboratory Tests
Goals of Therapy
Management
Treatment of Infection
Cardiovascular Resuscitation
Ventilation
Infusion
CVP
PAC
Pump (Vasoactive Agents)
Immunomodulation
General Support
Evidence-based Practice
Conclusion
SECTION C: MEDICAL AND DISORDERS
12:
Thyroid and Parathyroid Emergencies in Pregnancy
Maternal Hypothyroidism
Treatment
Myxedema Coma
Hypoparathyroidism
Management
Maternal Hyperthyroidism
Surgical
Thyroid Crisis or Storm
Hyperparathyroidism
Hyperemesis Gavidarum
13:
Acute Respiratory Diseases in Pregnancy
Introduction
Infections
Upper Respiratory Tract Infections (URTI)
Lower Respiratory Tract Infections (LRTI)
Acute Bronchitis
Pneumonia
Tuberculosis
Asthma
Management
Intrapartum Management
Respiratory Emergency in Pregnancy and Labor
Amniotic Fluid Embolism (AFE)
Pulmonary Edema
Adult Respiratory Distress Syndrome (ARDS)
Cystic Fibrosis
Sarcoidosis
14:
Acute Pancreatitis in Pregnancy
Causes and Risk Factors
Pathogenesis
Pathophysiology
Presentation, Symptoms and Signs
Investigations
Differential Diagnosis
Diagnosis
Prognostic Indicators
Management
Treatment
IV Fluids
Respiratory System Care
Cardiovascular Complications
Metabolic Complications
Antibiotics
Role of Surgery
Role of ERCP
Complications
LOCAL
SYSTEMIC
Pregnancy Considerations
Acknowledgement
15:
Acute Renal Failure in a Critically Ill Obstetric Patient
Definition
Renal Changes during Pregnancy
Pathogenesis
Clinical Phases of ARF
16:
Fatty Liver Disorder with Jaundice in Pregnancy
Introduction
Liver Functions in Normal Pregnancy
Acute Fatty Liver of Pregnancy
Pathogenesis and Etiology
Clinical Presentation
Maternal and Fetal Outcomes
Management
Supportive Care
Obstetric Management
Labor Analgesia and Anesthesia
Postpartum Care
Pre-eclampsia/Eclampsia
Epidemiology and Risk Factors
Pathogenesis and Causes
Clinical Presentation
Maternal and Fetal Outcome
Management
Supportive Care
Obstetric Management
Obstetric Analgesia and Anesthesia
HELLP Syndrome
Classification of HELLP Syndrome
Clinical Presentation
Differential Diagnosis (Table 16.2)
Maternal and Fetal Outcome
Management
Medical Management
Corticosteroid Therapy
Conservative Management
Obstetric Management
Viral Hepatitis
Clinical Presentation
Maternal and Fetal Outcome
Hepatitis E
Management
Obstetric Management
17:
Pregnancy with Cardiac Disease: A Critical Review
Introduction
Normal Physiological changes during Pregnancy Delivery and Postpartum
Risks to the Mother
Risk to the Fetus
Diagnosis of Maternal Heart Disease during Pregnancy
Symptoms
Signs
General Management
Risk Factors Precipitating Heart Failure
Intrapartum Management
Role of Antibiotics
Management of the 3rd Stage
Contraception
Management of Cardiovascular Complication during Pregnancy
Treatment of Acute Congestive Heart Failure during Pregnancy
Management of Congestive Heart Failure in Pregnant Patients consists of:
Management of Acute Pulmonary Edema
Rhythm Disorders
Management
18:
Critical Care in Severely Anemic Patient
Definition of Anemia Pregnancy
WHO4
Center for Disease Control and Prevention
Indian Council of Medical Research (ICMR)
Predisposing Factors for Anemia in Pregnancy
Impact of Maternal Anemia
Investigation for a Patient with Severe Anemia
Treatment of Severely Anemic Patients
Oral Iron Therapy
Side Effects
Response to Therapy
Cause of Failure
Parenteral Iron Therapy
Indications of Parenteral Iron Therapy
Iron Dextran
Preparation
Administration
Monitoring during Infusion
Contraindications
Side Effects
Iron Sucrose
Preparation
Administration
Monitoring during Infusion
Contraindications
Side Effects
Intramuscular Injection
Comparison between Iron Dextran and Iron Sucrose
Blood Transfusion
Conclusion
19:
Acute Renal Failure in Pregnancy
Introduction
Causes of Renal Failure
Obstetrical Causes
Prerenal
Renal
Postrenal
Nonobstetrical
Pathogenesis
Reversible Prerenal Acute Renal Failure
Established Acute Renal Failure
Clinical Presentation
Differential Diagnosis of Acute Renal Failure
Hemodynamically Stable, Nonseptic Patient
Urinary Tract Obstruction
Vascular Event
Rapidly Progressive Glomerulonephritis
Acute Interstitial Nephritis
Drugs
Investigations in Acute Renal Failure
Hematology
Biochemistry
Microbiology
Imaging
Consider
Management
Medical Management
Obstetrical Management
Prerenal
Renal
Postrenal
Nonobstetrical Management
Prognosis
SECTION D: MISCELLANEOUS
20:
Obstructed Labor and Rupture Uterus: Indian Perspective
Definition
Etiology
Course of Labor and Pathological Anatomy of Obstruction
Management
Prevention
Corrective Management
Studies on Destructive Operation by Others
Prognosis
Rupture of Uterus
Definition
Types
Causes of Rupture Uterus
Site of Rupture
Clinical Features
General
Prognosis
Management
Curative Management
21:
Severe Pre-eclampsia, Eclampsia: Obstetrician's Nightmare
Etiopathogenesis
Cardiovascular
Hematological
Renal
Hepatic
Risk Factors
Diagnosis
Laboratory Findings
Hematological
Imaging Studies
Findings in Eclampsia
MRI
Findings
Prediction of Pre-eclampsia
Management
Day Care
Management of Severe Pre-eclampsia/Eclampsia
Prevention of Seizures
Management of Eclampsia
General Management
Fluid Management19,20
Control of Convulsions and Hypertension
Obstetrical Management
Management of Complications
Investigations
Acute Renal Failure
Management of HELLP Syndrome21
Postpartum
Follow-up
Conclusion
SECTION E: FETUS IN CRITICALLY ILL PATIENTS
22:
Fetal Considerations in the Critically Ill Gravida
Etiology of Critical Illness in Pregnancy
Maternal and Fetal Physiology
Respiratory Physiology
Fetal Physiology
Clinical Implications of Altered Physiology
Fetal Considerations in Trauma
Maternal Radiological Investigation of the Abdomen
Complications of Maternal Trauma in the Fetus
Evaluation of the Fetus
Management of the Mother
Pre-eclampsia
Obstetric Hemorrhage
Sepsis
Cardiac Disease
Management of the Fetus
Prediction of Fetal Demise
Indications for Delivery
Cardioversion in Pregnancy
Medications
Perimortem Cesarean Section
23:
Care of Baby Born of Critically Ill “Mothers”
Introduction
Anticipation
Resuscitation of Newborn
A. Preventing Heat Loss
B. Initiating Adequate Respirations and Oxygenation
Positive Pressure Ventilation (PPV)
Adequacy of Ventilation
Technique
ET Intubation Indication
C. Maintenance of Circulation
Indication
Technique
Outcome of Chest Compression
D. Indication for Medications and Fluids
Condition in Mother Demanding Special Attention?
1. Shock
2. Hypertensive Disorder
Outcome of Baby
3. Viral Hepatitis
4. Diabetes Mellitus4–6
Problem
Management
Causes for Cyanosis
Cardiac problem in these babies are:
5. Thyroid Disorder9
Screening Program for Thyroid Dysfunction
Treatment for Neonatal Hypothyroidism
6. Renal
7. SLE11
8. Thrombocytopenic Purpura
9. Myasthenia Gravis
10. Isoimmunization
Management
11. Malignancy12
12. Mental Disorders
13. Polyhydramnios
14. Oligohydramnios
15. Antepartum Hemorrhage
16. PRON
17. Asthma
18. Cardiac Disorder
24:
Critical Preliminary Care of Surgical Neonates
Introduction
Communication
Neonatal Transport
Kangaroo Care
Temperature Maintenance and Exposure Prevention during Transport
Hydration
Investigations
Conclusion
SECTION F: PROCEEDINGS
25:
Anesthetic Management of the Critically Ill Obstetric Patient
Cardiovascular Disease and Pregnancy
Pre-eclampsia
Calcium Channel Blockers (Nifedipine, Nicardipine)
Fluid Management
Anesthetic Plan for Labor and Delivery
Anesthesia for LSCS
HELLP Syndrome
Management
The Anesthesiologist and Eclampsia
The Obstetric Patient with Severe Cardiac Disease
Anticoagulants
Digoxin
β Blockers
Ephedrine
Mitral Stenosis (MS)
Postoperative/Delivery Care
Aortic Stenosis (AS)
Principles of Management of Labor and Delivery
Regurgitant Lesions (MR and AR)
Management Guidelines for Labor and Delivery
Congenital Heart Disease (CHD)
Broadly CHD can be Divided into three Groups
Common Precautions to be Observed in all Patients of CHD
L → R Shunts
R → L Shunts
Precautions during General Anesthesia
Avoid Aortocaval Compression
Eisenmenger's Syndrome
Peripartum Cardiomyopathy
Management of Labor and Delivery: Principles
Obstetric Hemorrhage
General Principles to be kept in Mind
Management
Preventive Management
Patient Management
The Parturient with Acute Asthma
Preventive Management
Management of Labor and Delivery: Guidelines
Thyrotoxicosis
Management of Operative Delivery
Morbid Obesity
26:
Airway and Ventilation
Indications for Airway
Indications for Ventilation/Respiratory Support2
Causes of Respiratory Failure
Indications for Ventilatory Support
WHO CAN PROVIDE?
What are the ways and means to provide them?3
Airway
Technique of Insertion
The Combitube (esophagotracheal combitube)
Ventilation
Choice of Support Mode
Monitoring during Respiratory Support
Ventilatory Support in Special Conditions
In Hemodynamic Unstable Patients
In Patients with Pulmonary Embolism
PPH and Ventilation
ARDS and Ventilation
Complications Associated with Artificial Ventilation
27:
Antepartum Hemorrhage
Definition
Placenta Previa
Clinical Presentation
PV in OT
Problems at Cesarean
Abruptio Placentae
Clinical Presentation
Management
Vasa Previa
Key Points
INDEX
TOC
Index
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