Approach to Unconscious Obstetric Patient-1.pptx

Basic approach to an unconscious patient and management

1. Approach to an Unconscious Obstetric Patient Presenter: Dr B. Mwanza Moderator: Dr Sasa

2. Content Consciousness Level consciousness Unconsciousness Causes of Coma Critical care in Obstetrics Responding to an emergency Organizing a Critical Care Unit Admission Criteria Fetal Care in ICU

3. Consciousness Consciousness consists of awareness of ones surrounding and responsiveness to external stimulation and inner need. A normal level of consciousness (wakefulness) depends on activation of the cerebral hemispheres and by neurons located in the brainstem reticular activating system (RAS) Both components and the connections between them must be preserved for consciousness to be maintained LEVEL OF CONSCIOUSNESS Obtundation: Responds to verbal stimuli although slow and inappropriate Stupor: The subject can be aroused only by vigorous and repeated noxious stimuli Coma: Unarousable and unresponsive

4. Unconsciousness/ Coma Coma is a state of unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light or sound and lacks a normal wake sleep cycle and does not initiate voluntary actions. Clinically a coma is defined as a glasgow coma scale score of <8 lasting >6hrs A person in a state of coma is described as comatose

5. Causes of coma VASCULAR Hemorrhage: epidural, subdural, subarachnoid, intraperychymal Stroke: large hemispheric ischaemic stoke Anoxic briain injury (cardiac arrest) INFECTION Encephalitis Meningitis Severe systemic infections: malaria, typhoid fever, pneumonia, septicemia Traumatic Brain Injuries Blunt or Penetrating head injuries Metabolic imbalances DKA HHS Electrolyte imbalance Addisonian crisis Hashimoto encephalopathy Neoplastic + SOL Tumors Tuberculoma Nuerocysticercosis

6. Con’t Drugs and Toxins Alcohol Barbituates Sedatives Opiates Lead Carbon monoxide Degenerative Disease Wernicke – Korsakoff Syndrome

7. Critical care in Obstetrics Pregnant women with multisystem pathology need special care with improved technology and expertise of critical care obstetrics. A multidisciplinary approach much be employed to provide adequate health care to the patient. Women need ICU admission, when they need cardiovascular, or pulmonary support following multiorgan pathology or trauma. It is the responsibility of the skilled provider (physician) to make sure that all staff at the health post know how to respond to an emergency. A health care provider should be able to identify a woman with danger signs of pregnancy or in advanced labor, appropriately offer treatment and or call for the skilled provider. The skilled provider and staff should work together to plan for a way to respond to emergencies. Resuscitation, Appropriate management or timely referral.

8. Responding To An Emergency The skilled provider should perform a rapid initial assessment to determine what is needed for immediate stabilization, management, and referral. SHOUT FOR HELP. Position the woman lying down on her left side with her feet elevated. perform a Rapid Initial Assessment (RIA) to determine the woman’s degree of illness and assess her need for emergency care/stabilization ATLS protocols Airway Breathing Circulation Disability Exposure

9. Organization of a Critical Care Unit Critical care unit involves multidisciplinary approach The team members involve physicians, anesthetists, cardiologists, pulmonologists, intensivists, respiratory therapists, pharmacists and nurses. Obstetric critical care unit involves obstetricians, obstetric nurses and neonatologists There are three levels of adult critical care (ACOG) Level 1: Highest level of care: Severely ill patients are managed with the involvement of multidisciplinary team members. Level 2: Intermediate care or high dependency care units (HDU): This is the post ICU step down unit. These are within the labor ward. Care is provided by experienced obstetricians, midwives and nurses. Level 3: Other intensive care units: For patients requiring long-term ventilator support

10. ICU Admission Criteria Criteria for admitting a patient to ICU should be based on organ failure and need for organ support or in anticipation of deterioration in the medical condition. Altered level of consciousness of recent onset Hemodynamic instability (e.g., clinical features of shock, arrythmias) Need for respiratory support (e.g. escalating oxygen requirement, de–novo respiratory failure requiring non-invasive ventilation, invasive mechanical ventilation, etc.) Patients with severe acute (or acute–on–chronic) illness requiring intensive monitoring and/or organ support Any medical condition or disease with anticipation of deterioration Patients who have experienced any major intraoperative complication (e.g. cardiovascular or respiratory instability) Patients who have undergone major surgery with haemodynamic instability or high risk of developing postoperative complications

11. Common Conditions That May Lead To ICU Admission Hemorrhage APH PPH Nearly 75% of obstetric patients admitted in ICU are postpartum Hypertensive disorders Severe Preeclampsia Eclampsia HELLP syndrome

12. Sepsis syndrome Post abortal Pregnancy ( Chorioamnionitis,pyelonephritis ) Cardiopulmonary Heart disease in pregnancy Thromboembolism Trauma Puerperal sepsis

13. Fetal Care in ICU Fetal gestational age assessment is essential to estimate the approximate fetal survival rate following delivery. Effects of obstetric medications need to be carefully judged in terms of risks and benefits. Drug-related side effects that may arise are: beta agonists (tachycardia), indomethacin (platelet dysfunction, reduced renal perfusion), beta blockers (IUGR). Antenatal corticosteroids are to be given in the event of preterm delivery (< 34 weeks). Maternal drugs (sedatives), acidemia, hypoxia, blood pH, may alter the CTG tracings. However, fetal interest comes second and essential medications should not be withheld to the pregnant woman. (FDA drug risk categories. A, B, C, D, X)

14. Biophysical Profile Biophysical profile is a screening test for utero–placenta insufficiency. It evaluates the well being of the fetus using ultrasound and cardialtocograpy CTG to examine the fetus Fetal Biophysical Profile (BPP)—considers several parameters using real time ultrasonography as a high predictive value. 8–10: Normal; Less risk of fetal asphyxia 7-5: Suspect chronic asphyxia <4: Strongly suspect asphyxia

15. References Dr. Sayed Sujon . DC Dutta’s Textbook of Obstetrics. 8 th edition Dr. Sheila Nainan . Intensive Care Unit Admission and Discharge Criteria. 2023 Emergency Obstetric Care. Quick Reference Guide for Frontline Providers.2003