1
|
Gevaerd Martins J, Saad A, Saade G, Pacheco LD. The role of point-of-care ultrasound to monitor response of fluid replacement therapy in pregnancy. Am J Obstet Gynecol 2024:S0002-9378(24)00730-0. [PMID: 38969197 DOI: 10.1016/j.ajog.2024.06.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 05/05/2024] [Accepted: 06/15/2024] [Indexed: 07/07/2024]
Abstract
Fluid management in obstetrical care is crucial because of the complex physiological conditions of pregnancy, which complicate clinical manifestations and fluid balance management. This expert review examined the use of point-of-care ultrasound to evaluate and monitor the response to fluid therapy in pregnant patients. Pregnancy induces substantial physiological changes, including increased cardiac output and glomerular filtration rate, decreased systemic vascular resistance, and decreased plasma oncotic pressure. Conditions, such as preeclampsia, further complicate fluid management because of decreased intravascular volume and increased capillary permeability. Traditional methods for assessing fluid volume status, such as physical examination and invasive monitoring, are often unreliable or inappropriate. Point-of-care ultrasound provides a noninvasive, rapid, and reliable means to assess fluid responsiveness, which is essential for managing fluid therapy in pregnant patients. This review details the various point-of-care ultrasound modalities used to measure dynamic changes in fluid status, focusing on the evaluation of the inferior vena cava, lung ultrasound, and left ventricular outflow tract. Inferior vena cava ultrasound in spontaneously breathing patients determines diameter variability, predicts fluid responsiveness, and is feasible even late in pregnancy. Lung ultrasound is crucial for detecting early signs of pulmonary edema before clinical symptoms arise and is more accurate than traditional radiography. The left ventricular outflow tract velocity time integral assesses stroke volume response to fluid challenges, providing a quantifiable measure of cardiac function, which is particularly beneficial in critical care settings where rapid and accurate fluid management is essential. This expert review synthesizes current evidence and practice guidelines, suggesting the integration of point-of-care ultrasound as a fundamental aspect of fluid management in obstetrics. It calls for ongoing research to enhance techniques and validate their use in broader clinical settings, aiming to improve outcomes for pregnant patients and their babies by preventing complications associated with both under- and overresuscitation.
Collapse
Affiliation(s)
| | - Antonio Saad
- Department of Obstetrics and Gynecology, Inova Maternal-Fetal Medicine, Fairfax, VA
| | - George Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Luis D Pacheco
- Departments of Obstetrics and Gynecology and Anesthesiology, The University of Texas Medical Branch, Galveston, TX
| |
Collapse
|
2
|
Cornette J, Laker S, Jeffery B, Lombaard H, Alberts A, Rizopoulos D, Roos-Hesselink JW, Pattinson RC. Validation of maternal cardiac output assessed by transthoracic echocardiography against pulmonary artery catheterization in severely ill pregnant women: prospective comparative study and systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:25-31. [PMID: 27404397 DOI: 10.1002/uog.16015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/22/2016] [Accepted: 07/04/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Most severe pregnancy complications are characterized by profound hemodynamic disturbances, thus there is a need for validated hemodynamic monitoring systems for pregnant women. Pulmonary artery catheterization (PAC) using thermodilution is the clinical gold standard for the measurement of cardiac output (CO), however this reference method is rarely performed owing to its invasive nature. Transthoracic echocardiography (TTE) allows non-invasive determination of CO. We aimed to validate TTE against PAC for the determination of CO in severely ill pregnant women. METHODS This study consisted of a meta-analysis combining data from a prospective study and a systematic review. The prospective arm was conducted in Pretoria, South Africa, in 2003. Women with severe pregnancy complications requiring invasive monitoring with PAC according to contemporary guidelines were included. TTE was performed within 15 min of PAC and the investigator was blinded to the PAC measurements. Comparative measurements were extracted from similar studies retrieved from a systematic review of the literature and added to a database. Simultaneous CO measurements by TTE and PAC were compared. Agreement between methods was assessed using Bland-Altman statistics and intraclass correlation coefficients (ICC). RESULTS Thirty-four comparative measurements were included in the meta-analysis. Mean CO values obtained by PAC and TTE were 7.39 L/min and 7.18 L/min, respectively. The bias was 0.21 L/min with lower and upper limits of agreement of -1.18 L/min and 1.60 L/min, percentage error was 19.1%, and ICC between the two methods was 0.94. CONCLUSIONS CO measurements by TTE show excellent agreement with those obtained by PAC in pregnant women. Given its non-invasive nature and availability, TTE could be considered as a reference for the validation of other CO techniques in pregnant women. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. RESUMEN OBJETIVO Las complicaciones del embarazo más graves se caracterizan por trastornos hemodinámicos serios, debido a los cuales existe la necesidad de sistemas validados de monitorización hemodinámica para mujeres embarazadas. Aunque la cateterización de la arteria pulmonar (CAP) mediante termodilución es el patrón de referencia clínico para la medición del gasto cardíaco (GC), este método se usa con poca frecuencia debido a su naturaleza invasiva. La ecocardiografía transtorácica (ETT) permite la determinación no invasiva del GC. El objetivo de este estudio fue validar la ETT frente al CAP para determinar el GC en mujeres embarazadas gravemente enfermas. MÉTODOS: Este estudio consistió en un metaanálisis que combinó datos de un estudio prospectivo y una revisión sistemática. El estudio prospectivo se llevó a cabo en Pretoria (Sudáfrica) en 2003. Se incluyeron mujeres con complicaciones graves en el embarazo que requerían una monitorización invasiva mediante CAP según las directrices de ese momento. Se realizó una ETT en un plazo de 15 minutos de haber realizado el CAP y el investigador no tuvo acceso a las mediciones del CAP. Las mediciones comparativas se extrajeron de estudios similares obtenidos a partir de una revisión sistemática de la literatura y se añadieron a una base de datos. Se compararon las mediciones simultáneas del GC mediante ETT y CAP. La concordancia entre métodos se evaluó a través del método estadístico de Bland-Altman y de coeficientes de correlación intraclase (CCI). RESULTADOS Se incluyeron treinta y cuatro mediciones comparativas en el metaanálisis. Los valores medios del GC obtenidos mediante CAP y ETT fueron de 7,39 l/min y 7.18 l/min, respectivamente. El sesgo fue de 0,21 l/min, siendo los límites inferior y superior de la concordancia de -1,18 l/min y 1.60 l/min; el error porcentual fue del 19,1%, y el CCI entre ambos métodos fue de 0,94. CONCLUSIONES Las mediciones del GC en mujeres embarazadas mediante ETT muestran una excelente concordancia con las obtenidas mediante CAP. Dada su naturaleza no invasiva y su disponibilidad, la ETT podría considerarse como referencia para la validación de otras técnicas relacionadas con el GC en mujeres embarazadas. : ,。(pulmonary artery catheterization,PAC)(cardiac output,CO),,。(transthoracic echocardiography,TTE)CO。PACTTECO。 : meta。2003。PAC。PAC 15 minTTE,PAC。,。TTEPACCO。Bland-Altman(intraclass correlation coefficients,ICC)。 : meta34。PACTTECO7.39 L/min7.18 L/min。-1.18 L/min、1.60 L/min0.21 L/min,19.1%,ICC0.94。 : TTECOPACCO。,TTECO。.
Collapse
Affiliation(s)
- J Cornette
- Department of Obstetrics and Gynecology, Kalafong Provincial Tertiary Hospital University of Pretoria, Pretoria, South Africa
- Department of Obstetrics & Gynecology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - S Laker
- Department of Obstetrics and Gynecology, Kalafong Provincial Tertiary Hospital University of Pretoria, Pretoria, South Africa
- Department of Obstetrics and Gynecology, Kloof Mediclinic, Gauteng, South Africa
| | - B Jeffery
- Department of Obstetrics and Gynecology, Kalafong Provincial Tertiary Hospital University of Pretoria, Pretoria, South Africa
- Department of Obstetrics and Gynecology, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - H Lombaard
- Department of Obstetrics and Gynecology, Kalafong Provincial Tertiary Hospital University of Pretoria, Pretoria, South Africa
- Department of Obstetrics and Gynecology, University of Witwatersrand, Gauteng, South Africa
| | - A Alberts
- Department of Anesthesiology and Critical Care, Kalafong Provincial Tertiary Hospital University of Pretoria, Pretoria, South Africa
| | - D Rizopoulos
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - J W Roos-Hesselink
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - R C Pattinson
- Department of Obstetrics and Gynecology, Kalafong Provincial Tertiary Hospital University of Pretoria, Pretoria, South Africa
| |
Collapse
|
3
|
Ducas RA, Elliott JE, Melnyk SF, Premecz S, daSilva M, Cleverley K, Wtorek P, Mackenzie GS, Helewa ME, Jassal DS. Cardiovascular magnetic resonance in pregnancy: insights from the cardiac hemodynamic imaging and remodeling in pregnancy (CHIRP) study. J Cardiovasc Magn Reson 2014; 16:1. [PMID: 24387349 PMCID: PMC3882291 DOI: 10.1186/1532-429x-16-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 12/11/2013] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Cardiovascular disease in pregnancy is the leading cause of maternal mortality in North America. Although transthoracic echocardiography (TTE) is the most widely used imaging modality for the assessment of cardiovascular function during pregnancy, little is known on the role of cardiovascular magnetic resonance (CMR). The objective of the Cardiac Hemodynamic Imaging and Remodeling in Pregnancy (CHIRP) study was to compare TTE and CMR in the non-invasive assessment of maternal cardiac remodeling during the peripartum period. METHODS Between 2010-2012, healthy pregnant women aged 18 to 35 years were prospectively enrolled. All women underwent TTE and CMR during the third trimester and at least 3 months postpartum (surrogate for non-pregnant state). RESULTS The study population included a total of 34 women (mean age 29 ± 3 years). During the third trimester, TTE and CMR demonstrated an increase in left ventricular end-diastolic volume from 95 ± 11 mL to 115 ± 14 mL and 98 ± 6 mL to 125 ± 5 mL, respectively (p<0.05). By TTE and CMR, there was also an increase in left ventricular (LV) mass during pregnancy from 111 ± 10 g to 163 ± 11 g and 121 ± 5 g to 179 ± 5 g, respectively (p<0.05). Although there was good correlation between both imaging modalities for LV mass, stroke volume, and cardiac output, the values were consistently underestimated by TTE. CONCLUSION This CMR study provides reference values for cardiac indices during normal pregnancy and the postpartum state.
Collapse
Affiliation(s)
- Robin A Ducas
- Section of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Manitoba, Rm Y3531, Bergen Cardiac Care Centre, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada
| | - Jason E Elliott
- Department of Obstetrics, Gynecology & Reproductive Sciences, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Steven F Melnyk
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sheena Premecz
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Megan daSilva
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kelby Cleverley
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Piotr Wtorek
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
| | - G Scott Mackenzie
- Section of Cardiac Anesthesia, Department of Anesthesia, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Michael E Helewa
- Department of Obstetrics, Gynecology & Reproductive Sciences, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Davinder S Jassal
- Section of Cardiology, Department of Internal Medicine, Faculty of Medicine, University of Manitoba, Rm Y3531, Bergen Cardiac Care Centre, St. Boniface General Hospital, 409 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada
- Institute of Cardiovascular Sciences, St. Boniface Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Radiology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| |
Collapse
|
4
|
Abstract
The death of a mother during or after childbirth is one of the most tragic events in medicine. We have identified 10 specific recurrent errors that account for a disproportionate share of maternal deaths, primarily related to pulmonary embolism, severe preeclampsia, cardiac disease, and postpartum hemorrhage. Attention to these principles and the development and adoption of local or regional clinical protocols that address these issues will help reduce the likelihood and effect of error and of maternal mortality.
Collapse
|
5
|
Schneider MC, Beinder E, Fauchère JC, Siegemund M. Präeklampsie, Eklampsie und HELLP-Syndrom. DIE INTENSIVMEDIZIN 2011. [PMCID: PMC7123074 DOI: 10.1007/978-3-642-16929-8_82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Die Präeklampsie und die mit ihr assoziierten Krankheitsbilder Eklampsie und HELLP-Syndrom setzen Schwangere und deren Feten bedeutenden Risiken aus und zählen zu den Hauptursachen mütterlicher und fetaler Morbidität und Mortalität. Die Erkrankung kann sich ganz unterschiedlich äußern: als überwiegend mütterliches (Hypertonie, Proteinurie und weitere Organfunktionsstörungen) oder fetales Syndrom (fetale Wachstumsrestriktion, Verminderung der Fruchtwassermenge, fetale Asphyxie), aber auch als Kombination der mütterlichen und fetalen Erkrankung. Sie wird dennoch ausschließlich nach mütterlichen Kriterien eingeteilt [36]:
Schwangerschaftshypertonie: Erstmanifestation einer Hypertonie nach der 20. Schwangerschaftswoche (SSW) mit systolischen und/oder diastolischen Blutdruckwerten >140 bzw. >90 mm Hg, die 2-mal im Abstand von mindestens 6 h bei Fehlen einer Proteinurie gemessen werden. Schwangerschaftskomplikationen sind selten. Meist steigt der Blutdruck im Verlauf der Schwangerschaft nicht weiter an, bisweilen wird ein progredienter Anstieg ohne weitere Präeklampsiesymptome (außer einer möglichen fetalen Wachstumsrestriktion) beobachtet, selten die Progression in eine Präeklampsie. Postpartal normalisiert sich der Blutdruck wieder. Chronische Hypertonie: Hypertonie, die bereits vor der Schwangerschaft oder später als 12 Wochen nach der Entbindung besteht. Bei einer Pfropfpräeklampsie mit einer Inzidenz von etwa 25% sind die Risiken der Frühgeburtlichkeit, der fetalen Wachstumsrestriktion, der vorzeitigen Plazentalösung und des akuten Nierenversagens höher als bei der neu aufgetretenen Präeklampsie. Präeklampsie/Eklampsie: Schwangerschaftshypertonie mit Proteinurie, die durch >300 mg Protein im 24-h-Sammelurin bzw. durch zwei qualitative Bestimmungen (Uristix) mindestens einfach positiv im Abstand von mehr als 4 h definiert ist. Die Eklampsie als Komplikation einer schweren Präeklampsie äußert sich in tonisch-klonischen Krämpfen.
Collapse
|
6
|
Melchiorre K, Sutherland GR, Baltabaeva A, Liberati M, Thilaganathan B. Maternal Cardiac Dysfunction and Remodeling in Women With Preeclampsia at Term. Hypertension 2011; 57:85-93. [DOI: 10.1161/hypertensionaha.110.162321] [Citation(s) in RCA: 203] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Karen Melchiorre
- From the Fetal Maternal Medicine Unit (K.M., B.T.), Department of Obstetrics and Gynecology and the Department of Cardiology and Cardiothoracic Surgery (K.M., G.R.S., A.B.), St Georges Hospital, University of London, London, UK; and the Department of Obstetrics and Gynecology (K.M., M.L.), University of Chieti, Chieti, Italy
| | - George Ross Sutherland
- From the Fetal Maternal Medicine Unit (K.M., B.T.), Department of Obstetrics and Gynecology and the Department of Cardiology and Cardiothoracic Surgery (K.M., G.R.S., A.B.), St Georges Hospital, University of London, London, UK; and the Department of Obstetrics and Gynecology (K.M., M.L.), University of Chieti, Chieti, Italy
| | - Aigul Baltabaeva
- From the Fetal Maternal Medicine Unit (K.M., B.T.), Department of Obstetrics and Gynecology and the Department of Cardiology and Cardiothoracic Surgery (K.M., G.R.S., A.B.), St Georges Hospital, University of London, London, UK; and the Department of Obstetrics and Gynecology (K.M., M.L.), University of Chieti, Chieti, Italy
| | - Marco Liberati
- From the Fetal Maternal Medicine Unit (K.M., B.T.), Department of Obstetrics and Gynecology and the Department of Cardiology and Cardiothoracic Surgery (K.M., G.R.S., A.B.), St Georges Hospital, University of London, London, UK; and the Department of Obstetrics and Gynecology (K.M., M.L.), University of Chieti, Chieti, Italy
| | - Basky Thilaganathan
- From the Fetal Maternal Medicine Unit (K.M., B.T.), Department of Obstetrics and Gynecology and the Department of Cardiology and Cardiothoracic Surgery (K.M., G.R.S., A.B.), St Georges Hospital, University of London, London, UK; and the Department of Obstetrics and Gynecology (K.M., M.L.), University of Chieti, Chieti, Italy
| |
Collapse
|
7
|
Abstract
Hypertensive disorders of pregnancies remain a central public health concern throughout the world, and are a major cause of maternal mortality in the developing world. Although treatment options have not significantly changed in recent years, insight on the pathogenesis of preeclampsia/eclampsia has been remarkable. With improved animal models of preeclampsia and large-scale human trials, we have embarked upon a new era where angiogenic biomarkers based on mechanism of disease can be designed to assist in early diagnosis and treatment. There is also a growing recognition of how elusive the diagnosis of eclampsia can be, especially in the postpartum period. Proper treatment of these patients depends heavily on the correct diagnosis, especially by the emergency physician. Finally, large epidemiologic studies have revealed that preeclampsia, once thought to be a self-limited entity, now appears to portend real damage to the cardiovascular and other organ systems in the long term. This review will present the latest update on our understanding of the various hypertensive disorders of pregnancies and their treatment options.
Collapse
|
8
|
|
9
|
Abstract
Severe pre-eclampsia is a common disorder in developing countries but still remains a significant problem in developed societies. The management of severe pre-eclampsia in developing countries is frequently hampered by lack of adequate facilities; paradoxically those countries with sufficient resources have a lower incidence of the disease and consequently lack experience in the treatment of severe pre-eclampsia. The management of these patients is further compromised because obstetricians generally lack the necessary knowledge and skills in critical care and conversely critical care specialists may lack appreciation and knowledge of pregnancy physiology and pathophysiology. Patients with severe pre-eclampsia therefore present an interdisciplinary challenge to obstetricians and physicians, who need to be familiar with pregnancy physiology and the current concepts in the pathogenesis and pathophysiology of severe pre-eclampsia. Patients who develop multisystem disease are most appropriately managed by an experienced obstetrician in an obstetric intensive care unit with a physician in consultation.
Collapse
|
10
|
Guinn DA, Abel DE, Tomlinson MW. Early goal directed therapy for sepsis during pregnancy. Obstet Gynecol Clin North Am 2008; 34:459-79, xi. [PMID: 17921010 DOI: 10.1016/j.ogc.2007.06.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Sepsis is a leading cause of death in pregnancy and results in significant perinatal mortality. These deaths occur despite the younger age of pregnant patients, the low rate of comorbid conditions and the potential for effective interventions that should result in rapid resolution of illness. To date, no "evidence-based" recommendations are specific to the pregnant patient who is critically ill or septic. Optimal care for the septic patient requires a multidisciplinary team with expertise in obstetrics, maternal-fetal medicine, critical care, infectious disease, anesthesia, and pharmacy. Coordination of care and good communication amongst team members is essential. Incorporation of early goal directed therapy for suspected sepsis into obstetric practice is needed to optimize maternal and neonatal outcomes.
Collapse
Affiliation(s)
- Debra A Guinn
- Northwest Perinatal Center, 9701 SW Barnes Road, Suite 299, Portland, OR 97225, USA.
| | | | | |
Collapse
|
11
|
Abstract
AIM To assess the safety of labor epidural analgesia in subjects with pre-eclampsia. METHODS Nulliparous laboring women were included in the prospective study. One hundred pre-eclamptic nullipara who were given epidural analgesia (group I) were compared with 100 nullipara with pre-eclampsia who were not given epidural analgesia (group II). The outcome was further compared with 200 women who were not pre-eclamptic, but who were given epidural analgesia (group III), and also with 200 women who were normotensive and who were not given epidural analgesia (group IV). RESULTS In group I, 58% of subjects delivered normally compared with 60% in group II. The operative vaginal delivery rate was 28% in group I compared with 24% in group II (P = 0.62), and the cesarean section rate was 14% and 16% in groups I and II, respectively, (P = 0.8). The difference was not statistically significant. The incidence of a prolonged second stage of labor was also not increased in pre-eclamptic women who received epidural analgesia. Five of the neonates in group I had a 5-min APGAR score <6 compared with seven neonates in group II. The necessity of neonatal resuscitation was also not significantly increased in group I (P = 1.0). The incidences of fetal distress (P = 0.71), non-progressive second stage of labor (P = 0.66) and cephalopelvic disproportion (P = 0.90) were not statistically different in the pre-eclampsia group compared with the non-pre-eclampsia group. Similar results were noted when these outcome measures were compared with the other two groups. With regard to hypotension and tachycardia in the pre-eclamptic subjects who were given epidural analgesia, no statistical difference (P = 0.72) was seen when compared with the normotensive subjects. CONCLUSION In the absence of coagulopathy, epidural analgesia is a safe and effective method for labor pain relief, even for subjects with pre-eclampsia.
Collapse
Affiliation(s)
- Purvi Patel
- Department of Obstetrics and Gynecology, Medical College and Shree Sayaji General Hospital, Baroda, India.
| | | | | |
Collapse
|
12
|
Affiliation(s)
- Kjersti M Aagaard-Tillery
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | | |
Collapse
|
13
|
Ascarelli MH, Johnson V, McCreary H, Cushman J, May WL, Martin JN. Postpartum Preeclampsia Management With Furosemide: A Randomized Clinical Trial. Obstet Gynecol 2005; 105:29-33. [PMID: 15625138 DOI: 10.1097/01.aog.0000148270.53433.66] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This investigation was undertaken to estimate whether a brief postpartum course of furosemide for patients with preeclampsia benefits recovery and shortens hospitalization by enhancing diuresis, lessening severe hypertension, and reducing the need for antihypertensive therapy. METHODS Two hundred sixty-four patients with preeclampsia were enrolled. After spontaneous onset of postpartum diuresis and discontinuation of intravenous magnesium sulfate, patients were randomly assigned to receive either no therapy or 20 mg oral furosemide daily for 5 days with oral potassium supplementation. Patient outcomes were compared between treatment groups with regard to classification of hypertensive disease. RESULTS Only postpartum patients with severe preeclampsia (n = 70) who received furosemide compared with controls had significantly lower systolic blood pressure by postpartum day 2 (142 +/- 13 mm Hg compared with 153 +/- 19 mm Hg, P < .004) and required less antihypertensive therapy during hospitalization (14% compared with 26%, P = .371) and at discharge (6% compared with 26%, P = .045). No benefit was shown for patients with mild preeclampsia (n = 169) or superimposed preeclampsia (n = 25). Neither length of hospitalization nor frequency of delayed postpartum complications was positively affected by the intervention. CONCLUSION Brief postpartum furosemide therapy for patients with severe preeclampsia seems to enhance recovery by normalizing blood pressure more rapidly and reducing the need for antihypertensive therapy. Shortening of hospitalization and reduction of delayed postpartum complications were not benefitted.
Collapse
Affiliation(s)
- Marian H Ascarelli
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi 39216, USA
| | | | | | | | | | | |
Collapse
|
14
|
Reid CJ, Con A. Don't forget the A in eclampsia. Emerg Med Australas 2004; 16:92-3; author reply 93. [PMID: 15239770 DOI: 10.1111/j.1742-6723.2004.00543.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
15
|
Lew M. Reply. Emerg Med Australas 2004; 16:93. [PMID: 15239771 DOI: 10.1111/j.1742-6723.2004.00542.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Martin Lew
- Maroondah Hospital Emergency DepartmentMelbourne, Vic., Australia
| |
Collapse
|
16
|
Bridges EJ, Womble S, Wallace M, McCartney J. Hemodynamic Monitoring in High-Risk Obstetrics Patients, II. Crit Care Nurse 2003. [DOI: 10.4037/ccn2003.23.5.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Elizabeth J. Bridges
- Elizabeth J. Bridges is Deputy Commander of the 59th Clinical Research Squadron and senior nurse researcher at the 59th Medical Wing, Lackland AFB, San Antonio, Tex
| | - Shannon Womble
- Shannon Womble, Marlene Wallace, and Jerry McCartney are staff nurses in the surgical intensive care unit of the 59th Medical Wing at Lackland AFB
| | - Marlene Wallace
- Shannon Womble, Marlene Wallace, and Jerry McCartney are staff nurses in the surgical intensive care unit of the 59th Medical Wing at Lackland AFB
| | - Jerry McCartney
- Shannon Womble, Marlene Wallace, and Jerry McCartney are staff nurses in the surgical intensive care unit of the 59th Medical Wing at Lackland AFB
| |
Collapse
|
17
|
Affiliation(s)
- Linda S Polley
- Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI 48109, USA.
| |
Collapse
|
18
|
Abstract
Hypertensive disorders during pregnancy, which account for approximately 15% of pregnancy-related deaths, represent the second-leading cause of morbidity and mortality in the United States. New classifications recommended by the National Institutes of Health's Working Group on High Blood Pressure in Pregnancy have decreased the confusion often associated with these disorders. The cause of preeclampsia-eclampsia still remains elusive, but continued research has provided hope with regard to screening, improved diagnosis, and management. Risk factors that have recently gained attention include inherited thrombophilias, inherited metabolic disorders, and lipid disorders. Treatment and management of the hypertensive disorders of pregnancy have not changed substantially in the past 50 years. Prevention of preeclampsia-eclampsia has been unsuccessful, and recurrence risks remain high. Careful diagnosis, classification, and further investigation of the causes of hypertensive disorders in pregnancy are needed to achieve optimal management of affected women and their fetuses.
Collapse
Affiliation(s)
- Sherri A Longo
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Tulane University School of Medicine, New Orleans, LA 70112, USA
| | | | | |
Collapse
|
19
|
Bridges EJ, Womble S, Wallace M, McCartney J. Hemodynamic Monitoring in High-Risk Obstetrics Patients, I. Crit Care Nurse 2003. [DOI: 10.4037/ccn2003.23.4.53] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Elizabeth J. Bridges
- Elizabeth J. Bridges is the deputy commander of the 59th Clinical Research Squadron and the director of nursing research in the 59th Medical Wing, Lackland AFB, San Antonio, Tex
| | - Shannon Womble
- Shannon Womble, Marlene Wallace, and Jerry McCartney are staff nurses in the surgical intensive care unit of the 59th Medical Wing at Lackland AFB
| | - Marlene Wallace
- Shannon Womble, Marlene Wallace, and Jerry McCartney are staff nurses in the surgical intensive care unit of the 59th Medical Wing at Lackland AFB
| | - Jerry McCartney
- Shannon Womble, Marlene Wallace, and Jerry McCartney are staff nurses in the surgical intensive care unit of the 59th Medical Wing at Lackland AFB
| |
Collapse
|
20
|
Abstract
Eclampsia and severe pre-eclampsia are rare, but potentially life-threatening conditions that emergency physicians must be able to diagnose and treat promptly, because initial presentations to the ED are real possibilities. The treatment of the major complications of this disorder, hypertension and seizures, have been the focus of much research. Magnesium sulphate is now the first line agent for acute treatment and prophylaxis of seizures in eclampsia and pre-eclampsia. Severe pre-eclampsia should be treated with magnesium to prevent progression to eclampsia. Severe hypertension requires treatment with an intravenous antihypertensive agent familiar to the clinician. No single antihypertensive has been proven to be better than another, although in Australia, hydralazine is probably the initial intravenous agent of choice. Routine use of invasive haemodynamic monitoring and volume expansion is not recommended and consultation with obstetric colleagues is essential.
Collapse
Affiliation(s)
- Martin Lew
- Maroondah Hospital, Emergency Department, Mt Dandenong Road, East Ringwood 3135, Vic., Australia.
| | | |
Collapse
|
21
|
Singh U, Gopalan P, Rocke D. Anesthesia for the Patient with Severe Preeclampsia. Hypertens Pregnancy 2002. [DOI: 10.1201/b14088-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
22
|
Rokey R. Intensive Care of the Patient with Complicated Preeclampsia. Hypertens Pregnancy 2002. [DOI: 10.1201/b14088-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
23
|
Rokey R. Echocardiography and Pregnancy. Hypertens Pregnancy 2002. [DOI: 10.1201/b14088-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
24
|
Isler CM, Martin JN. Preeclampsia: Pathophysiology and practice considerations for the consulting nephrologist. Semin Nephrol 2002. [DOI: 10.1053/snep.2002.28671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
25
|
Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 2000. [DOI: 10.1067/mob.2000.107928] [Citation(s) in RCA: 1842] [Impact Index Per Article: 76.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
26
|
Gilbert WM, Towner DR, Field NT, Anthony J. The safety and utility of pulmonary artery catheterization in severe preeclampsia and eclampsia. Am J Obstet Gynecol 2000; 182:1397-403. [PMID: 10871455 DOI: 10.1067/mob.2000.106179] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The objective of this research was to study the safety and utility of pulmonary artery catheterization in the management of severe preeclampsia and eclampsia. STUDY DESIGN In a retrospective chart review from January 1, 1995, through December 31, 1997, a total of 115 patients admitted to the obstetric intensive care unit at Groote Schuur Hospital were found to have required placement of a pulmonary artery catheter. From this population 100 maternal charts were examined for medical and pregnancy history, including indication for pulmonary artery catheter placement, hemodynamic readings, complications, and subsequent management. RESULTS The initial indications for pulmonary artery catheter placement in cases of severe preeclampsia or eclampsia were renal failure in 53 cases (53%), pulmonary edema in 30 (30%), and eclampsia in 17 (17%). Subjective evaluation demonstrated that the pulmonary artery catheter was helpful in determining management in 93 cases (93%). There was a 4.0% complication rate, which included three venous thromboses and one case of cellulitis. Eleven patients required dialysis, and 3 women died. The mean (+/-SE) duration of catheter placement was 2.1 +/- 0.1 days and the mean (+/-SE) intensive care unit and hospital stays were 3.4 +/- 0.2 days and 11.4 +/- 0.8 days, respectively. The pulmonary artery catheter measurements of pulmonary artery wedge pressure and central venous pressure were increased in the cases of pulmonary edema (21.0 +/- 2.0 mm Hg and 9. 6 +/- 1.2 mm Hg, respectively) but were normal in the cases of renal failure and eclampsia. CONCLUSION Despite significant maternal morbidity and mortality, pulmonary artery catheter use in cases of severe preeclampsia or eclampsia was subjectively beneficial in 93 of 100 cases (93%), with an acceptable complication rate (4.0%).
Collapse
Affiliation(s)
- W M Gilbert
- Department of Obstetrics and Gynecology, the University of California, Davis, USA
| | | | | | | |
Collapse
|
27
|
Brown MA, Hague WM, Higgins J, Lowe S, McCowan L, Oats J, Peek MJ, Rowan JA, Walters BN. The detection, investigation and management of hypertension in pregnancy: full consensus statement. Aust N Z J Obstet Gynaecol 2000; 40:139-55. [PMID: 10925900 DOI: 10.1111/j.1479-828x.2000.tb01137.x] [Citation(s) in RCA: 235] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M A Brown
- Australasian Society for the Study of Hypertension in Pregnancy, Sydney NSW, Australia
| | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Williams KP, Wilson S. Antepartum middle mean cerebral blood flow velocity correlation with maternal hemodynamics. Hypertens Pregnancy 1999; 18:273-8. [PMID: 10586530 DOI: 10.3109/10641959909016200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine the correlation between simultaneous assessment of maternal middle cerebral blood flow velocity with the other maternal hemodynamic factors of cardiac output and mean arterial pressure. STUDY DESIGN Eight normotensive patients were assessed. Maternal cerebral blood flow velocity was assessed using transcranial Doppler. Cardiac output was assessed noninvasively using the thoracic electrical bioimpedance technique over four cycles. Transcranial assessment of cerebral blood flow velocity was done over four cycles. Statistical analysis was then done using the Pearson correlation coefficient and linear regression analysis with stepwise regression. A p-value of < 0.05 was considered significant. RESULTS The value of the hemodynamic parameters were cardiac output 8.6 +/- 2.6 L/min, mean arterial pressure 82 +/- 9.7 mm Hg, and mean maternal cerebral blood flow velocity 59.6 +/- 11 cm/s. The pulsatility index was 0.85 +/- 0.15. The mean blood pressure could only explain 42% of the variation in systolic maternal cerebral blood flow velocity and 32% of the variation in mean maternal cerebral blood flow velocity. The mean middle cerebral blood flow velocity did not correlate with cardiac output. CONCLUSIONS Middle cerebral artery velocity correlates moderately with mean arterial pressure but not with cardiac output. The control of mean arterial pressure cannot be used as the only indicator of appropriate reduction in cerebral blood flow velocity.
Collapse
Affiliation(s)
- K P Williams
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada.
| | | |
Collapse
|
29
|
Shear R, Leduc L, Rey E, Moutquin JM. Hypertension in pregnancy: new recommendations for management. Curr Hypertens Rep 1999; 1:529-39. [PMID: 10981117 DOI: 10.1007/s11906-996-0026-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Hypertension in pregnancy is a frequent complication that has substantial adverse perinatal outcomes. Hypertension may be preexisting (chronic) essential or secondary hypertension; a second entity is pregnancy induced (gestational hypertension, preeclampsia). Recent advances have identified newer markers for pregnancy hypertension: several potential candidate genes may explain the apparent family inheritance of preeclampsia, and some thrombophilic markers have been associated with the condition. Management options for mild to moderate hypertension include a short hospital stay to exclude ongoing severe hypertension and to ascertain fetal well-being. Outpatient care with appropriate maternal and fetal surveillance, including umbilical artery doppler velocimetry, is recommended for better perinatal outcomes. Acute care for severe hypertension includes the use of magnesium sulfate to prevent eclampsia and antihypertensive medication. Expeditious delivery is recommended when the maternal or fetal states cannot be stabilized. Follow-up after delivery allows the uncovering of any other coexisting hypertensive or cardiovascular disorder.
Collapse
Affiliation(s)
- R Shear
- Department of Obstetrics and Gynecology, Sainte-Justine Hospital, Université de Montréal, Montréal, Canada
| | | | | | | |
Collapse
|
30
|
Abstract
We review the evidence base for fluid management in pre-eclampsia. Current understanding of the relevant pathophysiology and the possible impact of styles of fluid management on maternal and fetal outcome are presented. There is little evidence upon which to base the management of fluid balance in pre-eclampsia. Reports are conflicting and no large prospective outcome studies of fluid management have been performed. Volume expansion does not appear to reduce the incidence of fetal distress. Pulmonary oedema and oliguria receive particular attention. There is no evidence of long-term renal damage in pre-eclampsia, but there are strong suggestions that pulmonary oedema is linked to fluid administration. Monitoring is discussed and some principles of management are suggested
Collapse
Affiliation(s)
- T Engelhardt
- Department of Anaesthesia and Intensive Care, University of Aberdeen, Aberdeen, UK
| | | |
Collapse
|
31
|
Abstract
We still do not have an ideal drug to treat acute severe hypertension in pregnancy. Hydralazine and labetalol are the safest agents, but they are inadequate to control blood pressure in some women. Both hypertensive encephalopathy and eclampsia now appear to be forms of an acute process known as reversible posterior leukoencephalopathy syndrome.
Collapse
Affiliation(s)
- W C Mabie
- Department of Obstetrics and Gynecology, University of Tennessee, Memphis 38103, USA
| |
Collapse
|
32
|
Anumba DO, Robson SC. Management of pre-eclampsia and haemolysis, elevated liver enzymes, and low platelets syndrome. Curr Opin Obstet Gynecol 1999; 11:149-56. [PMID: 10219916 DOI: 10.1097/00001703-199904000-00007] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pre-eclampsia remains a major cause of maternal and fetal ill-health. Defective placentation and endothelial dysfunction appear to underlie the clinical features. Recent publications regarding the diagnosis, treatment, prediction and prevention of pre-eclampsia, and contemporary issues in the management of the haemolysis, elevated liver enzymes, and low platelets syndrome, are discussed in this review.
Collapse
Affiliation(s)
- D O Anumba
- Department of Obstetrics and Gynaecology, The Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | | |
Collapse
|
33
|
Abstract
Preeclampsia/eclampsia affects only a small proportion of all pregnancies, yet accounts for much of the obstetric morbidity and mortality seen in the USA and UK. A full understanding of preeclampsia/eclampsia, its variable presentation and complex pathophysiology allows the consulting anesthesiologist to optimize a plan for anesthetic management of the afflicted patient.
Collapse
Affiliation(s)
- H Brodie
- Department of Anesthesiology, University of Maryland and School of Medicine, Baltimore, Maryland 21201, USA
| | | |
Collapse
|
34
|
Abstract
The complicated preeclamptic patient represents a challenge for the clinician faced with her antepartum or postpartum care. The most serious sequelae of preeclampsia account for a significant portion of maternal morbidity and mortality. Severe preeclampsia also results in an appreciable portion of perinatal morbidity and mortality. In this review, developing trends in the treatment of severe preeclampsia are discussed. Expectant treatment of the patient remote from term, anesthesia choices, and delivery route are reviewed. Developing trends in the pharmacological approach to complicated preeclampsia are discussed. New concepts in the treatment of cerebrovascular preeclampsia and hepatic rupture are outlined and reviewed.
Collapse
Affiliation(s)
- J W Van Hook
- Department of Obstetrics and Gynecology, University of Texas Medical Branch at Galveston 77555-0587, USA
| |
Collapse
|
35
|
Saphier CJ, Repke JT. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a review of diagnosis and management. Semin Perinatol 1998; 22:118-33. [PMID: 9638906 DOI: 10.1016/s0146-0005(98)80044-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia that threatens the gravida and her fetus. In this report, the diagnostic criteria and maternal and fetal risks of HELLP are defined. Prompt recognition and treatment in tertiary centers is emphasized, because the prognosis can be adversely affected by delayed or less than optimal diagnosis and treatment. Management guidelines are offered for treating this disorder. The potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Subsequent pregnancy outcome, contraception, and preventative strategies are considered.
Collapse
Affiliation(s)
- C J Saphier
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | |
Collapse
|
36
|
Fox DB, Troiano NH, Graves CR. Use of the pulmonary artery catheter in severe preeclampsia: a review. Obstet Gynecol Surv 1996; 51:684-95. [PMID: 8914161 DOI: 10.1097/00006254-199611000-00023] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The use of a balloon-tipped, flow-directed pulmonary artery catheter in critically ill and surgical patients has become commonplace in the United States since its introduction into clinical medicine in 1970. The capability of acquiring continuous hemodynamic and, more recently, oxygen transport data, has led to an enhanced understanding of pathophysiologic processes in disease states and to an improved ability to guide therapeutic decision making. The purpose of this paper is to review experience with the pulmonary artery catheter in subsets of women with severe preeclampsia.
Collapse
Affiliation(s)
- D B Fox
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | |
Collapse
|
37
|
|
38
|
Chung TK, Rogers MS, Baldwin S, Chang AM, Nicholls MG. Second and early third trimester atrial natriuretic peptide (ANP) levels in pregnancies subsequently complicated by hypertension. JOURNAL OF OBSTETRICS AND GYNAECOLOGY (TOKYO, JAPAN) 1995; 21:515-20. [PMID: 8542478 DOI: 10.1111/j.1447-0756.1995.tb01046.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To explore the clinical utility of measuring atrial natriuretic peptide (ANP) in the second and early third trimesters of pregnancy in order to predict pregnancy induced hypertension (PIH). METHODS AND MATERIALS The study was done in a University Teaching Hospital. A prospective study of 200 women in their first pregnancy was conducted. ANP was measured at 2 gestational windows, 20-26 weeks and 30-34 weeks. This was correlated with pregnancy outcomes, in particular PIH. Student's t-test was used to compare ANP levels between women who developed PIH and those who did not. The receiver operator curve (ROC) was used to determine its clinical utility. RESULTS ANP levels were lower at 20-26 weeks in women who subsequently developed PIH but there was no significant difference at 30-34 weeks between women who had normotensive pregnancies and those who later developed PIH. The character of the ROC would indicate that it is not useful for prediction. CONCLUSION ANP levels in the second and early third trimesters has limited clinical utility for the prediction of PIH.
Collapse
Affiliation(s)
- T K Chung
- Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, HOng Kong
| | | | | | | | | |
Collapse
|
39
|
Abstract
High blood pressure, which complicates approximately 10% of all pregnancies, remains a major cause of morbidity and mortality for both mother and fetus. A relative paucity of investigative data, as well as the frequent difficulty in making an etiological diagnosis by clinical criteria alone, may be among the reasons why there are many conflicts about the management of hypertension during pregnancy. This clinical conference summarizes current concepts regarding the hypertensive disorders of gestation, focusing on the most dangerous cause, preeclampsia-eclampsia. It further highlights a recent report of the Working Group on High Blood Pressure in Pregnancy convened by the National High Blood Pressure Education Program at the National Heart, Lung, and Blood Institute (the Consensus Report). Among the Working Group's most interesting recommendations in controversial areas were a return to the classification schema suggested by the American College of Obstetricians and Gynecologists in 1972, use of the fifth Korotkoff sound to determine diastolic blood pressure levels, and institution of treatment with antihypertensive drugs for sudden elevations of blood pressure near term to diastolic levels greater than or equal to 105 mm Hg or for levels of 100 mm Hg or higher in pregnant women with chronic hypertension. The Consensus Report further recommended parenteral hydralazine and methyldopa as the drugs of choice for the acute hypertensive crisis and management of chronic hypertension, respectively, based on the long histories of safe use of these agents in gravidas. Parenteral magnesium sulfate remained the preferred therapeutic approach for avoiding or treating the convulsive complication, eclampsia, but the Working Group underscored the need for controlled trials of magnesium's efficacy. Finally, they noted that diuretics should be avoided in preeclampsia, but that these drugs can be continued during gestation if taken before conception, and may be prescribed to pregnant women with chronic hypertension who appear overly salt sensitive.
Collapse
Affiliation(s)
- M D Lindheimer
- Department of Obstetrics and Gynecology, University of Chicago, Ill
| |
Collapse
|
40
|
Lindheimer MD, Cunningham FG. Hypertension and pregnancy: impact of the Working Group report. Am J Kidney Dis 1993; 21:29-36. [PMID: 8494016 DOI: 10.1016/s0272-6386(12)70252-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- M D Lindheimer
- Department of Obstetrics & Gynecology, University of Chicago, IL
| | | |
Collapse
|
41
|
Nolan TE, Wakefield ML, Devoe LD. Invasive hemodynamic monitoring in obstetrics. A critical review of its indications, benefits, complications, and alternatives. Chest 1992; 101:1429-33. [PMID: 1582312 DOI: 10.1378/chest.101.5.1429] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- T E Nolan
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta 30912
| | | | | |
Collapse
|
42
|
Abstract
Only one study has examined the clinical issues presented by critically ill obstetric patients with respect to medical indications for intensive care unit (ICU) admission and fetal and maternal morbidity and mortality. Therefore, a review of all obstetric patients admitted to a medical-surgical ICU in a large tertiary referral center over a five-year period was conducted. Obstetric, ICU-related, and diagnostic data were recorded for each patient. The diagnosis of the disease responsible for the patient's critical illness was categorized as obstetric or nonobstetric. The diagnosis that prompted ICU admission was determined for each patient and was categorized as respiratory failure, hemodynamic instability, or neurologic dysfunction. There were 32 obstetric admissions representing 0.4 percent of all deliveries during this time period. There was a predominance of postpartum admissions and obstetric diagnoses responsible for the patient's critical illness. Preeclampsia was the single most common diagnosis representing 22 percent of all patients. Hemodynamic instability was never the cause of antepartum ICU admission in patients with a viable fetus. In contrast, hemodynamic instability accounted for 52 percent of postpartum ICU admissions. Of the eight women admitted with viable pregnancies to the ICU, seven were delivered during the ICU stay and all fetuses survived. There was a high incidence of acute lung injury (25 percent) that was associated with nonpulmonary or pulmonary infection in all eight cases. However, the mortality was only 25 percent.
Collapse
Affiliation(s)
- S J Kilpatrick
- Department of OB-GYN, University of California, San Francisco 94143
| | | |
Collapse
|
43
|
Affiliation(s)
- F G Cunningham
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas 75235-9032
| | | |
Collapse
|
44
|
Abstract
Severe pregnancy induced hypertension (PIH, pre eclampsia) is a disease which is now treated in the intensive care unit rather than with sedation in a dark room. The pathophysiology is now well understood and allows for better and more effective management. This paper looks at the strict haemodynamic monitoring and management required to prevent complications such as eclampsia, DIC, HELLP syndrome, maternal and foetal death. The nurse's role in the management of severe PIH is discussed.
Collapse
|
45
|
|
46
|
European Society of Intensive Care Medicine. Expert panel: the use of the pulmonary artery catheter. Intensive Care Med 1991; 17:I-VIII. [PMID: 2071758 DOI: 10.1007/bf01704735] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
47
|
Crosby ET. Obstetrical anaesthesia for patients with the syndrome of haemolysis, elevated liver enzymes and low platelets. Can J Anaesth 1991; 38:227-33. [PMID: 2021995 DOI: 10.1007/bf03008152] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The syndrome of haemolysis, elevated liver enzymes and low platelets (HELLP Syndrome) is a consequence of severe preeclampsia/eclampsia. The clinical course is characterized by an unusual presentation with abdominal pain, and manifestations of inadequate haemostasis and excessive bleeding are common. Maternal and perinatal morbidity and mortality are high. We report our experience with 33 patients over a five-year period. The mean gestational age (GA) of the pregnancies was 34 +/- 2.8 wk including 11 patients who delivered 12 neonates of less than 34 wk GA. The most common presenting complaints were right upper quadrant or epigastric pain in 25 patients (76%) and nausea or vomiting in 14 patients (42%). Diagnosis was missed or delayed in 12 patients (36%). Thirty-one patients (94%) were delivered by Caesarean section and a deteriorating maternal condition was the most common indication for operative delivery. Twenty-three patients received general anaesthesia, eight received epidural anaesthesia and there were no complications related to the anaesthetic. There was clinical evidence of abnormal haemostasis: seven patients had excessive blood loss at Caesarean section, two had postpartum haemorrhage, three developed DIC and four developed wound haematoma. The average decrease in haemoglobin concentration was 32 g.L-1 and twelve patients (36%) received blood transfusions. There was one stillbirth. There were no neonatal deaths but morbidity was prominent and related primarily to prematurity. Delayed or missed diagnosis is common in HELLP syndrome and a premature delivery by Caesarean section is usual.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- E T Crosby
- Department of Anaesthesia, Ottawa General Hospital, University of Ottawa, Ontario, Canada
| |
Collapse
|
48
|
National High Blood Pressure Education Program Working Group Report on High Blood Pressure in Pregnancy. Am J Obstet Gynecol 1990; 163:1691-712. [PMID: 2104525 DOI: 10.1016/0002-9378(90)90653-o] [Citation(s) in RCA: 282] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This consensus report focuses the presentation, pathophysiology, and management of the hypertensive disorders of pregnancy expanding on recommendations first presented in 1988 by the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Practicing physicians should determine whether a patient's hypertension during pregnancy falls into the classification of (1) chronic hypertension, (2) preeclampsia, (3) preeclampsia superimposed on chronic hypertension, or (4) transient hypertension. The distinction, for management considerations, is made between hypertension that is present before pregnancy (chronic and preexisting) and that occurring as part of the pregnancy-specific condition preeclampsia. When maternal blood pressure reaches diastolic levels of 100 mm Hg or greater, treatment should be instituted to avoid hypertensive vascular damage. The report includes a discussion of antihypertensive therapy specific to the chronic or acute hypertension occurring concomitantly with pregnancy. The roles of calcium supplementation and low-dose aspirin to prevent preeclampsia and chronic and transient hypertension are under investigation.
Collapse
|
49
|
Clark SL, Cotton DB, Lee W, Bishop C, Hill T, Southwick J, Pivarnik J, Spillman T, DeVore GR, Phelan J. Central hemodynamic assessment of normal term pregnancy. Am J Obstet Gynecol 1989; 161:1439-42. [PMID: 2603895 DOI: 10.1016/0002-9378(89)90900-9] [Citation(s) in RCA: 277] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Ten carefully screened primiparous patients between 36 and 38 weeks' gestation underwent pulmonary artery catheterization, arterial line placement, and central hemodynamic assessment in the left lateral recumbent position. Studies were repeated in the same patients between 11 and 13 weeks post partum. Compared with the nonpregnant state, there was a significant fall in systemic vascular resistance, pulmonary vascular resistance, colloid oncotic pressure, and colloid oncotic pressure-pulmonary capillary wedge pressure gradient by the late phase of the third trimester (p less than 0.05). Pregnancy was associated with a significant rise in cardiac output and pulse in all patients (p less than 0.05). There was no significant change in pulmonary capillary wedge pressure, central venous pressure, left ventricular stroke work index, or mean arterial pressure. Normally the late phase of the third trimester is not associated with hyperdynamic left ventricular function as assessed by the left ventricular stroke work index/pulmonary capillary wedge pressure ratio.
Collapse
Affiliation(s)
- S L Clark
- Utah Valley Regional Perinatal Center, Brigham Young University, Provo
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
|