Point-of-care lung ultrasound patterns in late third-trimester gravidas with and without preeclampsia

The role of point-of-care ultrasound to monitor response of fluid replacement therapy in pregnancy

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.

Point-of-Care Ultrasound in Critical Care Obstetrics: A Scoping Review of the Current Evidence

OBJECTIVES

To synthesize the current evidence of maternal point-of-care ultrasound (POCUS) in obstetrics. A scoping review was conducted using PubMed, Clinicaltrials.gov, and the Cochrane library from inception through October 2023.

METHODS

Studies were eligible for inclusion if they described the use of POCUS among obstetric or postpartum patients. Two authors independently screened all abstracts. Quantitative, qualitative, and mixed-methods studies were eligible for inclusion. Case reports of single cases, review articles, and expert opinion articles were excluded. Studies describing detailed maternal nonobstetric sonograms or maternal first trimester sonograms to confirm viability and rule out ectopic pregnancy were also excluded. Data were tabulated using Microsoft Excel and summarized using a narrative review and descriptive statistics.

RESULTS

A total of 689 publications were identified through the search strategy and 12 studies met the inclusion criteria. Nine studies evaluated the use of lung POCUS in obstetrics in different clinical scenarios. Lung ultrasound (LUS) findings in preeclampsia showed an excellent ability to detect pulmonary edema (area under the receiver operating characteristic 0.961) and findings were correlated with clinical evidence of respiratory distress (21 of 57 [37%] versus 14 of 109 [13%]; P = .001). Three studies evaluated abdominal POCUS, two of the inferior vena cava (IVC) to predict postspinal anesthesia hypotension (PSAH) and fluid receptivity and one to assess the rate of ascites in patients with preeclampsia. Patients with PSAH had higher IVC collapsibility (area under the curve = 0.950, P < .001) and, in patients with severe preeclampsia, there is a high rate of ascites (52%) associated with increased risk of adverse outcomes. There were no studies on the use of subjective cardiac POCUS.

CONCLUSION

POCUS use in the management of high-risk obstetrics has increased. LUS has been the most studied modality and appears to have a potential role in the setting of preeclampsia complicated by pulmonary edema. Cardiac and abdominal POCUS have not been well studied. Trials are needed to evaluate its clinical applicability, reliability, and technique standardization before widespread use.

Thoracic ultrasound use in hospitalized and ambulatory adult patients: a quantitative picture

INTRODUCTION AND OBJECTIVES

Thoracic ultrasound (TUS) has been established as a powerful diagnostic and monitoring tool in the Intensive Care Unit (ICU). However, studies outside the critical care setting are scarce. The aim of this study was to investigate the value of TUS for hospitalized or ambulatory community patients.

MATERIALS AND METHODS

This was a retrospective study conducted from 2016 to 2020 in the TUS clinic at Heraklion University Hospital. TUS examination was performed using a standard ultrasound machine (EUB HITACHI 8500), and a high-frequency microconvex probe (5-8 MHz). Patients had been referred by their primary physician to address a range of different questions. The various respiratory system entities were characterised according to internationally established criteria.

RESULTS

762 TUS studies were performed on 526 patients due to underlying malignancy (n = 376), unexplained symptoms/signs (n = 53), pregnancy related issues (n = 42), evaluation of abnormal findings in X-ray (n = 165), recent surgery/trauma (n = 23), recent onset respiratory failure (n = 12), acute respiratory infection (n = 66) and underlying non-malignant disease (n = 25). Pleural effusion was the commonest pathologic entity (n = 610), followed by consolidation (n = 269), diaphragmatic dysfunction/paradox (n = 174) and interstitial syndrome (n = 53). Discrepancies between chest X-ray and ultrasonographic findings were demonstrated in 96 cases. The TUS findings guided invasive therapeutic management in 448 cases and non-invasive management in 43 cases, while follow-up monitoring was decided in 271 cases.

CONCLUSIONS

This study showed that TUS can identify the most common respiratory pathologic entities encountered in hospitalized and community ambulatory patients, and is especially useful in guiding the decision making process in a diverse group of patients.

Past and Present of Point-of-Care Ultrasound (PoCUS): A Narrative Review

This article aims to conduct a literature review to gain insight into point-of-care ultrasound (PoCUS). PoCUS is a rapid, accurate, non-invasive, and radiation-free imaging modality that can be used in stable and unstable patients. PoCUS can be performed parallel to physical examination, resuscitation, and stabilization; repeated exams in critical patients are essential for improving sensitivity. The review highlights how PoCUS, which was initially used to detect free intraperitoneal fluid in trauma patients, has developed into a life-saving diagnostic tool that could be utilized by treating physicians during various stages of diagnosis, resuscitation, operation, and postoperative critical care when managing sick patients. The review also notes the barriers to the widespread uptake of PoCUS in general internal medicine and the recent commercial availability of "pocket" or handheld probes that have made PoCUS more readily available. This review concludes that adopting a focused binary decision-making approach can maximize PoCUS's value in many clinical settings, including emergency departments, intensive care units, and operation theatres. Overall, the review emphasizes the importance of awareness of common indications, limitations, and strengths of this evolving and promising technology to determine its future trajectory: Providing comprehensive PoCUS training within internal medicine curriculums and supporting trainers to do so.

Point-of-Care Ultrasonography in the Intensive Care Unit for the Obstetric Patient

Point-of-care ultrasonography (POCUS) is a tool that can be used to evaluate critically ill obstetric patients, in the same way as for nonpregnant patients. With knowledge of the physiology and anatomical changes of pregnancy, POCUS can provide meaningful information to help guide clinical management. A POCUS cardiothoracic evaluation for left and right ventricular function, pulmonary edema, pleural effusion, and pneumothorax can be performed in pregnancy. A Focused Assessment with Sonography in Trauma examination in pregnancy is performed similarly to that in nonpregnant patients, and the information obtained can guide decision-making regarding operative versus nonoperative management of trauma. POCUS is also used to glean important obstetric information in the setting of critical illness and trauma, such as fetal status, gestational age, and placental location. These obstetric evaluations should be performed rapidly to minimize delay and enable pregnant patients to receive the same care for critical illness and trauma as nonpregnant patients.

A Call for Development of Point-of-Care Ultrasound Training Recommendations in Obstetrics and Gynecology Residency

Point-of-care ultrasound (POCUS) skillsets are now taught throughout training levels from medical school through fellowship given the broad utility in assisting with bedside procedures and triaging clinical presentations for expedited workup. This is reflected in training curricula for emergency medicine, internal medicine, and general surgery residencies. However, these skillsets are not formally taught or required in obstetrics and gynecology residency. We present the opinion that these skillsets and curricula should be developed for obstetrics and gynecology trainees given their exposure to patients with similar clinical presentations in which the clinical management would be aided by POCUS.

Lung Inflammation Is Associated with Preeclampsia Development in the Rat

Preeclampsia (PE) is an obstetric complication associated with significant health implications for the fetus and mother. Studies have shown a correlation between lung disease development and PE. Gas6 protein is expressed in the lung and placenta, and binds to the AXL Tyrosine kinase receptor. Recently, our laboratory utilized Gas6 to induce preeclamptic-like conditions in rats. Our objective was to determine the role of Gas6/AXL signaling in the maternal lung during PE development. Briefly, pregnant rats were divided into control, Gas6, or Gas6 + R428 (an AXL inhibitor). Immunofluorescence was performed to determine AXL expression. Bronchoalveolar lavage fluid (BALF) was procured for the assessment of inflammatory cell secretion. Western blot was performed to detect signaling molecules and ELISA determined inflammatory cytokines. We observed increased proteinuria and increased blood pressure in Gas6-treated animals. AXL was increased in the lungs of the treated animals and BALF fluid revealed elevated total protein abundance in Gas6 animals. Extracellular-signal regulated kinase (ERK) and protein kinase B (AKT) signaling in the lung appeared to be mediated by Gas6 as well as the secretion of inflammatory cytokines. We conclude that Gas6 signaling is capable of inducing PE and that this is associated with increased lung inflammation.

Gallbladder wall thickening in a woman with postpartum preeclampsia: A case report

Background

Preeclampsia (PE) is hallmarked by dysfunction of various organs; therefore, its diagnosis can be challenging, especially when patients present with right upper abdominal pain. Herein, we present a case of postpartum gallbladder wall thickening (GBWT) that led to a diagnosis of PE, rather than hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome or gallbladder and biliary disease.

Case Presentation

A 31-year-old postpartum woman presented with a fever, hypertension, headache, and right upper abdominal pain. HELLP syndrome and intracranial hemorrhage were initially suspected, due to the combination of symptoms and elevated levels of aspartate transaminase, alanine transaminase, and lactate dehydrogenase. However, hemolysis and thrombocytopenia were absent, and a computed tomography (CT) scan of the head did not indicate the presence of intracranial hemorrhage. Further, transabdominal ultrasound and CT revealed GBWT (edematous gallbladder); CT also revealed an enlarged heart, lung edema, pleural effusion, and ascites. Thus, PE, rather than HELLP syndrome or gallbladder or biliary disease, was diagnosed based on gestational hypertension and proteinuria, new-onset headache, liver dysfunction, and edema in several organs, including the lung. Nicardipine treatment quickly improved hypertension and headache, and, over time, the patient's urination increased, and edema subsided throughout the body. Furthermore, laboratory results improved, and the patient was discharged on postpartum day 11.

Conclusion

Postpartum gallbladder wall thickening can be a diagnostic sign of PE.

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Preeclampsia can cause edema in several organs.

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We present a case of postpartum gallbladder wall thickening.

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Gallbladder wall thickening can aid in the diagnosis of preeclampsia in cases with right upper abdominal pain.

Point-of-Care Ultrasound (POCUS) for the assessment of volume status and fluid management in patients with severe pre-eclampsia: A systematic review and meta-analysis

BACKGROUND AND AIMS

Appropriate volume assessment and fluid management can prevent maternal deaths in the severely pre-eclamptic (SPE) parturients. We planned a systematic review and meta-analysis (MA) to evaluate the role and ability of point-of-care ultrasound (POCUS) in the assessment of volume status and early detection of lung oedema in an SPE parturient.

METHODS

An e-literature search was done from several databases. Data were extracted under five domains including POCUS-derived parameters like echo comet score (ECS), lung ultrasound (LUS) scores, B-patterns, optic nerve sheath diameter (ONSD), E/e' ratio, presence of pleural effusion, pulmonary interstitial syndrome and pulmonary congestion. The risk of bias was assessed. Extracted data were analysed using MetaXL and Revman 5.3. Heterogeneity in the studies was evaluated using the Cochrane Q test and I2 statistics. Funnel plots were used for the assessment of publication bias.

RESULTS

Seven prospective studies including 574 parturients (including 396 pre-eclamptics) were selected. POCUS included lung, optic nerve, cardiac and thoracic US. In two studies, the ECS and LUS scores pre-delivery were higher in pre-eclamptics. Two studies found a mean ONSD of 5-5.84 mm before delivery. MA revealed a significantly lower mean ECS score at post-delivery than pre-delivery, and the summary prevalence of B-pattern and pleural effusion among SPE parturients was found to be 0.28 (0.03-0.84) and 0.1 (0-0.2), respectively. A good correlation was observed between B-line patterns and diastolic dysfunction (increased E/e' ratio), LUS score and thoracic fluid content, ONSD and ECS in individual studies.

CONCLUSION

POCUS parameters can be useful as early markers of fluid status and serve as useful tools in the precise clinical management of pre-eclampsia.