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Susanu C, Harabor A, Vicoveanu P, Vasilache IA, Călin AM. Anesthetic Considerations and Outcomes in Amniotic Fluid Embolism: A Retrospective Study over a 15-Year Period. J Clin Med 2024; 13:2916. [PMID: 38792456 PMCID: PMC11122586 DOI: 10.3390/jcm13102916] [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: 03/17/2024] [Revised: 04/24/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
(1) Background: A rare and unexpected consequence of childbirth, labor, or the immediate postpartum period is amniotic fluid embolism (AFE). This study aims to identify AFE cases during or immediately after birth from anesthetic management perspectives. Secondary goals include assessing patient clinical features, obstetric care techniques, birth outcomes, and case survival. (2) Methods: A retrospective observational study assessed AFE patients hospitalized in three Romanian clinical institutions from October 2007 to April 2023. Based on the Society of Maternal-Fetal Medicine (SMFM) criteria, we diagnosed 11 AFE patients. (3) Results: AFE occurred in eight cases (73%) during peripartum, two (18%) within 30 min after placental delivery, and 1 (9%) during a scheduled cesarean surgery. Only one of six cardiorespiratory arrest patients responded to external cardiac massage, while the other five (83%) needed defibrillation. The patients received, on average, five units of red blood cells, six of fresh frozen plasma, and two of activated platelets. Six patients (55%) received factor VIIa infusions. Maternal mortality was 36.3%. Six neonates (75%) needed neonatal resuscitation, and two (25%) died on the second and third days. (4) Conclusions: AFE management necessitates a multidisciplinary approach and the incorporation of advanced life support techniques to optimize outcomes for both the mother and newborn.
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Affiliation(s)
- Carolina Susanu
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University, 800216 Galati, Romania; (C.S.)
| | - Anamaria Harabor
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University, 800216 Galati, Romania; (C.S.)
| | - Petronela Vicoveanu
- Department of Mother and Newborn Care, Faculty of Medicine and Biological Sciences, ‘Ștefan cel Mare’ University, 720229 Suceava, Romania
| | - Ingrid-Andrada Vasilache
- Department of Mother and Child Care, “Grigore T. Popa” University of Medicine and Pharmacy Iasi, 700115 Iasi, Romania;
| | - Alina-Mihaela Călin
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, ‘Dunarea de Jos’ University, 800216 Galati, Romania; (C.S.)
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Buddeberg BS, Seeberger E, Bläsi C, Dutilh G, Steiner LA, Bandschapp O, Palanisamy A, Girard T. Is crystalloid co-loading necessary to prevent spinal hypotension during elective cesarean delivery? A randomized double-blind trial. Int J Obstet Anesth 2024; 58:103968. [PMID: 38485584 DOI: 10.1016/j.ijoa.2023.103968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 11/23/2023] [Accepted: 11/30/2023] [Indexed: 05/07/2024]
Abstract
BACKGROUND Hypotension is common during spinal anesthesia for cesarean delivery. Preventive strategies include fluid loading and phenylephrine. We hypothesized that if prophylactic phenylephrine infusion is used, omission of fluid loading would be non-inferior to fluid co-loading in maintaining cardiac output. We assumed that if there was a difference, the increase in cardiac output would be greater in the no-loading than in the co-loading group. METHODS Term pregnant women scheduled for elective cesarean delivery were randomized to receive 1 L crystalloid co-loading or maintenance fluids only. Phenylephrine was titrated to maintain blood pressure. Changes in cardiac output following spinal anesthesia were the primary outcome. The study was powered as a non-inferiority trial, allowing the no-loading arm to have a 50% greater change in cardiac output. Heart rate, dose of phenylephrine, occurrence of nausea and vomiting, Apgar scores and neonatal acid base status were secondary outcomes. RESULTS Data from 63 women were analyzed. In contrast to our hypothesis, there was 33% less increase in cardiac output with no loading (ratio 0.67, 95% CI 0.15 to 1.36), and 60% greater reduction of cardiac output with no loading (ratio 1.6, 95% CI 1.0 to 2.7). Total dose of phenylephrine was higher in the no-loading group. There may be a less favorable neonatal acid base status without volume loading. CONCLUSION Omission of crystalloid co-loading leads to a decrease in cardiac output which has a potentially unfavorable impact on neonatal acid base status. We conclude that crystalloid co-loading may be useful in the presence of phenylephrine infusion.
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Affiliation(s)
- B S Buddeberg
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland.
| | - E Seeberger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland
| | - C Bläsi
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland
| | - G Dutilh
- Department of Clinical Research, University of Basel, Switzerland
| | - L A Steiner
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - O Bandschapp
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
| | - A Palanisamy
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
| | - T Girard
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Switzerland; Department of Clinical Research, University of Basel, Switzerland
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Ambrožič J, Lučovnik M, Cvijić M. The role of lung and cardiac ultrasound for cardiovascular hemodynamic assessment of women with preeclampsia. Am J Obstet Gynecol MFM 2024; 6:101306. [PMID: 38301997 DOI: 10.1016/j.ajogmf.2024.101306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/10/2024] [Accepted: 01/25/2024] [Indexed: 02/03/2024]
Abstract
Preeclampsia remains the leading cause of maternal morbidity and mortality and is associated with abnormal body fluid homeostasis and cardiovascular dysfunction. Moreover, 2 distinct hemodynamic phenotypes have been described in preeclampsia, which might require different therapeutic approaches. Fluid restriction is mandatory in women at risk of pulmonary edema, whereas additional fluid administration may be required to correct tissue hypoperfusion in women with intravascular volume depletion. As clinical examination alone cannot discriminate among different hemodynamic patterns, optimal management of women with preeclampsia remains challenging. Noninvasive bedside ultrasound has become an important diagnostic and monitoring tool in critically ill patients, and it has been demonstrated that it can also be used in the monitoring of women with preeclampsia. Echocardiography in combination with lung ultrasound provides information on hemodynamic status, cardiac function, lung congestion, and fluid responsiveness and, therefore, could help clinicians identify women at higher risk of life-threatening complications. This review describes the cardiovascular changes in preeclampsia and provides an overview of the ultrasound methodologies that could be efficiently used for better hemodynamic assessment and management of women with preeclampsia.
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Affiliation(s)
- Jana Ambrožič
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia (Drs Ambrožič and Cvijić).
| | - Miha Lučovnik
- Division of Obstetrics and Gynecology, Department of Perinatology, University Medical Centre Ljubljana, Ljubljana, Slovenia (Dr Lučovnik); Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia (Drs Lučovnik and Cvijić)
| | - Marta Cvijić
- Department of Cardiology, University Medical Centre Ljubljana, Ljubljana, Slovenia (Drs Ambrožič and Cvijić); Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia (Drs Lučovnik and Cvijić)
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Pan ZB, Sheng ZM, Zhu M, Mei Z, Shen YP, Liu JP, Qian XW. Randomized Double-Blinded Comparison of Intermittent Boluses Phenylephrine and Norepinephrine for the Treatment of Postspinal Hypotension in Patients with Severe Pre-Eclampsia During Cesarean Section. Drug Des Devel Ther 2024; 18:639-650. [PMID: 38476203 PMCID: PMC10927372 DOI: 10.2147/dddt.s446657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/08/2024] [Indexed: 03/14/2024] Open
Abstract
Background Norepinephrine has fewer negative effects on heart rate (HR) and cardiac output (CO) for treating postspinal hypotension (PSH) compared with phenylephrine during cesarean section. However, it remains unclear whether fetuses from patients with severe pre-eclampsia could benefit from the superiority of CO. The objective of this study was to compare the safety and efficacy of intermittent intravenous boluses of phenylephrine and norepinephrine used in equipotent doses for treating postspinal hypotension in patients with severe pre-eclampsia during cesarean section. Methods A total of 80 patients with severe pre-eclampsia who developed PSH predelivery during cesarean section were included. Eligible patients were randomized at a 1:1 ratio to receive either phenylephrine or norepinephrine for treating PSH. The primary outcome was umbilical arterial pH. Secondary outcomes included other umbilical cord blood gas values, Apgar scores at 1 and 5 min, changes in hemodynamic parameters including CO, mean arterial pressure (MAP), HR, stroke volume (SV), and systemic vascular resistance (SVR), the number of vasopressor boluses required, and the incidence of bradycardia, hypertension, nausea, vomiting, and dizziness. Results No significant difference was observed in umbilical arterial pH between the phenylephrine and norepinephrine groups (7.303±0.38 vs 7.303±0.44, respectively; P=0.978). Compared with the phenylephrine group, the overall CO (P=0.009) and HR (P=0.015) were greater in the norepinephrine group. The median [IQR] total number of vasopressor boluses required was comparable between the two groups (2 [1 to 3] and 2 [1 to 3], respectively; P=0.942). No significant difference was found in Apgar scores or the incidence of maternal complications between groups. Conclusion A 60 µg bolus of phenylephrine and a 4.5 µg bolus of norepinephrine showed similar neonatal outcomes assessed by umbilical arterial pH and were equally effective when treating PSH during cesarean section in patients with severe pre-eclampsia. Norepinephrine provided a higher maternal CO and a lower incidence of bradycardia.
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Affiliation(s)
- Zheng-Bin Pan
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
- Department of Anesthesiology, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, People’s Republic of China
| | - Zhi-Min Sheng
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Miao Zhu
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Zhong Mei
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Yan-Ping Shen
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Jin-Ping Liu
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
| | - Xiao-Wei Qian
- Department of Anesthesiology, Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
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Nivatpumin P, Lertkovit S. Case report: Maternal cardiac arrest at 12 hours postpartum. Heliyon 2024; 10:e23337. [PMID: 38148823 PMCID: PMC10750056 DOI: 10.1016/j.heliyon.2023.e23337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 11/08/2023] [Accepted: 12/01/2023] [Indexed: 12/28/2023] Open
Abstract
Maternal cardiac arrest is a rare occurrence. In this case report, we present a detailed account of a 37-year-old pregnant woman with preeclampsia with severe features who underwent cesarean delivery. The patient experienced dyspnea and hypoxia at 12 hours postpartum, leading to cardiac arrest in the maternity ward. Advanced cardiac life support measures, including 15 minutes of chest compressions, were performed until spontaneous circulation was restored. This study explores the underlying factors contributing to maternal cardiac arrest during the postpartum period. Additionally, it highlights the effective strategies employed by our multidisciplinary team in managing and resolving this critical medical event.
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Affiliation(s)
- Patchareya Nivatpumin
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Saranya Lertkovit
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Zhang SJ, He SZ, Wu JJ, Chen YJ, Lyu GR. Evaluation of extravascular lung water and cardiac function in normal vaginal delivery by intrapartum bedside ultrasound. BMC Pregnancy Childbirth 2024; 24:13. [PMID: 38166871 PMCID: PMC10759567 DOI: 10.1186/s12884-023-06201-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Healthy parturients may experience pulmonary edema and disturbed cardiac function during labor. We aimed to evaluate the extravascular lung water (EVLW), intravascular volume, and cardiac function of normal parturients during spontaneous vaginal delivery by bedside ultrasound. And to explore the correlation between EVLW and intravascular volume, cardiac function. METHODS This was a prospective observational study including 30 singleton-term pregnant women undergoing spontaneous vaginal delivery. Bedside ultrasound was performed at the early labor, the end of the second stage of labor, 2 and 24 h postpartum, and 120 scanning results were recorded. EVLW was evaluated by the echo comet score (ECS) obtained by the 28-rib interspaces technique. Inferior vena cava collapsibility index (IVC-CI), left ventricle ejection fraction, right ventricle fractional area change, left and right ventricular E/A ratio, and left and right ventricular index of myocardial performance (LIMP and RIMP) were measured. Measurements among different time points were compared, and the correlations between ECS and other measurements were analyzed. RESULTS During the spontaneous vaginal delivery of healthy pregnant women, 2 had a mild EVLW increase at the early labor, 8 at the end of the second stage of labor, 13 at 2 h postpartum, and 4 at 24 h postpartum (P < 0.001). From the early labor to 24 h postpartum, ECS first increased and then decreased, reaching its peak at 2 h postpartum (P < 0.001). IVC-CI first decreased and then increased, reaching its minimum at the end of the second stage of labor (P < 0.001). RIMP exceeded the cut-off value of 0.43 at the end of the second stage of labor. ECS was weakly correlated with IVC-CI (r=-0.373, P < 0.001), LIMP (r = 0.298, P = 0.022) and RIMP (r = 0.211, P = 0.021). CONCLUSIONS During spontaneous vaginal delivery, the most vital period of perinatal care is between the end of the second stage of labor and 2 h postpartum, because the risk of pulmonary edema is higher and the right ventricle function may decline. IVC-CI can be used to evaluate maternal intravascular volume. The increase in EVLW may be related to the increase in intravascular volume and the decrease in ventricular function.
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Affiliation(s)
- Shi-Jie Zhang
- Department of Ultrasound, Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian Province, China
| | - Shao-Zheng He
- Department of Ultrasound, Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian Province, China
| | - Jing-Jing Wu
- Department of Obstetrics and Gynecology, Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Yong-Jian Chen
- Department of Ultrasound, Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian Province, China
| | - Guo-Rong Lyu
- Department of Ultrasound, Second Affiliated Hospital of Fujian Medical University, No. 34 North Zhongshan Road, Quanzhou, 362000, Fujian Province, China.
- Department of Clinical Medicine, Quanzhou Medical College, Quanzhou, Fujian Province, China.
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Hamroun A, Prouteau C, Lenain R, Roger C, Bauters A, Zawadzki C, Subtil D, Gibier JB, Stichelbout M, Coppo P, Lionet A, Maanaoui M, Hazzan M, Provôt F. The challenging follow-up of pregnancy in women with known thrombotic thrombocytopenic purpura: a single-center experience of a preemptive management protocol. J Nephrol 2023; 36:2519-2529. [PMID: 37816989 DOI: 10.1007/s40620-023-01790-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/30/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Although thrombotic thrombocytopenic purpura frequently affects women of childbearing age, there is no clear recommendation for the management of subsequent pregnancies in women with established thrombotic thrombocytopenic purpura. METHODS This single-center, retrospective, observational study included all women with hereditary thrombotic thrombocytopenic purpura or immune thrombotic thrombocytopenic purpura who had had at least one subsequent pregnancy after thrombotic thrombocytopenic purpura diagnosis between 2003 and 2022. The strategy comprised weekly surveillance of platelet count during pregnancy (and quarterly monitoring of ADAMTS13 activity) for women with immune thrombotic thrombocytopenic purpura, without any routine prophylactic treatment. In case of thrombocytopenia < 150,000/mm3 (with or without hemolysis relapse), women with hereditary thrombotic thrombocytopenic purpura systematically received plasma infusions twice weekly until platelet count normalized. RESULTS A total of 13 patients were included (7 with hereditary thrombotic thrombocytopenic purpura and 6 with immune thrombotic thrombocytopenic purpura, with 20 planned pregnancies (11 and 9, respectively). All pregnancies resulted in live births, and all mothers survived. There was a marked improvement in pregnancy terms in the hereditary thrombotic thrombocytopenic purpura group compared to index pregnancies (37 [35;39] versus 31 [24;38] weeks, p = 0.037) and birth weights (3265 [3029;3410] versus 2160 [1240;2705] grams, p = 0.016), with need for plasma support mostly starting during the third trimester (5/7 patients, 7/11 pregnancies). A single hereditary thrombotic thrombocytopenic purpura relapse occurred, with rapid resolution after plasma support intensification. There were no relapses in the immune thrombotic thrombocytopenic purpura group, with ADAMTS13 activity systematically above 40% during all monitored pregnancies. CONCLUSION These real-life data support the feasibility of a preemptive approach to pregnancy monitoring in women with known thrombotic thrombocytopenic purpura who undergo active surveillance within a multidisciplinary network.
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Affiliation(s)
- Aghiles Hamroun
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
- UMR1167 RID-AGE, Inserm, Institut Pasteur de Lille, Lille University, 59000, Lille, France
| | - Camille Prouteau
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - Rémi Lenain
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - Camille Roger
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - Anne Bauters
- Department of Hematology and Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, Lille University, Lille, France
| | - Christophe Zawadzki
- Department of Hematology and Transfusion, Pôle de Biologie Pathologie Génétique, CHU Lille, Lille University, Lille, France
| | - Damien Subtil
- CHU Lille, Hôpital Jeanne de Flandre, Lille University, 59000, Lille, France
- Lille University, EA 2694 Santé Publique, Épidémiologie Et Qualité Des Soins, F-59000, Lille, France
| | - Jean-Baptiste Gibier
- Regional and University Hospital Center of Lille, Department of Pathology, Pathology Institute, Lille University, 59037, Lille, France
| | - Morgane Stichelbout
- Regional and University Hospital Center of Lille, Department of Pathology, Pathology Institute, Lille University, 59037, Lille, France
| | - Paul Coppo
- French Reference Centre for Thrombotic Microangiopathies, Saint-Antoine Hospital, Paris, France
- Hematology Department, Saint-Antoine Hospital, Paris, France
- Sorbonne University, Paris, France
| | - Arnaud Lionet
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - Mehdi Maanaoui
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
- Inserm, CHU Lille, Institut Pasteur Lille, Lille University, U1190, EGID, F-59000, Lille, France
| | - Marc Hazzan
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France
| | - François Provôt
- Department of Nephrology, Dialysis, Transplantation, and Apheresis, Lille University, Lille University Hospital Center of Lille, 59000, Lille, France.
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Unal BS, Dennis AT. Perioperative Complications in Patients with Preeclampsia Undergoing Caesarean Section Surgery. J Clin Med 2023; 12:7050. [PMID: 38002664 PMCID: PMC10672454 DOI: 10.3390/jcm12227050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
Caesarean section has risks of bleeding, infection and thromboembolism, and neuroendocrine-metabolic, and inflammatory-immune responses that may worsen outcomes in patients with preeclampsia. There is little research examining perioperative, as opposed to peripartum, outcomes in patients with preeclampsia. We conducted a single-centrecentre retrospective cohort study of perioperative patients with preeclampsia over an eight-month period to determine the rate of perioperative complication. Seventy-two patients were included. The maternal complication rate was 59.7 per 100 operations (95% CI 48.2 to 70.3%). Severe complications included pulmonary oedema 2 (2.8%), haemorrhage > 1000 mL 5 (6.9%), and blood transfusion 2 (2.8%). Twenty (27.8%) patients had a hospital length of stay ≥7 days. The rate of anaemia (haemoglobin < 110 g/L) on hospital discharge was 42 per 100 operations (95% CI 31.0 to 53.2%). Patient representation rate to hospital after discharge was 23.6% per 100 operations (95% CI 15.3 to 34.6%). There were no maternal deaths. The neonatal complication rate was 38.9 per 100 operations (95% CI 28.9 to 51.1%) with one foetal death. Patients with preeclampsia undergoing caesarean section are a very high-risk surgical group who experience significant perioperative complications. Urgent action is needed to confirm these findings and improve outcomes in these patients.
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Affiliation(s)
- Busra Sara Unal
- Hospital Medical Officer, Western Health, St Albans, VIC 3021, Australia;
- The Joan Kirner Women’s and Children’s Hospital, St Albans Sunshine Hospital, Western Health, St. Albans, VIC 3021, Australia
| | - Alicia T. Dennis
- The Joan Kirner Women’s and Children’s Hospital, St Albans Sunshine Hospital, Western Health, St. Albans, VIC 3021, Australia
- Division of Obstetric Anesthesia, Department of Anesthesiology, Perioperative Medicine and Pain Medicine, Brigham and Women’s Hospital, Boston, MA 02115, USA
- Department of Critical Care, Obstetrics, Gynaecology and Newborn Health, Melbourne Medical School, The University of Melbourne, Parkville, VIC 3010, Australia
- The Royal Women’s Hospital, Parkville, VIC 3052, Australia
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Heitkamp A, Sandberg E, Moodley A, Burke J, van Roosmalen J, Gebhardt S, Vollmer L, de Vries JI, van den Akker T, Theron G. Pulmonary oedema in the course of severe maternal outcome in South Africa: A cohort study combined with clinical audit. Trop Med Int Health 2023; 28:677-687. [PMID: 37340987 DOI: 10.1111/tmi.13905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVES To describe the incidence and outcomes of pulmonary oedema in women with severe maternal outcome during childbirth and identify possible modifiable factors through audit. METHODS All women with severe maternal outcome (maternal deaths or near misses) who were referred to Tygerberg referral hospital from health facilities in Metro East district, South Africa, during 2014-2015 were included. Women with severe maternal outcome and pulmonary oedema during pregnancy or childbirth were evaluated using three types of critical incident audit: criterion-based case review by one consultant gynaecologist, monodisciplinary critical incident audit by a team of gynaecologists, multidisciplinary audit with expert review from anaesthesiologists and cardiologists. RESULTS Of 32,161 pregnant women who gave birth in the study period, 399 (1.2%) women had severe maternal outcome and 72/399 (18.1%) had pulmonary oedema with a case fatality rate of 5.6% (4/72). Critical incident audit demonstrated that pre-eclampsia/HELLP-syndrome and chronic hypertension were the main conditions underlying pulmonary oedema (44/72, 61.1%). Administration of volumes of intravenous fluids in already sick women, undiagnosed underlying cardiac illness, administration of magnesium sulphate as part of pre-eclampsia management and oxytocin for augmentation of labour were identified as possible contributors to the pathophysiology of pulmonary oedema. Women-related factors (improved antenatal care attendance) and health care-related factors (earlier diagnosis and management) would potentially have improved maternal outcome. CONCLUSIONS Although pulmonary oedema in pregnancy is rare, among women with severe maternal outcome a considerable proportion had pulmonary oedema (18.1%). Audit identified options for prevention of pulmonary oedema and improved outcome. These included early detection and management of preeclampsia with close monitoring of fluid intake and cardiac evaluation in case of suspected pulmonary oedema. Therefore, a multidisciplinary clinical approach is recommended.
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Affiliation(s)
- Anke Heitkamp
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam and Research Institute Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Evelien Sandberg
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ashley Moodley
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Jonathan Burke
- Department of Anaesthesiology and Critical Care, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stefan Gebhardt
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Linda Vollmer
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Johanna I de Vries
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam and Research Institute Amsterdam Reproduction & Development, Amsterdam, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gerhard Theron
- Department of Obstetrics and Gynaecology, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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Alves B, Cunha F, Pereira C. Epidural Anesthesia for Cesarean Section in a Pregnant Woman With Acute Pulmonary Edema: A Case Report. Cureus 2023; 15:e43994. [PMID: 37746384 PMCID: PMC10516584 DOI: 10.7759/cureus.43994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Although rare, acute pulmonary edema is the most common cause of death in pregnant women with severe hypertension. The authors report a case involving a pregnant woman at 36 weeks of gestation with preeclampsia, who exhibited pulmonary edema and required immediate cesarean delivery. The patient had type 1 respiratory failure and needed supplemental oxygenation with a Venturi mask. The cesarean section was performed successfully under epidural anesthesia. Women with severe preeclampsia and acute pulmonary edema remain a challenge when presented for cesarean delivery, and the best anesthetic option remains controversial.
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Affiliation(s)
- Barbara Alves
- Anesthesiology, Centro Hospitalar Tondela, Viseu, PRT
| | - Filipa Cunha
- Anesthesiology, Centro Hospitalar Tondela, Viseu, PRT
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11
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Feng S, Gu J, Yu C, Liu J, Ni J. Exploring the predictive value of combined ultrasound parameters for spinal anesthesia-induced hypotension in cesarean section: a prospective observational study. BMC Anesthesiol 2023; 23:255. [PMID: 37507678 PMCID: PMC10375731 DOI: 10.1186/s12871-023-02160-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/31/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Prophylactic vasopressor infusion can effectively assist with fluid loading to prevent spinal anesthesia-induced hypotension. However, the ideal dose varies widely among individuals. We hypothesized that hypotension-susceptible patients requiring cesarean section (C-section) could be identified using combined ultrasound parameters to enable differentiated prophylactic medical interventions. METHODS This prospective observational trial was carried out within a regional center hospital for women and children in Sichuan Province, China. Singleton pregnant women undergoing combined spinal-epidural anesthesia for elective C-sections were eligible. Women with contraindications to spinal anesthesia or medical comorbidities were excluded. Velocity time integral (VTI) and left ventricular end-diastolic area (LVEDA) in the supine and left lateral positions were measured on ultrasound before anesthesia. Stroke volume, cardiac output, and the percentage change (%) in each parameter between two positions were calculated. Vital signs and demographic data were recorded. Spinal anesthesia-induced hypotension was defined as a mean arterial pressure decrease of > 20% from baseline. The area under the receiver operating characteristic curve (AUROC) was used to analyze the associations of ultrasound measurements, vital signs, and demographic characteristics with spinal anesthesia-induced hypotension. This exploratory study did not have a predefined outcome; however, various parameter combinations were compared using the AUROC to determine which combined parameters had better predictive values. RESULTS Patients were divided into the normotension (n = 31) and hypotension groups (n = 57). A combination of heart rate (HR), LVEDAs, and VTI% was significantly better at predicting hypotension than was HR (AUROC 0.827 vs. 0.707, P = 0.020) or LVEDAs (AUROC 0.827 vs. 0.711, P = 0.039) alone, but not significantly better than VTI% alone (AUROC 0.827 vs. 0.766, P = 0.098). CONCLUSION The combined parameters of HR and LVEDAs with VTI% may predict spinal anesthesia-induced hypotension more precisely than the single parameters. Future research is necessary to determine whether this knowledge improves maternal and neonatal outcomes. TRIAL REGISTRATION ChiCTR1900025191.
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Affiliation(s)
- Shimiao Feng
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, 610000, China
| | - Juan Gu
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, 610000, China
| | - Chao Yu
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, 610000, China
| | - Jin Liu
- Department of Anesthesiology and Translational Neuroscience Centre, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, 610041, China.
| | - Juan Ni
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, No. 20, Section 3, Renmin South Road, Chengdu, 610000, China.
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12
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Dalkalitsis A, Zikopoulos A, Katrachouras A, Samara I, Gkrozou F. Non-Cardiogenic Pulmonary Edema Due to Administration of Atosiban. Cureus 2023; 15:e36799. [PMID: 37123811 PMCID: PMC10134783 DOI: 10.7759/cureus.36799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
We report the case of a pregnant woman, treated with atosiban for premature labor, who developed non-cardiogenic pulmonary edema. She corresponded initially to oxygen supplementation and furosemide administration to induce diuresis but the onset of preterm contractions combined with aggravation of respiratory failure led the patient to a cesarean section, and subsequently to the intensive care unit where she remained intubated for 24 hours. In this case report, we emphasize the importance of distinguishing between two types of pulmonary edema: cardiogenic and non-cardiogenic. The instant separation between these two categories, most of the time with transthoracic echocardiography while the patient is on early support of ventilation, increases the optimum outcome for the patient.
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13
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Baltaji S, Noronha SF, Patel S, Kaura A. Obstetric Emergencies. Crit Care Nurs Q 2023; 46:66-81. [PMID: 36415068 DOI: 10.1097/cnq.0000000000000438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Human gestation and birthing result in many deviations from usual physiology that are nonetheless normal to be seen. However, on occasion, certain complications in the obstetric patient can be life-threatening to both mother and fetus. Timely recognition of these disorders and allocation of the appropriate resources are especially important. These conditions often require an intensive care unit admission for closer monitoring and supportive care. They can affect an array of physiological systems and can lead to significant morbidity. Such complications are discussed in greater detail in this article.
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Affiliation(s)
- Stephanie Baltaji
- Division of Pulmonary and Critical Care Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania (Drs Baltaji and Patel); and Division of Pulmonary and Critical Care Medicine, West Penn Hospital, Pittsburgh, Pennsylvania (Drs Noronha and Kaura)
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14
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Easter SR, Hameed AB, Shamshirsaz A, Fox K, Zelop CM. Point of care maternal ultrasound in obstetrics. Am J Obstet Gynecol 2022; 228:509.e1-509.e13. [PMID: 36183775 DOI: 10.1016/j.ajog.2022.09.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 09/24/2022] [Accepted: 09/25/2022] [Indexed: 01/25/2023]
Abstract
Ultrasound is the hallmark imaging modality traditionally used by obstetricians for fetal diagnosis and surveillance. The COVID-19 pandemic highlighted the role of point of care ultrasound for expeditious assessment of the maternal cardiopulmonary status. The familiarity of obstetricians with ultrasound, coupled with the availability of ultrasound equipment without the need to transport the patient, make point of care ultrasound particularly valuable in the labor and delivery unit. The rising contribution of cardiopulmonary disorders to maternal morbidity and mortality carves out many potential applications for point of care ultrasound during labor and delivery. Obstetricians have access to the technology and the skills to obtain the basic views required to assess for the presence of pulmonary edema, ventricular dysfunction, or intra-abdominal free fluid. Point of care ultrasound can be used routinely for the evaluation of pulmonary complaints or in the assessment of hypotension and may play an essential role in the diagnosis and management of life-threatening emergencies such as shock, an amniotic fluid embolism, or cardiac arrest. We reviewed the currently established point of care ultrasound protocols for the evaluation of cardiopulmonary complaints through the lens of the obstetrician. We call on educators and academic leaders to incorporate maternal point of care ultrasound teachings into existing curricula. Point of care ultrasound is of enormous value for providers with limited access to diagnostic imaging or subspecialty providers. With the growing complexity of the obstetrical population, acquiring the clinical skills to meet these evolving needs is a requisite step in the ongoing efforts to reduce maternal morbidity and mortality.
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Affiliation(s)
- Sarah Rae Easter
- Division of Maternal-Fetal Medicine and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Afshan B Hameed
- Division of Maternal Fetal Medicine and Cardiology, University of California, Irvine, CA
| | - Amir Shamshirsaz
- Division of Maternal-Fetal Medicine and Surgical Critical Care, Baylor College of Medicine, Houston, TX
| | - Karin Fox
- Division of Maternal-Fetal Medicine, Baylor College of Medicine, Houston, TX
| | - Carolyn M Zelop
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Valley Hospital, Ridgewood, NJ; Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY
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15
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Nishikawa T, Fukuhara K. Betamethasone use and risk factors for pulmonary edema during the perinatal period: a single-center retrospective cohort study in Japan. BMC Pregnancy Childbirth 2022; 22:636. [PMID: 35962336 PMCID: PMC9373293 DOI: 10.1186/s12884-022-04918-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background A few studies have reported that maternal administration of antenatal corticosteroids increased the risk of pulmonary edema (PE). However, despite the increasing usage rate of betamethasone as antenatal corticosteroid, maternal administration of betamethasone as a risk factor for PE has not been well studied. This study aimed to evaluate how maternal backgrounds and complications, tocolytic agents, and betamethasone affect the incidence of PE during the perinatal period and determine the risk factor for PE. Methods This was a single-center retrospective cohort study in Kurashiki, Japan. The study subjects were patients who had been admitted to our hospital for perinatal management including pregnancy, delivery and puerperium between 2017 and 2020. The primary outcome measure was defined as the incidence of PE during hospitalization. First, in all study subjects, Cox proportional hazards model was used to determine the risk factor for PE during the perinatal period. Next, using propensity score matching, we divided the patients into the betamethasone and betamethasone-free groups and examined the association between betamethasone use and the incidence of PE with Cox proportional hazards model. Results During the study period, 4919 cases were hospitalized, and there were 16 PE cases (0.3%). In all analyzed subjects, the occurrence of PE was significantly associated with preeclampsia (hazard ratio 16.8, 95% confidence intervals (CI) 5.39–52.7, P < 0.001) and the combined use of the tocolytic agents such as ritodrine hydrochloride and magnesium sulfate, and betamethasone (hazard ratio 11.3, 95% CI 2.66–48.1, P = 0.001). In contrast, after propensity score matching, no statistically significant difference was found between the betamethasone and betamethasone-free groups in the incidence of PE (hazard ratio 3.19, 95% CI 0.67–15.3, P = 0.145). Conclusions A combined use of tocolytic agents and antenatal corticosteroids such as betamethasone may be an independent risk factor for PE during the perinatal period. On the other hand, betamethasone use alone may not be associated with the incidence of PE. When tocolytic agents and betamethasone are administrated to pregnant women, it is important to pay attention to the appearance of maternal respiratory symptoms.
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Affiliation(s)
- Takashi Nishikawa
- Department of Obstetrics and Gynecology, Kurashiki Central Hospital, Ohara Health Care Foundation, 1-1-1 Miwa, Kurashiki, Okayama, 7108602, Japan.
| | - Ken Fukuhara
- Department of Obstetrics and Gynecology, Kurashiki Central Hospital, Ohara Health Care Foundation, 1-1-1 Miwa, Kurashiki, Okayama, 7108602, Japan
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Nij Bijvank SW, Hengst M, Cornette JC, Huigen S, Winkelen AV, Edens MA, Duvekot JJ. Nicardipine for treating severe antepartum hypertension during pregnancy: Nine years of experience in more than 800 women. Acta Obstet Gynecol Scand 2022; 101:1017-1025. [PMID: 35707886 DOI: 10.1111/aogs.14406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 04/20/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Women with severe hypertension during pregnancy require prompt stabilization with a combination of magnesium sulfate and rapidly acting intravenously administered antihypertensives. It remains unknown which antihypertensive is best suited for pregnancy. The present study evaluated the intravenous use of the calcium antagonist, nicardipine. MATERIAL AND METHODS This multicenter, retrospective case series included all pregnant women beyond 20 weeks of gestation with severe antepartum hypertension that were treated with intravenous nicardipine. PRIMARY OUTCOME MEASURES successful treatment, time to successful treatment, and maternal safety. Severe hypertension was defined as systolic blood pressure (SBP) of 160 mm Hg or more and/or diastolic blood pressure (DBP) of 110 mm Hg or more. RESULTS This study included 830 women. After 1 h of treatment, two-thirds of the women had SBP below 160 mm Hg and DBP below 100 mm Hg. In three out of four women, the mean arterial pressure was below 120 mm Hg. Within 2 h of treatment, 77.4% of women achieved successful treatment. In all cases, nicardipine was eventually effective. Within the first 2 h, 42.7% of women experienced temporary low DBP (ie below 70 mm Hg) without clinical consequences for the mother or fetus. In all cases, the low DBP resolved after discontinuing or reducing the dosage of nicardipine. One case of fetal distress was attributable to maternal hypotension, and a cesarean section was performed at more than 2 h after initiating therapy. During treatment, headache, nausea, and vomiting decreased significantly. CONCLUSIONS To date, this was the largest case-series study on the use of nicardipine for treating severe antepartum hypertension in pregnancy. We found that nicardipine could effectively and safely treat this condition. Based on its high success rate and acceptable safety profile, nicardipine should be considered a first-line treatment in women with severe hypertension in pregnancy.
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Affiliation(s)
- Sebastiaan W Nij Bijvank
- Department of Obstetrics and Gynecology, Isala Women's and Children's Hospital, Zwolle, The Netherlands
| | - Micky Hengst
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jerome C Cornette
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sigrid Huigen
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Anne van Winkelen
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mireille A Edens
- Department of Clinical Epidemiology, Isala Women's and Children's Hospital, Zwolle, The Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics and Gynecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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17
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Como N, Gjermeni N, Meta E, Kraja D, Hysenaj Z, Osmenaj R, Gradica F, Rexhepi M, Mesi A. Severe Respiratory Failure from SARS-CoV-2, Complicated with Pneumothorax in a Pregnant Woman: A Case Report. Open Access Maced J Med Sci 2022. [DOI: 10.3889/oamjms.2022.8967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction:The first data for COVID-19 in pregnancy showed mild to moderate forms of the disease while current data speaks of severe forms in these subjects. Here we present a case of a severe form of COVID-19 in a gemelar pregnant woman complicated with pneumomediastin and pneumothorax,during her hospital stay, in a late stage of disease.
Case presentation: A 38 year-old multiparous woman was referred to university hospital at 25 weeks of gemelar pregnancy. On admission, the patient presented with signs of moderate respiratory insufficiency, which after 12 hours progressed further to severe ARDS. She tested pozitiv for SARS COV 2 on quantitative real-time polymerase chain reaction. Under these conditions it was decided that the pacient undergo a caesarean section for termination of pregnancy. Remdesivir200 mg/day and tocilizumab 8 mg/kg were administered,based on national guidelines. The patient's fever subsided, but her SpO2 remained at 94%, even with a 15 L/min oxygen mask. After 12 days the patient complains of a severe back pain and her respiratory condition rapidly worsened,reduced saturations up to 80% being under O2 therapy with facial mask with 15 l/min. Chest CT findings confirmed pneumomediastine and pneumothorax,which deteriorated the patient”s status. Thereafter tube thorakostomy was performed. There was a clinical and ABG analysis parameter”s improvement.The patient was discharged 34 days after cesarean delivery with a proper general health.
Conclusion: Our case highlights even more convincingly the fact that in pregnancy, can be severe to life-threating forms of Covid 19. Pneumothorax and pneumomediastinum are complications that can be encountered even in the late stages of severe forms with COVID 19 in pregnancy. Early diagnosis of these complications is essential in adequate management and treatment to avoid fatal outcome.
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Fischer J, Gerresheim G, Schwemmer U. Internistische Notfälle bei der schwangeren Patientin. Med Klin Intensivmed Notfmed 2022; 117:239-252. [PMID: 35312817 PMCID: PMC8935102 DOI: 10.1007/s00063-022-00910-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Peripartale Notfälle, die intensivmedizinisch behandelt werden müssen, stellen eine große Herausausforderung an das interdisziplinäre Behandlungsteam dar. Aufgrund physiologischer Veränderungen der Schwangeren können Symptome maskiert und eine Therapieeinleitung verzögert werden. Die peripartale Sepsis weist eine relativ hohe Inzidenz auf. Die antiinfektive Therapie richtet sich nach dem zu erwartenden Keimspektrum. Endokrinologische Notfälle sind selten, können jedoch fulminant und tödlich sein. Die Entstehung einer Ketoacidose wird durch erniedrigte Bikarbonatpuffer und Plazentahormone begünstigt. Im Rahmen einer Thyreotoxikose stehen zur Therapie Propylthiouracil und Thiamazol in Abhängigkeit vom Gestationszeitpunkt zur Verfügung. Das Sheehan-Syndrom ist eine Infarzierung des Hypophysenvorderlappens im Rahmen einer Hämorrhagie. Durch Produktionsausfall lebenswichtiger Hormone kann dieses letal enden. Ebenso akut ist die Entstehung eines Lungenödems. Dieses wird durch physiologische Veränderungen während der Schwangerschaft begünstigt. Kausal ist für die Therapie die Unterscheidung eines hyper- oder hypotensiven Lungenödems von Bedeutung.
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Affiliation(s)
| | | | - U Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum Neumarkt i.d.OPf., Neumarkt i.d.OPf., Deutschland.
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19
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Pre-eclampsia diagnosis and management. Best Pract Res Clin Anaesthesiol 2022; 36:107-121. [DOI: 10.1016/j.bpa.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 11/17/2022]
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20
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Dogra N, Bharti N, Rawat N, Singla K. Acute respiratory failure and pulmonary edema during peri-partum period in normotensive parturient – diagnosis and management. J Anaesthesiol Clin Pharmacol 2022; 38:316-317. [PMID: 36171938 PMCID: PMC9511837 DOI: 10.4103/joacp.joacp_129_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 06/14/2020] [Indexed: 11/17/2022] Open
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21
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Barbagallo M, Schiappa E. MOF in Pregnancy and Its Relevance to Eclampsia. POSTINJURY MULTIPLE ORGAN FAILURE 2022:205-239. [DOI: 10.1007/978-3-030-92241-2_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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22
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Bonnet MP, Garnier M, Keita H, Compère V, Arthuis C, Raia-Barjat T, Berveiller P, Burey J, Bouvet L, Bruyère M, Castel A, Clouqueur E, Gonzalez Estevez M, Faitot V, Fischer C, Fuchs F, Lecarpentier E, Le Gouez A, Rigouzzo A, Rossignol M, Simon E, Vial F, Vivanti AJ, Zieleskiewicz L, Sénat MV, Schmitz T, Sentilhes L. [Reprint of: Severe pre-eclampsia: guidelines for clinical practice from the French Society of Anesthesiology and Intensive Care (SFAR) and the French College of Gynaecologists and Obstetricians (CNGOF)]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021:S2468-7189(21)00246-4. [PMID: 34772654 DOI: 10.1016/j.gofs.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Marie-Pierre Bonnet
- Sorbonne Université, GRC 29, DMU DREAM, Department of Anaesthesiology and Intensive Care, Armand Trousseau University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Centre de Recherche épidémiologie et Statistiques Sorbonne Paris Cité (CRESS) U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France.
| | - Marc Garnier
- Sorbonne Université, APHP, GRC 29, DMU DREAM, Department of Anesthesiology and Critical Care Medicine, Tenon University Hospital, Paris, France
| | - Hawa Keita
- Université de Paris, Department of Anaesthesiology and Intensive Care, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Vincent Compère
- Department of Anaesthesiology and Critical Care, Rouen University Hospital, Rouen, France
| | - Chloé Arthuis
- Department of Obstetrics and Gynaecology, Nantes University Hospital, Mother and Child Hospital, Nantes, France
| | - Tiphaine Raia-Barjat
- Department of Gynaecology, Obstetrics, and Reproductive Medicine, Saint Etienne University Hospital, Université de Saint Etienne Jean Monnet, INSERM, U 1059 SainBioSE, F-42023 Saint Etienne, France
| | - Paul Berveiller
- Department of Obstetrics and Gynaecology - Poissy Saint-Germain Hospital, Poissy, France; Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France; Ecole Nationale Vétérinaire d'Alfort, BREED, Maison-Alfort, France
| | - Julien Burey
- Sorbonne Université, APHP, GRC 29, DMU DREAM, Department of Anesthesiology and Critical Care Medicine, Tenon University Hospital, Paris, France
| | - Lionel Bouvet
- Department of Anaesthesiology and Intensive Care, Mother and Child Hospital, Hospices Civils de Lyon, Bron, France; Université de Lyon, Claude Bernard Lyon 1, Villeurbanne, France
| | - Marie Bruyère
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Le Kremlin- Bicêtre, France
| | - Adeline Castel
- Department of Anaesthesiology and Intensive Care, Paule de Viguier University Hospital, Toulouse, France
| | - Elodie Clouqueur
- Department of Obstetrics and Gynaecology, Tourcoing Hospital, France
| | - Max Gonzalez Estevez
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Jeanne de Flandre Maternity Hospital, Lille University Hospital, Lille, France
| | - Valentina Faitot
- Department of Anaesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France
| | - Catherine Fischer
- Department of Anaesthesiology and Intensive Care, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Florent Fuchs
- Department of Obstetrics and Gynaecology, Montpellier University Hospital, Arnaud de Villeneuve Hospital, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique (IDESP), UMR INSERM - Université de Montpellier, Campus Santé, IURC, Montpellier, France
| | - Edouard Lecarpentier
- Department of Gynaecology, Obstetrics and Reproductive Medicine, Université de Paris Est Créteil, CHIC of Créteil, Créteil, France; INSERM U955 Institut Biomédical Henri Mondor, Créteil, France
| | - Agnès Le Gouez
- Department of Anaesthesiology and Intensive Care, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Agnès Rigouzzo
- Sorbonne Université, GRC 29, DMU DREAM, Department of Anaesthesiology and Intensive Care, Armand Trousseau University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mathias Rossignol
- Department of Anaesthesiology and Intensive Care and SMUR, Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Emmanuel Simon
- Department of Gynaecology, Obstetrics and Reproductive Biology, Dijon Bourgogne University Hospital, France; UFR Sciences de santé Dijon, Université de Bourgogne, France
| | - Florence Vial
- Department of Anaesthesiology and Intensive Care, Nancy University Hospital, Nancy, France
| | - Alexandre J Vivanti
- Division of Obstetrics and Gynaecology, Antoine Béclère University Hospital, Université de Paris Saclay, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Zieleskiewicz
- Department of Anaesthesiology and Intensive Care, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Université de Aix Marseille, France; Centre for Cardiovascular and Nutrition Research (C2VN), INSERM, INRA, Université de Aix Marseille, Marseille, France
| | - Marie-Victoire Sénat
- Department of Gynaecology and Obstetrics, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University de Paris-Saclay, UVSQ, CESP, INSERM, Villejuif, France
| | - Thomas Schmitz
- Centre de Recherche épidémiologie et Statistiques Sorbonne Paris Cité (CRESS) U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France; Department of Gynaecology and Obstetrics, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Aliénor d'Aquitaine Maternity Hospital, Bordeaux University Hospital, Bordeaux, France
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Bajwa SJS, Kurdi MS, Sutagatti JG, Bajwa SK, Theerth KA. 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. Indian J Anaesth 2021; 65:716-730. [PMID: 34898698 PMCID: PMC8607863 DOI: 10.4103/ija.ija_820_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/04/2021] [Accepted: 10/13/2021] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India
| | - Madhuri S. Kurdi
- Department of Anaesthesiology, Karnataka Institute of Medical Sciences (KIMS), Hubballi, Karnataka, India
| | - Jagadish G. Sutagatti
- Department of Radiodiagnosis, Karnataka Institute of Medical Sciences (KIMS), Hubballi, Karnataka, India
| | - Sukhwinder K. Bajwa
- Department of Obstetrics and Gynaecology, Bajwa Maternity and Nursing Home, Patiala, Punjab, India
| | - Kaushic A. Theerth
- Department of Anaesthesiology, Medical Trust Hospital, Ernakulum, Kerala, India
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Bonnet MP, Garnier M, Keita H, Compère V, Arthuis C, Raia-Barjat T, Berveiller P, Burey J, Bouvet L, Bruyère M, Castel A, Clouqueur E, Gonzalez Estevez M, Faitot V, Fischer C, Fuchs F, Lecarpentier E, Le Gouez A, Rigouzzo A, Rossignol M, Simon E, Vial F, Vivanti AJ, Zieleskiewicz L, Camilleri C, Sénat MV, Schmitz T, Sentilhes L. Guidelines for the management of women with severe pre-eclampsia. Anaesth Crit Care Pain Med 2021; 40:100901. [PMID: 34602381 DOI: 10.1016/j.accpm.2021.100901] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To provide national guidelines for the management of women with severe pre-eclampsia. DESIGN A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. METHODS The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE® methodology. RESULTS The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/-), 9 have a moderate level of evidence (GRADE 2+/-), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. CONCLUSIONS There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.
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Affiliation(s)
- Marie-Pierre Bonnet
- Sorbonne Université, GRC 29, DMU DREAM, Department of Anaesthesiology and Intensive Care, Armand Trousseau University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France; Centre de Recherche Épidémiologie et Statistiques Sorbonne Paris Cité (CRESS) U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France.
| | - Marc Garnier
- Sorbonne Université, APHP, GRC 29, DMU DREAM, Department of Anesthesiology and Critical Care Medicine, Tenon University Hospital, Paris, France
| | - Hawa Keita
- Université de Paris, Department of Anaesthesiology and Intensive Care, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Vincent Compère
- Department of Anaesthesiology and Critical Care, Rouen University Hospital, Rouen, France
| | - Chloé Arthuis
- Department of Obstetrics and Gynaecology, Nantes University Hospital, Mother and Child Hospital, Nantes, France
| | - Tiphaine Raia-Barjat
- Department of Gynaecology, Obstetrics, and Reproductive Medicine, Saint Etienne University Hospital, Université de Saint Etienne Jean Monnet, INSERM, U 1059 SainBioSE, F-42023 Saint Etienne, France
| | - Paul Berveiller
- Department of Obstetrics and Gynaecology - Poissy Saint-Germain Hospital, Poissy, France; Université Paris-Saclay, UVSQ, INRAE, BREED, Jouy-en-Josas, France; Ecole Nationale Vétérinaire d'Alfort, BREED, Maison-Alfort, France
| | - Julien Burey
- Sorbonne Université, APHP, GRC 29, DMU DREAM, Department of Anesthesiology and Critical Care Medicine, Tenon University Hospital, Paris, France
| | - Lionel Bouvet
- Department of Anaesthesiology and Intensive Care, Mother and Child Hospital, Hospices Civils de Lyon, Bron, France; Université de Lyon, Claude Bernard Lyon 1, Villeurbanne, France
| | - Marie Bruyère
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Bicêtre University Hospital, Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Le Kremlin- Bicêtre, France
| | - Adeline Castel
- Department of Anaesthesiology and Intensive Care, Paule de Viguier University Hospital, Toulouse, France
| | - Elodie Clouqueur
- Department of Obstetrics and Gynaecology, Tourcoing Hospital, France
| | - Max Gonzalez Estevez
- Department of Anaesthesiology, Intensive Care and Perioperative Medicine, Jeanne de Flandre Maternity Hospital, Lille University Hospital, Lille, France
| | - Valentina Faitot
- Department of Anaesthesiology and Intensive Care, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France
| | - Catherine Fischer
- Department of Anaesthesiology and Intensive Care, Cochin University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Florent Fuchs
- Department of Obstetrics and Gynaecology, Montpellier University Hospital, Arnaud de Villeneuve Hospital, Montpellier, France; Institut Desbrest d'Epidémiologie et de Santé Publique (IDESP), UMR INSERM - Université de Montpellier, Campus Santé, IURC, Montpellier, France
| | - Edouard Lecarpentier
- Department of Gynaecology, Obstetrics and Reproductive Medicine, Université de Paris Est Créteil, CHIC of Créteil, Créteil, France; INSERM U955 Institut Biomédical Henri Mondor, Créteil, France
| | - Agnès Le Gouez
- Department of Anaesthesiology and Intensive Care, Antoine Béclère Hospital, Assistance Publique-Hôpitaux de Paris, Clamart, France
| | - Agnès Rigouzzo
- Sorbonne Université, GRC 29, DMU DREAM, Department of Anaesthesiology and Intensive Care, Armand Trousseau University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Mathias Rossignol
- Department of Anaesthesiology and Intensive Care and SMUR, Lariboisière University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Emmanuel Simon
- Department of Gynaecology, Obstetrics and Reproductive Biology, Dijon Bourgogne University Hospital, France; UFR Sciences de santé Dijon, Université de Bourgogne, France
| | - Florence Vial
- Department of Anaesthesiology and Intensive Care, Nancy University Hospital, Nancy, France
| | - Alexandre J Vivanti
- Division of Obstetrics and Gynaecology, Antoine Béclère University Hospital, Université de Paris Saclay, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laurent Zieleskiewicz
- Department of Anaesthesiology and Intensive Care, Hôpital Nord, Assistance Publique des Hôpitaux de Marseille, Université de Aix Marseille, France; Centre for Cardiovascular and Nutrition Research (C2VN), INSERM, INRA, Université de Aix Marseille, Marseille, France
| | - Céline Camilleri
- "Grossesse et Santé, Contre la Prééclampsie" Association, Paris, France
| | - Marie-Victoire Sénat
- Department of Gynaecology and Obstetrics, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, University de Paris-Saclay, UVSQ, CESP, INSERM, Villejuif, France
| | - Thomas Schmitz
- Centre de Recherche Épidémiologie et Statistiques Sorbonne Paris Cité (CRESS) U1153, INSERM, Obstetrical, Perinatal and Paediatric Epidemiology (EPOPé) Research Team, Université de Paris, Paris, France; Department of Gynaecology and Obstetrics, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynecology, Aliénor d'Aquitaine Maternity Hospital, Bordeaux University Hospital, Bordeaux, France
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Randhawa JS, Ashraf H, Colombo JP, Kudla P. Postpartum Respiratory Distress Due to Hypertension-Related Pulmonary Edema. Cureus 2021; 13:e18179. [PMID: 34584816 PMCID: PMC8456067 DOI: 10.7759/cureus.18179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2021] [Indexed: 11/30/2022] Open
Abstract
We present the case of a 35-year-old female who presented to the emergency department (ED) shortly after undergoing a cesarean section with dyspnea. Her vitals on admission revealed hypertension, tachypnea, bradycardia, and suboptimal oxygen saturation. Physical examination was remarkable for crackles in the lower lung fields. Laboratory results revealed elevated lactate dehydrogenase (LDH), pro-B-type natriuretic peptide (pro-BNP), and D-dimer levels. A CT angiogram showed no pulmonary emboli, and an echocardiogram revealed a normal ejection fraction and no diastolic dysfunction. A chest X-ray was significant for pulmonary edema and vascular congestion. The patient was diagnosed with respiratory distress due to pulmonary edema that was secondary to hypertension. This unusual case report seeks to highlight the idea that elevated blood pressure in postpartum women should warrant careful monitoring, as its consequential manifestations may be lethal. Additionally, pulmonary edema secondary to hypertension should be considered as a differential in either postpartum or peripartum women who present with respiratory symptoms and elevated blood pressure.
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Affiliation(s)
| | - Hamza Ashraf
- Medicine, Saint Peter's University Hospital, New Brunswick, USA
| | - John Paul Colombo
- Medical Research, Saint Peter's University Hospital, New Brunswick, USA
- Medical Research, St. George's University School of Medicine, True Blue, GRD
| | - Paul Kudla
- Internal Medicine, Ascension St. John Hospital, Detroit, USA
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26
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Morikawa M, Saito Y, Mayama M, Noshiro K, Nakagawa-Akabane K, Umazume T, Chiba K, Watari H. Excessive gestational weight gain during the week prior to delivery as a predictor of maternal life-threatening complications in preeclamptic women. J Obstet Gynaecol Res 2021; 47:3498-3508. [PMID: 34254415 DOI: 10.1111/jog.14933] [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: 04/10/2021] [Revised: 06/21/2021] [Accepted: 07/01/2021] [Indexed: 11/29/2022]
Abstract
AIM To investigate the relationship between excessive gestational weight gain during the week prior to delivery (GWG) and severe morbidity and pregnancy termination among pregnant women with preeclampsia (hypertension with proteinuria). METHODS We compared GWG, laboratory data, and complication(s) between 94 preeclamptic women (preeclampsia group) with singleton pregnancies who delivered at ≥22 gestational weeks and 188 healthy women (control group) with singleton pregnancies undergoing elective cesarean deliveries. The gestational weeks at delivery were matched in the preeclampsia and control groups. RESULTS Among 282 total participants, median of GWG was significantly higher in the preeclampsia group than in the control group (1.6 kg vs. 0.5 kg, p < 0.0001). Furthermore, the GWG cutoff value for the preeclampsia group was 1.6 kg. The odds ratio for morbidity of preeclampsia among the women with GWG ≥1.6 kg at delivery was 12.5 (95% confidence interval, 6.31-24.5). In the preeclampsia group, 47 women with GWG ≥1.6 kg had significantly higher risks of hypoproteinemia, proteinuria, and renal dysfunction than those of 47 women with GWG < 1.6 kg. While, multivariate analysis showed 1.5 kg was a GWG cutoff value for predicting maternal morbidity (p < 0.0001); preeclamptic women with GWG ≥1.5 kg had a significantly higher risk of pulmonary edema than preeclamptic women with GWG < 1.5 kg (odds ratio, 7.77; 95% confidence interval, 1.64-36.7). CONCLUSION Excessive GWG in women with preeclampsia might be a predictor for severe maternal life-threatening complications requiring pregnancy termination.
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Affiliation(s)
- Mamoru Morikawa
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshihiro Saito
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Michinori Mayama
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kiwamu Noshiro
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kinuko Nakagawa-Akabane
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Takeshi Umazume
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Kentaro Chiba
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Hidemichi Watari
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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27
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Fischer J, Gerresheim G, Schwemmer U. [Internal medical emergencies in the pregnant patient : Peripartum sepsis, metabolic derailment, endocrinological emergencies and pulmonary edema]. Anaesthesist 2021; 70:795-808. [PMID: 34143232 PMCID: PMC8212281 DOI: 10.1007/s00101-021-00944-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 11/28/2022]
Abstract
Peripartale Notfälle, die intensivmedizinisch behandelt werden müssen, stellen eine große Herausausforderung an das interdisziplinäre Behandlungsteam dar. Aufgrund physiologischer Veränderungen der Schwangeren können Symptome maskiert und eine Therapieeinleitung verzögert werden. Die peripartale Sepsis weist eine relativ hohe Inzidenz auf. Die antiinfektive Therapie richtet sich nach dem zu erwartenden Keimspektrum. Endokrinologische Notfälle sind selten, können jedoch fulminant und tödlich sein. Die Entstehung einer Ketoacidose wird durch erniedrigte Bikarbonatpuffer und Plazentahormone begünstigt. Im Rahmen einer Thyreotoxikose stehen zur Therapie Propylthiouracil und Thiamazol in Abhängigkeit vom Gestationszeitpunkt zur Verfügung. Das Sheehan-Syndrom ist eine Infarzierung des Hypophysenvorderlappens im Rahmen einer Hämorrhagie. Durch Produktionsausfall lebenswichtiger Hormone kann dieses letal enden. Ebenso akut ist die Entstehung eines Lungenödems. Dieses wird durch physiologische Veränderungen während der Schwangerschaft begünstigt. Kausal ist für die Therapie die Unterscheidung eines hyper- oder hypotensiven Lungenödems von Bedeutung.
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Affiliation(s)
| | | | - U Schwemmer
- Klinik für Anästhesiologie und Intensivmedizin, Klinikum Neumarkt i.d.OPf., Neumarkt i.d.OPf., Deutschland.
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28
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Acute pulmonary edema due to severe preeclampsia in advanced maternal age women. Pregnancy Hypertens 2021; 25:150-155. [PMID: 34144403 DOI: 10.1016/j.preghy.2021.05.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/27/2021] [Accepted: 05/24/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Acute pulmonary edema is a rare complication in women with preeclampsia especially at advanced maternal age. We aimed to determine the cardiovascular hemodynamics in advanced maternal age women who developed acute pulmonary edema and preeclampsia. STUDY DESIGN Retrospective cohort study of women aged over 45 years giving birth at single university affiliated tertiary medical center which developed acute pulmonary edema due to severe preeclampsia. Clinical features were identified in order to predict and potentially prevent this severe complication of pregnancy. MAIN OUTCOME MEASURES Advanced maternal age women who developed acute pulmonary edema due to preeclampsia. RESULTS Overall, during the study period 90,540 women delivered in our hospital, of them, 540 women (0.6%) above the age of 45 years gave birth. Of those, 67 women (12.4%) had preeclampsia in which 4 women (6%) were complicated with acute pulmonary edema. The common clinical relevant characteristics for all four women were: preterm delivery by cesarean section for preeclampsia with severe features, non-restrictive fluid management around the time of delivery, post-partum pain control medication with non-steroidal anti-inflammatory drug, blood pressure stabilization with oral labetalol and a sudden hemodynamic deterioration to hypertensive crisis and pulmonary edema between post-operative days 4-9. CONCLUSION Although the precise trigger for the sudden presentation of acute pulmonary edema remains unknown, we suggest that there is a multi-factorial combination of etiologies that are common to women of advanced maternal age and women with preeclampsia that could have contributed to the development of pulmonary edema.
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da Silva WA, Pinheiro AM, Lima PH, Malbouisson LMS. Renal and cardiovascular repercussions in preeclampsia and their impact on fluid management: a literature review. Braz J Anesthesiol 2021; 71:421-428. [PMID: 33845102 PMCID: PMC9373504 DOI: 10.1016/j.bjane.2021.02.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/15/2021] [Accepted: 02/27/2021] [Indexed: 11/25/2022] Open
Abstract
Preeclampsia is a multifactorial condition associated with significant morbidity and mortality. Fluid therapy in these patients is challenging since volume expansion may precipitate pulmonary edema, and fluid restriction may worsen renal function. Furthermore, cardiac impairment may introduce an additional component to the hemodynamic management. This article reviews the repercussions of preeclampsia on renal and cardiovascular systems and the development of pulmonary edema, as well as to discuss fluid management, focusing on the mitigation of adverse outcomes and monitoring alternatives. The literature review was carried out using PubMed, Embase, and Google Scholar databases from May 2019 to March 2020. Papers addressing the subjects of interest were included regardless of the publication language. There is a current trend towards restricting the administration of fluids in women with non-complicated preeclampsia. However, patients with preeclampsia may experience hemorrhagic shock, requiring volume resuscitation. In this case, hemodynamic monitoring is recommended to guide fluid therapy while avoiding complications.
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Affiliation(s)
- Wallace Andrino da Silva
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, São Paulo, SP, Brazil; Universidade Federal do Rio Grande do Norte (UFRN), Hospital Universitário Onofre Lopes (HUOL), Natal, RN, Brazil.
| | - Aline Macedo Pinheiro
- Universidade Federal do Rio Grande do Norte (UFRN), Hospital Universitário Onofre Lopes (HUOL), Natal, RN, Brazil
| | - Paulo Henrique Lima
- Universidade Federal do Rio Grande do Norte (UFRN), Hospital Universitário Onofre Lopes (HUOL), Natal, RN, Brazil
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Takahashi K, Nishijima K, Yamaguchi M, Matsumoto K, Sugai S, Enomoto T. Noninvasive positive-pressure ventilation in pregnancy to treat acute pulmonary edema induced by tocolytic agents: a case report. J Med Case Rep 2021; 15:126. [PMID: 33743806 PMCID: PMC7981838 DOI: 10.1186/s13256-021-02704-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 01/28/2021] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND We report a case of pulmonary edema induced by tocolytic agents that was successfully managed with noninvasive positive-pressure ventilation (NPPV) and resulted in extended gestation. CASE PRESENTATION A 36-year-old Japanese pregnant woman received tocolytic therapy with ritodrine hydrochloride, magnesium sulfate, nifedipine, and betamethasone from 28 weeks of gestation. She developed respiratory failure. and her chest X-ray showed enlarged pulmonary vascular shadows. At 29 weeks and 1 day of gestation, she was diagnosed with pulmonary edema induced by tocolytic agents. Because respiratory failure worsened 2 days after ritodrine hydrochloride and magnesium sulfate were stopped, NPPV was initiated. Her respiratory status improved and she was weaned off of NPPV after 3 days. She underwent cesarean section because of breech presentation at 30 weeks and 0 days of gestation due to initiation of labor pains. CONCLUSIONS NPPV can be safely administered in cases of tocolytic agent-induced pulmonary edema during pregnancy.
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Affiliation(s)
- Kotaro Takahashi
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan.
| | - Koji Nishijima
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
| | - Masayuki Yamaguchi
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
| | - Kensuke Matsumoto
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
| | - Shunya Sugai
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
| | - Takayuki Enomoto
- Department of Obstetrics and Gynecology, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata, 951-8510, Japan
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Macias P, Wilson JG, Austin NS, Guo N, Carvalho B, Ortner CM. Point-of-Care Lung Ultrasound Pattern in Healthy Parturients: Prevalence of Pulmonary Interstitial Syndrome Following Vaginal Delivery, Elective and Unplanned Intrapartum Cesarean Delivery. Anesth Analg 2021; 133:739-746. [PMID: 33721873 DOI: 10.1213/ane.0000000000005464] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pregnancy-related cardiovascular physiologic changes increase the likelihood of pulmonary edema, with the risk of fluid extravasating into the pulmonary interstitium being potentially at a maximum during the early postpartum period. Data on the impact of labor and peripartum hemodynamic strain on lung ultrasound (LUS) are limited, and the prevalence of subclinical pulmonary interstitial syndrome in peripartum women is poorly described. The primary aim of this exploratory study was to estimate the prevalence of pulmonary interstitial syndrome in healthy term parturients undergoing vaginal (VD), elective (eCD), and unplanned intrapartum cesarean deliveries (uCD). Secondary aims were to estimate the prevalence of positive lung regions (≥3 B-lines on LUS per region) and to assess the associations between positive lung regions and possible contributing factors. METHODS In this prospective observational cohort study, healthy women at term undergoing VD, eCD, or uCD were enrolled. Following international consensus recommendations, a LUS examination was performed within 4 hours after delivery applying an 8-region technique. Pulmonary interstitial syndrome was defined by the presence of 2 or more positive lung regions per hemithorax. Ultrasound studies were reviewed by 2 blinded reviewers and assessed for interobserver reliability. RESULTS Seventy-five women were assessed (n = 25 per group). No pulmonary interstitial syndrome was found in the VD and eCD groups (each 0 of 25; 0%, 95% confidence interval [CI], 0-13.7). Pulmonary interstitial syndrome was found in 2 of 25 (8%, 95% CI, 1-26) women undergoing an uCD (P = .490 for VD versus uCD and P = .490 for eCD versus uCD). In 1 woman, this correlated clinically with the development of pulmonary edema. One or more positive lung regions were present in 5 of 25 (20%), 6 of 25 (24%), and 11 of 25 (44%) parturients following VD, eCD, and uCD, respectively (P = .136). Positive lung regions were predominantly found in lateral lung regions. The number of positive lung regions showed a weak correlation with patient age (r = 0.25, 95% CI, 0.05-0.47; P = .033). No significant association was found between LUS pattern and parity, duration of labor, labor augmentation, labor induction, estimated total intravenous fluid intake, or net intravenous fluid intake. CONCLUSIONS Although many focal areas of increased extravascular lung water (20%-44% prevalence) can be identified on LUS, the overall prevalence of pulmonary interstitial syndrome was 2.7% (2 of 75; 95% CI, 0.3-9.3) among healthy term parturients soon after delivery. Focal areas of positive lung water regions were weakly correlated with maternal age.
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Affiliation(s)
- Paul Macias
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Jennifer G Wilson
- Emergency Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Naola S Austin
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Nan Guo
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Brendan Carvalho
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Clemens M Ortner
- From the Departments of Anesthesiology, Perioperative and Pain Medicine
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Lehoczky L, Southworth AB, Martinez GZ, Belfort MA, Shamshirsaz AA, Shamshirsaz A, Sanz Cortes M, Nassr AA, Donepudi R, Whitehead WE, Johnson R, Meshinchi N, Espinoza J. Magnesium sulfate titration reduces maternal complications following fetoscopic closure of spina bifida. Prenat Diagn 2021; 41:983-988. [PMID: 33591585 DOI: 10.1002/pd.5923] [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: 06/11/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate if magnesium sulfate (MgSO4 ) titration following fetoscopic spina bifida closure is associated with fewer maternal complications than the Management of Myelomeningocele Study (MOMS) tocolytic regimen. METHODS This prospective cohort study included 73 consecutive patients undergoing fetoscopic closure of spina bifida between 2015 and 2020. A policy of using the MgSO4 regimen per the MOMS trial was changed to a flexible one in which MgSO4 was titrated according to the frequency of the uterine contractions following surgery. The frequency of maternal pulmonary edema, low maternal oxygen saturation requiring oxygen supplementation, atelectasis, hypocalcemia, and preterm delivery was compared before and after the policy was changed. RESULTS A higher proportion of women in the group that used the MOMS MgSO4 regimen had pulmonary edema compared to those in the flexible one (26.1% [6/23] vs. 6% [3/50]; p = 0.024). Multivariate analysis showed that the MOMS tocolytic regimen was independently associated with a higher risk of pulmonary edema (adjusted odds ratio: 8.57; 95% confidence interval: 1.54-47.7; p = 0.014) than a flexible one. There was no difference in the rate of preterm delivery. CONCLUSION Following fetoscopic closure of spina bifida, the MOMS MgSO4 regimen is associated with an increased risk of pulmonary edema than a more flexible regimen.
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Affiliation(s)
- Lucy Lehoczky
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA.,Department of Obstetrics and Gynecology, University of Kansas School of Medicine, Wichita, Kansas, USA
| | - Annie B Southworth
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Gabriela Z Martinez
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Michael A Belfort
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Alireza A Shamshirsaz
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Amir Shamshirsaz
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Magdalena Sanz Cortes
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Ahmed A Nassr
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Roopali Donepudi
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - William E Whitehead
- Department of Neurosurgery, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Rebecca Johnson
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Nazli Meshinchi
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
| | - Jimmy Espinoza
- Division of Fetal Therapy and Surgery, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Fetal Center, Houston, Texas, USA
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Angsubhakorn N, Benditt D. Relative Sinus Bradycardia: An Unexpected Finding in Preeclampsia With Acute Pulmonary Edema. Cureus 2021; 13:e13262. [PMID: 33728199 PMCID: PMC7948310 DOI: 10.7759/cureus.13262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Preeclampsia is a multifactorial pregnancy-specific syndrome, which can result in significant alterations in cardiovascular hemodynamics. We report an observation of unexpected relative bradycardia in a previously healthy woman who presented with postpartum preeclampsia and acute pulmonary edema. We observed an increase in heart rate following normalization of blood pressure, which suggested that the initial slower than expected heart rate may reflect a baroreceptor response to hypertension. Whether this finding should be regarded as a severe aspect of the disease spectrum needs further study.
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Affiliation(s)
| | - David Benditt
- Cardiac Arrhythmia Center, Cardiovascular Division, University of Minnesota, Minneapolis, USA
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Pachtman Shetty SL, Koenig S, Tenenbaum S, Meirowitz N. Point-of-care lung ultrasound patterns in late third-trimester gravidas with and without preeclampsia. Am J Obstet Gynecol MFM 2021; 3:100310. [PMID: 33465492 DOI: 10.1016/j.ajogmf.2021.100310] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 01/06/2021] [Accepted: 01/10/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Transthoracic point-of-care ultrasonography of the lungs has become a standard technique in critical care medicine for the evaluation of patients with respiratory signs or symptoms but has not been well studied in pregnancy. OBJECTIVE To compare lung ultrasound patterns in third-trimester gravidas with and without preeclampsia and assess interobserver agreement between 3 obstetrical providers and a physician expert in critical care lung ultrasound. STUDY DESIGN This is a prospective observational study of 262 women with singleton pregnancies between 32 0/7 and 41 6/7 weeks' gestation. Lung ultrasound examinations were performed and interpreted by a team of obstetrical care providers and then interpreted by an expert in point-of-care lung ultrasound. The number of B-lines in each of the 4 lung fields, indicating the accumulation of fluid in the interstitial space and the alveoli, was evaluated. The primary outcome was a positive study for pulmonary interstitial edema, defined as an ultrasound study with 3 or more B-lines in 2 or more bilateral lung fields. The secondary outcome was a lung ultrasound study with 1 or 2 B-lines in 1 or more lung fields or 3 B-lines in 1 lung field. Interobserver agreement in lung ultrasound interpretation between obstetrical care providers and an expert in critical care point-of-care ultrasonography of the lung was assessed. RESULTS Among healthy gravidas, no subject had a lung ultrasound examination positive for pulmonary interstitial edema. Notably, 2 patients with preeclampsia had positive lung ultrasound studies, and both had respiratory symptoms or signs of pulmonary edema. One or 2 B-lines or 3 B-lines in 1 lung field were identified in 11.4% of healthy gravidas and 18.6% of patients with preeclampsia. There was no difference in lung ultrasound patterns between healthy gravidas and those with preeclampsia. The obstetrical care providers and the lung ultrasound expert had a high proportion of agreement regarding the interpretation of negative lung ultrasound examinations. The 2 patients with clinical signs of pulmonary edema were judged to have positive studies by both the obstetrical team and the expert; however, the obstetrical team classified more studies as positive. CONCLUSION Lung ultrasound patterns in women with preeclampsia without respiratory symptoms or clinical signs of pulmonary edema are similar to the lung ultrasound patterns of healthy gravidas. Point-of-care lung ultrasound can be used to evaluate third-trimester gravidas with preeclampsia and respiratory complaints or signs concerning for pulmonary edema. Formal training is important before the widespread adoption of point-of-care lung ultrasound by obstetrical healthcare providers.
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Affiliation(s)
- Sarah L Pachtman Shetty
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, NY.
| | - Seth Koenig
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Sara Tenenbaum
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Natalie Meirowitz
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, NY
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35
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Korenc M, Zieleskiewicz L, Stopar Pintaric T, Blajic I, Ambrozic J, Lucovnik M. The effect of vitamin C on pulmonary oedema in patients with severe preeclampsia: A single-centre, randomised, placebo-controlled, double-blind trial. Anaesth Crit Care Pain Med 2021; 40:100800. [PMID: 33453456 DOI: 10.1016/j.accpm.2021.100800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine whether vitamin C in the first three days postpartum reduces pulmonary oedema (PE) assessed by lung ultrasound in patients with severe preeclampsia. DESIGN Randomised, placebo-controlled, double-blind trial. SETTING Tertiary perinatal centre. POPULATION Consecutively admitted patients with singleton pregnancies complicated by severe preeclampsia. METHODS Thirty-four patients received vitamin C (1.5 g/6 h) (n = 17) or placebo (n = 17) at days 1, 2, and 3 postdelivery. Mann-Whitney-U test was used to compare vitamin C vs placebo groups. A p ≤ 0.05 was considered statistically significant. MAIN OUTCOME MEASURES Lung ultrasound was performed once daily in the first three days following delivery. Echo Comet Score (ECS) on day 1 postdelivery was the primary outcome studied and was obtained using the 28-rib interspaces technique. ECS on days 2 and 3 postdelivery were secondary outcomes. RESULTS There was no significant difference in ECS on day 1 (median 23 (inter-quartile range (IQR) 21-61) vs 18 (IQR 8-35); p = 0.31). All ultrasound examinations on day 1 were performed within six hours from delivery. On days 2 and 3, ECS was significantly lower in vitamin C group compared to placebo (8 (IQR 3-14) vs 35 (IQR 15-78); p = 0.03 and 5 (IQR 3-10) vs 18 (IQR 18-44); p = 0.04, respectively). CONCLUSION A single dose of intravenous vitamin C did not reduce PE in postpartum patients with severe preeclampsia on day 1 after delivery. Repeated doses, however, seem to have a delayed effect with a reduction in PE detected on ultrasound on days 2 and 3 following delivery. TRIAL REGISTRATION This trial is registered at ClinicalTrials.gov: ID NCT03451266 (https://clinicaltrials.gov/ct2/show/NCT03451266?term=NCT03451266&draw=2&rank=1).
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Affiliation(s)
- Monika Korenc
- Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Slovenia
| | - Laurent Zieleskiewicz
- Department of Anaesthesiology and Critical Care Medicine, North Hospital, Aix Marseille University, Marseille, France
| | - Tatjana Stopar Pintaric
- Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Slovenia
| | - Iva Blajic
- Department of Anaesthesiology and Intensive Therapy, University Medical Centre Ljubljana, Slovenia
| | - Jana Ambrozic
- Department of Cardiology, University Medical Centre Ljubljana, Slovenia
| | - Miha Lucovnik
- Department of Perinatology, Division of Obstetrics and Gynaecology, University Medical Centre Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Slovenia.
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Pisani L, De Nicolo A, Schiavone M, Adeniji AO, De Palma A, di Gennaro F, Emuveyan EE, Grasso S, Henwood PC, Koroma AP, Leopold S, Marotta C, Marulli G, Putoto G, Pisani E, Russel J, Serpa Neto A, Dondorp AM, Hanciles E, Koroma MM, Schultz MJ. Lung Ultrasound for Detection of Pulmonary Complications in Critically Ill Obstetric Patients in a Resource-Limited Setting. Am J Trop Med Hyg 2020; 104:478-486. [PMID: 33319731 PMCID: PMC7866347 DOI: 10.4269/ajtmh.20-0996] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/27/2020] [Indexed: 02/02/2023] Open
Abstract
Critically ill parturients have an increased risk of developing pulmonary complications. Lung ultrasound (LUS) could be effective in addressing the cause of respiratory distress in resource-limited settings with high maternal mortality. We aimed to determine the frequency, timing of appearance, and type of pulmonary complications in critically ill parturients in an obstetric unit in Sierra Leone. In this prospective observational study, LUS examinations were performed on admission, after 24 and 48 hours, and in case of respiratory deterioration. Primary endpoint was the proportion of parturients with one or more pulmonary complications, stratified for the presence of respiratory distress. Secondary endpoints included timing and types of complications, and their association with “poor outcome,” defined as a composite of transfer for escalation of care or death. Of 166 patients enrolled, 35 patients (21% [95% CI: 15–28]) had one or more pulmonary complications, the majority diagnosed on admission. Acute respiratory distress syndrome (period prevalence 4%) and hydrostatic pulmonary edema (4%) were only observed in patients with respiratory distress. Pneumonia (2%), atelectasis (10%), and pleural effusion (7%) were present, irrespective of respiratory distress. When ultrasound excluded pulmonary complications, respiratory distress was related to anemia or metabolic acidosis. Pulmonary complications were associated with an increased risk of poor outcome (odds ratio: 5.0; 95% CI: 1.7–14.6; P = 0.003). In critically ill parturients in a resource-limited obstetric unit, LUS contributed to address the cause of respiratory distress by identifying or excluding pulmonary complications. These were associated with a poor outcome.
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Affiliation(s)
- Luigi Pisani
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Department of Intensive Care, Amsterdam University Medical Centers-Location AMC, Amsterdam, The Netherlands
| | - Anna De Nicolo
- Intensive Care Unit, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy
| | - Marcella Schiavone
- Thoracic Surgery Unit, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy
| | | | - Angela De Palma
- Thoracic Surgery Unit, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy
| | | | | | - Salvatore Grasso
- Intensive Care Unit, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy
| | - Patricia C Henwood
- Department of Emergency Medicine, Thomas Jefferson University Hospitals, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Stije Leopold
- Department of Internal Medicine, Amsterdam University Medical Centers - Location AMC, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Claudia Marotta
- Section of Operational Research, Doctors with Africa-Cuamm, Padova, Italy
| | - Giuseppe Marulli
- Thoracic Surgery Unit, Department of Emergency and Organ Transplantation (DETO), University of Bari, Bari, Italy
| | - Giovanni Putoto
- Section of Operational Research, Doctors with Africa-Cuamm, Padova, Italy
| | - Enzo Pisani
- Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | - James Russel
- Department of Cardiology, Connaught Hospital, University of Sierra Leone, Freetown, Sierra Leone
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Arjen M Dondorp
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Eva Hanciles
- Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers - Location AMC, Amsterdam, The Netherlands
| | | | - Marcus J Schultz
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Amsterdam University Medical Centers - Location AMC, Amsterdam, The Netherlands.,Department of Intensive Care, Amsterdam University Medical Centers-Location AMC, Amsterdam, The Netherlands
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Mowafy SMS, Elsayed M. Optic nerve sheath diameter versus extra-vascular lung water detected by ultrasound in volume status prediction in severe preeclampsia. EGYPTIAN JOURNAL OF ANAESTHESIA 2020. [DOI: 10.1080/11101849.2020.1816153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Sherif M. S Mowafy
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Mohamed Elsayed
- Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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Muñoz-Ortiz E, Gándara-Ricardo JA, Velásquez-Penagos JA, Giraldo-Ardila N, Betancur-Pizarro AM, Arévalo-Guerrero EF, Fortich-Hoyos FM, Sénior-Sánchez JM. Caracterización de la enfermedad cardiaca en pacientes embarazadas y desenlaces hospitalarios materno-fetales. REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Effect of High-Dose Intravenous Vitamin C on Postpartum Oxidative Stress in Severe Preeclampsia. REPRODUCTIVE MEDICINE 2020. [DOI: 10.3390/reprodmed1020009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: To determine whether high-dose intravenous vitamin C reduces oxidative stress in patients with severe preeclampsia in the first days postpartum. Methods: Biomarkers of oxidative stress were assessed as secondary outcomes of a single-center, randomized, placebo-controlled trial. Thirty-four patients with singleton pregnancies complicated by severe features of preeclampsia were randomized into two groups: intravenous vitamin C (1.5 g/6 h) (n = 17) or placebo (n = 17). Urinary concentrations of dityrosine, 8-hydroxy-2-deoxyguanosine (8-OHdg), 8-isoprostane, and N epsilon-(hexanoyl) lysine (HEL) were measured at days one and three after delivery and normalized for urinary creatinine in 22 of patients included (12 in vitamin C and 10 in placebo group). The Mann–Whitney U-test was used to compare values of oxidative stress biomarkers at days one and three after delivery in vitamin C vs. placebo groups (p ≤ 0.05 significant). Results: Dityrosine and 8-OHdg values did not differ significantly between the two study groups at day one after delivery (p = 0.23 and p = 0.77, respectively), but were significantly lower in the vitamin C group compared to the placebo group at day three after delivery (p = 0.04 and p = 0.03, respectively). Values of 8-isoprostane and HEL did not differ significantly between the two study groups at day one (p = 0.41 and p = 0.42, respectively), as well as at day three, after delivery (p = 0.25 and p = 0.24, respectively). Conclusion: High-dose intravenous vitamin C treatments in patients with severe preeclampsia reduced urinary levels of dityrosine and 8-OHdg (markers of protein and DNA oxidative damage, respectively) on day three after delivery. Vitamin C treatment had no significant effect on lipid peroxidation biomarkers, i.e., 8-isoprostane and HEL.
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40
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Reed A, Jordaan M, Cloete E, Dyer R. A retrospective audit of anaesthesia for caesarean section in parturients with eclampsia at a tertiary referral hospital in Cape Town. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.4.2406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Malhamé I, Mehta N, Raker CA, Hardy EJ, Spalding H, Bouvier BA, Savitz DA, Danilack VA. Identifying cardiovascular severe maternal morbidity in epidemiologic studies. Paediatr Perinat Epidemiol 2020; 34:452-459. [PMID: 31971615 DOI: 10.1111/ppe.12571] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/24/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiovascular severe maternal morbidity (CSMM) is rising and has become the leading cause of maternal mortality. Research using administrative data sets may allow for better understanding of this critical group of diseases. OBJECTIVE To validate a composite variable of CSMM for use in epidemiologic studies. METHODS We analysed delivery hospitalisations at an obstetric teaching hospital from 2007 to 2017. We utilised a subset of indicators developed by the Centers for Disease Control and Prevention based on ICD codes to form the composite variable for CSMM. Two expert clinicians manually reviewed all qualifying events using a standardised tool to determine whether these represented true CSMM events. Additionally, we estimated the number of CSMM cases among delivery hospitalisations without qualifying ICD codes by manually reviewing all hospitalisations with severe preeclampsia, a population at high risk of CSMM, and a random sample of 1000 hospitalisations without severe preeclampsia. We estimated validity of the composite variable. RESULTS Among 91 355 admissions for delivery, we captured 113 potential CSMM cases using qualifying ICD codes. Of these, 65 (57.5%) were true CSMM cases. Indicators for acute myocardial infarction, cardiac arrest, and cardioversion had the highest true-positive rates (100% for all). We found an additional 70 CSMM cases in the 2102 admissions with severe preeclampsia and a single CSMM case in the random sample. Assuming a rate of 1 CSMM case per 1000 deliveries in the remaining cohort, the composite variable had a positive predictive value of 57.5% (95% CI 47,9, 66.8), a negative predictive value of 99.8% (95% CI 99.8, 99.9), a sensitivity of 29.0% (95% CI 23.2, 35.4), and a specificity of 100% (95% CI 99.9, 100.0). CONCLUSION A novel composite variable for CSMM had reasonable PPV but limited sensitivity. This composite variable may enable epidemiologic studies geared towards reducing maternal morbidity and mortality.
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Affiliation(s)
- Isabelle Malhamé
- Department of Medicine of the Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Niharika Mehta
- Department of Medicine of the Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA.,Department of Obstetrics and Gynecology of the Warren Medical Alpert School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Christina A Raker
- Department of Obstetrics and Gynecology of the Warren Medical Alpert School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Erica J Hardy
- Department of Medicine of the Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA.,Department of Obstetrics and Gynecology of the Warren Medical Alpert School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Hannah Spalding
- Department of Medicine of the Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - Benjamin A Bouvier
- Department of Medicine of the Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA
| | - David A Savitz
- Department of Obstetrics and Gynecology of the Warren Medical Alpert School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Valery A Danilack
- Department of Obstetrics and Gynecology of the Warren Medical Alpert School of Brown University, Women & Infants Hospital, Providence, Rhode Island, USA.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
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Ashokka B, Loh MH, Tan CH, Su LL, Young BE, Lye DC, Biswas A, Illanes SE, Choolani M. Care of the pregnant woman with coronavirus disease 2019 in labor and delivery: anesthesia, emergency cesarean delivery, differential diagnosis in the acutely ill parturient, care of the newborn, and protection of the healthcare personnel. Am J Obstet Gynecol 2020; 223:66-74.e3. [PMID: 32283073 PMCID: PMC7151436 DOI: 10.1016/j.ajog.2020.04.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/03/2020] [Accepted: 04/03/2020] [Indexed: 01/08/2023]
Abstract
Coronavirus disease 2019, caused by the severe acute respiratory syndrome coronavirus 2, has been declared a pandemic by the World Health Organization. As the pandemic evolves rapidly, there are data emerging to suggest that pregnant women diagnosed as having coronavirus disease 2019 can have severe morbidities (up to 9%). This is in contrast to earlier data that showed good maternal and neonatal outcomes. Clinical manifestations of coronavirus disease 2019 include features of acute respiratory illnesses. Typical radiologic findings consists of patchy infiltrates on chest radiograph and ground glass opacities on computed tomography scan of the chest. Patients who are pregnant may present with atypical features such as the absence of fever as well as leukocytosis. Confirmation of coronavirus disease 2019 is by reverse transcriptase-polymerized chain reaction from upper airway swabs. When the reverse transcriptase-polymerized chain reaction test result is negative in suspect cases, chest imaging should be considered. A pregnant woman with coronavirus disease 2019 is at the greatest risk when she is in labor, especially if she is acutely ill. We present an algorithm of care for the acutely ill parturient and guidelines for the protection of the healthcare team who is caring for the patient. Key decisions are made based on the presence of maternal and/or fetal compromise, adequacy of maternal oxygenation (SpO2 >93%) and stability of maternal blood pressure. Although vertical transmission is unlikely, there must be measures in place to prevent neonatal infections. Routine birth processes such as delayed cord clamping and skin-to-skin bonding between mother and newborn need to be revised. Considerations can be made to allow the use of screened donated breast milk from mothers who are free of coronavirus disease 2019. We present management strategies derived from best available evidence to provide guidance in caring for the high-risk and acutely ill parturient. These include protection of the healthcare workers caring for the coronavirus disease 2019 gravida, establishing a diagnosis in symptomatic cases, deciding between reverse transcriptase-polymerized chain reaction and chest imaging, and management of the unwell parturient.
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Affiliation(s)
- Balakrishnan Ashokka
- Department of Anaesthesia, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - May-Han Loh
- Department of Anaesthesia, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Cher Heng Tan
- Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Lin Lin Su
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Obstetrics & Gynaecology, National University Hospital, Singapore
| | - Barnaby Edward Young
- Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; National Centre for Infectious Diseases, Singapore
| | - David Chien Lye
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Infectious Diseases, Tan Tock Seng Hospital, Singapore; Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore; National Centre for Infectious Diseases, Singapore
| | - Arijit Biswas
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Obstetrics & Gynaecology, National University Hospital, Singapore
| | - Sebastian E Illanes
- Department Obstetrics & Gynecology, Faculty of Medicine, Universidad de los Andes, Santiago, Chile
| | - Mahesh Choolani
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Obstetrics & Gynaecology, National University Hospital, Singapore
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Point-of-care ultrasound in pregnancy: gastric, airway, neuraxial, cardiorespiratory. Curr Opin Anaesthesiol 2020; 33:277-283. [DOI: 10.1097/aco.0000000000000846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Gratz I, Baruch M, Takla M, Seaman J, Allen I, McEniry B, Deal E. The application of a neural network to predict hypotension and vasopressor requirements non-invasively in obstetric patients having spinal anesthesia for elective cesarean section (C/S). BMC Anesthesiol 2020; 20:98. [PMID: 32357833 PMCID: PMC7195764 DOI: 10.1186/s12871-020-01015-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 04/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Neural networks are increasingly used to assess physiological processes or pathologies, as well as to predict the increased likelihood of an impending medical crisis, such as hypotension. Method We compared the capabilities of a single hidden layer neural network of 12 nodes to those of a discrete-feature discrimination approach with the goal being to predict the likelihood of a given patient developing significant hypotension under spinal anesthesia when undergoing a Cesarean section (C/S). Physiological input information was derived from a non-invasive blood pressure device (Caretaker [CT]) that utilizes a finger cuff to measure blood pressure and other hemodynamic parameters via pulse contour analysis. Receiver-operator-curve/area-under-curve analyses were used to compare performance. Results The results presented here suggest that a neural network approach (Area Under Curve [AUC] = 0.89 [p < 0.001]), at least at the implementation level of a clinically relevant prediction algorithm, may be superior to a discrete feature quantification approach (AUC = 0.87 [p < 0.001]), providing implicit access to a plurality of features and combinations thereof. In addition, the expansion of the approach to include the submission of other physiological data signals, such as heart rate variability, to the network can be readily envisioned. Conclusion This pilot study has demonstrated that increased coherence in Arterial Stiffness (AS) variability obtained from the pulse wave analysis of a continuous non-invasive blood pressure device appears to be an effective predictor of hypotension after spinal anesthesia in the obstetrics population undergoing C/S. This allowed us to predict specific dosing thresholds of phenylephrine required to maintain systolic blood pressure above 90 mmHg.
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Affiliation(s)
- Irwin Gratz
- Cooper University Hospital, 1 Cooper Plaza, Camden, NJ, 08103, USA.
| | | | - Magdy Takla
- Cooper University Hospital, 1 Cooper Plaza, Camden, NJ, 08103, USA
| | | | - Isabel Allen
- University of California - San Francisco, San Francisco, CA, USA
| | - Brian McEniry
- Cooper University Hospital, 1 Cooper Plaza, Camden, NJ, 08103, USA
| | - Edward Deal
- Cooper University Hospital, 1 Cooper Plaza, Camden, NJ, 08103, USA
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Abstract
PURPOSE OF REVIEW This review summarizes current understanding of the pathophysiology of cardiogenic pulmonary edema, its causes and treatment. RECENT FINDINGS The pathobiology and classification of pulmonary edema is more complex than the hydrostatic vs. permeability dichotomy of the past. Mechanisms of alveolar fluid clearance and factors that affect the clearance rate are under intensive study to find therapeutic strategies. Patients need early stabilization of oxygenation and ventilation, preferably with high-flow nasal cannula oxygen or noninvasive ventilation whereas the diagnostic cause is quickly sought with echocardiography and other testing. SUMMARY Treatments must be initiated early, whereas evaluation still is occurring and requires multimodality intervention. The general treatment of cardiogenic pulmonary edema includes diuretics, possibly morphine and often nitrates. The appropriate use of newer approaches - such as, nesiritide, high-dose vasodilators, milrinone, and vasopressin receptor antagonists - needs larger clinical trials.
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Keepanasseril A, Monárrez-Espino J, Vadivelu P, Kumar Maurya D. Risk factors of pulmonary edema in women with preeclampsia from south India: a case-control study. J Hum Hypertens 2020; 34:727-734. [DOI: 10.1038/s41371-020-0300-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/16/2019] [Accepted: 01/02/2020] [Indexed: 12/28/2022]
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da Silva WA, Varela CVA, Pinheiro AM, Scherer PC, Francisco RP, Torres MLA, Carmona MJC, Bliacheriene F, Andrade LC, Pelosi P, Malbouisson LMS. Restrictive versus Liberal Fluid Therapy for Post-Cesarean Acute Kidney Injury in Severe Preeclampsia: a Pilot Randomized Clinical Trial. Clinics (Sao Paulo) 2020; 75:e1797. [PMID: 32725073 PMCID: PMC7362722 DOI: 10.6061/clinics/2020/e1797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 05/04/2020] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES The aim of this study was to determine whether a restrictive compared to a liberal fluid therapy will increase postoperative acute kidney injury (AKI) in patients with severe preeclampsia. METHODS A total of 46 patients (mean age, 32 years; standard deviation, 6.8 years) with severe preeclampsia were randomized to liberal (1500 ml of lactated Ringer's, n=23) or restrictive (250 ml of lactated Ringer's, n=23) intravenous fluid regimen during cesarean section. The primary outcome was the development of a postoperative renal dysfunction defined by AKI Network stage ≥1. Serum cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) were evaluated at postoperative days 1 and 2. ClinicalTrials.gov: NCT02214186. RESULTS The rate of postoperative AKI was 43.5% in the liberal fluid group and 43.5% in the restrictive fluid group (p=1.0). Intraoperative urine output was higher in the liberal (116 ml/h, IQR 69-191) than in the restrictive fluid group (80 ml/h, IQR 37-110, p<0.05). In both groups, serum cystatin C did not change from postoperative day 1 compared to the preoperative period and significantly decreased on postoperative day 2 compared to postoperative day 1 (p<0.05). In the restrictive fluid group, NGAL levels increased on postoperative day 1 compared to the preoperative period (p<0.05) and decreased on postoperative day 2 compared to postoperative day 1 (p<0.05). CONCLUSION Among patients with severe preeclampsia, a restrictive fluid regimen during cesarean section was not associated with increased postoperative AKI.
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Affiliation(s)
- Wallace Andrino da Silva
- Departamento de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
| | - Carlo Victor A. Varela
- Departamento de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Aline Macedo Pinheiro
- Departamento de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Paula Castro Scherer
- Departamento de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rossana P.V. Francisco
- Departamento de Obstetricia e Ginecologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Marcelo Luis Abramides Torres
- Departamento de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Maria José C. Carmona
- Departamento de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Fernando Bliacheriene
- Departamento de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Lúcia C. Andrade
- Departamento de Nefrologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate (DISC), Universitè degli Studi di Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Luiz Marcelo S. Malbouisson
- Departamento de Anestesia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Abstract
Pregnant patients can suffer from the same respiratory diseases as the general population in addition to unique syndromes of pregnancy (such as pre-eclampsia and tocolytic induced pulmonary edema, and pregnancy induced cardiomyopathy). Pregnancy by itself may add certain challenges such as difficult intubation. The critically ill pregnant patient requires a multidisciplinary approach and early inclusion of obstetrical expertise is paramount in managing these patients especially in the third trimester.
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Affiliation(s)
- Robert C. Hyzy
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
| | - Jakob McSparron
- Division of Pulmonary and Critical Care, University of Michigan, Ann Arbor, MI USA
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Roth C. Birthing life and death: women's reproductive health in early twentieth-century Rio de Janeiro. ACTA ACUST UNITED AC 2019; 25:921-941. [PMID: 30624473 DOI: 10.1590/s0104-59702018000500003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 01/23/2018] [Indexed: 11/22/2022]
Abstract
This article explores women's reproductive health in early twentieth-century Rio de Janeiro, showing that elevated and sustained stillbirth and maternal mortality rates marked women's reproductive years. Syphilis and obstetric complications during childbirth were the main causes of stillbirths, while puerperal fever led maternal death rates. Utilizing traditional sources such as medical dissertations and lesser-used sources including criminal investigations, this article argues that despite official efforts to medicalize childbirth and increase access to clinical healthcare, no real improvements were made to women's reproductive health in the first half of the twentieth century. This, of course, did not make pregnancy and childbirth any easier for the women who embodied these statistics in their reproductive lives.
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Affiliation(s)
- Cassia Roth
- Professor, Department of History / University of Georgia . Athens - GA - USA
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Malhamé I, Dayan N, Moura CS, Samuel M, Vinet E, Pilote L. Peripartum cardiomyopathy with co-incident preeclampsia: A cohort study of clinical risk factors and outcomes among commercially insured women. Pregnancy Hypertens 2019; 17:82-88. [DOI: 10.1016/j.preghy.2019.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/15/2019] [Accepted: 05/08/2019] [Indexed: 02/06/2023]
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