1. ROLE OF INTENSIVIST IN CARE OF CRITICALLY ILL MOTHER Kenyatta National Hospital & UoN, College of Health Sciences Symposium Venue: Lecture Theatre III – College of Health Sciences, University of Nairobi, KNH Campus Date: 7 th February, 2014 By Dr. P.O.R. Olang’ University of Nairobi.

2. OUTLINE Introduction Challenges Indications for ICU admission Recent concepts in critical care management of obstetric patients with special focus on ventilatory strategies, treatment of shock and nutrition specific issues of importance in managing individual critical illnesses.

3. Introduction Definition: An intensivist is a doctor who provides care to patients who require intensive care. Intensive care involves close monitoring and support for critically ill patients. The intensivist works alongside other specialists and specially trained nurses and paramedics in the ICU The main indication for the critically ill obstetrical patient's admission to the ICU is respiratory failure and a need for mechanical ventilation

4. Introduction… A wide gap exists in delivery of obstetrical critical care between developed and developing nations. This gap of quality care delivery between the two worlds is due to several factors, including clinical and economical. It may be attributable to the lower literacy rates, paucity of research in obstetrical critical care, poverty, lack of awareness, and the socio-cultural and behavioral factors prevalent in developing nations.

5. Introduction… The commonest indication for Intensive Care Unit (ICU) admission of obstetric patients is hemorrhage, both ante-partum and post-partum. Hypertensive disorders, pre-eclampsia, and its related complications are also major contributory factors for such admissions. These reflect the lack of proper antenatal care and timely management of obstetrical emergencies, especially in the developing countries The obstetrician's involvement is of prime importance when managing such cases in the ICU

6. Challenges There are no established universal criteria for the admission of critically ill obstetric patients to the intensive care unit (ICU). Huge variations in the indications of ICU admission, mortality and morbidity rates, as well as the demographic characteristics Shortage of qualified intensive care specialists for handling such cases in developing nations

7. Challenges… Economic factors, socio-cultural characteristics, and different hospital protocols and management policies, further widen the gap of bringing uniform admission criteria One of the most striking similarities in all such patients is their young age, which in fact is a good prognostic indicator, provided they receive timely interventions for their acute pathologies

8. Indications for ICU admission Conditions related to pregnancy – eclampsia, severe pre-eclampsia, haemorrhage, amniotic fluid embolism, acute fatty liver, peri-partum cardiomyopathy, aspiration syndromes, infections etc. Medical diseases that may be aggravated during pregnancy - congenital heart diseases, rheumatic and non-rheumatic valvular diseases, pulmonary hypertension, anemia, renal failure etc. Conditions that are not related to pregnancy – trauma, asthma, diabetes, autoimmune diseases etc.

9. MONITORING DURING CRITICAL ILLNESS Invasive monitoring is essential in most critically ill patients both during surgical procedures and during the ICU stay. Central venous pressure monitoring is used to guide fluid administration The pulmonary artery catheter is extremely useful for measuring central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), systemic vascular resistance (SVR), cardiac output (CO), pulmonary artery (PA) pressure, and mixed venous oxygen saturation (SvO ₂).

10. COMORBID DISORDERS COMPLICATING PREGNANCY Sepsis: Early goal-directed therapy Tight control of hyperglycemia Steroid therapy Protein C Symptomatic and supportive treatment

11. COMORBID DISORDERS COMPLICATING PREGNANCY… Diabetes Tight glycemic control with insulin is recommended since such control decreases mortality and morbidity and improves outcome Cardiac diseases The commonest cause of mortality among pregnant patients admitted in the ICU Further potentiated by significant cardiovascular and physiological changes of pregnancy

12. COMORBID DISORDERS COMPLICATING PREGNANCY… Morbidity is further increased in cardiac pregnant patients with a potential risk of thromboembolic phenomenon and influenced by:  A history of heart failure, transient ischemic stroke or severe arrhythmias  Severe valvular heart disease  New York Heart Association (NYHA) class II and above  Ejection fraction < 40%

13. COMORBID DISORDERS COMPLICATING PREGNANCY… Pulmonary diseases Pulmonary edema, advanced chronic obstructive pulmonary disease, infections, and pulmonary embolism are among the major causes for respiratory failure, which necessitate the admission of pregnant patients to the ICU Commonest underlying etiology for pulmonary edema includes cardiac diseases, non-judicious use of tocolytics, over-enthusiastic use of intravenous fluids, and to some extent pre-eclampsia. The most feared complication is ARDS. Amniotic fluid embolism rapidly increases maternal mortality. The symptoms include sudden hypoxia, shock, coagulopathy, and cardiac arrest.

14. Conclusion Intensivists evaluate patients to determine whether or not they are candidates for the ICU. Patients must have treatable conditions; an intensivist may believe that the patient is better served by hospice or other supportive care if there is no reasonable chance of recovery.hospice Management begins with history, clinical examination with emphasis on individual organ-based approach and special consideration of gestational age of foetus. Intensive care team must involve the obstetricians to monitor foetal well-being.

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