N E W SLETTER O F THE IND IAN COLLEG E O F O B STETRICIANS & GYNAECOLOG ISTS

ISSUE SEPTEMBER 2017 | Pages 32 ICOG CAMPUS

ADVANCING STANDARDS OF EDUCATION & HEALTHCARE PRACTICES

Critical Care in Obstetrics

www.icogonline.org President’s Address

Anyone who stops learning is old, Whether at 20 or 80 Anyone who keeps learning, stays young. The greatest thing in life is to keep your mind young.

- Henry Ford

ear Colleagues,

It gives me great pleasure to communicate with you once again through the DICOG Newsletter. This wonderful academic communication has become extremely popular as it is a focused publication on subjects of day to day importance to all of us.

Dr. Rishma Dhillon Pai Critical care in obstetrics is a major issue of concern given the high maternal mortality President FOGSI rate in our country.

FOGSI is working at many levels to improve maternity care. Our ‘Manyata’ programme is a massive Pan India One to help improve quality care in nursing homes where majority of the deliveries take place and help in their accreditations. FOGSI Mamta TV in all our waiting rooms, which help educate patients on important health issues while they wait for their doctor. The PMSMA programme with government of India will improve antenatal care. We have three critical care conferences coming up in Ahmedabad, Indore and Patna, which will help gynaecologists improve their expertise.

I congratulate Dr. Mala Arora and Dr. S. Shanthakumkari for bringing out this important newsletter.

Chairperson’s Address ive women in India die every hour during childbirth. WHO statistics show that 303,000 mothers are lost per year around the globe. These are precious young Flives lost largely due to preventable causes. In an endeavor to save these lives we need to train our obstetricians in the art of Critical Care. Every mother that becomes critically ill merits to be stabilized and safely transferred to an intensive care / high dependency unit. Adequate training and minimal equipment can arm the obstetrician at the grass root level to stabilize critically ill mothers.

This newsletter presents an insight into critical care as well as the conference isan endeavor to impart this training.

Dr. Mala Arora Today we are seeing a decline in maternal mortality rate in our country, which has Chairperson ICOG dropped from 254/100,000 in 2006 to 139/100,000 in 2016 and we hope to continue this [email protected] trend over the coming years.

2 ICOG CAMPUS SEPTEMBER 2017 Secretary’s Message

ear All !

Obstetrics in general deals with healthy young women who participate in the Dprocess of pregnancy and childbirth with the aim of having a healthy baby and remaining healthy themselves. We often quote philosophers in saying that a pregnant woman should never be referred to as a "patient" because pregnancy care is usually considered a normalcy event! Nevertheless, catastrophic events related to pregnancy can be life threatening and history is full of examples where tragedies have ensued due to lack of "Critical care in Obstetrics".

Less than 2percent of women may need intensive critical care during pregnancy or peripartum period but if this is insuffiicent in any way then the final outcome can escalate to even maternal and fetal mortality. Hence the importance of critical care in Obstetrcis cannot be understated. Massive postpartum hemorrhage and the complications hypertensive disorders are the most common indications of ICU admissions in the obstetric population Dr. S. Shantha Kumari and knowing the frequence of both these conditions in our women, it is imperative that Secretary ICOG every obstetrician keep herself abreast with the basics of critical care. The incidence of ICU admission for pregnant and postpartum women ranges from 0.7 to 13.5 per 1000 deliveries. The recent statement on the availability of ICU for surgical patients has created a buzz in the medical fraternity and although the doctors must read the entire document and understand the finer details, the nutshell message is that every surgical patient should have access to critical care when needed. The paradox is that "when needed" may sometimes be a retrospective observation and then the damage is huge.

I whole heartedly appreciate this initiative on increasing awareness on this very crucial subject - especially in an era that maternity wards are being frequented by women who are older than what they used to be in the preceding decades such that theirown co morbidities are high. Thanks to the advancement of care in parallel medical subspecialities, it is not unusual to find women with significant health conditions like severe heart disease, recipients of liver transplants or even treated cases of malignancies get pregnant and reach out forObstetric care. Such care will always carry the risk of requirng critical care at any time. The onus is now on teh Obstetrcian to do teh best by the pregnant women and thus keep abreast the lastest developments in obstetric critical care.

ICOG Office Bearers – 2017

Dr. Rishma Pai Dr. Mala Arora Prof. C. N. Purandare

President FOGSI-ICOG Chairperson ICOG Dean ICOG

Dr. Hrishikesh D. Pai Dr. S. Shantha Kumari Dr. Sushma Pandey Dr. Uday Thanawala

Secretary General FOGSI Secretary ICOG Vice Chairperson ICOG Vice Chairperson Elect 2017

ICOG CAMPUS SEPTEMBER 2017 3 From the Editor’s Pen

reetings to All! our mothers from wrath of obstetrical complications. We present to you yet Ganother issue of ‘ICOG This dedicated issue of ICOG Campus Campus’ dedicated to ‘Critical Care in aims to sensitize the obstetricians about Obstetrics’ the critical issues of their obstetric patients. It covers in its ambit special It is a well-known fact that obstetric features on need and setting up of practice entails dealing with life HDU/ICU, concept of Labour-delivery- threatening complications requiring an recovery units, physiological aspects urgent critical care. This necessitates in critically ill patients, antibiotics High Definition Unit(HDU) /Intensive Dr. Monika Gupta in sepsis, critical appraisal of blood Editor-in-Chief Care Unit(ICU) like care including transfusion and simplified overview continuous patient monitoring, MD, DNB, FICOG, MAMS of ABG analysis. Few interesting near invasive monitoring facilities, and a Associate Professor, Obgyn miss case scenarios with management trained multi-disciplinary manpower protocols will provide a ready reckoner VMMC & Safdarjung Hospital, capable to address these special New Delhi for the practitioners. Intriguing brain interventions to save critically ill teasers at the end to keep up with the FOGSI-Kamini Rao Yuva Orator mothers. Awardee 2016 tradition. Critical care in obstetrics is a much ICOG Travel Fellowship (ART) We expect that our readers will needed area to be developed in Awardee 2016 enrich themselves about this highly country like us with high mortality and specialized and progressively Joint Secty, AOGD 2015-16 morbidity. For every maternal death, expanding discipline, which is the [email protected] there are some 80 maternal morbidities. need of an hour. 09312796171 If we can cater to these morbidities aptly, we will be able to save many of I wish happy reading to all. www.icogonline.org

ICOG Governing Council Members 2015 - 17

Dr. Alka Kriplani, New Delhi Dr. Mandakini Megh, Mumbai Dr. Sadhana Gupta, Gorakhpur Dr. Alpesh Gandhi, Ahmedabad Dr. Maninder Ahuja, Faridabad Dr. Sarita Agrawal, Raipur Dr. Anita Singh, Patna Dr. Milind Shah, Solapur Dr. Sushma Pandey, Patna Dr. Basab Mukherjee, Kolkata Dr. Parag Biniwale, Pune Dr. Sunita Tandulwadkar, Pune Dr. Bhaskar Pal, Kolkata Dr. Pragnesh Shah, Ahmedabad Dr. Suvarna Khadilkar, Mumbai Dr. Himanshu Roy, Patna Dr. Prashant Acharya, Ahmedabad Dr. Tushar Kar, Odisha Dr. Kawita Bapat, Indore Dr. Rajat Mohanty, Odisha Dr. Urvashi Verma, Agra Dr. Krishnendu Gupta, Kolkata Dr. Rajat Kumar Ray, Odisha Dr. Laxmi Shrikhande, Nagpur Dr. S. Sampathkumari, Chennai

4 ICOG CAMPUS SEPTEMBER 2017 Guest Editors "Critical Care in Obstetrics"

Dr. Alpesh Gandhi, Consultant, Obstetrics & Gynaecology, Arihant Hospital, Ahmedabad • Vice President FOGSI 2013 • Governing Council Member ICOG

Dr. Kawita Bapat, Director of One Centre for Gynaecological Excellence, Indore • Chairperson Female Breast Diseases Committee FOGSI • Past president Indore Obgyn Society • Governing Council Member ICOG • Treasurer, Ims Indore Chapter

Guest Editors - Previous Issues

Dr. Sadhana Gupta, Senior Consultant Obstetrician & Gynecologist, Gorakhpur • May Issue Vice President FOGSI-2016 • Governing Council Member ICOG 2015-17.

Dr. Sarita Agrawal, Prof & HOD, AIIMS, Raipur • Vice President FOGSI-2015 • Governing Council Member ICOG 2015-18.

Dr. Parul Kotadwala, Consultant Ob-Gyn, Ahmedabad • ICOG Governing Council Member. June Issue

Dr. Parag Biniwale, Consultant Obgyn, Pune • ICOG Governing Council Member, Hon. Secretary, ICOG (2018-20).

Dr. Sunita Tandulwadkar, Vice-President FOGSI (2017) • Elected Board Member, ISGE (2013- July Issue 2017), Clinical Secretary, Indian Society of Assisted Reproduction (ISAR) • Chief, Ruby Hall IVF & Endoscopy Centre, Pune.

Dr. Laxmi Shrikhande, Member Governing Council ICOG (2012 - 2017) • Senior Vice President FOGSI 2012 Director-Shrikhande IVF & Surrogacy Centre, Nagpur, Maharashtra.

Dr. Duru Shah, Director, Gynaecworld, the center for women’s health and fertility • August Issue President, ISAR • Founder President, The PCOS Society, Past President, FOGSI and IMS • Past Chairperson, ICOG Prof.

Dr. Bharati Dhorepatil, Director & Chief IVF Consultant, Shree Hosp’s Ssmile IVF Center Vice President FOGSI 2016 • President ( Elect), Pune OBGYN Society. National Co-ordinator, FOGSI- PCOS Registry • Ex. Chairperson, Clinical Research Committee, FOGSI.

"ICOG Campus" Team

Dr. Sharda Patra Dr. Bindiya Gupta Lady Hardinge Medical College & Smt SK Hospital, New Delhi UCMS & GTB Hospital, Delhi

Lt Col (Dr) Reema Kumar Dr. Puneet K Kochhar Army Hospital (Research and Referral), New Delhi Elixir Fertility Centre, Delhi

Dr. Abha Rani Sinha Chairperson Quiz Committee FOGSI (2015-2017)

ICOG CAMPUS SEPTEMBER 2017 5 ICOG Past Chairpersons

Late Dr. C. L. Jhaveri, Mumbai Late Dr. C. S. Dawn, Kolkata Late Dr. Behram Anklesaria, Ahmedabad (1989-96) (1997-1999) (2011)

Dr. Mahendra N. Parikh, Mumbai Dr. Rohit V. Bhatt, Baroda Dr. Usha B. Saraiya, Mumbai (2000-2002) (2003-2005) (2006-2008)

Dr. Duru Shah, Mumbai Dr. A. K. Debdas, Jamshedpur Dr. Hiralal Konar, Kolkata (2009-2010) (2012) (2013)

Dr. Atul Munshi, Ahmedabad Dr. Dilip Kumar Dutta, Kalyani Prof. Krishnendu Gupta, Kolkata (2014) (2015) (2016)

List of Academic Council members

Advisory Group Working Group

Current Office Bearers of FOGSI Selected Directors of Certificate Courses Dr. Rishma Dhillon Pai, Dr. M. G. Hiremath, Dr. Vidya A Bhat, Dr. Shanti Roy, Dr. Parul Kotdawala, Dr. Ranjana Khanna, Dr. Rajesh Modi Dr. Narendra Malhotra, Dr. Jayam Kannan, Dr. Bhaskar Pal, Dr. Sunita Tandulwadkar, Dr. Alpesh Gandhi, Dr. Rishma D. Pai. Dr. Jaideep Malhotra – President Elect Dr. Hrishikesh D. Pai, Dr. Jaydeep Tank, Dr. Madhuri Patel, Dr. Sarita Bhalerao Dr. Suvarna Khadilkar

Current Office Bearers of ICOG Selected members from Governing Council Dr. C.N. Purandare – Dean ICOG, Dr. Bhaskar Pal, Dr. Basab Mukherjee, Dr. Mala Arora – Chairperson, Dr. Laxmi Shrikhande, Dr. Maninder Ahuja Dr. Sushma Pandey – Vice Chairperson, Dr. Milind Shah, Dr. Parag Anand Biniwale, Dr. S. Shantha Kumari – Secretary, Dr. Pragnesh J. Shah, Dr. S. Sampathkumari Vacant – Chairperson Elect Dr. Sunita Tandulwadkar Dr. Atul Munshi - Chairperson Academic Council, Dr. Uday Thanawala – Vice Chairperson Elect

Past Presidents of FOGSI (last 5 years) Nominated members from FOGSI Dr. Shah P. K., Dr. Divakar Hema, Dr. V. P. Paily, Dr. Gokul Chandra Das, Dr. Suchitra N. Pandit, Dr. Prakash Trivedi Dr. Phagun Shah, Dr. Arun Baruwa, Dr. Alka Kriplani Dr. Mala Arora, Dr. Indira Devi, Dr. Nandita Palshetkar

Past Chairpersons of ICOG From YUVA Brigade Dr. Saraiya Usha B., Dr. Dr. Shah Duru, Dr. Debdas A. K, Dr. Indranil Dutta, Dr. Aruna Suman, Dr. Kiranmai, Dr. Konar Hiralal, Dr. Dilip Kumar Dutta, Dr. Shyjus Nair Dr. Krishnendu Gupta

6 ICOG CAMPUS SEPTEMBER 2017 The Need and Indications Dr. Alpesh Gandhi for admissions to High Consultant, Obstetrics & Gynaecology, Dependency Unit (HDU)/ Arihant Hospital, Ahmedabad Intensive Care Unit (ICU) Vice President FOGSI 2013

What is the Need ? be admitted to an HDU because they are at Admission Indications risk of requiring intensive care admission Obstetric disorders constitute 2/3 of Safe Maternity is viewed as a basic human (step up) or at the same time, patients in admissions and 1/3 is due to pregnancy right worldwide. Health of a woman reflects the Intensive Care Unit who have had an with medical disorders in obstetric HDU/ health of the nation. Maternal mortality is improvement in their condition require a stay ICU. Antenatal admissions are more an important indicator of maternal health. in the High Dependency Unit (HDU) before common with medical complications and Because of various government schemes admission to a general ward (step down). hypertensive disease of pregnancy while and efforts by many organizations in India, HDU would not normally accept patients post-partum patients are admitted more hospital delivery rate has improved a lot and requiring mechanical ventilation, but could with hemodynamic instability mostly from reached up to 84% and MMR has reached manage those receiving close monitoring. obstetric haemorrhage, infection and post- up to 167 deaths per 100,000 live births in Patients with multi organ failure cannot be operative complication. 2013 in India. MMR in developed countries kept in HUD but patients requiring single is < 20. Maternal mortality is ‘just the tip organ support can be admitted in HDU. During examination, a quick initial of the iceberg’. There is a vast base to this assessment is done. Obstetric Patient with Critically ill obstetric patient is safer if iceberg – which is unseen and known as following conditions/diagnosis may require admitted in Obstetric HDU/ICU than MICU maternal morbidity (near miss). Recent admission in Obstetric HDU: WHO systematic review, global prevalence because if required, patient can be shifted of SAMM (defined as severe life-threatening easily and promptly to LR or Operation a. Hemodynamic instability theatre, neonates can be taken care better obstetric complication necessitating an b. Respiratory dysfunction, urgent medical intervention in order to as NICU is near and foetal monitoring is prevent likely death of mother), varies from also possible. Obstetric HDU and Obstetric c. Neurologic complications. 0.01 to 8.23%. The case fatality ratio is 0.02– ICU are nearer to each other in the obstetric d. Acute kidney injury 37%. Incidence of high-risk pregnancy is department and so step up and step down approximately 15% in India. At every 5 min, facility can be used easily. In Obstetric e. Hematological complications one woman dies from a pregnancy related ICU, beds have the facility to be converted High Dependency care unit admissions are complication in India (UNICEF). Prevalence into labour table. In Obstetric HDU/ICU, a mainly constitutes of high risk patient likely of SAMM necessitating urgent medical trained or experienced dedicated full time to develop problems, having Single organ intervention can be as high as 8.23% in India obstetrician and staff is trained in obstetric dysfunction, requiring minimal O2 support, (WHO). complications/emergencies is always blood transfusion or non invasive monitoring. available. Care of critically ill patients is a unique Obstetric ICU admissions are mainly challenge in obstetrics as deterioration is Triage policy constitute of patients requiring two or more fast and there may be an existing comorbid organ systems support, Invasive monitoring, Patients may be transferred directly to medical condition. In UK, nearly 30% big Ventilatory support, Inotropic support, Obstetric HDU/ICU from an emergency hospitals are having High Dependency care massive blood transfusion, renal replacement department if required, or from a ward if Unit facility. In our country, the facility therapy, risk of sudden catastrophic they rapidly deteriorate, or immediately after was nearly nil before 2010. Therefore, these deterioration or multidisciplinary team is surgery if the surgery is very invasive and women are being managed in the labour required. the patient is at high risk of complications. rooms or routine wards without monitoring While shifting or referring of a patient to Depending on the clinical condition and facilities and trained health care providers. In Obstetric HDU/ICU, the decision has to be severity of illness, the Obstetrician will order to provide timely care to these mothers informed to relatives & consent is taken, take decision whom to admit in obstetric and reduce preventable maternal deaths, patient should be escorted by doctor /staff HDU/ICU or who will require routine care close monitoring and skill-based services by with case sheets and all existing treatment / delivery. trained professionals in a dedicated obstetric high dependency unit (HDU)/ICU with state- of-the-art technology is the need of the hour. Examination room / LR Obstetric ICU/HDU Obstetric Emergency Obstetric ICU is an dedicated to manage HD U only for obstetric patients having Ro om critical obstetrical or medical or surgical complications, managed by staff oriented for obstetric physiology and pathology. An Obstetric HDU is an area in the obstetric department where patients can be cared for ICU more extensively than on a normal ward, Wards OT but not to the point of intensive care. So they are intermediate care units. Patients may

ICOG CAMPUS SEPTEMBER 2017 7 Criteria for admission in Obstetric HDU/ICU: Obstetric HDU Obstetric ICU • Systolic Blood Pressure(SBP) < 90 or > • RR < 8 or >35 per minute • S.potassium <2.0 or > 7.0 mmol L 160 mm Hg • Heart rate <50 or >140 beats / minute • pH < 7.1 or > 7.7 • Diastolic Blood Pressure: < 50 or > • Systolic B.P. < 80 mm Hg, or 30 mm Hg • PaO2 < 6.6 kPa and/or PaCO2 > 8.0 kPa. 110 mm Hg below patient’s usual B.P. • SaO2 < 90% on supplemental oxygen. • Mean Arterial Blood Pressure < 60 mm of • U/O < 400 ml in 24 hrs, or < 160 ml in 8 • Need for advanced Hg hrs and unresponsive to simple routine • Respiratory support • Heart Rate < 60 or >110 per minute measures. • Inotropic support • Respiratory Rate: > 25 per minute • GCS < 8 in the context of non-traumatic • DIC • Urine < 0.5ml /Kg/Hour (< 30 ml per coma. hour) • Any unarousable patient. • Multi-organ failure • Any organ dysfunction • S. sodium <110 or >160 mmol L • ARDS

SCOPE OF HDU: Conditions which may require admission in Obstetric HDU/ICU Obstetric Complications Pregnancy with Medical Complications • Pregnancy / Labor Pain with Severe Anemia (< 7 gm %) and its § Gestational Diabetes. complications. § Accidental Hemorrhage- Placental abruption, couvelaire uterus § Diabetic Ketoacidosis § Post Partum Hemorrhage § Cardiac Diseases § Placenta Previa § Jaundice § Adherent Placenta and other placental abnormalities. § Thyrotoxicosis § Obstetric hysterectomy § Thyroid storm § Severe Preeclampsia/ Hypertensive crisis § Pheochromocytoma § Eclampsia § Endocrinal crisis like addison’s disease etc. § Broad ligament hematoma § Post operative ARF and other renal problems § HELLP Syndrome § Leukemia and other hemolytic disorders. § Pregnancy with DIC § Dengue § Sepsis & systemic inflammatory response syndrome (SIRS). § complications of Malaria § Pregnancy with Thrombophylias. § Asthma and other respiratory problems. § Multiple gestation with complications § PPCM-Postpartum cardiomyopathy § Pregnancy with complications due to uterine anomaly and § Appendicectomy or any other surgical emergency pathologies § Hydatidiform Mole § Pregnancy with OHSS. (Ovarian Hyperstimulation syndrome) § Ruptured Ectopic § Acute Panceatitis § Burns during pregnancy § Trauma § Perforation during abortion § Poisoning § Postoperative patients requiring hemodynamic monitoring, or § Pregnancy with Cancer intensive nursing care § Pulmonary edema due to peri-operative fluid overload, CCF, complication of severe pre-eclampsia or tocolytic therapy with β-agonists etc. (Pregnancy with H1NI, Pyometra, HIV and infectious diseases should be admitted in Isolation Room in Obstetric HDU/ ICU) including oxygen and patent IV line, References 2. Saravanakumar K, Davies L, Lewis M, monitoring the vitals of the patient should Cooper GM. High dependency care in an 1. Souza JP, Gülmezoglu AM, Vogel J, Carroli be continued and ensuring patent airway. obstetric setting in the UK. Anaesthesia. G, Lumbiganon P, Qureshi Z, Costa MJ, Baby should be shifted with mother if she 2008 Oct;63(10):1081-6. Fawole B, Mugerwa Y, Nafiou I, Neves I, has delivered. Wolomby-Molondo J-J, Bang HT, Cheang 3. Dattaray C, Mandal D, Shankar U, Conclusion K, Chuyun K, Jayaratne K, Jayathilaka CA, Bhattacharya P, Mandal S. Obstetric Mazhar SB, Mori R, Mustafa ML, Pathak patients requiring high-dependency It is important to provide critical care LR, Perera D, Rathavy T, Recidoro Z, Roy unit admission in a tertiary referral services to obstetric patients and if quality M, Ruyan P, Shrestha N, Taneepanichsku centre. International Journal of Critical obstetric health care is provided in time, then S, Tien NV, Ganchimeg T, et al. Moving Illness and Injury Science. 2013;3(1):31-35. we should be able to save 80% of 3,03,000 beyond essential interventions for doi:10.4103/2229-5151.109416. pregnant women who die in the world every reduction of maternal mortality (the 4. Ryan M, Hamilton V, Bowen M, McKenna year (WHO-2015). It is said that, dedicated WHO Multicountry Survey on Maternal P. The role of a high-dependency unit in obstetric HDU/ICU to provide quality and Newborn Health): a cross-sectional a regional obstetric hospital. Anaesthesia. emergency care is the need of the hour. study. The Lancet. 2013;381:1747–55. 2000 Dec;55(12):1155-8.

8 ICOG CAMPUS SEPTEMBER 2017 Standardization of Labor Rooms at Delivery Points - Dr. Pratima Mittal Professor & Head, a Critical Intervention for Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi Improving Maternal and Vice President FOGSI (Elect) 2018 Fetal Outcomes

Introduction services. It is being recommended that, if ventilation, a ceiling/wall mounted fan. there is adequate space available without any The best indicator of a country’s health is • Vital monitors in each labor area is significant resource constraints, all the maternal and perinatal mortality. High desirable facilities with more than 500 deliveries in institutional delivery rates have not a month should be upgraded to have labor • Adequate light; ambient light, with resulted in proportionate reduction in these rooms as per the LDR concept. One LDR additional focus lights for the labor tables mortalities. This points out to the need of unit has four LDR beds. No of beds for LDR and examination tables for procedures. providing quality services in the Labor concept is calculated by formula Rooms. Providing a skilled health care • Each labor bed should have recommended provider, availability of adequate resources No. of LDR beds = {(Projected LDR events specifications: and presence of an enabling environment can in a year)*(Average length of stay)} / {(365)* § Adjustable side rails. definitely lead to translation of competencies (Occupancy rate)} into action. Most important is to practice § Facilities for Trendelenburg/reverse Calculation: evidence based good clinical practices with positions. readiness or preparedness to deal with the Step 1: Determine the number of LDR events § Facilities for height adjustment immediate complications. in a year, i.e. the number of vaginal births (hydraulic pump preferably). per annum (projected number of births Standardization of per annum plus the projected number of § Stainless steel IV rod. Labor Rooms unplanned C-section births). § Mobility: swiveling castor wheels & Labor Rooms at every delivery point should Step 2: Take 0.67 days or 16 hours (12 hours brakes. be the focus area for delivering high quality for labor and delivery, 4 hours recovery, § Mattress should be in three parts services during childbirth. They should be including the room clean-up) as the average and seamless in each part with a thin standardized throughout the country. The length of stay. cushioning at the joints, detachable at Govt. of India released guidelines in 2016 perineal end. explaining how to upgrade the Labor Rooms Step 3: 75% or 0.75 is the recommended for standardization i.e. constructing new occupancy rate for health facilities. § Disposable draw sheet. labor rooms /delivery units as per need or Step 4: Insert the numbers attained in the § Steel basins attachments. reorganizing the existing labor rooms. The above steps, in the formula, and calculate guidelines focus on five important areas: the number of LDR beds required. For e.g., § Calf support, handgrip, leg support. 1. Space and Lay out LDR bed requirement for a hospital with Newborn Care Area (NBCA) centrally located 7200 projected deliveries (6120 normal with the following: 2. Equipment and accessories deliveries 1080 C-sections out of which 600 • Radiant warmer. 3. Consumables are unplanned C-sections) can be calculated as follows: • Resuscitation kit with functional bag and 4. Human resources • Number of LDR events in a year: mask. 5. Practice and Protocols (6120+600) = 6720 • Mucus extractor. 1. Space and Layout • Number of LDR beds required = (6720* • Pre-warmed baby receiving towels. 0.67)/ (365*0.75) = 16 beds or four LDR The most important factor for defining the • Shoulder roll. space and layout of the labor room is the Units • Pediatric stethoscope. number of labor beds in the facility. Two The LDR based labor room complex will types of labor rooms are being recommended: have two main components—Core LDR unit • A clock with seconds hand on the wall • Labor-delivery-recovery (LDR) room and support areas. A standard LDR unit near the NBCA. should have 4 labor areas with one labor concept (a pregnant woman spends the • An oxygen cylinder/oxygen concentrator table each, one nursing station, one newborn duration of labor, delivery, and 4 hours in the vicinity of the NBCA. postpartum in the same bed) care area, two toilets and two washing areas. Recommended components of the LDR unit Nursing Station: centrally located with a • Conventional labor rooms (a pregnant are: storage cupboard for storing documents woman is admitted to labor room only at and supplies, a white board on the wall Labor Area or near full dilation of cervix and is shifted next to the nursing station. The space below to the postpartum ward after 2 hours). • Each measuring 10’X 10’ the platform should be used for storing the LDR concept is more client-centric and crash trolley loaded with 5 trays (autoclaved • An opaque partition between two ensures better care, privacy and comfort to delivery tray, baby tray, episiotomy tray, consecutive labor areas. the pregnant woman during labor process. It normal drug tray and emergency drug tray) also obviates the need for having additional • Each having one labor table, one stool for There should be one crash trolley per labor waiting area or labor area and associated birth companion, adequate lighting and table.

ICOG CAMPUS SEPTEMBER 2017 9 Toilets two in number (western style) with Table 1: Equipment and Accessories wash basin • Fetoscope • protective eye cover for provider. Handwashing Area: a steel sink , two elbow- • Autoclaved delivery tray for each labor • Gown for mother operated taps with 24x7 running water table supply, a geyser, soap dispenser and hand • Disposable sheet for covering labor table • Stethoscope for each delivery washing protocols on the wall above the hand washing area. • Protein urea test kit • Radiant warmer Washing Area: area of 6’2” X 6’having two • Glucometer (calibrated for venous blood • Baby digital thermometer samples) taps with running water supply and a geyser. • Baby forehead thermometer • Digital BP instrument Support area includes waiting /registration • Pediatric resuscitator bag (volume 250 area, triage /examination room, procedure • Adult digital thermometer ml) with masks of 0 and 1 size room, staff rooms, changing room, store room, clean and dirty utility room, and air • Wall clock with seconds hand 1 in each • Baby weighing scale Labor room and 1 opposite to each NBCC handling unit. • Mucus extractor • Tags for mother and baby It is recommended that each labor room • Disposable baby receiving sheets complex has access to CSSD for supply of • Cheatle forceps • Socks and caps for the baby (disposable) sterile utilities to labor rooms. • Disposable sterile gloves • Disposable cord clamp Conventional labor rooms: • Disposable utility gloves • Color coded buckets/ bins [yellow, red, Where space for LDR rooms is not available, • A sterile tray with Sim’s speculum and blue & white (puncture proof for sharps)] the labor rooms should be upgraded using swab with color-coded bags and biomedical the Conventional Labor Room concept. waste segregation and disposal Calculations of beds is by same formula as of LDR • Hb test kit • Hub cutter concept but average stay is taken as 0.33 days (In • Sanitary napkins (@2for each delivery) LDR Concept it is 0.67 days) • Plastic buckets of which the inner bucket • Sterile pad (@4 sterile pads for each should be perforated or fenestrated for The recommended number of labor tables delivery) chlorine solution. per health facility as per delivery load are: • M C P card (one M C P card and a safe • Mops with stand < 20 deliveries /month 1 motherhood booklet for each delivery) • Overhead water storage tank 20-99 deliveries /month 2 • Standardized Case sheet including the Safe Child birth Checklist and Partograph • Autoclave (electrical or gas stove) 100-199 deliveries /month 4 • Disposable gowns for service provider (Only horizontal autoclaves to be used) 200-499 deliveries /month 6 and birth companion >500 deliveries /month to be calculated • Disposable face masks and caps and shoe as per LDR covers for service provider and birth concept companion Conventional labor rooms will have all the facility of LDR complex but there is one 3. Consumables attendants and category 2(High Risk cases) labor room having required no of labor beds. in which regular care by an obstetrician is Consumables such as cotton, thread, gauze, Women are kept in separate area before and needed. The institutions where there is an catgut, IV drip sets, needles, medicines-oral after delivery and are observed routinely for HDU, category 2 cases should be sent and and parenteral, leucoplast, soap, hand-wash, 2 hrs after child birth. category 1 cases should be delivered by the betadine solution, mosquito repellent etc. nurses in the labor rooms. The institutions The labor tables should be placed in a way 4. Human Resources managing category 2 cases, the obstetrician that there is a distance of at least 3’ from the should be available all the time. side wall, at least 2’ from head end wall, and All the labor rooms should have human at least 6’ from the second table in case of resources in adequate numbers strictly Labor Room Protocols: Labor Room two-table labor room. as per recommendations1. HR posted in protocols should be in place regarding entry Labor rooms should not be rotated outside to labor room for women in labor and staff There should be a reception and registration the labor rooms. Number of Obstetricians, working in labor room, protocol for safe care area near the entry of the labor room complex Medical officers, anesthetists, pediatrician, in the labor room. There should be display that is separate from the regular in patient Staff nurses/ANMs/cleaning staff, guard of all essential practice protocols e.g. AMTS, reception area of the mothers in labor and in should be as per number of deliveries and Partograph, Essential Newborn care, hand emergency. available cesarean facility. washing etc.) Essential Practices to be followed: The 2. Equipment and All normal deliveries in labor room should essential practices should be performed in all Accessories be conducted by staff nurses. OBG, EmOC the delivery cases. (Table 2) All the labor rooms should have equipment trained M O and anesthetists should also be and accessories with appropriate available on call at all times. One should remember, induction/ augmentation should not be done routinely. specifications and in adequate quantities, as 5. Practices and Also, whenever needed, augmentation of per the recommendations1,2 (Table 1) Protocols labor should be done only in centers capable Other equipment and supplies: Triaging: Every client coming to the institution of performing cesarean sections. HIV Kits for delivery should be triaged into two Don’ts (harmful practices) categories by the examining obstetrician— Refrigerator • No routine enema category 1(Low risk cases) which can Wheel chairs and stretchers undergo a normal delivery by skilled birth • No routine shaving

10 ICOG CAMPUS SEPTEMBER 2017 Table 2 : Essential Practices for all Delivery Cases facilities: general waste, medical waste, and At the time of admission In Labor room After Delivery hazardous waste. It is important to dispose • Measurement of BP and • Partograph • Assessment of maternal all kinds of waste properly, since improper temperature of mother bleeding disposal of medical and hazardous chemical • Active management of waste poses the most immediate health risk • Measurement of Fetal third stage of labor • Assessment of to the community2. Heart Rate newborn condition • Delayed cord clamping by measurement of Supportive supervision for quality of care • Measurement of • Essential newborn care temperature and Labor room should have a cleanliness Hemoglobin Drying and wrapping of respiratory rate checklist for cleanliness assessment. There • Measurement of urine baby • Assessment of should be periodic review of the availability protein • Immediate resuscitation maternal condition by of essential supplies. Senior faculty should • Assessment of gestational if required. measurement of BP and observe practices to ensure all essential age temperature • Skin to skin contact of the practices are being performed appropriately newborn and in timely manner. Periodically a labor room practice review meeting should be • Immediate initiation of organized at each facility. breastfeeding • Injection vitamin K · Conclusion Universal implementation of standard • No routine induction/augmentation of Assessing pregnant women requiring HDU/ practices and adherence to the guidelines labor ICU care A maternal early warning system all over the country will definitely help in (Modified Obstetric Early Warning System) to • No place for routine suctioning of the reducing maternal and perinatal mortality. assess women requiring special care is being baby tested. This includes regular recording of References • No pulling of the baby. Allow natural variables like, pulse, systolic blood pressure, 1. Guidelines for Standardization of Labour slow delivery (3 minutes – 1min for head, diastolic blood pressure, respiratory rate, Rooms at delivery points 2016 http:// 1 min for shoulders and 1min for body). temperature, oxygen saturation, mental nhm.gov.in/images/pdf/programmes/ Only assist when required at the time of status (AVPU) and urine output. These are maternal-health/guidelines/Labor_ delivery of body (prevents PPH) recorded on a colour-coded chart and if Room%20Guideline.pdf • No routine episiotomy 2 or more values are in the yellow zone or 1 value is in the red zone, it is a trigger to 2. Maternal and Newborn Health Tool Kit • No fundal pressure scale up the care. This system is envisaged 2013 http://cghealth.nic.in/ehealth/2014/ • No immediate cord cutting to be especially useful for use at the primary RMNCH_A/2Maternal_Newborn_ and secondary care levels to enable early Health_Toolkit.pdf • No immediate bathing of the newborn recognition of critical conditions needing • No routine resuscitation on warmer tertiary care referrals. 3. Daksh skill Labs for RMNCH-A services 2014 http://nhm.gov.in/images/pdf/ (every baby should not be kept on warmer Bio-medical Waste (BMW) Management programmes/maternal-health/guidelines/ unless there is an indication) Biomedical waste is the waste that is generated SKILLS_LAB_TRAINING_MANUAL_ Skill Training The teams are being trained during examination, immunization, in the skill of conducting normal deliveries, investigations, diagnosis and treatment FACILITATOR.pdf and http://nhm.gov. identifying cases at risk and managing such as bandages or surgical sponges; which in/images/pdf/programmes/maternal- immediate complications. Uniform protocols includes blood, blood products (fresh or health/guidelines/SKILLS_LAB_ for conduct of deliveries as developed by dried blood) or other body fluids. There are TRAINING_MANUAL_Participant%20. GOI should be followed.1,2,3, three kinds of waste generally found in health pdf

Do What You Can With All You Have, Wherever You Are

- Theodore Roosevelt

ICOG CAMPUS SEPTEMBER 2017 11 Impact of Physiological Changes in Management Dr. Jyotsna Suri Professor & Senior Specialist, of Critically Ill Obstetric Obstetrics & Gynaecology, Patient VMMC & Safdarjung Hospital, New Delhi

Introduction of approximately 1500 mL, of which • The other remarkable change is the 1000 mL is plasma volume and 500 mL increase in cardiac output by almost 40% Pregnancy is a period during which many is erythrocytes1. This volume expansion (Figure 2). This translates to a cardiac physiological changes take place as an may be even greater in multifetal output of 6L/min from a non-pregnant adaptation to support the growing fetus gestations. However, the blood volume value of 4L/min3. The increase in heart and to protect the mother during parturition. may expand little, if at all, in patients with rate and stroke volume is responsible for An understanding of these changes by the severe preeclampsia or eclampsia.2 the increase in CO (CO=HR*SV). critical care physician and obstetrician is very important as the treatment strategies • Systemic vascular resistance (SVR) is the and goals change with respect to the altered afterload against which the heart must physiology. Almost all the body systems pump. It has been seen that there is a undergo alterations during pregnancy, which includes the cardiovascular system, haematological system, respiratory system, gastrointestinal and urinary systems. Cardiovascular system • The physiological and anatomical changes in the cardiovascular system during pregnancy, labor and parturition are described in Table 1. As is seen, the most prominent change is the increase in plasma volume, to the tune of 50% (Figure 1). This represents an increase Fig. 1: Volume changes in pregnancy Fig. 2: HR & SV during pregnancy

Table1: Physiological and Anatomical changes in the cardiovascular system in pregnancy.

Parameter Change Antenatal period Labor Post partum Plasma Volume Increase 50% Increases from 6 weeks, Remains Same There is fall due to blood peaks 30- 32weeks loss Stroke volume Increase 20% Increases from early During straining in 2nd Normal in 6 weeks pregnancy Peaks at 20 stage(valsalva) there is a weeks, gradually falls fall

Heart rate Increase 15-20 bpm Rise more in 2nd half Further rise seen Prelabor level by 1 hour; normal in 6- 12 weeks Arterial Blood Pressure* Decrease 10-15% Declines by 5-10mmHg in Rise by 10-25 % during Normal values 2nd T, normal values in 3rd contractions. T Cardiac output** Increase 40% Increases from 8 weeks, Further increase by 25- Immediate post partum peaks at 32 weeks 50% rise by 80%**;.pre labor level in 1 hr ;Normal by 6-12 wks Uterine Blood Flow ~ 10 % of Cardiac ouput at - - - term Cardiac anatomy Heart rotated cephalad - - - and to the left, Increase chamber size, particularly the left atrium *The reduction in blood pressure in pregnancy is predominantly secondary to a decrease in the diastolic component which in turn is due to reduction in systemic vascular resistance because of progesterone, and the development of the placenta, a low resistance vascular bed. ** The increased cardiac output that develops in pregnancy is further augmented during the third stage of labour as a result of auto-transfusion of blood from the utero-placental to maternal circulation as the uterus contracts

12 ICOG CAMPUS SEPTEMBER 2017 fall in SVR starting in early pregnancy, Table 2: Cardiovascular features mimicking heart disease reaching a nadir at approximately 14–24 weeks of gestation, then rising to pre- • Signs • Auscultation pregnancy values by term.3 The primary - Peripheral edema - S3 gallop cause of the fall in SVR is likely to be - JVP - Systolic ejection murmur peripheral arterial vasodilatation in early • Symptoms • Chest x-ray pregnancy, mediated by progesterone - Reduced exercise tolerance - Change in heart position & size and vasodilators such as nitric oxide.4 - Dyspnea - Increased vascular markings Critical implications • EKG of cardiovascular - Nonspecific ST-T wave changes - Axis deviation changes in pregnancy - LVH 1. The absence of normal increase in blood volume and hemo-concentration in Haematological Table 3: Normal ABG values in non- preeclampsia/eclampsia is responsible for system pregnant and pregnant women poor tolerance of these patients to blood Parameter Non pregnant Pregnant There are many haematological changes, loss after vaginal or operative delivery as during normal pregnancy. There is a drop pH 7.35-7.45 7.40-7.46 compared to normal patients. At the same in the haemoglobin by at least 1g/dl; this pCO 35-45 mmHg 27-34 mmHg time increased vascular permeability in 2 being mainly a result of increased plasma these patients can lead to pulmonary pO2 80-100 mmHg 95-105 mmHg volume and dilutional effect. There is also a oedema when vigorous intravenous HCO 22-26 meq/l 18-21 meq/l leukocytosis, especially during third trimester 3 fluids are given. and labour, with the leukocyte count being SPO2 93-100% 95-100% 2. The normal increase in CO is not seen on an average 15000/µL and at times reaching in certain cardiac conditions like severe as high as 25000/µL1,5. This is a very important is increased in pregnancy because of increase in 6. The minute volume mitral stenosis, which has more or less change which has to be interpreted cautiously the tidal volume by 40% also increases by 40%, from 7.5 L/min to 10.5 fixed output which leads to several critical as it may lead to a wrong diagnosis of infection. L/min8. This results in a fall in the arterial hemodynamic changes in the mother. Platelet count may decrease marginally pCO2 from a normal of 40mmHg to a level Besides, increase in blood volume and because of hemodilution though there may of 30mmHg in pregnancy. To compensate for heart rate makes the patient of heart be a rise in platelet volume. The condition this respiratory alkalosis there is an increased disease more vulnerable for heart failure. known as “gestational thrombocytopenia” may be seen in 5-10% of the pregnant women excretion of the bicarbonate by the kidneys, 3. This fall in SVR is very important to take and is a diagnosis of exclusion, after ruling leading to a fall of serum bicarbonate to about into consideration when treating critically out other common causes e.g, preeclampsia, 20 mEq/L from a normal of 24 mEq/L. This ill pregnant patients with sepsis, as the folate deficiency, lupus and autoimmune compensated respiratory alkalosis can result in a SVR in them is reduced due to endotoxins. thrombocytopenic purpura6. decreased buffering capacity for further metabolic acidosis (as in sepsis). 4. A fall in pulmonary vascular resistance Pregnancy is a procoaguable state which is a (PVR) is also observed in normal physiological mechanism to decrease blood The arterial blood gas analysis in pregnancy pregnancy. The change in PVR may affect loss during parturition. However it is a double is also altered, with the pH being more the shunting in pregnant patients with edged sword as it makes a pregnant woman towards alkaline side (Table 3). septal cardiac defects. more prone to venous thromboembolism Besides these changes there are other 7 5. Another important cardio-vascular by 4-6 fold . The levels of factors VII, VIII, changes, such as decrease in the expiratory change in pregnancy which can affect IX, X, XII, fibrinogen and Von Willerband reserve volume and residual volume, leading the care of the critically ill gravida, is factor increases whereas the levels of natural to decrease in functional residual capacity the decrease in venous return with a anticoagulants antithrombin III and protein by about 500ml. However it is the 20% fall resultant drop in cardiac output in the C are unchanged or increased, whereas in residual volume which further increase supine position also called the supine- protein S levels fall. Fibrinolytic activity also alveolar ventilation. The decrease in functional hypotension syndrome. This is of utmost decreases, mainly due to a sharp rise in the residual capacity can result in rapid fall in oxygen importance in patients with fixed cardiac plasminogen activator inhibitors. in response to respiratory insults. Vital capacity, which is the maximum volume of air expired output states, e.g severe mitral stenosis; Respiratory system and in cases where a decrease in CO after maximum inspiration however remains can be life threatening e.g severe aortic The respiratory tract undergoes many unchanged in pregnancy. stenosis. Hence the importance of nursing changes during pregnancy, mediated initially Due to the requirements of the fetus, the these patients in the lateral position and by changes in the endocrine system and later goals of respiratory support are different, for of using a wedge while performing by the enlarging uterus, in order to provide achieving adequate fetal oxygenation. PaO2 caesarean section cannot be undermined. oxygen for increased maternal demands of 70mmHg and SpO2 of 95% are required and for fetal physiology. These changes act to meet this (vs 55mmHg and 88% in non 6. The decrease in the colloid osmotic to lower maternal PCO2 to half that of the pregnant). pressure and the colloid osmotic pressure- fetus, thereby facilitating more effective gas pulmonary capillary occlusion pressure exchange. Urinary system gradient during pregnancy makes these women susceptible to fluid overload Oxygen consumption in pregnancy increases The renal pelvis, calyces and ureters increase and pulmonary oedema especially in the by 30–50 mL/min, two-thirds of which covers in size due to the rising progesterone additional maternal requirements (mainly the background of hypertensive disorders of levels. The enlarging uterus may also cause kidneys) and one-third is for the developing compression of the ureturs at the pelvic brim pregnancy. fetus. Under the effect of progesterone there resulting in mild to moderate hydronephrosis, 7. Many of the cardiovascular features which is an increase in the depth of respiration which is more pronounced on the right are encountered in cases of heart disease though the rate remains fairly constant. The side. By the third trimester, 80% of women are also seen in normal pregnancy, which minute volume which is product of respiratory will have evidence of hydronephrosis9. The can lead to a diagnostic dilemma (Table rate and tidal volume and is defined as the amount result of these changes is mild obstruction and 2). of air moved into and out of the lungs in 1 minute, urinary stasis, increasing the risk of infection and

ICOG CAMPUS SEPTEMBER 2017 13 Table 4: Changes in the thyroid hormones during pregnancy • Can dramatically impact treatment of critically ill women NORMAL CHANGES IN PREGNANCY • Almost all clinicians will encounter and Physiological Changes Impact treat pregnant women at some time Iodine clearance (renal & transplacental) Relative iodine deficiency state Risk of fetal & Maternal hypothyroidism • Under-appreciation of changes will lead to suboptimal treatment or outright Plancental deiodination of T4 T4  Reverse T3 mistakes TBG  TT3 & TT4 levels  FT4 same References 1st trimester HCG  FT4  & TSH  1. Cunningham FG, Leveno KJ, Bloom SL, (Weak TSH effect) Fetal & placental devp et al: Maternal physiology. In: Williams 3rd trimester – placenta enlarge, preparation FT4  & TSH  Obstetrics. Twenty-Second Edition. New for delivery Mild hypothyroidism York, McGraw-Hill, pp 121–150 TSHR Ab reduced Grave’s disease improvement 2. Zeeman GG, Cunningham FG: Blood Postpartum increase in thyroid Ab Postpartum thyroiditis volume expansion in women with Grave’s disease exacerbation antepartum eclampsia. Presented at the Annual Meeting of the Society for misinterpretation of diagnostic imaging. does not recognize kidneys as a priority area. Gynecologic Investigation, Los Angeles, Hence the perfusion rapidly falls and acute There is an increase in the renal blood flow CA, March 18, 2002 tubular necrosis is a common occurrence and glomerular filtration rate by about 50%. 3. Bosio PM, McKenna PJ, Conroy R et in obstetric patients who have been The daily urine output however is not altered haemodynamically challenged. Immediate al. Maternal central hemodynamics in to a significant extent. The serum urea and and aggressive fluid resuscitation is essential hypertensive disorders of pregnancy. creatinine hence are reduced and the normal to prevent this dreaded complication. Obstet Gynecol 1999; 94: 978–984. upper limit of serum creatinine is considered to 4. Weiner CP, Knowles RG & Moncada S. be 0.8mg/dl. Gastrointestinal Induction of nitric oxide synthases early Loss of glucose through the kidneys is normal tract in pregnancy. Am J Obstet Gynecol 1994; in pregnancy due to increased GFR and reduced The progestogenic effect leads to a lower 171: 838–843. distal tubular re-absorption; therefore, screening sphincter tone; and this along with raised 5. Taylor DJ, Phillips P, Lind T: Puerperal for gestational diabetes using urinalysis alone is intragastric pressures due to the effect of unreliable. Alteration in GFR also causes an haematological indices. Br J Obstet the growing uterus leads to reflux and Gynaecol 1981; 88:601 increase in the urinary protein excretion. It heartburn. The decreased gastric emptying was seen that the 95th percentile of urinary time seen typically during labor, can give rise to 6. Yeomans ER, Gilstrap LC. Physiologic protein excretion in normal pregnant aspiration during general anaesthesia. changes in pregnancy and their impact 10 patients over 24 hrs was 260 mg/day , which on critical care. Crit care med 2005;33 The stasis of the gall bladder predisposes a justifies the cut off of 300mg /day for defining (suppl):5256-258 preeclampsia. pregnant woman to stone formation. The alkaline phosphatise may be increased due to 7. Heit JA, Kobbervig CE, James AH et In pregnancy there occurs a marked rise in all placental production and does not necessarily al. Trends in the incidence of venous components of the renin-angiotensin system. indicate hepatic obstruction. However the thromboembolism during pregnancy or resulting in a large increase in extracellular elevated transaminase levels do indicate an postpartum: a 30-year population-based water volume (by 4–7 L) and retention of underlying pathology as they are not altered study. Ann Intern Med 2005; 143: 697–706. sodium and water, which acts to maintain during pregnancy. normal blood pressure. This water retention 8. Spatling L, Fallenstein F, Huch A et causes a decrease in plasma sodium from 140 to Thyroid gland al. The variability of cardiopulmonary adaptation to pregnancy at rest and 136 mmol/L The dynamics of the thyroid hormones during exercise. Br J Obstet Gynaecol undergo several changes as the pregnancy The clinical significance of high GFR becomes 1992; 99(Suppl 8): 1–40. more significant when considering the drug progresses. The clinician should be familiar levels in some conditions, e.g, in epileptics with this so as to interpret the values correctly 9. Carlin A, Alfirevic z. Best Practice on phenytoin, where the drug levels in the in the context of the trimester of pregnancy & Research Clinical Obstetrics and serum become lower during pregnancy, (Table 4) Gynaecology Vol. 22, No. 5, pp. 801–823, which may necessitate changes in the dosage. 2008 Conclusion A very important point of consideration is, 10. Higby K, Suiter CR, Phelps JY, et al: • Profound changes in physiology and that the blood supply of the kidney is the first Normal values of urinary albumin and anatomy take place in pregnancy to be compromised in case of any obstetric total protein excretion during pregnancy. haemorrhage, as physiologically the body • These affects most organ systems Am J Obstet Gynecol 1994; 171:984 –989.

You Are Never Too Old To Set Another Goal Or To Dream A New Dream

- C.S. Lewis

14 ICOG CAMPUS SEPTEMBER 2017 Antimicrobials in Sepsis: Dr. Rekha Bharti Associate Professor, An Update Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi

Introduction pathogens, the presence of invasive devices, inflammatory states of noninfectious patient’s comorbidities and immune status. origin (BPS) Antimicrobial therapy plays a crucial role in the management of patients with sepsis • Dosing strategies of antimicrobials • Combination therapy (administering and septic shock. In sepsis, mortality is not should be optimized based on accepted more than one antimicrobials) is not necessarily caused by infection itself, but also pharmacokinetic/pharmacodynamics routinely recommended for ongoing by the physiologic response to infection that principles and specific drug properties in treatment of most serious infections, leads to multi-organ dysfunction. Therefore, patients with sepsis or septic shock.(BPS) including bacteremia and sepsis without shock (weak recommendation, low starting antimicrobials early after recognition Patients with sepsis have an increased volume quality of evidence). However, this does of sepsis not only prevents injury caused by of distribution due to the rapid expansion not preclude the use of multidrug therapy the microbial activity and toxin production of extracellular volume as a consequence of to broaden antimicrobial activity. but also modifies host responses to infection, aggressive fluid resuscitation. This leads to thereby averting further damage caused by suboptimal drug levels of antimicrobials in Combination antimicrobial therapy the sepsis. these patients.5, 6 As appropriate antimicrobial targets and accelerates clearance of a suspected or known pathogen rather International dosing is central in improving outcome, antimicrobial therapy in these patients, than broadening antimicrobial coverage. Guidelines for should always be initiated with a full, high Multidrug therapy refers to administering Management of Sepsis end-loading dose of each agent used. Even multiple antimicrobials to broaden the and Septic Shock (2016)1 in patients with altered renal function, full spectrum of therapy. loading dose of antimicrobials should be • Administration of IV antimicrobials as • If combination therapy is initially used given and adjustments are only required in soon as possible after recognition and for septic shock, de-escalation with calculating total dose and dose frequency. within one hour for both sepsis and septic discontinuation of combination therapy shock (strong recommendation, moderate Also, different antimicrobials have different within the first few days should be done quality of evidence). Each hour delay in the required plasma targets for optimal in response to clinical improvement and/ administration of antimicrobial therapy outcomes. or evidence of infection resolution. This is associated with substantial increase applies to both targeted (for culture- ü For aminoglycosides and positive infections) and empiric (for in mortality, adjusted OR 1.119 per hour fluoroquinolones, clinical success delay, 95% CI 1.103-1.136, p<.0001.2 culture-negative infections) combination depends on higher peak plasma levels in therapy (BPS) • Appropriate routine microbiologic relation to pathogen minimum inhibitory • Antimicrobial treatment duration of 7 cultures (including blood) should be concentration (MIC). to 10 days is adequate for most serious obtained before starting antimicrobial ü For Vancomycin, higher trough plasma infections associated with sepsis and therapy in such patients if doing so concentration (lowest concentration septic shock. Longer courses can be results in no substantial delay in the start reached, before the next dose of given to patients who have a slow clinical of antimicrobials (BPS). However, if there antimicrobial) is required response, undrainable foci of infection, is delay in obtaining culture samples bacteremia with S aureus, some fungal antimicrobial therapy should be initiated. ü For Beta-lactams, longer duration of plasma concentration above the and viral infections, or immunologic • Empiric broad-spectrum therapy pathogen MIC is required for superior deficiencies, including neutropenia. with one or more antimicrobials are microbiological and clinical cures (weak recommendation, low quality of recommended for these patients to cover evidence) This can be achieved by once daily dosing all likely pathogens (including bacterial • Shorter courses are appropriate in and potentially fungal or viral coverage) for aminoglycosides, optimizing dose within a nontoxic range for fluoroquinolones, patients with rapid clinical resolution (strong recommendation, moderate following effective source control of quality of evidence). administering loading dose according to the actual weight of patient for vancomycin intra-abdominal or urinary sepsis and As compared to monotherapy, multidrug and by increasing the frequency of dosing those with anatomically uncomplicated antibiotic therapy is associated with for beta lactams. For example, Gentamicin pyelonephritis (weak recommendation, decreased 28-day mortality, 36.3% and 29%, administered as 5-7 mg/Kg every 24 low quality of evidence) 3 respectively, HR 0.77; 95% CI 0.67–0.88. The hours, Ciprofloxacin as 500mg every 12 • Patients with sepsis and septic shock survival rates are better with appropriate hours, levofloxacin 750 mg every 24 hours, should have daily assessment for de- than inappropriate initial antimicrobial vancomycin as loading dose of 25-30 mg/kg escalation of antimicrobial therapy in therapy, 52.0% and 10.3%, respectively, OR (instead of usual 1 gram) and piperacillin/ (BPS) 9.45; 95% CI, 7.74 to 11.54; p < 0.0001.4 tazobactam as 3.75 mg 6 hourly (instead of • Procalcitonin levels can be used to support 4.5 mg 8 hourly).7, 8, 9 However, the choice of empiric antimicrobial shortening of the duration of antimicrobial regimens in patients with sepsis and septic • Antimicrobial therapy should be therapy and discontinuation of empiric shock are complex and should be according narrowed after pathogen identification antibiotics in patients who initially to the anatomic site of infection, properties and sensitivities are established and/or appeared to have sepsis, but subsequently of antimicrobials to penetrate that site, adequate clinical improvement is noted. have limited clinical evidence of infection prevalent pathogens within the community Systemic antimicrobial prophylaxis (weak recommendation, low quality of & hospital, resistance patterns of these should not be given to patients with severe evidence)

ICOG CAMPUS SEPTEMBER 2017 15 • Specific anatomic diagnosis of infection Cefoperazone-Sulbactam 3gm IV 12 hourly. References requiring emergent source control should Alternative regimen- Imipenem 1g IV 8 be identified or excluded as rapidly as hourly or Meropenem 1gm IV 8 hourly. 1. Rhodes A, Evans LE, Alhazzani W, possible in patients with sepsis or septic De-escalate to Ertapenem 1 gm IV OD, if Levy MM, Antonelli M, Ferrer R, et al. shock. Measures to control source of Imipenem/meropenem is initiated. Monitor Surviving Sepsis Campaign: International infection be implemented as soon as renal function if aminoglycoside is used. Guidelines for Management of Sepsis and medically and logistically practical after Septic Shock: 2016. Intensive Care Med. For necrotizing fasciitis- Empirical therapy the diagnosis is made (BPS). 2017;43(3):304-377. with Piperacillin-Tazobactam 4.5 gm IV 6 • Intravascular access devices that are a hourly or Cefoperazone-Sulbactam 3 gm IV 2. Kumar A, Roberts D, Wood KE, Light B, possible source of sepsis or septic shock 12 hourly + Clindamycin 600-900 mg IV 8 Parrillo JE, Sharma S, et al. Duration of should be promptly removed after other hourly. Alternative regimen- Imipenem 1g hypotension before initiation of effective vascular access has been established (BPS). IV 8 hourly or Meropenem 1gm IV 8 hourly antimicrobial therapy is the critical + Clindamycin 600-900 mg IV TDS/linezolid determinant of survival in human septic Timing of 600 mg IV BD/daptomycin 6mg/kg/day. shock. Crit Care Med. 2006;34(6):1589-96. Antimicrobials Alternative regimen- Ceftriaxone 2g IV OD. 3. Kumar A, Zarychanski R, Light B, Parrillo Administration For secondary peritonitis, Intra-abdominal J, Maki D, Simon D et al. Early combination Funk et al stated, if “Time is tissue” when abscess/ GI perforation- Empirical therapy antibiotic therapy yields improved it comes to thrombolytic therapy for acute with Piperacillin-Tazobactam 4.5 gm IV 8 survival compared with monotherapy myocardial infarction and thrombotic stroke, hourly or Cefoperazone-Sulbactam 3 gm IV in septic shock: a propensity-matched then an appropriate rule for life-threatening 12 hourly, In sick patients-fluconazole iv 800 analysis. Crit Care Med. 2010;38(9):1773- infections, particularly septic shock, is mg loading dose day 1, followed by 400 mg 85. “Speed is life.”10 OD. Alternate regimen- Imipenem 1g IV 8 4. Kumar A, Ellis P, Arabi Y, Roberts D, Light, However, there could be barriers to timely hourly or Meropenem 1gm IV 8 hourly or Parrillo JE, et al, Initiation of inappropriate administration of antimicrobials either due to Doripenem 500 mg 8 hourly or Ertapenem antimicrobial therapy results in a fivefold delayed recognition of sepsis and septic shock 1 gm IV OD. Source control is important to reduction of survival in human septic or delay in administering antimicrobials reduce bacterial load, if excellent source control shock. Chest. 2009;136(5):1237-1248. due to limited vascular access and need for is achieved antimicrobials for 5-7 days; otherwise 2-3 weeks. 5. Pletz MW, Bloos F, Burkhardt O, lengthy infusions. Various policies have Brunkhorst FM, Bode-Böger SM, Martens- been proposed to minimize delay in starting For community acquired Pneumonia- Lobenhoffer J, et al. Pharmacokinetics antimicrobials, like administering antibiotics Empirical therapy- Amoxycillin-clavulanate of moxifloxacin in patients with severe prior to transfer from emergency rooms, to 1.2 g IV TDS Or Ceftriaxone 2g IV OD Duration sepsis or septic shock. Intensive Care Med order all initial IV antibiotics as stat doses, 5-8 days. Alternative regimen- Piperacillin- 2010; 36:979-83. administering 1st dose of antibiotics as bolus Tazobactam 4.5 gm IV 6 hourly or Imipenem and to use standardized treatment approach 1g IV 6 hourly or Cefoperazone-Sulbactam 6. Blot S, Koulenti D, Akova M, Bassetti based on symptom-based treatment pathway 3 gm IV 12 hourly. If MRSA is a concern- M, De Waele JJ, Dimopoulos G, et & sepsis protocols.1 add Linezolid 600mg IV/Oral 12 hourly. If al. Does contemporary vancomycin dosing achieve therapeutic targets in a Antimicrobial atypical pneumonia suspected- Doxycycline 100mg 12 hourly or Azithromycin 500 mg heterogeneous clinical cohort of critically Protocols for oral/IV OD. ill patients? Data from the multinational Obstetric Infections DALI study. Crit Care. 2014;18(3):R 99. For mastitis with abscess- Drainage with (Recommendations as per National antibiotic cover for MRSA, Clindamycin 300 7. Barza M, Ioannidis JP, Cappelleri JC, Treatment Guidelines for Antimicrobial QID or Vancomycin 15 mg/kg IV 12 hourly Lau J. Single or multiple daily doses of Use in Infectious Diseases for obstetric (maximum 1gm 12 hourly) Or Teicoplanin 12 aminoglycosides: a meta-analysis. BMJ. infections)11 mg/kg IV 12 hourly x 3 doses followed by 6 1996 Feb 10;312(7027):338-45. For sepsis in Pregnancy/after pregnancy- mg once daily IV 8. Men P, Li HB, Zhai SD, Zhao RS. Piperacillin-Tazobactam 4.5 g IV 6 hourly For ventilator Associated Pneumonia- Association between the AUC0-24/MIC or Cefoperazone+Sulbactam 3 g IV 12 Beta Lactam + beta lactamase inhibitor- Ratio of Vancomycin and Its Clinical hourly and MRSA cover with Vancomycin/ Piperacillin/ Tazobactam Plus Effectiveness: A Systematic Review and Teicoplanin may be required if suspected or Aminoglycoside (Amikacin, Gentamicin, Meta-Analysis. PLoS One. 2016; 11(1): colonized. or Tobramycin) OR Antipseudomonal e0146224. For septic abortion/Endomyometritis/Septic fluroquinolone (Cipro/ Levofloxacin), For 9. Zelenitsky S, Rubinstein E, Ariano R, Pelvic Vein Phlebitis- Empirical therapy with MRSA- Vancomycin or Linezolid. Second Iacovides H, Dodek P, Mirzanejad Y,et Ampicillin 500 mg 6 hourly + Metronidazole line Therapy- Meropenem 60 mg/kg/day I/V al. Vancomycin pharmacodynamics and 500 mg IV 8 hourly. In case of previous every 8 hrly and Vancomycin 40 mg/kg/day survival in patients with methicillin- partial treatment with antibiotics, send blood I/V every 6-8 hourly. Third line Therapy- resistant Staphylococcus aureus- cultures and start Piperacillin-Tazobactam or Colistin base IV 2.5-5 mg/kg/day I/V every associated septic shock. Int J Antimicrob Cefoperazone-sulbactam till the sensitivity 6-12 hrly (1mg= 30000 IU) and Vancomycin Agents 2013; 41:255–260. - 40 mg/kg/day I/V every 6-8 hourly report is available. Alternative regimen- 10. Funk DJ, Kumar A. Antimicrobial therapy Ceftriaxone 2g IV OD. Conclusion for life-threatening infections: speed is life. Crit Care Clin. 2011;27(1):53-76. For uncomplicated Pyelonephritis- Empirical Key to mortality reduction in sepsis and septic therapy with Amikacin 1 g OD IM/IV or shock is, to administer early and appropriate 11. National Treatment Guidelines for Gentamicin 7 mg/kg/day OD, Alternative antimicrobials. Early refers to antimicrobials Antimicrobial Use in Infectious Diseases. regimen- Piperacillin-Tazobactam 4.5g IV 6 within 1 hour after recognition of potential National Centre for Disease Control, hourly or Cefoperazone+Sulbactam 3 g IV 12 septic shock; and appropriate refers to Directorate General of Health Services, hourly or Ertapenem 1 g IV OD antimicrobials with, in-vitro activity against Ministry of Health & Family Welfare, For complicated Pyelonephritis- Empirical all suspected pathogens, penetration of Government of India. Version 1.0 therapy with Piperacillin-Tazobactam 4.5 suspected anatomical site of infection, proper (2016). http://pbhealth.gov.in/AMR_ gm IV 6 hourly or Amikacin 1 g OD IV or route, dose and frequency of administration. guideline7001495889.pdf.

16 ICOG CAMPUS SEPTEMBER 2017 Blood Transfusion: What and When and How?

Dr. Monika Gupta Dr. Divya Pandey Associate Professor, Assistant Professor, Obstetrics & Gynaecology, Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi VMMC & Safdarjung Hospital, New Delhi

Introduction b. If patient becomes Various Blood hemodynamically unstable due to Hemorrhage is the leading cause of Products transfused in ongoing hemorrhage. intensive care unit admission and one of Clinical practice the leading causes of death in the obstetric II. Intrapartum Period Whole blood population.1This highlights the significance a. Hb <7gram% (in labor); Decision of A unit of whole blood has a volume of 350 of an in depth understanding of the BT depends on medical history or ml and one unit increases hemoglobin by indications for and complications associated symptoms. 1 g/dl and hematocrit by 3%. It is used with blood product replacement in obstetric III. Postpartum Period in case of non-availability of Packed Red practice. Moreover, it becomes incumbent Blood Concentrates(PRBCs). There is no a. Anemia with signs of shock/ on the part of physician to be sure that a justification for whole blood transfusion to acute hemorrhage with signs of particular blood product is indicated and stop bleeding due to coagulopathies. It must that standard transfusion practices as well as hemodynamic instability. be used within 30 minutes of removing from precautions are practiced. b. Hb <7gm% (postpartum); Decision refrigerator. The rate of transfusion should The aims of blood transfusion (BT) are to of BT depends on medical history or be 150-200 ml/hr and should be completed increase the oxygen carrying capacity of symptoms. within 4 hours (discard unit if this period has exceeded). ABO and Rh compatibility blood by giving red blood cells, to restore Blood Transfusion in and Cross matching is a must. However, in the blood volume so as to maintain effective special conditions tissue perfusion and to replace platelets, emergency, till availability of compatible 4 coagulation factors and other plasma Post operative period blood, O negative blood can be used. proteins. The decision of blood transfusion In hemodynamically stable post-operative Packed Red Blood Cell Concentrates(PR- in a critically ill patient should be made surgical patients, transfusion should be BCs) /Packed Cell Volume(PCV)/Red judiciously, balancing between the benefits considered if Hb<=8g/dl or in presence Cell Concentrates(RCC)/Plasma Reduced and risks. of symptoms of inadequate oxygen Blood(PRB)2,3 Indications of Blood delivery(chest pain of cardiac origin, A unit of PRBC has a volume of 200 ml and orthostatic hypotension or tachycardia Transfusion in one unit increases hemoglobin by 1 g/dl and unresponsive to fluid resuscitation or Obstetrics patients2,3 hematocrit by 3%. Its indicated in cases with congestive heart failure). severe anemia during pregnancy associated I. Antepartum Period Patients in the intensive care unit and with with maternal decompensation, severe acute 1. Pregnancy <34 weeks sepsis5 blood loss following spontaneous delivery or cesarean section, intrapartum Hb < 7 gm%, a. Hb <5gram% even without clinical • In critically ill, normovolaemic patients, replacement of acute blood loss in obstetric signs of cardiac failure or hypoxia. transfusion is considered at a Hb level of hemorrhage along with other components ≤7 mg/dl with a target of 7-9 g/dl. b. In 5-7 gram % in presence of and post-partum anemia with signs of impending heart failure. • During the early resuscitative phase shock. It must be used within 30 minutes of of severe sepsis if there is evidence of removing from refrigerator and should be 2. Pregnancy >34 weeks inadequate oxygen delivery to the tissues completed within 4 hours (discard unit if this a. Hb <7gram% even without clinical (central venous oxygen saturation <70%, period has exceeded). The rate of transfusion signs of cardiac failure or hypoxia. mixed venous oxygen saturation <65% or should be 150-200 ml/hr. The target Hb lactate concentration >4 mmol/L), blood to be achieved is 7-9 gm/dl. ABO and Rh b. Patient with severe anemia who is transfusion is considered to achieve a compatibility and cross matching is a must. decompensated. target Hb of 9-10 g/dl. In emergency, till availability of compatible 3. Anemia not due to hematinic blood, O negative blood can be used. • In the later phases of severe sepsis, the deficiency (e.g. Hemoglobinopathy guidelines are similar to those for other Platelet Rich Plasma (PRP) or Bone marrow failure syndromes). critically ill patients with target Hb of 7-9 Hematologist should always be 1 PRP unit has 50-70 ml volume and g/dl. consulted. increases platelet count by 5-8x109/l. One • Blood transfusion should not be used Platelet pharesis unit increases platelet 4. Acute Hemorrhage to assist weaning from mechanical by 40-50x109/l. It is indicated in bleeding a. Always indicated if Hb <6gm% ventilation if the Hb is >7 g/dl. due to thrombocytopenia, with count less

ICOG CAMPUS SEPTEMBER 2017 17 than 50X109/l where surgery or delivery is There is no evidence to support the every hour during transfusion and on anticipated and cases where platelet count prophylactic use of rFVIIa to reduce blood completion of transfusion and four is less than 20X109/l. The rate of transfusion loss for caesarean section.4 It is important hours after completion of transfusion. should be 50-150 ml/hr. A unit of PRPs should to ensure adequate levels of platelets and • Documentation be transfused immediately and should be clotting factors because rFVIIa increases completed within 30 minutes of removal clotting by acting on these subtrates.8 There ü Informed Consent. If patient is from optimal storage condition. The target is no risk of viral transmission as the drug is not in a condition to give consent, platelet count to be achieved is 50X109/l . derived from recombinant technology. retrospective consent can be taken ABO and Rh compatibility is needed. once she recovers. Massive Blood Fresh Frozen Plasma(FFP)6 Transfusion ü Reason for transfusion, and signature of the person administering. 1 unit of FFP has 50-70ml volume and 1 ml In patients, likely to need massive transfusion, of FFP contains 1 unit of coagulation factor resuscitation is started with blood products ü Record GC, PR, BP, RR before, during activity. It is indicated for replacement of as soon as possible to prevent dilution and on completion of the transfusion. multiple coagulation factors, Disseminated coagulopathy. The blood products are Record the volume and type of blood Intravascular Coagulation (DIC), depletion administered in a ratio of 4 unitsRCCS:4 units products transfused, unique donation of coagulation factors with patients with FFP: 4 units Platelets: 4 units cryoprecipitate. no. of all products transfused, blood large amount of transfusion and warfarin group, time of start and completion of overdose. The dose of FFP is 12-15ml/kg Protocol to be transfusion and any adverse effect. Followed for Blood and rate of transfusion is 150-300 ml/hr. ü Note type and volume of each unit Transfusion It should be transfused as soon as possible transfused. preferably, but can be done within 6 hours Once the decision to transfusion has been • The blood component pack with the BT of thawing and must be completed within 30 made, everyone involved in the transfusion set should be stored for 24 hours in case minutes. The aim of transfusion is to achieve process must ensure that right blood gets to adverse reaction investigations need to be target PT and APTT INR less than 1.5. ABO right patient in right time. compatibility is needed; however cross carried out. CHECKLIST8,9 matching is not required. Anti D prophylaxis • In case of any transfusion reaction the is not needed, if Rh negative women has • Verify patient/component compatibility transfusion is stopped and blood product received Rh positive FFP. and identity; done by two people, atleast returned to blood bank with the bag and one of whom should be a doctor or Cryoprecipitate6 BT set and maternal blood sample with registered nurse. details of reaction documented on the It is indicated in correction of microvascular • Donation number on blood bag label transfusion reaction form. bleeding in massively transfused patients should match the accompanying with hypofibrinogenemia. It has no Important aspects document. advantage over FFP and is especially useful There is no evidence of benefit of warming in patients who need fluid restriction. The • Check blood bag for signs of hemolysis, blood, when transfusion is slow. Keeping rate of transfusion should be 150-300 ml/hr. clotting or contamination; Check for any patient warm is more important than warming It should be transfused as soon as possible leaks/seal/discoloration. the blood. Warmed blood is needed for large preferably but can be done within 6 hours • BT SET: must be new (170-200u filter). volume rapid transfusion in adults>50 ml/ of thawing. The transfusion should be Change the set atleast 12 hourly during kg/hour. Routine use of pre-medication is completed within 30 minutes. The target is to BT or after every four units of blood. not recommended. Use separate i/v line for achieve Fibrinogen level more than 150 mg/ fluids or I/V drugs.8,9If a patient needs more dl. Although ABO compatibility is preferred • Use slow infusion through 21-25 G than three units of blood within 24 hours, but not essential. 1 unit/10 kg body weight cannulas; for rapid infusion, use large then calcium must be administered. raises plasma fibrinogen by 50mg/dl. Anti bore cannulas e.g.14 G. Transfusion Reactions D prophylaxis is not needed, if Rh negative • Platelets should be administered before women receive Rh positive cryopecipitate. Red Cell Concentrate(RCC) with same Acute transfusion reactions must be recognised and managed efficiently. The Newer Alternative : Recombinant Factor set and if it is to be used after RCC severity of the reactions can be categorized VIIa (rFVIIa) transfusion, use a separate BT set. as mild, moderate and severe category. It is a promising new alternative to blood • Start BT; Note baseline observations, Category1: Mild- The earliest sign is component therapy. The mechanism of action encourage patient to notify in case of urticarial rash leading to pruritis due to is to augment the intrinsic clotting pathway discomfort, shivering, itching, flushing, hypersensitivity reaction. On recognition, by binding with tissue factor and directly shortness of breath. Ensure patient is in the transfusion should be slowed and activating factors IX and X. Its use may be setting, where can be directly observed. antihistamine should be administered considered as a treatment for life-threatening • Monitoring intramuscularly. If there is no improvement postpartum hemorrhage (PPH), but should ü Before start of BT [record baseline within 30 minutes or there is worsening, treat not delay or be considered a substitute for a observations; general condition(GC), as moderate category. live-saving procedure such as embolisation temperature, pulse rate(PR), blood or surgery, or transfer to a referral centre.6 Category2: Moderately severe- Flushing, pressure(BP), respiratory rate (RR)and The most commonly reported effective urticaria, rigors, fever, restlessness and fluid balance (intake/output charting]. dose is 50-100 ug/kg intravenously every 2 tachycardia. Patient complain of anxiety, hours until hemostasis is achieved, with vast ü Monitoring is continued 15 minutes pruritis, palpitations, mild breathlessness and majority of patients requiring only one dose.7 after starting transfusion, atleast headache. Immediately transfusion, should

18 ICOG CAMPUS SEPTEMBER 2017 be stopped. This is due to hypersensitivity or In all cases of 2. Treatments for iron-deficiency anaemia febrile-non- hemolytic transfusion reaction. reactions in pregnancy.Available online at http:// Airway should be managed and oxygen apps.who.int/rhl/pregnancy_childbirth/ • Report all BT reactions to blood bank and administered. The blood unit with BT set, medical/anaemia/gwguide/en/ (last doctor responsible for the patient. freshly collected urine and new blood accessed on 2/12/16). sample (plain and EDTA vial) should be • Record, type of transfusion, time lapse 3. Blood transfusion in Obstetrics. Greentop returned to the blood bank. Antihistamine, between start of transfusion and reaction; Guidelines No.47,May 2015. IV corticosteroid and bronchodilators (if volume and bag number. bronchospasm) should be given. If there is 4. Carson JL, Grossman BJ, Kleinman S, • Immediately take blood sample from clinical improvement, restart the transfusion Tinmouth AT, Marques MB, Fung MK, et different site for - repeat ABO/Rh/ al. Red blood cell transfusion: A clinical slowly with new blood unit. However if antibody screen and cross match, CBC, practice guideline from the AABB. Ann there is no clinical improvement within coagulation screen, urea and creatinine, Intern Med. 2012;157:49–58. 15min or there is worsening, treat as category electrolyte. 3. Collect urine for next 24 hours for evidence 5. Retter A, Wyncoll D, Pearse R, Carson of hemolysis. If available, WBC filter may be • Return to blood bank: blood bag and BT D, McKechnie S, Stanworth S, et al. used in repeated transfusion. set, blood culture in blood culture bottle, first specimen of patient’s urine following Guidelines on the management of Category 3: Life Threatening- Rigors, fever, reaction and completed transfusion anaemia and red cell transfusion in adult restlessness, hypotension, tachycardia, reaction form. critically ill patients. Br J Haematol. hemoglobinuria and unexplained 2013;160:445–64. bleeding(DIC).The patient may complain of Conclusion 6. K Rege, J Bamber, MC Slack, S anxiety, chest pain, pain along transfusion Blood and its components are life-saving but Arulkumaran, P Cartwright, D Stainsby, line, respiratory difficulty, loin/back pain and with inherent risks. So a blood transfusion FAM Regan, Bood Transfusion in headache. The reason for severe reaction may should be ordered judiciously based on Obstetrics,Green Top Guidelines be acute intravascular hemolysis, bacterial benefits versus risks assessment. The No.47,Dec 2007,Minor revision July contamination, septic shock, fluid overload, collected blood should be separated into its 2008.,pg 1-10. anaphylaxis, or Transfusion Related Acute components and used in conditions with Lung Injury(TRALI). On recognition of this specific requirements for optimal utilization. 7. Andrea J.Fuller,Brenda Bucklin,Blood category, stop transfusion and manage as in The aim should be to minimize unnecessary component therapy in obstetrics,Henry category 2. Adrenaline (1:1000) can be given blood transfusions, thereby promoting L.Galan, William F. Rayburn editors, in the dose of 0.01mg/kg body wt as slow proper use. Recombinant factor VIIa is a new Obstetric and Gynecological Emergencies, intramuscular injection. Senior doctor must adjunct for treatment of massive hemorrhage Philadelphia,Saunders Obstet Gynecol be notified. New blood sample should be and should be considered, if available. Clin N Am 34(2007) 443-458. sent. 24 hour urine sampling should be done Early recognition of BT reactions and their 8. The Clinical Use of Blood. available online and intake output monitoring to be done. management can help in reducing morbidity. at http://www.who.int/bloodsafety/ Bleeding from puncture sites and wounds clinical_use/en/Handbook_EN.pdf.(last should be assessed to rule out DIC. If patient References accessed on 2/12/16) is hypotensive, crystalloids and/or inotropes 1. Heinonen S, Tyrvainen E, Saarikoski S, should be given. Acute Renal Failure(ARF) et al. Need for maternal critical care in 9. Blood transfusion: summary of NICE and bacteremia should be managed (if obstetrics: a population based analysis. guidance: BMJ 2015;351:h5832. doi: http:// present). Int J Obstet Anesth 2002;11(4):260–4. dx.doi.org/10.1136/bmj.h5832

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- Richard David Bach

ICOG CAMPUS SEPTEMBER 2017 19 ABG Analysis - What an Dr. JC Suri Professor and Head, Department of Pulmonary, Obstetrician Should Know? Critical Care & Sleep Medicine, VMMC & Safdarjung Hospital, New Delhi

Introduction substance that can either absorb or donate Metabolic Acidosis : primary decrease in protons to a solution. The important extra bicarbonate levels Acid-base disturbances are commonly cellular buffers at physiologically relevant encountered in critically ill patients in Metabolic Alkalosis : primary increase in the pH are: bicarbonate ICUs and result from a wide variety of bicarbonate levels (HCO - + H+  H Co  H O + CO ); plasma metabolic and respiratory disorders. 3 2 3 2 2 Respiratory Acidosis : primary increase in the - + Besides, telling about the seriousness of the proteins (protein + H  H-proteins); CO2 levels underlying diseases, acid-base disturbances Hemoglobin (Hgb- +H+  H-hgb); and Respiratory Alkalosis : primary decrease in the have significant hemodynamic and other phosphates (HPO 2‑ + H+  H Po ‑). The 4 2 4 CO levels physiological effects. So, an early diagnosis 2 principal buffering system for non carbonic and treatment of these disturbances is an In each of the four primary disorders, the acid in the extracellular fluid is the carbonic important component of the management initial process not only alters acid-base acid – bicarbonate pair. of critically-ill patients. This requires a equilibrium directly, but sets in motion systematic approach to interpretation of Clinically when we assess a patient’s acid secondary compensatory responses that blood gases and simultaneously measured – base status we evaluate the carbonic changes the other component of the pCO2 – electrolytes. acid bicarbonate system, since it is easily Bicarbonate pair, so as to bring the ratio of measured. HCO - to pCO back towards normal and Acid-Base Terminology 3 2 thus helps normalize the pH. The pCO – HCO , buffer system is reflected The acidity of body fluid is measured in 2 3 in the following formula In metabolic acidosis the primary disturbance terms of hydrogen ion concentration [H+] and is fall in the HCO - level, the body in an   3 expressed as pH, which is the negative log CO2 gas CO2 (dissolved) + H2O H2CO3 + - attempt to return the pH back to normal +  of the [H ]. The normal pH varies between H + HCO3 induces a fall in pCO2 via hyperventilation. 7.36 and 7.44 with an average of 7.4, which The relation of pH to this buffering system Similarly, in metabolic alkalosis the primary + corresponds with the [H ] concentration of is expressed by the Henderson – Hasselbalch increase in bicarbonate is compensated for by 40 Nano equivalents. equation: a decrease in ventilation and increase in pCO2. In respiratory acidosis the compensatory • Acidemia is defined as increase in absolute log HCO3 Kidney Metabolic + pH = pK + = = - [H ] and fall in pH below 7.36, whereas response is a rise in HCO3 due to decreased (0.03) x pCO2 lung Respiratory renal excretion of HCO -. The compensatory • Alkalemia is defined as decrease in [H+] Thus the pH, is determined by the ratio of 3 responses have following characteristics. and a rise in pH above 7.44. the serum bicarbonate concentration to the

partial pressure of CO2 in the arterial blood. 1. The compensatory process tends to • Acidosis is a pathophysiological process The bicarbonate concentration is regulated return the pH back to normal but never that tends to acidify body fluids (lower by the kidneys and the pCO2 is regulated by completely, except in cases of primary - plasma [HCO3 ], or increase in PaCO2) the lungs. respiratory alkalosis. and if unopposed will lead to a decrease The interrelation of [H+], pCO and [HCO - 2. Compensatory process requires normal in pH 2 3 ] can also be illustrated by the Henderson functioning kidneys and lungs and take • Alkalosis is a pathophysiological process equation time to occur. that tends to alkalinize body fluids (raise pCO2 3. The lack of compensation in an plasma [HCO3-], or lower PaCO2) and if [H+] = 24 × [HCO -] appropriate interval defines the presence unopposed will lead to increase in pH 3 This equation is helpful as a bedside tool of a second primary disorder. Acid-Base Physiology to predict or evaluate the accuracy, in other 4. The compensatory response creates a The acid-base status of the body is normally terms the internal consistency of the three second laboratory abnormality. kept within the narrow range of pH despite acid base parameters. 5. The appropriate degree of compensation the daily production of large amount of acid, Simple Acid-Base can be predicted. as a result of various metabolic activities. The Disorders pH of the body fluids is determined by the a. Metabolic acidosis: the expected change As already mentioned, the pH of a solution is in pCO is as follows: amount of acid produced, the ability of the - 2 determined by the ratio of HCO3 and pCO2. lungs and kidney to excrete the acid load and - The pathologic processes that primarily pCO2 = [1.5 X (Serum HCO3 )] + 8 + 2 or the buffering capacity of the blood. change the bicarbonate levels are referred pCO2 = last two digits of the pH If an extra acid or base is introduced, the body to as metabolic disorders and pathologic b. Metabolic alkalosis: the expected change tends to mitigate the change in pH through processes that primarily alter the CO 2 in pCO is as follows: the action of multiple buffers and activation levels in blood are referred to as respiratory 2 - of compensatory mechanisms. A buffer is a disorders. pCO2 = 40 + 0.6 ( ∆ [HCO3 ] ) or

20 ICOG CAMPUS SEPTEMBER 2017 - ∆pCO2 = 0.6 (Measured HCO3 – 24) Any significant deviation from this rule alkalemia, a decrease in the level of pCO2 implies the existence of a mixed acid-base levels indicate primary respiratory alkalosis c. Acute respiratory acidosis: the expected disorder. and an increase in the levels of HCO - indicate increase in bicarbonate is as follows: 3 a. When delta anion gap (∆AG) is greater primary metabolic alkalosis. A quick trick ∆ pCO2 ∆ [HCO -] = than delta HCO - (∆HCO3-) it indicate is to see the direction of change in pH and 3 10 3 mixed high anion gap acidosis and pCO2 and interpret is as : d. Chronic respiratory acidosis: the primary metabolic alkalosis. • Primary Metabolic Condition expected increase in bicarbonate level - is as follows: b. When ∆ HCO3 is greater than ∆AG it pH changes in the same direction as pCO2 indicates mixed high anion gap and or pH is abnormal but pCO2 remains ∆ pCO2 ∆ [HCO -] = 3.5 × normal anion gap acidosis, or a mixed unchanged 3 10 high anion gap acidosis and chronic • Primary Respiratory Condition e. Acute Respiratory alkalosis : the expected respiratory alkalosis with a compensating decrease in the HCO - level are: 3 hyperchloremic acidosis. pH changes in the opposite direction ∆ pCO as pCO2 or pH is abnormal but HCO3-  ‑ 2 Urine anion gap :- In patients with a ∆ [HCO3 ] = 2 × 10 hyperchloremic metabolic acidosis, one can remains unchanged f. Chronic Respiratory alkalosis: the use urine anion gap to distinguish between Step IV: Is there appropriate compensations - expected decrease in the HCO3 level renal tubular acidosis (RTA) and acidosis for the primary disturbance? In an effort to are: caused by diarrhea. Urine anion gap is preserve the pH, the primary disorder sets off ∆ pCO calculated as follows: a compensatory reaction which is predictable  ∆ [HCO -] = 5 × 2 3 10 (Urine Na+ + urine K+) – (Urine Cl-) as shown below As mentioned earlier the Primary defect in A negative urine anion gap suggests diarrhea Step V: If a metabolic acidosis is present, is metabolic acidosis is fall in HCO3 which as a cause of metabolic acidosis where as there an increased anion gap? can occur due to one of the following three a positive urine anion gap suggests the Step VII: If there is an increase in anion mechanisms: presence of RTA with a distal acidification gap, is the delta anion gap equal to delta a. Excess acid production that overwhelms defect. bicarbonate. If not, there is an additional renal capacity for excretion, e.g., diabetic Approach to a patient non-gap acidosis or a metabolic alkalosis. ketoacidosis. with acid-base Step VIII: Put it all together – what is the b. Loss of alkali that leaves un-neutralized disorder. most likely diagnosis? acid behind, e.g., diarrhea. The approach to acid-base derangements References c. Renal excretory failure, i.e. normal total should emphasize a search for the cause, 1. Stewart PA: How to Understand Acid- acid production in face of poor renal rather than immediate attempt to normalize base: A Quantitative Acid-Base Primer function, e.g., chronic renal failure of any the patient. A full consideration of the careful for Biology and Medicine. Elsevier, New cause. history such as vomiting, diarrhea, sepsis, diabetes, renal disease, alcohol or other York, 1981 In order to differentiate between these toxin ingestion should be given. A detailed 2. Fencl V, Jabor A, Kazda A, et al: Diagnosis causes, it is important to calculate anion gap. physical examination for evidence of fever, The anion gap is shown in the following of metabolic acid-base disturbances in signs of volume depletion, tachypnea or critically ill patients. Am J Respir Crit Care equation: bradypnea, hypo or hypertension should Med 2000; 162:2246-2251 - - be carried out. Serum electrolytes such as Unmeasured anion (UA) + Cl + HCO3 = + + + - - 3. Julie A. Breyer, Basic Acid-Base Unmeasured cation (UC) + Na Na , K , Cl and HCO3 should be measured in every case. A stepwise, conventional, Terminology. 6th National Critical Care UA – UC = Anion gap = Na+ - (CI- + HCO -) 3 approach is as follows: Medicine Review Course. = 12 Step I: Do the numbers make sense? Check 4. Narins RG, Emmett M. Simple and mixed If the metabolic acidosis is caused by the for the internal consistency of various acid-base disorders: a practical approach. addition of Cl- as anion; then it will parameters with the help of Henderson Medicine, 1980;59(3):161-86 be designated as normal anion gap acidosis, equation: [H+]=24XpCO /HCO - 2 3 5. Gabow PA, Kaehny WD, Fennessey and if the metabolic acidosis is caused by the Step II: Determine whether the patient PV, et al. Diagnostic importance of an addition of anion other than Cl-, then it is is acidemic (pH<7.36) or an alkalemic increased serum anion gap. N Engl J Med, designated as high anion gap acidosis. (pH>7.44). In mixed disorders the pH may 1980;303:854-58 be in the normal range, but the bicarbonate Delta anion gap (∆AG):- It is the difference 6. Jocobson HR, Seldin DW. On the level, the pCO or the anion gap will be between the patient’s anion gap and a normal 2 generation, maintenance, and correction abnormal and signal the presence of an acid- anion gap. of metabolic alkalosis. Am J Physiol, base disturbance. ∆AG = observed AG – upper normal AG 1983;245:F425-32 Step III: Is the primary or overriding ∆HCO = lower normal HCO - – observed 7. Wrenn K. The delta (∆) gap: an approach 3 3 disturbance respiratory or metabolic? In the HCO - to mixed acid-base disorders. Ann Emerg 3 patients with acidemia an increase in pCO 2 Med, 1990;19:1310-13 In an uncomplicated high anion gap levels indicate primary respiratory acidosis metabolic acidosis, delta anion gap is equal and a decrease in bicarbonate levels indicate 8. Melvin L.Morganroth, M.D. The Journal to the delta bicarbonate. metabolic acidosis, where as in patients with of Critical Illness Vol. 5, No. 5, May, 1990

ICOG CAMPUS SEPTEMBER 2017 21 Few ABG Case Illustrations

CASE 1 CASE 3

A 22 year postpartum woman presents with fever and foul lochia A 34 year-old diabetic patient presents with nausea, vomiting and abdominal pain. pH=7.32 pCO2=22.5 pO2=92 Na=137 K=4.1 Cl=100 pH=7.46 pO2=88 pCO2=33

HCO3=11 Lactate- 4 HCO3=22 Na=133 K=3.5 Step 1 Cl=86 Finger-prick glucose=430 pH shows acidemia pH and pCO suggest respiratory alkalosis. Step 2 2 Associated with CO2 and pH both moving in same direction 7 Predicted delta HCO3 = 2 × = 1.4; (decrease) and hence metabolic. 10 Step 3 Hence appropriate. AG = 133 – (86 + 22) = 25; delta AG = 13; delta [HCO } is 1.4. As delta AG > delta {HCO } there is wide AG metabolic Compensation: predicted pCO2 should be = 1.5 X [HCO3] + 8 + 2 = 3 3

1.5 X [11] + 8 + 2 = (16.5 + 8) + 2 = 24.5 + 2. Given pCO2 is 22.5; thus acidosis and metabolic alkalosis appropriate respiratory compensation is present. Step 4 Diagnosis: Diabetic Ketoacidosis (Metabolic Acidosis)

Anion gap (AG) = {Na – (HCO3 + Cl)} = 137-111 = 26; thus wide AG with Vomiting (Metabolic Alkalosis) metabolic academia (due to addition of lactic acid). Step 5 CASE 4

Delta anion (14) = delta bicarbonate (15); hence simple disorder A 34 year old lady is admitted to the hospital with persistent Diagnosis – Post Partum Sepsis with Lactic Acidosis community acquired pneumonia. That has poorly responded to a weak-long antimicrobials therapy. She mild cyanosis and CASE 2 tachypnoeic. Her lab data are as follows.

A 35 years old preeclamptic patient presents with discomfort in the pH=7.44 pCO =25 pO =48 left leg. 2 2

o BP is 170/95 HR=100 RR=28 Temp=99.5 F HCO3=17

History, pH and pCO2 suggest chronic respiratory alkalosis. pH=7.53 pCO2=16 pO2=97 Na=136 K=4.0 Cl=100 Compensation: predicted HCO =14 (40 - 25) 3 Delta HCO = × 5 = 7.5; 3 10 pH and pCO2 show evidence of respiratory alkalemia. 40-16 hence appropriate metabolic compensation.. Predicted delta HCO = 2 × = 4.8 3 10 or predicted [HCO3] should be 19.2. Diagnosis: Chronic Respiratory Alkalosis with

However given [HCO3] is 14. Therefore , metabolic acidosis is also Appropriate Metabolic Compensation. present. AG = 136 – 114 = 22; hence respiratory alkalemia with wide AG metabolic acidosis. Diagnosis : Deep Vein Thrombosis with Pulmonary Embolism

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- A. A. Milne

22 ICOG CAMPUS SEPTEMBER 2017 near miss case scenario

Massive Post-Partum Dr. Sunita Malik Professor, Haemorrhage Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi

Case Scenario Etiopathogenesis using visual aids that correlate the size and appearance of blood on specific A 25 year old G2 P1L1, admitted in active 4 T’s surfaces and measuring the difference labor at 40+3 weeks with 3 cm dilatation after • Tone : most common cause is uterine into the weight of bloody materials and uncomplicated pregnancy. Patient had normal which complicates 1 in 20 births and the known weight of the same materials progress in cervical dilatation with a prolonged 4 is responsible for at least 80 percent of when dry. Pictorial Reference Guide to second stage requiring oxytocin augmentation cases of PPH.3 (Overdistension of uterus Aid Visual Estimation of Blood Loss can 5 and ultimately vacuum extraction (VE) delivery (eg, multiple gestation, polyhydramnios, also be used. (Figure 1) of a 3600-gram neonate. Placenta delivered macrosomia), Intra amniotic infection, • Assessment of severity of within 5 minutes but she started bleeding after Functional/ anatomic distortion of uterus, haemorrhage — The Advanced Trauma that. Oxytocin was increased to 20 U in D5 RL Uterine relaxant drugs like Magnesium Life Support manual describes four and running at 125 cc/hr. Patient passed large sulfate, Nifedipine, Bladder distension ) classes of haemorrhage to emphasize the clots 20 minutes after delivery. BP 120/80, pulse progressive signs and symptoms leading 90. Uterus soft and flaccid. Patient received 1 • Trauma : lacerations (including uterine to the shock state.6 ampoule of carboprost intramuscular and 1000 rupture) or surgical incisions; uterine mcg misoprost per rectal. inversion. Class I haemorrhage involves a blood volume loss of up to 15 percent. The heart rate is Patient’s blood was typed and crossed. Oxytocin • Tissue : Retained products of conception minimally elevated or normal, and there is infusion was continued and dose increased to or clots no change in blood pressure, pulse pressure, 80U and uterine massage continued. Bleeding • Thrombin : Coagulopathy women with or respiratory rate. did not stop. Vitals deteriorated; BP 90/60, pulse an inherited disease (Haemophilia, 130. Lab studies other than haematocrit sent Von Willebrandt disease, H/O previous Class II haemorrhage occurs when there is a (20ml of blood withdrawn). Pelvic exam and PPH), Acquired bleeding diathesis 15 to 30 percent blood volume loss and is cerical exploration done. It revealed bleeding (Gestational Thrombocytopenia, manifested clinically as tachycardia (heart from cervical os with no tears in cervix or vagina HELLP), severe reduction of clotting rate of 100 to 120), tachypnea (respiratory rate and “boggy” uterus. Clots expressed. Patient’s factors due to persistent heavy bleeding of 20 to 24), and a decreased pulse pressure vitals further deteriorated BP 70/40, pulse and hemodilution of the remaining Class III haemorrhage involves a 30 to 40 158. Despite 3 ampoules of carboprost and IM clotting factors (Severe Pre-eclampsia- percent blood volume loss, resulting in methylergonovine, bleeding continued and there eclampsia, Intrauterine fetal demise, a significant drop in blood pressure and was “oozing” from IV site as well. Patient shifted Severe infection, Abruptio placenta, changes in mental status to OT. Call for help sent. Multidisciplinary team Amniotic Fluid Embolism), Therapeutic approached. Emergency laparotomy followed by anticoagulation Class IV haemorrhage involves more than 40 percent blood volume loss leading to stepwise devascularisation was done. Bleeding Management did not stop and vitals did not improve so significant depression in blood pressure and subtotal hysterectomy was resorted to. She was • Thorough history taking helps in mental status. Pulse pressure is narrowed shited to ICU for further management. After knowing the at risk cases and taking (≤25 mmHg), and tachycardia is marked adequate resuscitation with blood products and adequate precautions to prevent PPH. (>120). Urine output is minimal or absent. two days of ICU stay, patient was received in the Personal or family history of previous The skin is cold and pale, and capillary refill High Definition Unit (HDU). Both mother and PPH, obesity, high parity, Asian or is delayed. baby were discharged in good condition on 10th Hispanic race, precipitous labour, uterine • Laboratory evaluation postoperative day. overdistention, chorioamnionitis, uterine inversion, leiomyoma, Couvelaire uterus,  Complete blood count, including On probing this patient in the postoperative inherited bleeding diathesis, acquired platelet count – For every 500 ml period, she revealed history of bleeding after bleeding diathesis (eg, amniotic fluid of blood loss, haemoglobin levels delivery in her previous pregnancy as well for embolism, abruptio placentae, sepsis, falls by one gram/dl; however, the which she required blood transfusion. fetal demise), assisted reproductive initial haemoglobin/ haematocrit value Background technology, and use of some drugs does not accurately reflect the amount (uterine relaxants, antithrombotic drugs, of blood loss acutely. Postpartum hemorrhage (PPH) is an obstetric possibly antidepressants.  for multiple emergency. It is one of the top five causes Type and crossmatch units of packed red cells. of maternal mortality in both high and low • Patient Assessment - Vital signs : Blood per capita income countries, although the pressure, heart rate, respiratory rate,  Coagulation studies -- prothrombin absolute risk of death from PPH is much peripheral oxygen saturation, and urine time, activated partial thromboplastin lower in high-income countries. PPH more output. time, INR, fibrinogen. The coagulation than 1000 ml and continuing to bleed or • Estimation of blood loss: Quantify the panel should be repeated every 30 clinical shock is known as massive PPH. It amount of blood loss by collecting blood to 60 minutes to observe trends until occurs in 1 to 5 percent of deliveries.1,2 in graduated volumetric containers, PPH is controlled.

ICOG CAMPUS SEPTEMBER 2017 23 A Pictorial Reference Guide to Aid Visual Estimation of Blood Loss at Obstetric Haemorrhage: Accurate Visual Assessment is Associated with Fewer Blood Transfusions Dr Patrick Bose, Dr Fiona Regan, Miss Sara-Paterson Brown Replacement of blood components coagulation and require prompt a b c is more important than crystalloid control of uterine haemorrhage to infusion if massive hemorrhage has prevent death. Planned hysterectomy occurred or is likely. Aggressive use is often the appropriate first-line Soiled Sanitary Towel Soaked Sanitary Towel Small Soaked Swab 10x10cm of plasma replacement is important approach for placenta accreta. 30ml 100ml 60ml to reverse dilutional coagulopathy,  Suture deep pelvic bleeders. d e f the 1:1 pRBC : FFP ratio is maintained until tests of hemostasis are available.8  Tamponade pelvic bleeding with pelvic packing. ABL 50cm diameter (500ml), 75cm diameter (1000ml) and 100cm diameter (1500ml)  Administer uterotonic drugs to

Incontinence Pad Large Soaked Swab 45x45cm 100cm Diameter Floor Spill reverse atony: It should be possible to Maternal mortality — Maternal mortality 250ml 350ml* 1500ml* determine within 30 minutes whether after PPH averages approximately 2 percent, g h i uterotonic treatment will reverse with wide variations worldwide depending atony. If it does not, prompt invasive on both the overall health of pregnant intervention is usually warranted. women in the population and the resources for treatment of PPH.9 PPH on Bed only PPH Spilling to Floor Full Kidney Dish Begin with oxytocin -40 units in 1 liter 1000ml 2000ml 500ml of normal saline or Ringer’s lactate. References *Multidisciplinary observations of estimated blood loss revealed that Using an intravenous infusion pump, scenarios (e-f) are grossly underestimated (> 30%) 1. Sheldon WR, Blum J, Vogel JP, et al. For Further Information please contact Miss Sara Paterson-Brown start at 10 to 40 milliunits per minute. Delivery suite, Queen Charlottes Hospital, London Adjust rate to achieve and maintain Postpartum haemorrhage management, Fig. 1: Pictorial Reference Guide to Aid uterine contraction. 15 units in 250 ml risks, and maternal outcomes: findings Visual Estimation of Blood Loss normal saline or Ringer’s lactate may from the World Health Organization (adapted from Bose P, Regan F, Paterson‐Brown S. Queen Multicountry Survey on Maternal and Charlottes Hospital, London) be given if a high concentration must be administered rapidly. Expect rapid Newborn Health. BJOG 2014; 121 Suppl • Protocol of management of PPH response. 1:5.  Assemble team and notify appropriate Carboprost tromethamine (PGF2alpha, 2. Callaghan WM, Kuklina EV, Berg CJ. departments (obstetrics, nursing, Hemabate) 250 micrograms Trends in postpartum haemorrhage: anesthesiology, blood bank, intramuscularly every 15 to 90 United States, 1994-2006. Am J Obstet laboratory). minutes, as needed, to a maximum of Gynecol 2010; 202:353.e1. 2 mg (eight doses)  Initiate uterine massage and/or 3. Combs CA, Murphy EL, Laros RK Jr. manual compression and establish Misoprostol- 800mcg sublingual may Factors associated with postpartum large-bore (two 16- or 18-gauge, help later as it takes 1-2.5 hrs to haemorrhage with vaginal birth. Obstet ideally 14-gauge) intravenous access. increase uterine tone Gynecol 1991; 77:69.  Tamponade bleeding from the uterine Trenexamic acid- 0.5-1g in addition 4. Bateman BT, Berman MF, Riley LE, Leffert cavity. Balloon tamponade should decreases the blood loss further LR. The epidemiology of postpartum haemorrhage in a large, nationwide be initiated early if bleeding is brisk,  Inspect the vagina and cervix for sample of deliveries. Anesth Analg 2010; particularly if the patient is not lacerations; repair as necessary. 110:1368. hemodynamically stable, and blood Evacuate any retained products of products are not readily available. Foley conception. Replace uterus if inverted. 5. Bose P, Regan F, Paterson‐Brown S. catheter, Bakri balloon, Sengstaken Improving the accuracy of estimated  Perform laparotomy if the above Blakemore Oesophageal Catheter, blood loss at obstetric haemorrhage measures fail. Surgical approaches that Condom Catheter or Urological Rusch using clinical reconstructions. BJOG. Balloon may be used. are quick, relatively easy, and effective should be tried first. In utilizing these 2006;113:919–924.  Administer oxygen (10 to 15 liters/ measures, the surgeon should be 6. Westhoff G, Cotter AM, Tolosa JE. minute) by face mask. Anaesthesia cognizant of the amount of blood loss Prophylactic oxytocin for the third team should evaluate airway and and the stability of the patient, and stage of labour to prevent postpartum breathing; intubate if indicated. should perform hysterectomy rather haemorrhage. Cochrane Database Syst  Fluid Therapy and Blood product than resort to temporizing measures if Rev 2013;CD001808. transfusion7 her cardiovascular status is unstable or if it appears that the anesthesiologist 7. Postpartum Haemorrhage, Prevention Crystalloid - Upto 2L isotonic will not be able to keep up with her amd Managemnt. GreenTop guidelines crystalloid (target systolic pressure 90 fluid needs. Options include: no.52 mmHg) and maintain urine output at  Ligate bleeding sites. 8. Shakur H, Elbourne D, Gülmezoglu M, et >30 mL/hour. al. The WOMAN Trial (World Maternal  Perform uterine artery ligation, Colloid - Upto 1.5L until blood arrives Antifibrinolytic Trial): tranexamic acid for including the utero-ovarian arcade. the treatment of postpartum haemorrhage: Blood - May start with O, Rh neg, K Arterial embolisation if available in an international randomised, double neg, then group specific in case of dire emergency hours, may be done. blind placebo controlled trial. Trials 2010; emergency  Place a B-Lynch stitch or other uterine 11:40. FFP - After 4 units of RBC, FFP at the compression suture, if bleeding stops 9. Ruiz Labarta FJ, Pintado Recarte MP, rate of 12-15ml/ Kg to be given. If PT/ by compression Alvarez Luque A, et al. Outcomes of pelvic APTT are ≥1.5 times the normal  Perform hysterectomy - Hysterectomy arterial embolization in the management Platelet Concentrate - 1 pool of platelets is the last resort for atony, but should of postpartum haemorrhage: a case series if count < 75000/ml & haemorrhage not be delayed in women who study and systematic review. Eur J Obstet continuing have disseminated intravascular Gynecol Reprod Biol 2016; 206:12.

24 ICOG CAMPUS SEPTEMBER 2017 near miss case scenario

Cardiomyopathy in Dr. Harsha Gaikwad Professor, Pregnancy Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi

Case scenario of the Heart Failure Association of the challenging physiological concerns due to European Society of Cardiology.1 Incidence the tendency of weight gain, oedema, fatigue, A 20 yrs old primigravida with 8 months is 0.1% of all pregnancies. and breathlessness, which may be assumed amenorrhea was admitted to emergency room to be normal and thus delaying the diagnosis with complaints of difficulty in breathing for 1 Predisposing factors of PPCM in many patients. Also, oxidative week, more so in lying down position and loss of stress increases during pregnancy. fetal movements for one day. • Preclampsia There was no significant past, medical or surgical • Gestational hypertension Clinically, PPCM may present as dilated history. cardiomyopathy (DCM) but the left ventricle • Autoimmune disorder may not always be dilated. The ejection On general examination, pulse was 120 /min, • Viral myocarditis fraction is nearly always reduced below labored breathing with rate of 35/min, BP was 45%.1 144/105, SPO2 was 85%, mild pallor and pedal • Prolonged tocolysis PPCM is considered an independent disease, oedema was present. Bilateral fine crepitation • Antioxidant deficiency at lung bases were heard on auscultation. Her whose diagnosis relies on the exclusion complete blood count, kidney function test and • Malnutrition, selenium deficiency of other cardiomyopathies.1,5 It remains a liver function tests were within normal range. • And other malnutrition diagnostic challenge. There must be high Obstetrical sonography showed a 32 week index of suspicion while evaluating a patient IUFD fetus in longitudinal lie. Arterial blood • Abnormal hemodynamic response of cardiomyopathy as it may present as acute gas analysis showed metabolic acidosis, chest • Apoptosis and inflammation onset or an insidious onset of heart failure. radiograph showed bilateral alveolar infiltrates. Sometimes the presentation can be in the • Prolactin Cardiology and pulmonology referrals were made. form of abdominal discomfort, chest pain She was given supportive therapy in the form of • Genetic forms of cardiomyopathy that is pleuritic in nature and associated with injection furosemide 40 mg., palpitations.1,6 Diagnostic Criteria Injectable Soda bicarbonate , non invasive 6 All 4 of the following: Management Protocol ventilation was started with Fio2 50% and PEEP Investigations of 8. Injection labetalol and magnesium sulphate Classic were administered. She was later intubated as she • Electrocardiogram (ECG)- no specific • Development of cardiac failure in the last was not responding to non invasive ventilation findings peculiar to PPCM, should be month of pregnancy or within 5 months and was induced with dinoprostone gel. postpartum performed to rule out or point pulmonary Her condition improved after delivery and embolism or an acute ischemic event. • No identifiable cause for the cardiac failure was extubated after 24 hrs of delivery. Her • Echocardiography- most important tool echocardiography was done which showed global • No recognizable heart disease before the last for diagnostic confirmation or exclusion hypokinesia, with dilated left ventricle, ejection month of pregnancy of PPCM fraction of 30%. She was started on carvedilol Additional 3.125 mg OD, tab torsemide and spironolactone • Chest X-ray- signs of decompensated 10/25mg OD, tab ramipril 2.5mg BD and low Strict echocardiographic indication of left heart failure with pulmonary congestion molecular weight heparin. ventricular dysfunction: or oedema / pneumonia /pleural effusion. Patient improved symptomatically and was a. Ejection fraction <45% and/or • Cardiac magnetic resonance imaging. discharged after two weeks. She was diagnosed b. Fractional shortening <30% • Cardiac catheterization/myocardial as a case of peripartum cardiomyopathy biopsies. retrospectively. c. End-diastolic dimension >2.7 Biomarkers: NT-pro BNP, 16-kDa Prolactin, Background Challenge in Diagnosis Interferon-γ , Asymmetric Dimethylarginine Peripartum cardiomyopathy (PPCM) is PPCM may induce cardiovascular disease (ADMA), Cathepsin D, Soluble FMS-like defined as a non-familial form of peripartum in a non-cardiac patient in the situation of tyrosine kinase-1 (sFlt-1) and microRNA- heart failure characterized as an ‘idiopathic pre-existing complications of pregnancy, i.e 146a . gestational hypertension, pre-eclampsia and cardiomyopathy presenting with heart failure Treatment secondary to left-ventricular (LV) systolic HELLP syndrome.1 It is also reported that dysfunction towards the end of pregnancy certain genetic forms of cardiomyopathies PPCM is treated according to the ESC or in the months following delivery, where may get unmasked and present as PPCM guidelines for heart failure in pregnancy.1 The no other cause of heart failure is found’ as due stress of pregnancy. 2,3,4 Pregnancy, therapeutic interventions need to consider proposed by the Working Group on PPCM delivery, and the peripartum period pose the health of the mother and the fetus.

ICOG CAMPUS SEPTEMBER 2017 25 Non-pharmacological (candesartan, valsartan) if intolerant to a position statement from the Heart therapy ACE inhibitors Failure Association of the European Society of Cardiology Working Group on • Nitrates or hydralazine if sensitive to • fluid restriction 2L/day peripartum cardiomyopathy. Eur J Heart above two • low sodium diet 2gm/day Fail.2010;12:767–778. • Loop diuretic as per GFR • light daily activity 2. Van Spaendonck-Zwarts KY, Posafalvi • Vasodilators (hydralazine, isorbide A, Van den Berg MP, Hilfiker-Kleiner D, Antepartum mangemnt dinitrite), Bollen IA, Sliwa K, Alders M, Almomani • Beta-blocker, thiazide diuretics, or • Beta blockers R, van Langen IM, Van der Meer P, Sinke furosemide treatment can be given in RJ, van der Velden J, Van Veldhuisen D J, some patients with PPCM before delivery, • Aldosterone antagonist van Tintelen JP,Jongbloed JD. Titin gene however, as diuretic therapy may impair • Warfarin if ejection fraction<35% mutations are common in families with perfusion of the placenta with potential both peripartum cardiomyopathy and A general agreement among experts (study harm to the fetus, the lowest dosages dilated cardiomyopathy. Eur Heart J. group of PPCM of the HFA/ESC) suggests possible of diuretic therapy have to be 2014 Aug 21;35(32):2165-73 continued therapy with standard heart used. failure medications for a minimum of 12 3. van Spaendonck-Zwarts KY, van • i.v. infusion of an inotrope (e.g. months Tintelen JP, van Veldhuisen DJ, van dobutamine) should only be considered der Werf R, Jongbloed JD, Paulus WJ, The use of an intrauterine device is in patients with severe hypotension and/ Dooijes D, van den Berg MP. Peripartum recommended for PPCM patients since or signs of cardiogenic shock. cardiomyopathy as a part of familial hormonal contraceptives may interact with dilated cardiomyopathy. Circulation • As soon as haemodynamic stability is heart failure medication. 2010; 121: 2169 – 2175. achieved, inotropes should be tapered and general recommendations for Conclusion 4. van Tintelen JP, Pieper PG, van patients with heart failure in pregnancy The symptoms of PPCM are generally Spaendonck-Zwarts KY, van den Berg should be followed.1 overlapping with other pregnancy related MP.Pregnancy, cardiomyopathies and genetics. Cardiovascular Res 2014; 101: • Early treatment with beta-blockers at conditions like preeclampsia, anemia, 571– 578. very low dosages appears to be protective congenital or valvular heart ailments and even in patients with severely depressed myocarditis. The patient may present with 5. Selle T, Renger I ,Labidi S, Bultmann ejection fraction. fatigue, shortness of breath and oedema I ,Hilfiker-Kleiner D. Reviewing that may be found in otherwise normal peripartum cardiomyopathy: current • LMWH may be considered if ejection pregnant female. Therefore, the diagnosis of state of knowledge. Future Cardiol 2009; fraction is less than 35% peripartum cardiomyopathy is that of high 5:175–189. degree of suspicion. Post partum 6. Johnson-Coyle L, Jensen L, Sobey management References A; American College of Cardiology • ACE inhibitors (captopril, ramipril, 1. Silwa K et al. Current state of knowledge Foundation; American Heart Association. analapril) on aetiology, diagnosis, management, and Peripartum cardiomyopathy: review and practice guidelines. Am J Crit Care. • Angiotensin receptor blockers therapy of peripartum cardiomyopathy: 2012;21(2):89-98.

Don't take rest after your first victory because if you fall in second, more lips are waiting to say that your first victory was just luck

- A.P.J. Abdul Kalam

26 ICOG CAMPUS SEPTEMBER 2017 near miss case scenario

Dr. Achla Batra Eclampsia and PRES Professor, Obstetrics & Gynaecology VMMC & Safdarjung Hospital, New Delhi

Case Scenario PRES can develop in association with a vast then extracellular oedema. Probably in array of conditions2 early cases the oedema is vasogenic but if A 25-year-old primigravida at 36 weeks gestation, the condition is not corrected it becomes presented with complaints of acute onset • Acute hypertension cytotoxic later. headache, altered sensorium, reduced vision and • Gestational hypertensive diseases one episode of seizure. She was a booked patient Differential Diagnosis but was a defaulter for last 3 months There was • HIV infection causing immunosuppression In a woman presenting with eclampsia and no past history of hypertension, cardiac diseases, • Cisplatin, Tacrolimus, Cyclosporine A vision disturbance, confusion, behavior vision abnormalities or seizures. The patient and steroid drugs. was disoriented, restless, afebrile with bilateral disturbance and change of consciousness, pedal oedema. Blood pressure was 170/110 • Hemolytic uremic syndrome PRES should be kept in mind but differential diagnosis like cortical blindness, retinal mmHg with a heart rate of 100 beats per minute. • Glomerulonephritis Her respiratory rate was 20 breaths per minute detachment or hypertensive encephalopathy and chest was clear on auscultation. Room air • Blood transfusion should also be considered. Altered sensorium or unconsciousness could be saturation was 98%. Pupils were equal and • Porphyria reactive to light. Bilateral plantar reflexes were due cerebrovascular accident or cortical flexor. There was no focal neurological deficit. • Tumors vein thrombosis. CT and MRI confirm the diagnosis of PRES and exclude other Other system examinations were normal. She • Hypercalcemia was immediately given loading dose of Magsulf conditions. PRES and eclampsia share many clinical and intravenous labetalol 20mg and shifted to Imaging critical care obstetric ward. Her blood pressure and etiopathogenic characteristics and reduced to 160/100 mm of Hg but patient started patients may present with a combination The presence of oedema is responsible for the complaining of total loss of vision. Complete blood of these two entities. Earlier retrospective characteristic picture seen on CT and MRI. picture (Hb of 10.8 g %), renal and liver function studies and case series reported a very low The regions affected in the CT are observed as 1,3 tests, clotting parameters, and electrocardiogram incidence of PRES (7%) with eclampsia. diffuse hypodense area. In the MRI imaging, were done and found to be normal. Urine analysis More recent reports have found PRES in a they are seen as iso/hypo intense areas in revealed proteinuria 2+. high proportion of eclamptic women (>90%) T1 weighted images while they are seen possibly due to wider availability of imaging as hyperintense areas in T2 weighted and A neurological consult was taken who found modalities of CT scan and Magnetic resonant FLAIR images involving mostly posterior no gross neurological abnormality and ordered imaging(MRI).4 PRES can occur any time in cortical, sub-cortical and deep parenchymal a MRI. Before MRI could be done patient had pregnancy with preeclampsia but most cases areas. All brain structures, especially the another seizure which was controlled by giving of PRES are diagnosed in postpartum due parietal and occipital lobes, may display additional 2gm magnesium sulphate. As she had to presence of typical features and ease of involvement.5 poor bishop score, she was immediately prepared performing imaging studies postpartum. for cesarean under general anesthesia she Visual abnormalities (blurred vision, delivered a female child of 2.5 kg with an APGAR Pathogenesis hemianopsia) are found in 26 % to 67% of the score of 6.9. patients with PRES and cortical blindness in The exact pathogenesis of the condition is 8% to 33 %. Cortical aetiology of blindness After cesarean, her blood pressure remained not known. A rapid rise in blood pressure is being diagnosed more often due to wider in range of 160-170systolic and 110 -100 and leads to altered autoregulation of cerebral availability of imaging modalities. 6 Among blindness and disorientation persisted. She blood flow producing dilatation of cerebral patients with a follow-up CT or MRI, was given labetelol for blood pressure control arterioles with opening up of endothelial 49%-75% have a resolution of the initial and magnesium sulphate was continued for 24 tight junctions and leakage of plasma and red abnormalities within 5 days to 17 months.7 hours after delivery. Fundus examination was cells into the extracellular space, producing normal. MRI was done which revealed oedema cerebral oedema. The cerebral white matter Management in posterior hemisphere and a diagnosis of PRES is more susceptible to accumulation of Two important aspects was made. On 4th post-operative day her vision fluid in the extracellular spaces (vasogenic started improving and by 6th day it was 6/6. oedema) as it is composed of myelinated • Termination of pregnancy She was discharged on 10th post-operative day fiber tracts in a cellular matrix of glial cells, • Control of hypertensive emergency with a normal blood pressure not on any anti- arterioles, and capillaries. The posterior hypertensive medicine circulation has less sympathetic innervation Aim of treatment of the vertebrobasilar vasculature to protect Background the parenchyma from rapid increases in • Decrease the MAP by 20–25 % within the first 2 hours The terms posterior reversible arterial blood pressure and is therefore more encephalopathy syndrome (PRES) refer to involved in this type of damage. According • Bring down blood pressure to 160/100 a clinico-radiologic entity first described to another hypothesis, patients with PRES mmHg within the first 6 hours. by Hinchey et al in 1996, characterized by develop vasospasm secondary to sudden and • Control seizures headaches, confusion, visual disturbances, severe rises in blood pressure and ischaemia seizures, and posterior transient changes of of brain tissue. Ischaemic damage to brain More rapid blood pressure reduction is oedema on neuroimaging.1 tissue first produces cytotoxic oedema and not recommended since it can aggravate

ICOG CAMPUS SEPTEMBER 2017 27 the cerebral perfusion pressure alterations cerebellum and brainstem, may cause neurologic symptoms. Am J Obstet and promote ischemia. Intravenous transtentorial cerebral herniation. Gynecol. 2016;215(2):239.e1-5. antihypertensive drugs are necessary.8 Due to these complications of ischaemia and/ 5. 5. Hugonnet E, Da Ines D, Boby H, Claise Appropriate choices include labetolol, or bleeding, permanent neurological deficits B, Petitcolin V, Lannareix V, et al. Posterior nicardipine, or nifedepin. Nicardipine has may remain or even death can occur if reversible encephalopathy syndrome higher selectivity for blood vessels than PRES is not adequately and quickly treated. (PRES): Features on CT and MR imaging. the myocardium and causes less reflex Permanent deficit is mostly in form of Diagn Interv Imaging 2013;94:45–52. tachycardia than nifedipine. Furthermore, epilepsy. Death is reported in up to 15% of the the dosage of nicardipine can be more easily 6. Karuppannasamy, Divya, et al. “Cortical patients with PRES.2,12 Delayed identification adjusted.9 visual loss in posterior reversible or care of the patient appears to be involved encephalopathy syndrome in late Magsulf is the drug of choice for control of in most patients with a fatal outcome. postpartum eclampsia: Case series.” seizures. It helps cerebral vasodilatation Summary Indian journal of ophthalmology 62.5 by inhibiting calcium-dependent (2014): 635. vasoconstriction and shows neuroprotective Early recognition of PRES in eclampsia activity by preventing ischemia. It also is of paramount importance because 7. Casey SO, Sampaio RC, Michel E et al. decreases blood brain barrier permeability prompt control of blood pressure will Posterior reversible encephalopathy 10 syndrome: utility of fluid attenuated and limit vasogenic oedema. Propofol, cause reversal of the syndrome. Delivery, inversion recovery MR imaging in the benzodiazepines and phenytoin are Antihypertensive, control of seizure and detection of cortical and subcortical recommended for the treatment of cases anti-edema measures are the main stay lesions. Am J Neuroradiol. 2000 ;21:1199- developing refractory status epilepticus. of treatment. Delay in the diagnosis and 206.l treatment can result in permanent damage Complications of to affected brain tissues 8. Varon J, Marik PE. Clinical review: the Posterior Reversible management of hypertensive crises. Crit Encephalopathy References Care. 2003;7:374-84. 11 Syndrome 1. Hinchey J, Chaves C, Caplan LR. A 9. Demirel I, Ozer AB, Bayar MK et reversible posterior leukoencephalopathy • Cerebral ischemia Cerebral infarction al. Anesthesia and Intensive Care syndrome. N Engl J Med 1996;334:494- is the earliest sign of irreversibility in Management in a Pregnant Woman 500. PRES. Ischemia following vasogenic with PRES: A Case Report. Case Rep edema may involve conversion to 2. Servillo G, Striano P, Striano S, Tortora F, Anesthesiol. 2012, Article ID 745939, 5 cytotoxic edema with longer exposure to Boccella P, De Robertis E, et al. Posterior pages, 2012.Case Rep Anesthesiol. 2012.; the initial source of toxicity, which can reversible encephalopathy syndrome 745939. doi:10.1155/2012/745939. lead to necrosis and apoptosis (PRES) in critically ill obstetric patients. 10. Euser AG, Bullinger L, Cipolla MJ. Intensive Care Med 2003;29:2323–6. • Cerebral hemorrhage Hemorrhage may Magnesium sulphate treatment decreases occur in the cerebral, subarachnoid or 3. McKinney AM, Short J, Truwit CL, et al blood-brain barrier permeabilityduring intraventricular region. This occurs (2007) Posterior reversible encephalopathy acute hypertension in pregnant rats. Exp because of leak or rupture of vessels syndrome:incidence of atypical regions of Physiol.2008 ;93 :254-61. within ischaemic foci due to oxidative involvement and imaging findings. AJR 11. Trikha A, Sharma A, Kumar R. Posterior stress with overproduction of reactive Am J Roentgenol 189: 904–912 reversible encephalopathy syndrome. J oxygen species (ROS) and oxidative 4. Mayama M, Uno K, Tano S, Yoshihara Obstet Anaesth Crit Care 2014;4:59-63. damage to lipid membranes in the blood- M, Ukai M, Kishigami Y, Ito Y, Oguchi 12. Lee VH, Wijdicks EF, Manno EM et al. brain-barrier. H. Incidence of posterior reversible Clinical spectrum of reversible posterior • Cerebral herniation Edema of the encephalopathy syndrome in eclamptic leukoencephalopathy syndrome. posterior part of the brain, particularly and patients with preeclampsia with ArchNeurol 2008 ;65: 205-10.

The Only Limit To Our Realization Of Tomorrow Will Be Our Doubts Of Today

- Franklin D. Roosevelt

28 ICOG CAMPUS SEPTEMBER 2017 near miss case scenario

Acute Pyelonephritis in Dr. Archana Kumari Assistant Professor, Pregnancy Obstetrics & Gynaecology, VMMC & Safdarjung Hospital, New Delhi

Case Scenario Complications • Blood culture- bacteremia present in 15- 30% of hospitalized patients A 22years old primigravida presented in Acute Pyelonephritis may result in obstetrics emergency as a referred case in early significant maternal morbidity, as well • Imaging- Renal ultrasound is the labour at 36+4 weeks of gestation with complaints as fetal morbidity and mortality. Gram- preferred to avoid contrast or radiation of high grade fever and left sided flank pain for negative bacteria possess endotoxin that, exposure. Symptoms and fever persisting 3 days along with breathlessness for 1 day. On when released into the maternal circulation, beyond the first 24-48 hours of treatment examination, she was conscious, oriented. Her can lead to a cascade response of cytokines, warrant a repeat urine culture and renal PR -124b/min, temp -1030F, RR-34b/min and histamine, and bradykinin. The resulting ultrasound to rule out persistent infection Spo2 was 88%. Her urine microscopy showed capillary endothelial damage, diminished and urinary tract pathology.6,7 field full of pus cells, TLC was 18,000/cmm and vascular resistance, and alterations ultrasound KUB revealed left sided pyonephrosis in cardiac output may lead to serious Differential Diagnosis suggestive of acute pyelonephritis. complications. 20% of women with severe • Nephrolithiasis- Fever is rare and renal She was admitted immediately to the obstetrical pyelonephritis develop complications like USG shows kidney stones anaemia, bacteremia, septic shock, acute critical care and started on oxygen therapy and • Abruption of placenta- fever is absent and respiratory syndrome, acute renal failure, Intravenous antibiotics. ABG showed respiratory uterus is tense and tender. Either there is preeclampsia, intrauterine growth restriction acidosis. Chest X-ray revealed bilateral opacities vaginal bleeding or USG reveals a large and preterm labour.5 Anemia may be due suggestive of Acute respiratory distress syndrome. retroplacental hematoma. The patient was intubated and put on ventilator. to endotoxin mediated hemolysis. Acute However, her saturation remained below 90%. renal failure associated with microabscesses • Intraamniotic infections- history of Anticipating that vaginal delivery may not be and suppurative pyelonephritis can occur prolonged rupture of membranes. 6 tolerated due to increased oxygen consumption independent of sepsis. Examination reveals uterine tenderness and foul smelling vaginal discharge. in ARDS, emergency cesarean section was done Clinical Features and a 1.78 Kg girl baby was delivered. Following Urine routine does not reveal bacteria cesarean, her condition gradually improved, fever Patients present with fever, flank pain and Treatment subsided and weaned off the ventilator after 28 lower urinary tract infection symptoms due hours. to ascending infection from lower urinary • Hospitalization is required for treatment tract and intravenous antibiotics till woman Background is afebrile for 24 to 48 hours and shows Diagnosis Urinary tract infection is one of the symptomatic improvement. most common medical complications of • Urine routine and microscopy • Initial empiric therapy of pyelonephritis pregnancy.1 Pregnancy related anatomical characteristically demonstrates significant with parenteral, broad spectrum beta- changes such as pressure on the bladder bacteriuria, pyuria, red blood cells and lactams guided by local microbiology and from enlarging uterus, increase in the occasional leucocyte casts. susceptibility data as well as expected size of the ureters due to smooth muscle • Urine culture and sensitivity patient tolerance (Table 1) relaxation, decreased bladder tone and the immunosuppression of pregnancy further increase the risk of UTI in pregnancy. Risk Table 1: Diagnosis and treatment of acute pyelonephritis (normal renal function) of UTI starts at 6th week and peaks during Diagnosis Symptoms + urine culture: the 22-24th weeks. In majority of the cases, it is preceded by asymptomatic bacteriuria.2 Fever > 38°C, lumbar pain, skeletal and joint pains, If left untreated ,it progresses to acute nausea/vomiting pyelonephritis in 20-40% of the cases.3 It with or without accompanying dysuria, polyuria occurs in 1-2% of pregnant women in the ≥ 105 CFU/ml in mid-stream urine specimen setting of routine prenatal screening for asymptomatic bacteriuria.4 Mild or moderate acute Ceftriaxone 1 g every 24 h pyelonephritis Cefepime 1 g every 24 h Risk Factors for Amoxicillin with clavulanic acid 1.2 g every 12 h Development of Aztreonam 1 g every 8–12 h Pyelonephritis • Presence of asymptomatic bacteriuria Severe acute pyelonephritis/ Ticarcillin with Clavulanic acid 3.1 g every 6 h • Multiparity immunosuppression/ Piperacillin with Tazobactam 3.375 g every 6 h • Diabetes mellitus urinary stasis Meropenem 0.5 g every 8 h • Urinary tract stones or malformations Ertapenem 1 g every 24 h Doripenem 1 g every 8 h • Low socioeconomic status

ICOG CAMPUS SEPTEMBER 2017 29 • Fluoroquinolones and aminoglycosides immunosuppression, diabetes, sickle cell for Monitoring Antimicrobial Resistance should be avoided during pregnancy. anemia, neurogenic bladder) or recurrent/ Trends (SMART) program: 2009-2010. persistent UTIs before pregnancy, Diagn Microbiol Infect Dis. 2011; 70: 507- • Once afebrile for 48 hours, switch to oral one should consider antimicrobial 511. therapy guided by culture and sensitivity prophylaxis. results and discharged to complete 10- 14 2. Matuszkiewicz-Rowińska J, Małyszko days of treatment. • Antimicrobial prophylaxis J, Wieliczko M. Urinary tract infections in pregnancy: old and new unresolved • Options for oral therapy mainly limited to For recurrences associated with sexual diagnostic and therapeutic problems. beta-lactams, eg. cephalexin or amoxicillin- activity – Post-coital prophylaxis with Arch Med Sci. 2015; 11: 67-77. clavulonate; in the second trimester, single antibiotic dose (e.g. Nitrofurantoin trimethoprim-sulfamethoxazole can be 50–100 mg p.o. or cephalexin 250–500 mg 3. Farkash E, Weintraub AY, Sergienko R, et given. Nitrofurantoin and fosfomycin p.o.)9,11 For other women -Nitrofurantoin al. Acute antepartum pyelonephritis in are not appropriate for treatment of 50–100 mg in the evening until the end of pregnant: a critical analysis of risk factors pyelonephritis due to inadequate tissue the pregnancy. Follow- up urine culture and outcomes. Eur J Obstet Gynecol levels 8 is performed only at the beginning of Reprod Biol. 2012; 162:24–7. the third trimester. In case of significant • Carbapenems are reserved for the 4. Pazos Otero N, Fuentes Ricoy L, Ferrandez bacteriuria, prophylactic doses should treatment of more severe cases, and those Perez B, Martinez Vazquez C, Martinez be replaced by another course of caused by multi-drug resistant bacteria. Poch M, Osuna Diaz JL. [Pyelonephritis antimicrobials, based on susceptibility and pregnancy. Our experience in a Prevention testing.12 general hospital]. An Med Interna. 2007; • Treatment of asymptomatic bacteriuria Conclusion 24(12): 585-7 in pregnancy- Pregnant women are at risk of serious 5. Rahiman F, Balasubramanian T, Shejina Asymptomatic bacteriuria (ASB) is complications from untreated urinary M, Musambil M. A Review on Urinary defined as isolation of same bacterial Tract Infection in Pregnancy. Int J Pharma 5 tract infection and pyelonephritis. Hence strain in quantitative counts of ≥10 cfu/ Res Rev. 2015; 4:26–33. ml in two consecutive urine specimens it is imperative to assess risk factors for or a single catheterized urine specimen UTI in pregnancy and screen pregnant 6. Hill JB, Sheffield JS, McIntire DD, Wendel with one bacterial species isolated in women at their first antenatal visit. GD Jr. Acute pyelonephritis in pregnancy. a quantitative count ≥102cfu/ml in the ASB should be treated with appropriate Obstet Gynecol. 2005; 105: 18-23. absence of symptoms of urinary tract antibiotics and follow up cultures 7. Wing DA, Fassett MJ, Getahun D. Acute 9 infection. Since 30% of women fail to should be done to avoid persistence or pyelonephritis in pregnancy: an 18-year clear asymptomatic bacteriuria following recurrence of infection. Antimicrobial retrospective analysis. Am J Obstet Am J a short course of therapy, a follow-up prophylaxis throughout the pregnancy Obstet Gynecol. 2014; 210:219 culture should be obtained as a test of cure after completion of treatment.10 is required for women with risk factors 8. Vazquez JC, Abalos E. Treatments for or with recurrence of infection. symptomatic urinary tract infections • Avoidance of incomplete therapy/ during pregnancy. Cochrane Database recurrence The case presented here validates the Syst Rev. 2011; CD002256. fact that early diagnosis and prompt All pregnant women with ASB should 9. Nicolle LE, Bradley S, Colgan R, Rice have periodic screening after therapy, management of acute pyelonephritis is imperative to prevent severe life JC, Schaeffer A, Hooton TM.Infectious since as many as one third of them Diseases Society of America guidelines threatening complications like ARDS experience a recurrent infection. Follow- for the diagnosis and treatment of up cultures should be obtained 1–2 weeks in pregnancy. Multidisciplinary care asymptomatic bacteriuria in adults. Clin after treatment and then repeated once a involving obstetricians, nephrologists, Infect Dis.2005; 40: 643–654 month.11 microbiologists and intensivists is required for care of such cases. 10. Widmer M, Gülmezoglu AM, Mignini • Treatment of persistent /recurrent L, Roganti A. Duration of treatment bacteriuria Furthermore, early assessment of fetal for asymptomatic bacteriuria during Longer antibiotic therapy using the wellbeing and plan of delivery at term pregnancy. Cochrane database Syst Rev. same agent (e.g. 7 instead of 3 days of are necessary to optimize both maternal 2011. treatment) or another first line drug is and fetal outcome. 11. Berard A, Santos F, Ferreira E, Perreault S. recommended. Subsequent treatment References Urinary tract infections during pregnancy. courses are administered until the 2011; 113-32. bacterial counts drop to non-significant 1. Hoban DJ, Nicolle LE, Hawser S, Bouchillon levels.9 If bacteriuria persists despite S, Badal R antimicrobial susceptibility of 12. Hooton TM. Urinary tract infections and repeated courses of therapy, as well as in global inpatient urinary tract isolates of asymptomatic bacteriuria in pregnancy. women with additional risk factors (e.g. Escherichia coli: results from the Study UpToDate.com; updated 2017.

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30 ICOG CAMPUS SEPTEMBER 2017 Brain Dr. Abha Rani Sinha Associate Professor, Obst & Gynae, Patna Medical College, Patna, Teasers Chairperson Quiz Committee FOGSI (2015-2017)

Q. 1. Name the condition diagnosed with the help of Q. 2. Name the condition in which this blood picture is the findings seen in this MRI seen

Q. 3. Which scoring system is used for regular observation of vital signs in an obstetric patient to grade the severity of her illness ?

Q. 4. Why dextran containing fluids should be avoided in hypovolemic resuscitation?

Q. 5. What is the Investigation of choice for diagnosis of DVT in obstetric patients ?

Answers to Brain Teasers – August Issue

1. Ovarian cortical strips transplanted in the forearm

2. Cobble stone appearance of tube (indicative of intraluminal adhesions) in Genital tuberculosis

3. C. Zona Pellucida Thickness

4. A. Long arm of X chromosome

5. Hypo-osmotic swelling test

ICOG CAMPUS SEPTEMBER 2017 31 8328522 / L470944