Maternal Critical Care Case Based Discussion

Transcription

1 Maternal Critical Care Case Based Discussion Dr Lucy Mackillop Obstetric Physician Honorary Senior Clinical Lecturer Women s Centre John Radcliffe Hospital, Oxford OAA meeting Oct 2 nd 2014

2 Case 1 31 year old Caucasian primip 31/40 5/7 history of severe RUQ/epigastric pain 3 trips to GP gaviscon/ranitidine Presents to DGH with vomiting, severe RUQ pain and reduced fetal movements

3 Case 1 Recent UTI 3/7 of amoxycillin (sensitive) No PMHx No FHx BP 110/60 Urine 1+ protein 30/40 uterus. No FH

4 Case 1 Scan IUD confirmed. Extensive free fluid is seen throughout the abdominal cavity. The whole of the superior portion of the right lobe of the liver appears heterogenous with a disorganised parenchymal pattern. It also appears increased in echogenicity in comparison with the lower portion of the liver. A liver infarction cannot be excluded with this appearance. No obvious placental abruption seen.

5 Case 1 midday Na136 mmol/l K 4.9 mmol/l Glucose 6.2 mmol/l Creatinine108 umol/l Bili12umol/L ALT 284IU/L* Alk Phos 265IU/L* ALB 30G/L* TSH 3.31mU/L HBA1C 4.9% Hb9.3g/dl* WBC *9/l* Neutrophils 20 Leukocytes 2 PLTs143 10*9/l* Haematocrit 0.270l/l* PT 14.5 sec APTT 37.8 secs Fibrinogen3.6g/l D-Dimer 7420ug/l FEU*

6 Case pm ITU-to-ITU transfer On admission, sitting up, BP 90/50 ph 7.1, BE -2, Lactate 3.8 PT 17, APTT 56, Alb 28 Hb 9.6, WBC 28, Plt 146 K 7.3, Cr 162, anuric ALT 367, bili 12

7 Case 1 So what do you do? dialyse Correct coagulopathy CT scan..delivery?

8

9 Clinical assessment

10 Encephalopathy Grade 0 - Minimal hepatic encephalopathy (previously known as subclinical hepatic encephalopathy). Lack of detectable changes in personality or behaviour. Minimal changes in memory, concentration, intellectual function, and coordination. Asterixis is absent. Grade 1 - Trivial lack of awareness. Shortened attention span. Impaired addition or subtraction. Hypersomnia, insomnia, or inversion of sleep pattern. Euphoria, depression, or irritability. Mild confusion. Slowing of ability to perform mental tasks. Asterixis can be detected. Grade 2 - Lethargy or apathy. Disorientation. Inappropriate behaviour. Slurred speech. Obvious asterixis. Drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behaviour, and intermittent disorientation, usually regarding time. Grade 3 - Somnolent but can be aroused, unable to perform mental tasks, disorientation about time and place, marked confusion, amnesia, occasional fits of rage, present but incomprehensible speech Grade 4 - Coma with or without response to painful stimuli

11 Acute Liver Failure 54 admissions with pregnancy related liver failure (18 AFLP, 32 HELLP) 7 (13%) patients died 4 (7%) had a liver transplant The presence of encephalopathy + high lactate (>2.8 mg/dl) predicted death or liver Tx (sensitivity 90%, specificity 86%) (c.f. not standard King s College Criteria (INR, age, bili, drug toxicity))

12 Case 1 Liver haematoma evacuated and packed (no adenoma seen) Hysterotomy (no comment on findings) Listed for a liver Tx Spontaneous recovered (de-listed day 8) Post op recovered complicated by hypertension

13 Case pregnant again Normal booking BP, urine, LFTs Given aspirin Normal uterine artery dopplers at 23 weeks Oedema from 29 weeks Borderline hypertension from 30 weeks Admitted, given steroids Hypertension and proteinuria 31 weeks delivered next day Mother and baby well!

14 Management of Acute Liver Failure Identify the problem! Early involvement of Liver Unit Supportive treatment N-acetyl cysteine Neomycin and Lactulose Treatment of hypoglycaemia?apheresis Empty Uterus Multidisciplinary approach

15 Case 2 22 years old, para 1 gravida 3 TOP aged 15 1 previous pregnancy (uncomplicated) 2008 Mild asthma This pregnancy: New partner Uncomplicated until 32 weeks Unwell for 1/52 Saw midwife ( ) tired, not sleeping, hayfever Saw GP ( ) breathless

16 : Ambulance called because of worsening SOB Also reported: Mild burning central chest pain on inspiration Abdominal pain epigastric / RUQ / suprapubic No diarrhoea >24 hours vomiting, not managing fluids Cough, white sputum Still smoking 20/day

17 Drug History Longstanding: Becotide inhaler Salbutamol inhaler Prescribed the previous evening: Erythromycin 250mg QDS Prednisolone 30mg OD (5/7 course) Penicillin allergy details unknown No alcohol or illicit drugs

18 Examination Unwell, struggling to breathe, talking in 4 word sentences Cold peripheries, dry CVS P110 (sinus tachycardia), BP 145/69 CRT <2s Normal heart sounds Resp RR 60, Sa02 98% on room air Lots of upper airway noise, some wheeze Abdo Soft, mild tenderness over upper abdomen Fetus breech, appropriate size for dates Urine Protein 1+, ketones 4+, ph 5

19 What are you going to do? Oxygen Nebuliser Senior/Colleague support (!) IV access, blds ABGs ECG Chest x-ray

20 What is the diagnosis? Mild burning central chest pain on inspiration Abdominal pain epigastric / RUQ / suprapubic No diarrhoea >24 hours vomiting, not managing fluids Cough, white sputum Fulminating PET/HELLP Pulmonary Embolus Acute severe Asthma Pneumonia Heart failure Myocardial Infarction Aortic Dissection Oesophageal rupture Pancreatitis CVS: P110 (sinus tachycardia), BP 145/69 CRT <2s Normal heart sounds Resp: RR 60, Sa02 98% on room air Lots of upper airway noise, some wheeze Abdo: Soft, mild tenderness over upper abdomen Fetus breech, appropriate size for dates Urine: Protein 1+, ketones 4+, ph 5

21 ABG 15/ AIR ph 7.27 paco kpa (8.5 mmhg) pao kpa (99 mmhg) HCO3 8.6 lactate 0.6 BEx Cl 111 Na 135 K 4.6 Ca 1.36 BM 4.2 mmol/l Ketones 4.0 mmol/l (normal <1) Anion gap 20 (normal 8-12)

22 Other results Hb 13.6 Na 131 WCC K 4.8 Neut Urea 2.2 Lymph 1.43 Creat 84 Plt PT CRP 15 APTT 28 Bil 17 Urate 691 Ethanol NEG CK 46 Salicyl. NEG ALT 22 Paracet NEG Alk ph 299 Alb 48

23 Subsequently Taken to theatres at 1700 Fluid resuscitated Invasive monitoring Urinary catheter Arterial line ECG Monitoring Pulse oximetry Emergency caesarean section at 2100 GA (induction at 2050) 1900gm male, Apgar 7 / 10/10

24 Intubation pao2 HCO3 ph 0 15:00 21:00 03:00 09:00 Time 7.1

25 Intubation pao2 HCO3 ph 0 15:00 21:00 03:00 09:00 Time 7.1

26 AICU admission Recovered overnight Easy to ventilate, no inotropic support required Acidosis improved with bicarbonate Given Mg, propofol, midazolam, fentanyl, ceftriaxone Extubated the next morning Discharged to ward the next day

27 So what caused all of this? The possibilities: Pre-eclampsia Acute fatty liver of pregnancy Diabetic ketoacidosis Starvation Ketoacidosis

28 Metabolic Acidosis Anion gap (12-16) = (Na+K) (Cl+HCO 3 ) Increased anion gap Lactic acid production Ketoacid production Exogenous acids Reduced renal acid secretion Type A = tissue hypoperfusion Type B = no tissue hypoperfusion DM etoh Starvation Gene defect Methanol, aspirin, ethylene glycol CKD Normal anion gap GI loss of HCO 3 Renal loss of HCO 3 Reduced renal acid secretion Diarrhoea Bowel resection Type 2 RTA After Tx of ketoacidosis Type 1/4 RTA, CKD

29 Accelerated starvation in pregnancy Pregnancy: Increased cortisol, glucagon from placenta and human placental lactogen Increased insulin resistance Relative lack of insulin More prone to ketosis Possibly a mechanism for adapting the mother to metabolism of fat, so that less expendable fuels (glucose, amino acids) are spared for the fetus.

30 Non fasting Fasting Fasting (pregnancy) carbohydrate carbohydrate carbohydrate placenta Hormones e.g. HPL and cortisol Adipose tissue Adipose Adipose pancreas tissue pancreas tissue pancreas insulin glucagon insulin glucagon insulin glucagon Free fatty acids glucose glycogen Free fatty acids glycogenesis glucose glycogen Free fatty acids glycogenesis glucose glycogenesis glycogen gluconeogenesis liver liver liver glucose glucose gluconeogenesis β oxidation β oxidation β oxidation glycolysis glycolysis pyruvate pyruvate pyruvate Acetyl CoA Acetyl CoA Acetyl CoA Citric acid cycle Citric acid cycle Citric acid cycle ATP ketones ATP ketones ATP Frise CJ et al. Starvation ketoacidosis in pregnancy Eur J Obstet Gynecol (2012)

31 Mahoney (1992) 30/40 twin pregnancy admitted for preterm labour Vomited profusely on day 5 Severe acidosis, ketotic Treatment: bicarbonate, antibiotics and emergency CS

32 Mahoney (1992) 30/40 twin pregnancy admitted for preterm labour Vomited profusely on day 5 Severe acidosis, ketotic Treatment: bicarbonate, antibiotics and emergency CS Keay and Fox (2000) Similar presentation at 35/40 Fetal compromise so underwent emergency CS Treatment: bicarbonate, insulin and dextrose

33 Mahoney (1992) 30/40 twin pregnancy admitted for preterm labour Vomited profusely on day 5 Severe acidosis, ketotic Treatment: bicarbonate, antibiotics and emergency CS Keay and Fox (2000) Similar presentation at 35/40 Fetal compromise so underwent emergency CS Treatment: bicarbonate, insulin and dextrose Burbos et al (2009) Admitted at 33/40 with 24 hr history of vomiting SOB on day 5, severe acidosis (high anion gap), ketotic Treatment: dextrose. Recovered and subsequently delivered at 40/40

34 Schilthuis & Aarnoudse (1980) Pt with T1DM at 28/40 in preterm labour given ritodrine Rapid development of ketoacidosis Intrauterine death

35 Schilthuis & Aarnoudse (1980) Pt with T1DM at 28/40 in preterm labour given ritodrine Rapid development of ketoacidosis Intrauterine death Land et al (1992) 32/40 twin pregnancy, admitted in preterm labour Given b agonists (terbutaline, ritodrine, salbutamol) Developed vomiting then metabolic acidosis (ph 7.02) Severe ketonaemia Intrauterine death Treatment: bicarbonate, dextrose, antibiotics 6/12 later: normal response to glucose, salbutamol and starvation

36 Management of Starvation Ketoacidosis Consider ketone testing (capillary) on women in later pregnancy with vomiting ABG analysis in women with ketonuria, or who are unwell Consider 10% dextrose as an adjunct to fluid resuscitation Insulin, alongside dextrose if required, if the glucose levels increase, or ketones remain elevated Repeated assessment of capillary ketones and blood gas Consider admission to level 2 or 3 critical care Consider delivery if the acidosis fails to respond to these measures, or evidence of fetal compromise

37 Thank you