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The term placenta accreta or placenta accrete syndrome is used to describe a spectrum of an abnormal placental implantation and firm adherence which are classified according to the depth of invasion into the uterus. A 28-year-old elderly primigravida presented AIIMS OPD to for the 1st time at 13+2 weeks of gestation with brownish discharge per vaginum. Ultrasonography done showed 12 weeks single intrauterine pregnancy with subchorionic haemorrhage of 3.7×2.52 cm with placenta being fundoanterior. She underwent myomectomy 2 years back and during her antenatal care in 3rd trimester growth scan at 30+2 weeks of gestation placenta was fundoanterior with loss of retroplacental hypoechoic in the upper margin of placenta at the myomectomy scar site with small extra uterine collection seen measuring 7.6×2.3 cm and hence possibility of placenta accreta was suggestive by the above findings confirmed by MRI. Emergency cesarean section done at 36+6 weeks of gestation for leaking per vaginum. Manual removal of placenta was tried but it failed and soon atonic PPH developed. Seeing no response with uterotonics internal iliac artery ligation was also attempted but failed. Immediate decision for hysterectomy was taken as a life-saving method. On adhesiolysis in the fundal region placental tissue perforating uterine serosa was visible on the surface of uterus, hence diagnosis of placenta percreta was confirmed which was further confirmed on histopathological report. Currently hysterectomy or local resection is preferred over conservative management with methotrexate.
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Background: The management of critically ill obstetric patients presents a unique challenge. Dedicated High Dependency Unit (HDU) and Intensive Care Unit (ICU) for obstetric patients are widely available in India. The data regarding obstetric critical care is invaluable in formulating policy decisions. The objective is to study the profile of cases admitted to obstetric HDU and ICU and to evaluate maternal outcome and co-morbid conditions.Methods: This was a prospective observational study between January 2017 and June 2018.Results: Total number of obstetric admissions was 7966. Total admissions to obstetric ICU were 60. ICU cases accounted for 0.7% of all obstetric admissions and 1.1% all deliveries. Obstetric cases formed 1.6% of total ICU admissions. Number of admissions to HDU was 576. HDU cases accounted for 7.2 % of all obstetric admissions. HDU utilization rate was 11.32%. Hypertensive disorders of pregnancy (n=22, 33.3%), obstetric haemorrhage (n=18, 30%), septic abortion (n=2, 3.3%) were the most common conditions necessitating admission.Conclusions: Hemorrhage was the most common indication for admission to HDU. Delayed identification and referral were the important obstacles. There is a need for early booking at peripheral centres. Introduction of obstetric ICU and multidisciplinary approach has brought down the incidence of maternal mortality in present centre.
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Resumen: El embarazo es un estado que impone un verdadero desafío para el sistema cardiovascular materno. Las pacientes obstétricas que se complican con preeclampsia, enfermedad cardiaca, sepsis, hemorragia y tromboembolia pulmonar, se caracterizan por profundas alteraciones hemodinámicas, las cuales representan las principales causas de morbilidad y mortalidad materna extrema, por lo que existe la necesidad de una correcta evaluación y monitoreo validado de estos parámetros en este tipo de pacientes. El objetivo de esta revisión es describir la tecnología disponible a la cabecera del enfermo para la implementación de este monitoreo hemodinámico en la paciente embarazada de alto riesgo.
Abstract: Pregnancy is a state, which poses a real challenge to the maternal cardiovascular system. Obstetric patients who are complicated by preeclampsia, heart disease, sepsis, hemorrhage and pulmonary thromboembolism are characterized by profound hemodynamic alterations, which represent the main causes of morbidity and extreme maternal mortality, so there is a need for a correct evaluation and monitoring of these parameters, which is validated in this type of patients. The objective of this review is to describe the technology available at the patient's bedside for the performance of this hemodynamic monitoring in the high-risk pregnant patient.
Resumo: A gravidez é um estado que representa um verdadeiro desafio para o sistema cardiovascular materno. A paciente obstétrica que apresenta complicações como pré-eclâmpsia, doenças cardíacas, sepse, hemorragia e tromboembolismo pulmonar, se caracterizam por profundas alterações hemodinâmicas que representam as principais causas de morbimortalidade materna extrema, por isso é necessária uma avaliação correta e a monitorização desses parâmetros, que esteja validado nesse tipo de pacientes. O objetivo desta revisão é descrever a tecnologia disponível à beira do leito para a realização da monitorização hemodinâmica na paciente obstétrica de alto risco.
ABSTRACT
El hígado graso agudo del embarazo, descrito en 1934, es una complicación gestacional poco frecuente y potencialmente fatal. El daño hepático materno ocurre por depósito citoplasmático perinuclear de microvesículas de grasa en el hepatocito relacionada con deficiencia enzimática autosómica recesiva en la vía de la oxidación mitocondrial de los ácidos grasos del feto. El objetivo de este artículo es exponer un caso de hígado graso agudo del embarazo acontecido en nuestro medio con criterios clínicos compatibles así como estudio histopatológico confirmatorio. Se trata de una paciente de 43 años procedente y residente de la ciudad de El Alto, La Paz (Bolivia), presenta ictericia, coluria, se automedica con paracetamol, asociándose al cuadro clínico nauseas acompañadas con vómitos, ausencia de movimientos fetales de producto único de 35 semanas; durante su evolución en UTI presenta encefalopatía hepática grado II y hemorragia digestiva, fallece a los 3 días de internación en UTI, se realiza necropsia hepática compatible con hígado graso agudo del embarazo. Cabe destacar la realización de estudio histopatológico en el presente caso, la cual no se realiza de manera rutinaria en nuestro medio, el cual reporta esteatosis hepática macro y microvacuolar asociada a proceso inflamatorio crónico activo acentuado difuso compatible con hígado graso agudo del embarazo, lo cual apoya los criterios clínicos de Swansea.
Acute fatty liver of pregnancy, described in 1934, is a rare but potentially fatal gestational complication. The damage in mother's liver is produced by perinuclear cytoplasmic deposit of fat micro vesicles in hepatocyte related with autosomal recessive enzymatic deficiency in mitochondrial oxidative fatty acids pathway of fetus. The objective of this paper is present an acute fatty liver of pregnancy occurred with clinical criteria and confirmation histopathological study. The present case is about a 43-year old patient, resident of El Alto, La Paz (Bolivia), with jaundice, choluria, auto medicated with acetaminophen, curses also with nausea and vomiting, absence of fetal movements of 35-week fetus, during her evolution in ICU presents hepatic encephalopathy and digestive hemorrhage, dies at 3th day in ICU, hepatic necropsy confirms acute fatty liver of pregnancy. It's worth mentioning the histopathological study, scarcely performed in our country, which, in this case, reports macro and microvacuolar steatosis in liver, associated to an active diffuse chronic inflammatory process compatible with acute fatty liver of pregnancy, in concordance with clinical Swansea criteria.
Subject(s)
Humans , Female , Fatty Liver/complications , LiverABSTRACT
Objetivo: Evaluar la morbilidad materna aguda severa y la gravedad de las patologías obstétricas tratadas en la Unidad de Cuidados Intensivos. Diseño: Estudio de serie de casos, descriptivo y analítico. Ámbito: Unidad de Cuidados Intensivos en un centro asistencial privado. Materiales y Métodos: Durante 22 años y 5 meses, se registraron, en forma consecutiva, todos los datos referidos a las características poblacionales, los diagnósticos de ingreso, los puntajes de gravedad, la morbilidad materna aguda severa y la mortalidad en la Unidad de Cuidados Intensivos. Resultados: Se registraron 130.092 nacimientos, 1005 pacientes obstétricas ingresaron en la Unidad de Cuidados Intensivos, con una relación de 7,7 ingresos por cada 1000 nacimientos. La edad promedio era 33 ± 5.2 años. Prevalecieron los ingresos relacionados con las hemorragias obstétricas graves (44,5%) y la hipertensión arterial inducida por el embarazo (25,7%), ambos grupos con 100% de supervivencia materna. Los puntajes al ingreso fueron: APACHE II 7,3 ± 4,6; SAPS II 22,7 ± 16,5 y SOFA 1,8 ± 0,6. La mediana de estadía en la Unidad de Cuidados Intensivos fue de 3 días (rango 2-4) y el puntaje de intervenciones terapéuticas fue de 18,7. Alrededor de las dos terceras partes de las enfermas presentaron daño orgánico. La morbilidad materna aguda severa fue de 2,8/1000 nacimientos y la razón de mortalidad materna, de 8,4/100.000 nacimientos. La mitad de los decesos fueron por causas directas: endometritis puerperal (3 casos), embolia de líquido amnió- tico (2 casos) y miocardiopatía dilatada periparto (un caso). Conclusiones: En relación con el número de nacimientos, los ingresos en la Unidad de Cuidados Intensivos fueron escasos. La morbilidad materna aguda severa fue baja con una razón de mortalidad materna hospitalaria inferior a la registrada en los hospitales públicos del área metropolitana.(AU)
Objective: To evaluate the incidence of the maternal near-miss and the severity of all diseases that motivated obstetrical admissions to the Intensive Care Unit. Design: Retrospective case series study. Setting: Intensive Care Unit in a private medical institution. Materials and Methods: During 22 years and 5 months, the following data were obtained: demographics, admission diagnoses, severity of illness, maternal near-miss and overall maternal mortality rate in the Intensive Care Unit. Results: A total of 130,092 deliveries occurred during the study period. There were 1,005 pregnancy-associated admissions to the Intensive Care Unit, which represented a ratio of 7.7/1000 deliveries. The mean age of these patients was 33 ± 5.2 years. The main reasons for admissions were: severe obstetric hemorrhage (44.5%) and pregnancy-induced hypertension (25.7%), with 100% survival. At admission the median APACHE II score was 7.3 ± 4.6, SAPS II score 22.7 ± 16.5 and SOFA score 1.8 ± 0.6. The median length of stay in the Intensive Care Unit was 3 days (range 2-4) and the therapeutic intervention score system was 18.7. Nearly two-thirds of the patients suffered organ damage. The maternal near-miss was 2.8/1000 deliveries and the maternal mortality rate was 8.4/100,000 deliveries. Half of the deaths were due to direct causes: puerperal endometritis (3 cases), amniotic fluid embolism (2 cases) and peripartum cardiomyopathy (one case). Conclusions: Regarding the number of births, admissions to the Intensive Care Unit were scarce. The maternal near-miss was low and overall maternal mortality rate in the Intensive Care Unit was lower than that registered in public hospital of metropolitan area.(AU)
Subject(s)
Humans , Female , Pregnancy , Pregnancy , Morbidity , Pregnancy Complications , Critical CareABSTRACT
BACKGROUND AND OBJECTIVES: The assessment of illness severity and prognosis of obstetric patients by scoring systems is still a controversial issue. Preeclampsia is a leading cause of severe maternal morbidity and mortality, and a major cause of obstetric admission to intensive care unit. There is paucity of data regarding the predictability of critically ill preeclamptic women and the application of scoring systems to this population. This study aimed to evaluate and compare the application of APACHE II, SAPS II and MPM II scoring systems between a preeclamptic population and a non obstetric female population. METHODS: A case-control study was conducted on 28 preeclamptic women and 56 non obstetric female patients, admitted to a general intensive care unit over a period of 10 years. The predictive accuracy of the prognostic evaluation systems was estimated by the area under the receiver operator characteristic curve. RESULTS: The mortality rate was 21.4 percent (6:28) for the study group and 35.7 percent (20:56) for the control group, with an OR = 0.49 (95 percentCI = 0.17-1.41). The main causes of ICU admission of preeclamptic women were HELLP syndrome, coma and pulmonary edema. In the preeclamptic population, only the MPM II score showed an area under the ROC curve statistically different from 0.500, while in the control group, all scoring systems had their areas under the ROC curves statistically different from 0.500. CONCLUSIONS: The application of APACHE II and SAPS II to evaluate critically ill preeclamptic women may be not appropriate.
JUSTIFICATIVA E OBJETIVOS: A avaliação de gravidade e do prognóstico de pacientes obstétricas através de escores é ainda tema controverso, sendo escassa a informação sobre mulheres com pré-eclâmpsia. Esta é uma das maiores causas de morbidade materna grave e de mortalidade materna, além de ser também uma das principais causas de internação obstétrica em UTI. Os objetivos deste estudo foram avaliar e comparar a aplicação do APACHE II, SAPS II e MPM II em população de mulheres com pré-eclâmpsia e em população feminina não-obstétrica. MÉTODO: Foi realizado um estudo caso-controle com 28 mulheres pré-eclâmpticas e 56 pacientes femininas não-obstétricas admitidas em unidade de terapia intensiva geral, num período de 10 anos. A acurácia preditiva dos sistemas de avaliação prognóstica foi estimado através da área sob a curva ROC. RESULTADOS: A taxa de mortalidade no grupo de estudo foi de 21,4 por cento (6:28) e 35,7 por cento (20:56) no grupo controle, com OR = 0,49 (95 por centoCI = 0,17-1,41). As principais causas de admissão à UTI de mulheres com pré-eclâmpsia foram: síndrome HELLP, coma e edema pulmonar agudo. Na população com pré-eclâmpsia, apenas o escore MPM II mostrou uma área sob a curva ROC estatisticamente diferente de 0,500, enquanto que no grupo controle, todos os sistemas de escore apresentaram uma área estatisticamente diferente de 0,500. CONCLUSÕES: De acordo com os achados do presente estudo, concluímos que a aplicação do sistema APACHE II e SAPS II para avaliar mulheres com pré-eclâmpsia em estado grave de saúde é possivelmente inapropriado.