- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Jaundice in Pregnancy |
73 |
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Rajesh Chawla and Prashant Nasa |
|
A 25-year-old female at 34 weeks of pregnancy had been admitted to the hospital with jaundice for 5 days, altered mental status, and decreased urine output for 8 h. Her antenatal status was fine, with no history of pregnancy-induced hypertension. HBsAg and HIV were negative.
Jaundice in pregnancy can occur due to pregnancy-related and unrelated diseases. Pregnancy-related liver diseases are real threat to the survival of the fetus and the
mother.
Rapid diagnosis is needed to manage them appropriately.
Step 1: Initiate resuscitation
Airway intervention may be required in the following conditions:
•Altered mental status and seizures.
•Acute respiratory failure not responding to conservative measures.
•Cesarean section under general anesthesia.
•Shock – to reduce work of breathing.
•Always anticipate difficult airway in pregnant patients.
•Endotracheal intubation should be performed sooner rather than later to protect the airway.
•Intubation must be performed by the senior intensivist.
R. Chawla, M.D., F.C.C.M. (*)
Department of Respiratory, Critical Care & Sleep Medicine, Indraprastha Apollo Hospitals, New Delhi, India
e-mail: drchawla@hotmail.com
P. Nasa, M.D., F.N.B.
Department of Critical Care Medicine, Max Superspeciality Hospital, New Delhi, India
R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, |
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DOI 10.1007/978-81-322-0535-7_73, © Springer India 2012 |
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R. Chawla and P. Nasa |
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•Difficult airway equipment for airway management must be thoroughly checked before proceeding to intubation, and the alternative plan for definitive airway including surgical access should be identified.
•Raised intracranial pressure (ICP) in the jaundiced pregnant patient is a serious concern, and therefore, proper sedation should be ensured with minimal manipulation during intubation.
•Supplemental oxygen may be required in some patients depending on their oxygen saturation, target SpO2 more than 95%.
Circulation
•Two large-bore intravenous cannulae (14G or 16G) should be placed to administer fluids.
•Be careful of associated coagulopathy.
•A Foley’s catheter should be placed to monitor urine output.
•Use fluid administration judiciously to optimize preload and at the same time to avoid overload, which might increase ICP.
•Nurse in the left lateral position (30° wedge to the right hip) to prevent supine hypotension syndrome.
Disability (neurological)
•Perform a brief neurological assessment including Glasgow coma score, pupil size, and reaction to light in case of altered mental status.
Step 2: Take history and perform physical examination
Take detailed history that should cover the following:
•Details about pregnancy (trimester of pregnancy)
•Antenatal evaluation and immunization
•History of hypertension, pregnancy-induced hypertension during the previous pregnancy, complications and outcome of previous pregnancy, and family history of hypertension
•Duration of jaundice and pruritus, other constitutional symptoms such as malaise, nausea, anorexia, fever, weight loss or increased abdominal girth from ascites, and seizures
•History of abdominal surgery, medication history (amount and time of acetaminophen, herbal medications), and transfusion history
•History of alcohol consumption, HIV and hepatitis risk factors, intravenous drug abuse, exposure to travel, occupational, and recreational history
•History of hepatitis B or C in the spouse
In physical examination, also look for the signs of acute liver failure:
•Altered mental status
•Icterus, anemia
•Ecchymotic patches/bleeding from gastrointestinal tract or urinary tract
•Epigastric or right upper quadrant abdominal tenderness
•Peripheral edema, hyperreflexia, or clonus
•Seizures
73 Jaundice in Pregnancy |
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587 |
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Table 73.1 Stages of hepatic encephalopathy |
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|
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Stage |
Mental status |
|
Neuromuscular function |
1 |
Impaired attention, irritability, depression |
Tremor, incoordination, apraxia |
|
2 |
Drowsiness, behavioral changes, memory |
Asterixis, slowed or slurred speech, ataxia |
|
|
impairment, sleep disturbances |
|
|
3 |
Confusion, disorientation, somnolence, |
Hypoactive reflexes, nystagmus, clonus, |
|
|
amnesia |
|
muscular rigidity |
4 |
Stupor and coma |
|
Dilated pupils and decerebrate posturing, |
|
|
|
oculocephalic reflex |
Table 73.2 Physiological changes in liver tests during normal pregnancy |
|||
Test |
|
Normal range |
|
Bilirubin |
Unchanged or slightly decreased |
||
Aminotransferases |
Unchanged |
||
Prothrombin time |
Unchanged |
||
Alkaline phosphatase |
Increases two to four fold |
||
Fibrinogen |
Increases by 50% |
||
Triglycerides |
Increases |
||
Globulin |
Increases in a- and b-globulins |
||
|
|
Decreases in gamma globulin |
|
Cholesterol |
Increases twofold |
||
Hemoglobin |
Decreases in later pregnancy |
||
WBC |
|
Increases |
•Hypotension (hypovolemia, hemolysis, sepsis)
•Spider angioma and palmar erythema may be normal in pregnancy
Step 3: Assess the severity of hepatic encephalopathy
One should assess the severity of hepatic encephalopathy to plan the appropriate treatment (Table 73.1).
Step 4: Send investigations
•Complete blood cell count.
•Liver function tests—remember normal physiological changes in pregnancy (Table 73.2).
•Renal function tests and serum electrolytes.
•Arterial blood gas analysis and blood glucose.
•Hepatotropic virus profile (IgM anti-HEV, IgM anti-HAV, IgM anti-HCV, antiHBc antibody, HBeAg, HBsAg).
•Coagulation profile (prothrombin time, activated partial thromboplastin time, fibrinogen, fibrin degradation product).
•Uric acid.
•The antinuclear factor—to exclude autoimmune hepatitis.
•Additional tests—peripheral smear, serum lactate dehydrogenase levels, reticulocyte count, and Coombs’ test—to exclude thrombotic thrombocytopenic purpura (TTP).
588 |
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R. Chawla and P. Nasa |
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Table 73.3 Classification of liver diseases in pregnancy |
|
|
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Pregnancy-unrelated liver diseases |
|
|
|
Liver diseases coincident |
Pregnancy-related liver diseases |
Preexisting liver diseases |
with pregnancy |
Intrahepatic cholestasis of pregnancy |
Hepatitis B and C |
Biliary disease |
(ICP) |
|
|
Preeclampsia and eclampsia |
Autoimmune liver disease |
Budd–Chiari syndrome |
Hemolysis, elevated liver enzymes, |
Wilson’s disease |
Drug-induced |
low platelet (HELLP) syndrome |
|
hepatotoxicity |
Acute fatty liver of pregnancy (AFLP) |
Cirrhosis and portal |
Viral hepatitis A and E |
|
hypertension |
|
Hyperemesis gravidarum |
|
|
•Ultrasonography is considered safe and is the preferred abdominal imaging modality during pregnancy.
•MRI with contrast is preferable to CT scanning during pregnancy to avoid ionizing radiation.
•Transthoracic echocardiography.
Step 5: Differential diagnosis
The various conditions that can cause acute hepatic failure can be divided into those related to pregnancy and those unrelated to pregnancy (Tables 73.3 and 73.4).
A.Hyperemesis gravidarum
•Incidence: 0.3–2.0% of all pregnancies.
•Usually within the first trimester.
•Symptoms: intractable vomiting, resulting in dehydration, ketosis, and weight loss of 5% or more.
•The cause remains unclear.
•Risk factors: obesity, psychiatric illness, molar pregnancy, preexisting diabetes, multiple pregnancies, and hyperthyroidism (60%).
•Serum aminotransferases can rise up to 20 times, but jaundice is rare.
B.Viral hepatitis
•Diagnosis of viral hepatitis in pregnancy is not different from the diagnosis in the nonpregnant state.
•Herpes simplex virus in patients who are immunosuppressed, and in the pregnant woman, can cause fulminant hepatitis. Aminotransferases are high, and other signs of hepatic failure such as prothrombin time are elevated, but jaundice (increase in bilirubin) is rare.
Step 6: Management
A.AFLP
•Prompt delivery is essential (steroids if fetal maturity in doubt).
•Supportive treatment, control of hypertension (discussed in Chap. 19), and correction of coagulation abnormalities and hypoglycemia.
Table 73.4 Comparison of severe preeclampsia–eclampsia, intrahepatic cholestasis of pregnancy, HELLP syndrome, and AFLP
|
Severe |
Intrahepatic cholestasis |
|
|
|
preeclampsia–eclampsia |
of pregnancy |
HELLP syndrome |
AFLP |
Trimester |
Second to third |
Second to third |
Third |
Third |
Incidence (%) |
1–5 |
0.1 |
0.2–0.6 |
0.005–0.01 |
Family history |
Occasionally |
Often |
No |
Occasionally |
Presence of preeclampsia |
Yes |
No |
Yes |
50% |
Typical clinical features |
Hypertension, edema, |
Pruritus, mild jaundice, |
Hemolysis |
Liver failure with coagulopathy, |
|
proteinuria, neurological |
elevated bile acids |
Thrombocytopenia (<50,000 |
encephalopathy, hypoglycemia, |
|
deficits (headaches, seizures, |
|
often) |
disseminated intravascular coagulation |
|
coma) |
|
|
|
Aminotransferases |
None/mild |
Mild to 10to 20-fold |
Mild to 10to 20-fold |
300–500 typical but variable ++ |
|
|
elevation |
elevation |
|
Bilirubin |
Normal— <5 mg/dL |
<5 mg/dL |
<5 mg/dL unless massive |
Often <5 mg/dL, higher if severe |
|
|
|
necrosis |
|
Hepatic imaging |
Normal—hepatic infarcts |
Normal |
Hepatic infarcts hematomas, |
Fatty infiltration |
|
|
|
rupture |
|
Histology (usually not |
Periportal hemorrhage, |
Normal–mild cholesta- |
Patchy/extensive necrosis |
Microvesicular fat in zone 3 |
performed) |
necrosis, fibrin deposits |
sis, no necrosis |
and hemorrhage |
|
Recurrence in subsequent |
20% risk |
45–70% |
4–19% |
Subunit, long-chain 3-hydroxyacyl- |
pregnancies |
|
|
|
CoA dehydrogenase defect—yes |
|
|
|
|
No fatty acid oxidation defect—rare |
Pregnancy in Jaundice 73
589