Beruflich Dokumente
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Transferred from referring hospital
7/16/2010 3
|+!
"
A Postoperation:
Patient was immediately brought to MICU !/
BP=87/56 HR=122 RR = 17 O2 sat = 74%.
Pupils fixed and 4mm dilated
(+) pallor, harsh breath sounds
Dobutamine and Dopamine drips were continued
Hooked to mechanical ventilator
Transfused 1 unit PRBC
|+!
"
A 1st MICU day, 1st hospital day
,
GCS 3 (O1V1M1), pupils 4-5 mm dilated
No neurosurgical intervention was advised
Waiver for no heroic measures was signed
*/Transferred to regular room
inotropics were continued
|+!
"
A 2nd Hospital day
-
Onteral feeding was suggested
Patient was pronounced dead.
7/16/2010 6
+
A 25 year old, married to an OFW
A G1P0, 28 weeks AOG
A Admitted due to seizures
A BP 170/100 and given MgSO4 IV at another
institution
A Unremarkable past medical and prenatal history
A Family history was remarkable for HPN and DM
7/16/2010 7
+
A Intubated and hypotensive on admission
A Pupils were fixed and dilated
A Absent corneal reflex
A CT scan: massive hemorrhage
A Referred to OB service: stat CS
A Delivered to a Preterm baby boy
A Both mother and baby succumbed
7/16/2010 8
|!!0
A RARO but CATASTROPHIC in pregnant patients
A Anatomical classification:
Subarachnoid hemorrhage
Intracerebral hemorrhage
7/16/2010 9
|
7/16/2010 10
+1|!"!!0
A ANOURYSMS and AV malformation ʹ
congenital defects in cerebrovascular
vasculature
7/16/2010 11
| !"|
! |
A Posterior communicating
23%
A Vertebral/basilar
10%
7/16/2010 13
|1+4
A 95% are asymptomatic and identified
incidentally
1 -2 % RUPTURO per year
7/16/2010 14
0 %(& 2
*'% !
'
1st
2nd
3rd
Postpartum
7/16/2010 15
|"|0|4
A 1-5 POR 10,000 pregnancies
A Maternal mortality: 30-40%
A Risk of cerebral infarction/hemorrhage
Increased 1st 6 weeks pospartum but not during
pregnancy itself
PHYSIO OGIC change :
A Increaed blood volume, stroke volume and cardiac
output
A Ostrogen = vasodilation
7/16/2010 16
||
A Not altered in pregnancy
7/16/2010 17
!1 %% $%
A GRADO I: Alert with or without nuchal rigidity
A GRADO II : Drowsy or severe headache with no
neurologic deficits other than those of the
cranial nerves
A GRADO III: Focal neurologic deficit such as
mild hemiparesis
A GRADO IV: Stupor with severe neurologic
deficits
A 0"51+"
7/16/2010 18
"0
!( 6 2)$
UMBAR CT/MRI
CT SCAN
PUNCTURO ANGIO
"0|"4"
+|
7/16/2010 19
0|!
GOSTATIONA
AGO
TORM PROTORM
7/16/2010 20
CS
NOURO SX
STAB O
AWAIT
NOURO SX SPONTANOOUS
ABOR
7/16/2010 21
NONSURGICA
DO IVORY FOR
UNSTAB O MATORNA
FOTA INDICATIONS
MANAGOMONT
7/16/2010 22
NOURO SX
STAB O MOTHOR
AWAIT
SPONTANOOUS
ABOR
PROTORM
NONSURGICA
MATORNA
MANAGOMONT
UNSTAB O MOTHOR
DO IVORY FOR
FOTA INDICATIONS
7/16/2010 23
] Uncal herniation
MOTHOR ] IV and SAH
2nd HD
D
] Cardiac arrest O
A
] Respiratory distress
syndrome T
FOTUS st
61 H H
7/16/2010 24
M
MOTHOR
FOTUS
7/16/2010 25
| 1"!
"+00|4
MA. PI AR ANONUOVO-CHUA MD
July 16, 2010
1"!
A Irreversible loss of function of the brain,
including the brain stem
A 3 CARDINA FINDINGS
Coma or Unresposiveness
Absence of brainstem reflexes
Apnea
u u
7/16/2010 27
1"!0|4
A Rare/uncommon
7/16/2010 28
To deliver the fetus
immediately, to initiate
supportive care ?
"
or to allow the fetus to
to allow further fetal die as the mother is
maturation ? removed from
mechanical ventilation?
7/16/2010 29
7/16/2010 30
7/16/2010 31
A BJOG, 2003
A CASO ROPORT
A 33 Y/O G1P0, 26 wks
A Massive ICH
A Dilated pupils; GCS 5
A Indication for delivery: oligohydramnios (1285 g)
A Mechanical ventilation stopped postoperatively
A Follow up at 2 years = no developmental abN
7/16/2010 32
7/16/2010 33
MODICA
OGA OTHICA
|"
OBSTOTRICA NOONATA
7/16/2010 34
"||"
A Somatic support
Nonneurological care provided after brain death
A Aggressive respiratory and cardiovascular
support
Mechanical ventilation
treatment of hypotension (maintain MAP 80-110
mmHg)
A Dopamine
A Dobutamine
7/16/2010 35
"||"
A 50 % experience hemodynamic changes
7/16/2010 36
A Sympathetic nervous system ->
7/16/2010 37
A Uterus has no autoregulation as well as other
parts of the circulation
+!0!7
"+0
!"
!4
7/16/2010 38
"||"
A Ondocrine abnormalities
A Infection
A Nutritional support
7/16/2010 39
1||"
A Tertiary center with
adequate neonatal facilities
A Maternal serum screen for
chromosomal abnormalities
and NTD
A Ultrasound
to rule out congenital
anomalies
growth monitoring
7/16/2010 40
1||"
A Assessment of fetal well-being
Daily FHB monitoring starting at 24 weeks
7/16/2010 41
A Perfusion of the
p p
and p
are the most
important determinants
of fetal well-being.
7/16/2010 42
A UTORINO CONTRACTION/PAIN ->
A INCROASOD MATORNA B OOD PROSSURO ->
A CONVU SION ->
A TRANSIONT MATORNA HYPOXIA ->
A UTORINO ARTORY VASOSPASM ->
A DIMINISHOD UTORINO B OOD F OW ->
A IMPAIROD UTOROP ACONTA PORFUSION ->
A FOTA HYPOXIA ->
A 1"4|"
MOCHANISM OF BRADYCARDIA
7/16/2010 43
MATORNA
HYPOTONSION
FOTA
BRADYCARDIA
MATORNA
HYPOTHORMIA
7/16/2010 44
|"
A Complications of
prematurity
RDS, hyperbilirubinemia
and apnea of prematurity
A Counselling of families
regarding short term and
long term complications of
preterm delivery
7/16/2010 45
0"!||"
7/16/2010 46
A Pregnant woman ʹ as a
human incubator
Prolonging life-support
measures for the sake of
the fetus
Maternal autonomy
A No life support before 24
weeks?
A Oxtensive education and
counselling of the family
Prognosis of mother and
fetus
7/16/2010 47
A Organ donation
OTHICA BURDON
A Perimortem CS
4 minute rule
>24 weeks AOG
Doctrine of
Implied consent
7/16/2010 48
To deliver the fetus
immediately, to initiate
supportive care ?
"
or to allow the fetus to
to allow further fetal die as the mother is
maturation ? removed from
mechanical ventilation?
7/16/2010 49
] Uncal herniation
MOTHOR ] IV and SAH
2nd HD
D
] Cardiac arrest O
A
] Respiratory distress
syndrome T
FOTUS st
61 H H
7/16/2010 50
||+
A Brain death in pregnancy is unfortunately rare
A An intensive multi-disciplinary approach is
recommended in the clinical management of
these cases
A Uterine blood flow is critical to fetal survival
and maturation.
A Applicable in our setting?
7/16/2010 51
6%* 8 92( ':1
$' 2$ 8 9;
&$ ' 8 9:<
=6)*
7/16/2010 52