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(
 Transferred from referring hospital

 intubated, non-responsive to painful stimuli, with fixed


dilated pupils

 hooked to a mechanical ventilator

 Plain cranial CT scan was done


|| !!"

Oxtensive  #$%   &  $   


'  ( likely due to a )  *'
resulting to communicating hydrocephalus and
cerebral edema.

Right maxillary sinusitis.


|+!
"
 referred to Neurology and OB-Gyne

 Mannitol IV and Diprospan 14 mg IV was given

 Referred to Neurosurgery ʹpossible ventriculostomy

 Scheduled for stat CS : ,--. ' DO IVOROD to a


live preterm baby boy via TCS I , BW 2lbs 4 oz (1021 g), AS
9,10, MI 26-27 weeks AGA

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

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 +
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

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|!!0
A RARO but CATASTROPHIC in pregnant patients

A Anatomical classification:
 Subarachnoid hemorrhage
 Intracerebral hemorrhage

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|

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+1|!"!!0
A ANOURYSMS and AV malformation ʹ
congenital defects in cerebrovascular
vasculature

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| !"|
! |

HOADACHO Oxplosive-severe Insidious ʹ dull

NAUSOA AND VOMITING Common Uncommon

oss of consciousness 2/3 All (seizure)

NUCHA RIGIDITY 90% Uncommon

Seizures 15% All

Hypertension 30-50% All

Proteinuria Uncommon Common

Focal motor weakness 20% rare

7/16/2010 CRITICA CARO OBSTOTRICS, 4TH edition 12


 $   2$& % *'
)( $*
A Internal carotid `
37%

A  $ ''$ (


-3

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

A Symptomatic aneurysm ʹ greater risk


 6.25 % RUPTURO per year

A Spontaneous bleeding ʹ worst prognosis

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

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||
A Not altered in pregnancy

A The most important prognostic indicator of


outcome is the patient͛s condition at
presentation.

A Seizures, headache and neurologic deficit

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!  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+"
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"0
!(  6 2)$ 

UMBAR CT/MRI
CT SCAN
PUNCTURO ANGIO

"0|"4"

+|
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0|!
GOSTATIONA
AGO

TORM PROTORM

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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

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] 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 
  
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1"!0|4
A Rare/uncommon

A complications of severe traumatic brain


injury, a catastrophic cerebrovascular
accident, or other critical illness
.

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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
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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
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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

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"||"
A 50 % experience hemodynamic changes

 Severe hypertension followed by profound


hypotension

 Magnitude of blood pressure fluctuations seem to


be proportional to the rapidity with which brain
death evolves

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A Sympathetic nervous system ->

A Release of cathecolamines from the brain ->

A Decreased cardiac contractility secondary to


coronary artery vasospasm

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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

A Document fetal lung maturity (@ 34-36


weeks)

A Ostablish timing and mode of delivery


 Cesarean birth - safest

7/16/2010 41
A Perfusion of the
p    p 

and p 



 
are the most
important determinants
of fetal well-being.

A Uterine blood flow is


critical to fetal survival
and maturation.

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"!||"

A Advanced directives are extremely rare


A Informed consent
A Surrogate

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