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Emergencies in Obstetrics
Paul C. Browne, M.D. Associate Professor Department of Obstetrics and Gynecology USC School of Medicine
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Disclosures Nature of Financial Relationship: Grant/Research Support–
USC School of Medicine March of Dimes
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Objectives 1. Define “Emergency 2. Triage for Pregnancy Emergencies
3. Maternal versus Fetal Emergencies 4. Change in Mental Status 5. Hemorrhage 6. Cardiac/Pulmonary Insufficiency 8. Trauma 9. Cardiac Arrest 10. Appropriate Maternal Evaluation 11. Appropriate Fetal Evaluation
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Definition of Emergency
“An emergency is the sudden onset of symptoms which, in the opinion of a reasonable and prudent lay person, require immediate medical attention and where lack of treatment would pose a significant health risk to the mother or her unborn child”
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Components of Emergency
Sudden onset Symptoms which require immediate attention Lack of treatment may cause harm Mother and/or fetus
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Courtesy mybloodyourblood.org
Examples Chronic bleeding Acute bleeding Sudden-onset is an emergency Courtesy mybloodyourblood.org
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Courtesy activebodycare.co.uk
Examples Symptoms which require immediate attention Preterm labor Courtesy activebodycare.co.uk
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Courtesy topnews.in and statejournal.com
Examples Lack of Treatment may cause harm Courtesy topnews.in and statejournal.com
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Fetal Emergencies No Fetal Movement Vaginal Bleeding Preterm Labor
Abdominal Trauma
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Viability World Health Organization/ACOG State of South Carolina
20 weeks gestation 350 Grams State of South Carolina Completion of “Second Trimester” Your ER Positive fetal heart rate
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Statement of AAP Less than 23 weeks gestation
No mandate to resuscitate secondary to uniformly poor outcomes 23-25 weeks Resuscitation on a case by case basis in consultation with the parents and NICU professionals Greater than 25 weeks Ethical mandate for resuscitation in absence of an anomaly incompatible with life
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Maternal Emergencies Altered mental status Hemorrhage/DIC Cardiopulmonary insufficiency Trauma Cardiopulmonary arrest
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Change in Mental Status
Disorientation Aphasia Slurred Speech
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Causes of Altered Mental Status
Recreational Drugs Hypotension (internal bleeding) Diabetes Seizure (post-ictal eclampsia)
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Triage of Altered Mental Status
Vital signs Pulse, Blood Pressure IV access Fingerstick glucose Urine drug screen Fetal heart rate by doppler Abbreviated EEG J Clin Neurophysiol Feb;24(1):16-21
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Courtesy Scripps Mercy Hospital
Mental Status Score Courtesy Scripps Mercy Hospital
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Triage of Altered Mental Status
Majority of cases will be caused by drug use or metabolic disturbance Easily corrected in ER setting
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Altered Mental Status Triage
Hypoglycemia Treat and release Hypotension Improved without bleeding Seizure Only with known seizure disorder
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Treatment IV Hydration Oxygen Serial Vital Signs
D5LR at 125 ml/hr Oxygen 2 liters/minute nasal cannula Serial Vital Signs Serial Mental Status Checks Monitor fetal status
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Courtesy pregnancy.about.com
Recreational Drug Use Observation admission DHSS referral Arrange outpatient drug rehab Schedule birth defect screening Courtesy pregnancy.about.com
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Intracranial Hemorrhage
Rare cause of altered mental status Lateralizing signs Often associated with seizures Source of medical-legal action
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Courtesy casereports.net and catscanman.net
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Pearls in management of altered mental status
Global neurological dysfunction Drugs, metabolic disturbance, low BP Focal neurological dysfunction Seizure disorder, migraines, CVA Parallel workups Differential diagnosis evolves
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Summary-Altered Mental Status
Usually corrected in ER Secure patient Start IVF with dextrose/give O2 Obtain labs/imaging Serial neuro checks until resolution Admit for substance abuse and eclampsia
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Hemorrhage 2nd leading cause of maternal death Unique physiology
Pregnant women are prepared to bleed Increased blood volume Increased blood clotting Decompensate with rapid hemorrhage Abruptio placenta Severe trauma Difficult cesarean section
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2007 SC DHEC Vital Statistics
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Courtesy thepregnancyzone.com
Bleeding Courtesy thepregnancyzone.com
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Triage of Bleeding Blood from vagina Blood from anywhere else Labor
Rupture of membranes Abruption Blood from anywhere else Trauma Epistaxis (nosebleed) GI bleeding
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Vaginal Bleeding First Thing Confirm fetal heart rate Important labs
Baseline hematocrit Platelet Count Fibrinogen Drug screen Sterile Speculum Exam Locate source of bleeding Ask the big question Did you have sex within the past 24 hours?
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Blood from Anywhere Else
Stop the bleeding Need consultants Trauma surgeons, hematologists Important labs Baseline hematocrit Platelet count Work-up coagulopathy Von Willebrand disease Factor IX Deficiency
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Bleeding-What’s the Baseline?
Hct > 30% Platelets >150,000 Fibinogen > 250 mg% Courtesy robetech.com
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Most likely incorrect diagnosis in Obstetrics?
DIC-Disseminated Intravascular Coagulation
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DIC versus Coagulopathy
DIC is a primary diagnosis Coagulopathy occurs with Excessive surgical blood loss Amniotic fluid embolism Prophylactic anti-coagulation Pre-eclampsia Sepsis
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Best Description Coagulopathy DIC “any disorder of blood coagulation”
“a serious medical condition that develops when the normal balance between bleeding and clotting is disturbed” Thefreemedicaldictionary.com
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Skin manifestations of DIC
Courtesy dermaamin.com
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Consumption versus DIC
Exhaustion of pro-coagulants from hemorrhage versus inappropriate depletion of pro-coagulants internally Macro clotting versus microvascular clotting At ml, recovery time to replace lost pro-coagulants is exceeded
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Consumption-Abruption
Courtesy cbbsweb.org
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DIC-Amniotic Fluid Embolism
Courtesy brown.edu
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Treatment of DIC Stop the inciting process
Sepsis Surgical blood loss Anticoagulation with heparin Stop intravascular clotting Recombinant Factor VIIa Directly initiate thrombin formation at sites of abnormal bleeding
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Treatment of Coagulopathy
Replacement of whole blood PRBC’s and Clotting factors Replacement of clotting factors FFP, dehydrated FFP (cryo) Recombinant Factor VII/Fibrin glue Rapid direct initiation of thrombin
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Emergency Release Blood
Whole Blood not available Make Whole Blood from Packed RBC’s and Fresh Frozen Plasma Order 2 units of each stat Order 2 additional units of PRBC’s and FFP cross-matched
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Emergency Release Blood
Men-Opos PRBC’s Women-Oneg PRBC’s Both-ABpos FFP Palmetto Health Baptist Blood Bank
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Bleeding-What’s the Baseline?
Hct > 30% Platelets >150,000 Fibinogen > 250 mg% Courtesy robetech.com
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Replacement Plain IVF work well PRBC/FFP is OK for emergency
Lactated Ringers 0.5 normal saline PRBC/FFP is OK for emergency PRBC’s best for hemorrhage FFP at 1:1 units PRBC’s Platelets don’t usually help
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Factor viia 80 patients with postpartum hemorrhage 2.5% mortality
95% effective Majority of patients require 1 dose Ceska Gynecol 2010;75:297
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Clin Obstet Gynecol 2010;53:219
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Topical Hemostatics Lattice frame for coagulation Fibrin glue Collagen
Potato starch Fibrin glue
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Lattice for fibrin deposition
Courtesy cardinal.com
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Lattice for fibrin deposition
Courtesy policemag.com
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Courtesy laparoscopyhospital.com
Fibrin Glue Courtesy laparoscopyhospital.com
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Treatment of Coagulopathy
Lattice material Must have circulating anticoagulants for these to work Ineffective in DIC Replacement FFP and Factor VIIa Correct the deficiency of pro-coagulants Initiate thrombin formation at site of abnormal bleeding
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Summary-Coagulopathy
Not all bleeding disorders are DIC Chicken versus the egg Bleeding then coagulopathy (not DIC) Coagulopathy then bleeding (DIC) Most common clinical situation Abruption Difficult cesarean section Treat with replacement and Factor VIIa
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Cardio-Pulmonary Insufficiency
Rare but serious emergency Tachypnea/tachycardia combination Presenting symptoms SOB Syncopal episode at home Best question to ask Orthopnea
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Courtesy answerbag.com
Symptoms Courtesy answerbag.com
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Causes of Cardiopulmonary Insufficiency
Fluid overload Pre-eclampsia Tocolysis Cardiomyopathy Pulmonary Embolism
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Triage of SOB/Syncope Vital signs Oxygen saturation Oxygen treatment
Pulse, respiratory rate, BP Oxygen saturation Normal > 92% Oxygen treatment Cannula is usually sufficient Humidity IV access (Lactated Ringers)
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What makes Pregnant Women Unique?
Respiratory rate higher Decrease TLC, FRC Normal less than 26/minute Pulse higher Compensates for increased cardiac output Often greater than 100/minute
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Helpful Laboratory Studies
Echocardiogram Ejection fraction Renal function tests Not helpful CXR Typically shows cardiomegaly and poor pleural demarcation in bases BNP Always elevated ABG Rarely shows CO2 retention
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Cardiac Function
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Pulmonary Function Courtesy glowm.com
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Treatment for SOB Diuresis Fluid restriction Oxygen Sedatives
Lasix mg IV Fluid restriction Oxygen Sedatives Morphine 5-10 mg IV Xanax 0.25 mg po
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Cardio/Pulmonary Insufficiency
Automatic admission Critical care if available Lots of consults OB, Cardiology, Pulmonary, Renal
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Remote Fetal Monitoring
Only if Viable Protocol with OB nursing Critical care should not be responsible Courtesy delphine.latte.com
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Summary-Cardio-Pulmonary Insufficiency
Elevate head Tilt pelvis Oxygen saturation monitoring EKG LISTEN! Rales-Pulmonary Fluid Overload Wheezes-Allergies or asthma
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Trauma Usual causes Unusual causes MVA Fall Domestic Violence
Gunshot/Shotgun injury Knife wound
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Courtesy centralnewyorkinjurylawyer.com
Trauma Courtesy centralnewyorkinjurylawyer.com
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Courtesy Volvo
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Courtesy howstuffworks.com
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Courtesy coloribus.com
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Trauma Categorize Trauma Blunt (most common) Sharp (less common)
Injury to abdomen Injury to other areas (head, extremities) Sharp (less common) Injury to other areas
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Doumentation When OB was first contacted When OB responded
When fetal cardiac activity was confirmed
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Laceration Repair Verbal orders to ER physician Local anesthesia
Lidocaine +/- epinephrine Oral/IM antibiotic therapy Acetominophen Narcotics
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Courtesy thestir.cafemom.com
X-Rays Courtesy thestir.cafemom.com
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X-Rays Always when medically indicated Appropriate to have permission
Plain films have less exposure CT scans without contrast MRI may be best imaging Appropriate to have permission Disclaimers Can’t do when unconscious Establish next-of-kin
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Courtesy University of Rochester
Imaging Studies Courtesy University of Rochester
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Priority List Head/Spine injury work-up
X-Rays/MRI, neuro checks Poor anesthesia risk for delivery Work-up for occult abdominal hemorrhage Ruptured liver/spleen Extremity injury
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Summary-Trauma Fetus is rarely injured Placenta is often injured
Litigation is frequent Document fetal events Document interactions with OB Team approach is best Have a plan for rapid transfer
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Courtesy babble.com
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Causes for arrest during pregnancy
Trauma Pre-eclampsia Magnesium toxicity PE/Amniotic fluid embolism Anesthesia Cardiac disease Marfan Syndrome Aortic Dissection Acute coronary syndrome
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Why are Pregnant ER Patients Different?
Less Risky Behavior Less Alcohol Less Drugs/Medication Less likely to be charged with an MVA Drive with their children Wear their seat belts Less likely to settle disputes with violence Suicide attempts are usually overdose Don’t frequent clubs
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Survival from Cardiac Arrest
Out of hospital 40% survival In-hospital 25% survival
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Arrest in Women Arrest occurs 1/3 as often as in men
Lower incidence of ventricular fibrillation Lower resuscitation rates after arrest (29 versus 32%) Lower survival rates following resuscitation (11 versus 15%) Circulation 2001;104:2699
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Arrest secondary to Anesthesia complications
malpractice cases 69 patient deaths or severe brain injuries alleged secondary to OB anesthesia 18% OB cases versus 7% of non-OB cases related to airway problems Anesthesiaology 2009;110:131
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Courtesy digital02.com
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What’s different doing CPR on pregnant women?
Left lateral decubitus position Hands-only bystander Airway and CPR for healthcare providers Cesarean section in 5 minutes Courtesy AHA
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Anesthes Intensive Care
Year Citation Number of Cases Outcome 2011 J Matern Fetal Neo Med 2 0% Isreal Med J 1 Anesthes Intensive Care 100% Transplant Proc
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Courtesy medgadget.com
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Survival Therapeutic Hypothermia Survival Normothermia
Australia 77 patients 49% 26% P<0.05 Europe 275 patients 55% 39% N Engl J Med 2010;363:1262
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Summary Cardiac Arrest
Rare event during pregnancy CPR must be adapted LLD, rapid cesarean section Poor chance for survival Brain injury most significant sequela Brain cooling for adults improves intact survival
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Transfer
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Questions?
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