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Obstetrical crisis in the PACU

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Presentation on theme: "Obstetrical crisis in the PACU"— Presentation transcript:

1 Obstetrical crisis in the PACU
Dr. Jagdeep Ubhi Royal Columbian Hospital

2 Outline Gestational Hypertension Postpartum Hemorrhage

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4 Case One 25 year old G1P1 admitted to PACU post operatively from a caesarean section for an abnormal heart tracing. Intraoperative blood loss 1500 ml Vital signs: BP 160/100, HR 72, RR 12, T 36.6 One 18 ga IV Indwelling foley catheter 5 minutes after arrival patient has a tonic clonic seizure What is the appropriate management

5 Hypertensive disorders of pregnancy (HDP)
Incidence 5 to 10% of pregnancies Pre-eclampsia syndrome most serious (3.9%) WHO review of maternal mortality Hypertensive disorders 16% Hemorrhage 13% Abortion 8% Sepsis 2% Berg et al. (2003) : 16% of 3201 related to hypertensive disorders of pregnancy Over half preventable

6 HDP Diagnosis Diastolic blood pressure>90mmHg Severe hypertension
>160 mmHg systolic >110 mmHg diastolic Proteinuria 0.3g/24 hour urine collection >2+ on dipstick Sign of systemic endothelial dysfunction

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8 Pre-eclampsia Pregnancy specific syndrome that can affect every organ system in the body Headaches or visual symptoms Epigastric or right upper quadrant pain Thrombocytopenia Renal or cardiac involvement Fetal growth restriction Eclampsia 10% postpartum 1:2000 births

9 ETIOPATHOGENESIS Placental implantation Immunologic factors
Abnormal trophoblastic proliferation Immunologic factors Endothelial cell activation Genetic factors

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11 Abnormal trophoblastic invasion

12 Immunologic factors Semiallogenic fetal graft
Intolerance or dysregulation Maternal-Placental interface Acute graft rejection Inferential data First pregnancy increased incidence New partner = new antigentic load Immunized against pre-eclampsia

13 Endothelial cell activation
Placental factors lead to ischemic changes Activated state of leukocytes in maternal circulation Increased oxidative stress Increased cytokines e.g. interleukin 1 and TNF Generation of free oxygen radicals Modify nitrous oxide and prostaglandin balance Atherosis Activation of coagulation cascade Thrombocytopenia Increased permeability edema, proteinuria

14 Genetic factors Multifactorial and polygenetic Incident risk
20-40% for daughters of pre-eclamptic mothers 11-37% for sisters 22-47% of twin studies 60% of identical twins

15 pathogenesis Vasospasm Endothelial cell activation
Vascular constriction leading to hypertension Endothelial cell damage leading to interstitial leakage Endothelial cell activation Placental factors secreted into maternal circulation Promotes dysfunction of vascular endothelium Widespread endothelial cell dysfunction Intact epithelium has anticoagulant properties and blunts response to smooth muscle agonists by secreting nitric oxide

16 Pathophysiology Cardiovascular system Blood and coagulation Kidney
Hemodynamic changes Blood volume changes Blood and coagulation Thrombocytopenia, Hemolysis, HELLP Syndrome Kidney Liver Brain

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21 Posterior reversible encephalopathy syndrome

22 Management Termination of pregnancy Birth of an infant
Restoration of health to the mother

23 Eclampsia Tonic clonic convulsions Immediate management Protect airway
Short acting Post ictal state Visual changes Magnesium sulfate

24 Magnesium sulfate Loading dose 4 grams over 20 minutes then 1 gram per hour infusion Renal excretion Risk for respiratory depression Loss of patellar reflexes by 5mmol/L Respiratory depression > 5-6 mmol/L Treatment is calcium gluconate 1gram IV Magnesium sulfate is now also used for neuroprotection in preterm pregnancies

25 Management of severe hypertension
Calcium channel blockers Nifedipine capsules 5–10 mg to be bitten and swallowed, or just swallowed, every 30 min Hydralazine IV - Start with 5 mg IV; repeat 5–10 mg IV every 30 min, or 0.5–10mg/hr IV, to a maximum of 20mg IV (or 30 mg IM) Beta blocade Labetalol IV Labetalol Start with 20 mg IV; repeat 20–80 mg IV q 30min, or 1–2 mg/min, max 300 mg

26 Fluid management High risk for development of pulmonary edema
Fluid restrict to 80 mls/h Tolerate oliguria and elevated creatinine

27 Case One Protect the airway Padded bed Magnesium sulfate
Frequent vital signs One to one nursing Laboratory evaluation Maintain blood pressure less than 160/110

28 Summary of hypertension
Definition DBP > 90 mmHg If proteinuria or adverse features, think pre- eclampsia Treatment is delivery, but not out of the woods yet Magnesium sulfate prophylaxis to reduce mortality Antihypertensives to reduce the risk of stroke Run the patient dry

29 Postpartum Hemorrhage
Hemorrhage is a leading cause of maternal morbidity. Worldwide it results in half the cases of maternal mortality Hospital delivery is one of the main reasons for a decline in mortality due to availability of blood products

30 Postpartum Hemorrhage
Leading cause of death in the world 140,000 cases/year Maternal mortality 386/100,000 Sierra Leone 2000/100,000 Canada 5/100,000

31 Worldwide impact

32 Postpartum Hemorrhage
BC Perinatal database 27% increase in PPH [6.3 to 8%]1 Transfusion rate 17.8/10,000 to 25.5/10,000 Surgical/angiographic intervention 1.8/10,000 to 5.6/10,000 Perinatal Services BC, Dec 16, 2011

33 Postpartum hemorrhage
Definition Loss of 500 mls of blood or more

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35 Etiology 4 T’s of PPH Tone Tissue Trauma Thrombin

36 Etiology Process Clinical Risk factors Abnormalities of uterine contraction [Tone] over distended uterus multiple gestation uterine muscle exhaustion prolonged labour intra amniotic infection chorioamnionitis functional/anatomic distortion of the uterus fibroid uterus Retained Products of conception [Tissue] retained products incomplete placenta at delivery abnormal placenta abnormal placenta U/S retained blood clots atonic uterus Genital Tract Trauma lacerations of the cervix, vagina or vulva operative delivery uterine rupture previous uterine surgery uterine inversion Abnormalities of Coagulation [Thrombin] von Willebrand’s Disease thrombocytopenia with pre-eclampsia

37 Hemostasis at the placental site
600 ml/min flow thorough the intervillous spaced Flow carried by spiral arteries approximately 120, and their veins These vessels are avulsed with delivery of the placenta

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42 Uterine atony Oxytocin - Synthetic hormone Methylergonovine maleate
In small doses increases tone and frequency of contractions. In large doses can cause tetany Very few side effects In large doses rarely can cause water intoxication 20 units per liter infusion for PPH IV Methylergonovine maleate Ergot produces tetany 0.25 mg IM q 5 min to max of 1.25 mg Can cause vasospam so contraindicated in hypertensive patients Carboprost – 15 methyl analog of PGF2alph 0.25 mg q15 min to max of 2 mg Smooth muscle contraction

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45 Definition Placenta accreta is the abnormal attachment of chorionic villi to the myometrium Absence of an intervening decidua basalis (Nitabuch’s layer) Placenta Accreta 75-78% Attachment of chorionic villi to myometrium Placenta Increta 17% Invasion of villi into myometrium Placenta Percreta 5% Penetration to or through uterine serosa+/- adjacent organs Miller DA, Chollett JA, Goodwin TM. Clinical risk factors for placenta previa–placenta accreta. Am J Obstet Gynecol 1997;177:210-4

46 Miller D et al, AJOG 1997 .

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48 Increasing incidence? Breen et al Obstet Gynecol 1977 - 1:7000
Miller et al AJOG :2500 Wu et al AJOG :533

49 Epidemiology Incidence 1:530 – 1:2500 1-3
10 fold increase in the last 30 years1 Risk Factors Previous C-section Other uterine surgery D&C/Asherman’s, myomectomy Advanced maternal age and parity Smoking Placenta previa 10% - element of accreta4 40% - anterior previa and >=2 previous c-sections1 Flora Advanced maternal age – related previous scar as AMA no longer became significant when controlling for this. Localized differences in oxygen tension within uterine scar may contribute. In vitro studies suggest differences in oxygen tension determine if the cytotrophoblasts will invade rather than proliferate. Abnormal invasion because of abnormal expression of growth, angiogenesis 1. Committee on Obstetric Practice. ACOG committee opinion no Placenta accreta. Int J Obstet Gynecol 2002;77:77-8. 2. Usta IM, Hobeika EM, Musa AA, Gabriel GE, Nassar AH. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol 2005;193: 3. Miller DA, Chollett JA, Goodwin TM. Clinical risk factors for placenta previa–placenta accreta. Am J Obstet Gynecol 1997;177:210-4. 4. Angstmann T, Gard G, Harrington T, et al. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet Gynecol 2010;202:38.e1-9. 5. STERGIOS K. DOUMOUCHTSIS & SABARATNAM ARULKUMARAN. The morbidly adherent placenta: an overview of management options. Acta Obstetricia et Gynecologica. 2010; 89: 1126–1133

50 Number of Caesarean Sections
Could include a risk on rising C-section rates and accreta Number of Caesarean Sections Usta IM, Hobeika EM, Musa AA, Gabriel GE, Nassar AH. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol 2005;193:

51 http://www. perinatalservicesbc

52 Location of Previa and risk of Placenta Accreta (with> 1 prior CD)
Anterior/central previa: 29% (36/124) Posterior previa 6.5% (4/62) RR 4.5 Hospital records Jan 1985 to Dec 1994. 155,670 deliveries 62 accreta 55/590 (9.3%) with previa 7 of 155,080 without Miller D et al AJOG 1997

53 Complications Rates of each complication Flora
Post-partum hemorrhage (3000 mL to 5500 mL)1-2 Placenta increta (3630 ± 2216 mL)3 Placenta percreta (12,140 ± 8343 mL)3 Massive transfusion (21%)5 Transfusion-related complications (DIC, TRALI, Hemolytic rxn, infection) Surgical complications6 Ureteric/bladder/bowel injury Fistula formation Thrombosis Limb ischemia Infection/Sepsis1-6 Increased length of stay / ICU admission5 Maternal death (7%)5 Rates of each complication Flora 1. Angstmann T, Gard G, Harrington T, et al. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet Gynecol 2010;202:38.e1-9. 2. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol 2005;192: 3. Sumigama S, Itakura A, Ota T, et al. Placenta previa increta/percreta in Japan: a retrospective study of ultrasound findings, management and clinical course. J Obstet Gynaecol Res 2007;33: 4. Usta IM, Hobeika EM, Musa AA, Gabriel GE, Nassar AH. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol 2005;193: 5. DOUMOUCHTSIS SK & ARULKUMARAN S. The morbidly adherent placenta: an overview of management options. Acta Obstetricia et Gynecologica. 2010; 89: 1126–1133 6. O’Brien JM, Barton JR, Donaldson ES. Obstetrics: the management of placenta percreta: conservative and operative strategies. Am J Obstet Gynecol 1996;175:

54 Estimated blood loss in Placenta Accreta
>2000 ml – 66% >5000 ml – 15% >10,000 ml - 6.5% >20,000 ml – 3% 90.5% 62 histologically confirmed cases among 155,670 deliveries Miller D et al AJOG 1997

55 Management Options Proceed to Hysterectomy Ureteric stents
Caesarean Hysterectomy Following delivery of the baby after leaving placenta intact Adjuncts Interventional Radiology Balloon Catheter occlusion Embolization Ureteric stents Proceed to Hysterectomy

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57 Conclusion Recognition of clinical risk factors
Importance of early diagnosis PPH is a symptom, make a diagnosis Targeted treatment

58 Questions?


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