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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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Presentation on theme: "Emergencies in Obstetrics Paul C. Browne, M.D. Associate Professor Department of Obstetrics and Gynecology USC School of Medicine."— Presentation transcript:

1 Emergencies in Obstetrics Paul C. Browne, M.D. Associate Professor Department of Obstetrics and Gynecology USC School of Medicine

2 Disclosures Nature of Financial Relationship: Grant/Research Support– USC School of Medicine March of Dimes

3 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

4 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”

5 Components of Emergency Sudden onset Symptoms which require immediate attention Lack of treatment may cause harm Mother and/or fetus

6 Examples Chronic bleeding Acute bleeding Sudden-onset is an emergency Courtesy mybloodyourblood.org

7 Examples Symptoms which require immediate attention Preterm labor Courtesy activebodycare.co.uk

8 Examples Lack of Treatment may cause harm Courtesy topnews.in and statejournal.com

9 Fetal Emergencies No Fetal Movement Vaginal Bleeding Preterm Labor Abdominal Trauma

10 Viability World Health Organization/ACOG –20 weeks gestation –350 Grams State of South Carolina –Completion of “Second Trimester” Your ER –20 weeks gestation –Positive fetal heart rate

11 Statement of AAP Less than 23 weeks gestation –No mandate to resuscitate secondary to uniformly poor outcomes 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

12 Maternal Emergencies Altered mental status Hemorrhage/DIC Cardiopulmonary insufficiency Trauma Cardiopulmonary arrest

13 Change in Mental Status Disorientation Aphasia Slurred Speech

14 Causes of Altered Mental Status Recreational Drugs Hypotension (internal bleeding) Diabetes Seizure (post-ictal eclampsia)

15 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

16 Mental Status Score Courtesy Scripps Mercy Hospital

17 Triage of Altered Mental Status Majority of cases will be caused by drug use or metabolic disturbance Easily corrected in ER setting

18 Altered Mental Status Triage Hypoglycemia –Treat and release Hypotension –Improved without bleeding Seizure –Only with known seizure disorder

19 Treatment IV Hydration –D5LR at 125 ml/hr Oxygen – 2 liters/minute nasal cannula Serial Vital Signs Serial Mental Status Checks Monitor fetal status

20 Recreational Drug Use Observation admission –DHSS referral –Arrange outpatient drug rehab –Schedule birth defect screening Courtesy pregnancy.about.com

21 Intracranial Hemorrhage Rare cause of altered mental status Lateralizing signs Often associated with seizures Source of medical-legal action

22 Courtesy casereports.net and catscanman.net

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25 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

26 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

27 Hemorrhage 2 nd 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

28 2007 SC DHEC Vital Statistics

29 Bleeding Courtesy thepregnancyzone.com

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31 Triage of Bleeding Blood from vagina –Labor –Rupture of membranes –Abruption Blood from anywhere else –Trauma –Epistaxis (nosebleed) –GI bleeding

32 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?

33 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

34 Bleeding-What’s the Baseline? Hct > 30% Platelets >150,000 Fibinogen > 250 mg% Courtesy robetech.com

35 Most likely incorrect diagnosis in Obstetrics? DIC-Disseminated Intravascular Coagulation

36 DIC versus Coagulopathy DIC is a primary diagnosis Coagulopathy occurs with –Excessive surgical blood loss –Amniotic fluid embolism –Prophylactic anti-coagulation –Pre-eclampsia –Sepsis

37 Best Description Coagulopathy –“any disorder of blood coagulation” DIC –“a serious medical condition that develops when the normal balance between bleeding and clotting is disturbed” Thefreemedicaldictionary.com

38 Skin manifestations of DIC Courtesy dermaamin.com

39 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

40 Consumption-Abruption Courtesy cbbsweb.org

41 DIC-Amniotic Fluid Embolism Courtesy brown.edu

42 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

43 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

44 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

45 Emergency Release Blood Men-Opos PRBC’s Women-Oneg PRBC’s Both-ABpos FFP Palmetto Health Baptist Blood Bank

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49 Bleeding-What’s the Baseline? Hct > 30% Platelets >150,000 Fibinogen > 250 mg% Courtesy robetech.com

50 Replacement Plain IVF work well –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

51 Factor viia 80 patients with postpartum hemorrhage 2.5% mortality 95% effective Majority of patients require 1 dose Ceska Gynecol 2010;75:297

52 Clin Obstet Gynecol 2010;53:219

53 Topical Hemostatics Lattice frame for coagulation –Collagen –Potato starch Fibrin glue

54 Lattice for fibrin deposition Courtesy cardinal.com

55 Lattice for fibrin deposition Courtesy policemag.com

56 Fibrin Glue Courtesy laparoscopyhospital.com

57 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

58 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

59 Cardio-Pulmonary Insufficiency Rare but serious emergency Tachypnea/tachycardia combination Presenting symptoms –SOB –Syncopal episode at home Best question to ask –Orthopnea

60 Symptoms Courtesy answerbag.com

61 Causes of Cardiopulmonary Insufficiency Fluid overload Pre-eclampsia Tocolysis Cardiomyopathy Pulmonary Embolism

62 Triage of SOB/Syncope Vital signs –Pulse, respiratory rate, BP Oxygen saturation –Normal > 92% Oxygen treatment –Cannula is usually sufficient –Humidity IV access (Lactated Ringers)

63 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

64 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

65 Cardiac Function

66 Pulmonary Function Courtesy glowm.com

67 Treatment for SOB Diuresis –Lasix mg IV Fluid restriction Oxygen Sedatives –Morphine 5-10 mg IV –Xanax 0.25 mg po

68 Cardio/Pulmonary Insufficiency Automatic admission Critical care if available Lots of consults –OB, Cardiology, Pulmonary, Renal

69 Remote Fetal Monitoring Only if Viable Protocol with OB nursing –Critical care should not be responsible Courtesy delphine.latte.com

70 Summary-Cardio-Pulmonary Insufficiency Elevate head Tilt pelvis Oxygen saturation monitoring EKG LISTEN! –Rales-Pulmonary Fluid Overload –Wheezes-Allergies or asthma

71 Trauma Usual causes –MVA –Fall –Domestic Violence Unusual causes –Gunshot/Shotgun injury –Knife wound

72 Trauma Courtesy centralnewyorkinjurylawyer.com

73 Courtesy Volvo

74 Courtesy howstuffworks.com

75 Courtesy coloribus.com

76 Trauma Categorize Trauma –Blunt (most common) Injury to abdomen Injury to other areas (head, extremities) –Sharp (less common) Injury to abdomen Injury to other areas

77 Doumentation When OB was first contacted When OB responded When fetal cardiac activity was confirmed

78 Laceration Repair Verbal orders to ER physician Local anesthesia –Lidocaine +/- epinephrine Oral/IM antibiotic therapy Acetominophen Narcotics

79 X-Rays Courtesy thestir.cafemom.com

80 X-Rays Always when medically indicated –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

81 Imaging Studies Courtesy University of Rochester

82 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

83 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

84 Courtesy babble.com

85 Causes for arrest during pregnancy Trauma Pre-eclampsia Magnesium toxicity PE/Amniotic fluid embolism Anesthesia Cardiac disease –Marfan Syndrome Aortic Dissection –Acute coronary syndrome

86 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

87 Survival from Cardiac Arrest Out of hospital –40% survival In-hospital –25% survival

88 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

89 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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91 Courtesy digital02.com

92 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

93 YearCitationNumber of Cases Outcom e 2011J Matern Fetal Neo Med 20% 2011Isreal Med J 10% 2011Anesthes Intensive Care 1100% 2011Transpla nt Proc 10%

94 Courtesy medgadget.com

95 Survival Therapeutic Hypothermia Survival Normothermia Australia 77 patients 49%26% P<0.05 Europe 275 patients 55%39% P<0.05 N Engl J Med 2010;363:1262

96 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

97 Transfer

98 Questions?


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