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Emergencies in Obstetrics

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Presentation on theme: "Emergencies in Obstetrics"— 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 Courtesy
Examples Chronic bleeding Acute bleeding Sudden-onset is an emergency Courtesy

7 Courtesy
Examples Symptoms which require immediate attention Preterm labor Courtesy

8 Courtesy and
Examples Lack of Treatment may cause harm Courtesy and

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

10 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

11 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

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 Courtesy Scripps Mercy Hospital
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 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

20 Courtesy
Recreational Drug Use Observation admission DHSS referral Arrange outpatient drug rehab Schedule birth defect screening Courtesy

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

22 Courtesy and



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 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

28 2007 SC DHEC Vital Statistics

29 Courtesy
Bleeding Courtesy


31 Triage of Bleeding Blood from vagina Blood from anywhere else 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

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 DIC “any disorder of blood coagulation”
“a serious medical condition that develops when the normal balance between bleeding and clotting is disturbed”

38 Skin manifestations of DIC

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

41 DIC-Amniotic Fluid Embolism

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




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

50 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

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 Fibrin glue Collagen
Potato starch Fibrin glue

54 Lattice for fibrin deposition

55 Lattice for fibrin deposition

56 Courtesy
Fibrin Glue Courtesy

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 Courtesy
Symptoms Courtesy

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

62 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)

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

67 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

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

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 Unusual causes MVA Fall Domestic Violence
Gunshot/Shotgun injury Knife wound

72 Courtesy
Trauma Courtesy

73 Courtesy Volvo

74 Courtesy

75 Courtesy

76 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

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 Courtesy
X-Rays Courtesy

80 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

81 Courtesy University of Rochester
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

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


91 Courtesy

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 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

94 Courtesy

95 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

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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