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Obstetrical Emergencies
Kimberly Westra DNP, MSN, CRNA, MBA©
Obstetrical Anesthesia Care● United States is one of
developed eight countries in the world where maternal mortality has increased since 1990
● US Parturient are 3x more likely to die from maternal complications than women in Germany, Britain, Japan!
Maternal Death● Most common causes of
maternal death are:● Hemorrhage● Hypertensive Disorders● Thromboembolic events● Infection/Sepsis
Maternal Mortality by State
Maternal Morbidity Risk● Increase mortality has
doubled in 21st Century affecting approximately 50,000 annually
● Higher number of Cesarean Sections in comparison to other countries world wide
● Maternal Obesity has significantly increased
Maternal Death Causes
Cesarean Section ● Emergent versus Non
emergent –communication with OB team essential
● Stat is a true clinical emergency may require general anesthesia if not time for Spinal (SAB)
● Spinal preferred if possible
STAT Cesarean Section● May see transient
elevation in systolic BP due to direct laryngoscopy: consider lidocaine 1-1.5mg/kg, Esmolol 1mg/kg, fentanyl 1mg/kg
● Have adjunct Airway devices & trained assistants at bedside for induction
● Parturient airway edema may require smaller ETT
STAT Cesarean Section● Consider Risk of Cannot
intubate/ventilate scenario due to high risk for airway loss in stat C/S
● Once ETT through cords, OB incision begins!
● Use of BIS indicated for increase risk of recall: no versed, limited narcotic, limited volatile due to risk of newborn respiratory impairment
OB Anesthesia Basics● Regional technique
preferred to GA for C/S or non-obstetrical cases
● Postpone surgery for elective cases until post partum
● Defer to 2nd trimester (viable fetus)
● Left Uterine Displacement routinely
● Appropriate denitrogenation & preoxygenation
● Additional airway tools in immediate access.
● Standard of care consistent
OB & Non Elective Surgery● Trauma● Acute Appendicitis ● Acute Complex
Cholycystitis● Malignancies● Cervical Incompetence
Preterm Labor Risk Factors● Noncaucasian● Advanced Maternal Age
> 35 ● Low Prenatal Weight● Multiple Gestations● H/O cervical
incompetence● H/O previous preterm
labor
Placental Transfer of Substances/Medication● Placental transfer of
medications occurs in:● Bulk flow (water)● Active Transport (amino
acids, ions)● Pinocytosis (large
molecules such as immunoglobulins)
● “Breaks” like blood/RH sensitization
● Diffusion such as respiratory gases and most drugs from anesthesia hence concern for anesthetic impact on fetus
Placenta, Inhalationals, IV Medications● Most inhalationals & IV
medications freely cross the placenta
● Limited respiratory depression if narcotics given within 10 minutes of induction
● Morphine results in the most significant newborn respiratory
● Fentanyl result in least amount of newborn respiratory depression
● Paralytic Agents cross placenta without difficulty as they are quaternary ammonium salts
Teratogenicity Agents● ACE inhibitors● Alcohol● Androgens● Antithyroid● Benzo● Chemotherapy*● Cocaine● Coumadin
● Diethylstibersterol● Lead● Lithium● Mercury● Phenytoin● Streptomycin● Valproic Acid
Tocolytics: Magnesium● Magnesium (b2 smooth
muscles)● Magnesium IV often
6GM over 30-60 minutes then infusion
● Magnesium GTT often 2-4GM/hr
● Magnesium infusions potentiate muscle relaxant effects
● Consider discontinuation if proceed to GA with use of muscle relaxants
Tocolytics: Magnesium● Theraputic Magnesium
levels are monitored and GTT adjusted
● Ideal MG level is 4-8mg/dl
● Magnesium potentiates muscle relaxants…
● Magnesium works on Ca channels inhibiting voltage in muscle cell
● Side effects: dry mouth, nausea, flushing, blurred vision, peripheral muscle fatigue/weakness, dizziness, confusion
Tocolytic Adjuncts● Glucocorticoids may be
used to supplement other tocolytics: inhibition of inflammatory mediators
● Betamethasone aids in promoting surfactant production in fetus
● Calcium Channel Blockers: Nifedipine
● Nifedipine also limits voltage of Ca channels in muscle cell
Obstetrical Emergencies● Maternal Hemmoraghe● Amniotic Fluid
Embolism● Placental Abruption● Impending Maternal
Death● Maternal Trauma
Maternal Trauma● Leading cause of
maternal death!!● Fetal death secondary to
maternal death/ or placenta abruption
● Trauma scenarios:● Maternal death/stat
postmortem C/S● Stable Maternal/Fetal
distress● Trauma to uterus/
rupture
Maternal Trauma● Violence against women:
domestic abuse and homicide
● Lifestyle Risks● Access to care or delays
in treatment due to rural location
● Call for Help early for OB and Neonatologist.
Maternal Trauma● Impending death with
viable fetus● Assess Maternal & Fetal
Trauma scenario● Call OB & NICU team to
Trauma bay● Consider mechanism of
trauma: trajectory, acceleration and deceleration, blunt/penetrating
● Large Bore IV● Massive Transfusion
Protocol blood products available
● Rapid infusion device for resuscitation
● Invasive monitors● Care team resources● Spine precautions● Proximity to Trauma Bay
or OR
Trauma & OB● Consider effect of trauma
of fetus is directly related to mechanism of trauma
● Consider gestational age of fetus and the extent and duration of disruption of fetal blood flow
● Is this a viable fetus? One life or two….
● Fetal tissue & oxygenation disrupted by traumatic injury can result in fetal Bradycardia or death
● FHR may be a 1st sign of fetal compromise in trauma!
Trauma & OB● Maternal physiological
changes of pregnancy may predispose the parpituents to rapid falls in Pa02 during brief apnea periods resulting in maternal and fetal hypoxia
● Increased risk of aspiration to due to anatomical changes & decreased LES tone with increased progesterone levels
● Primary & Secondary Survey in Trauma Bay
● FHR assessment by Trauma preferably OB team
Trauma & OB● Placental abruption
occurs in 2-4% of minor accidents & up to 50% of major trauma
● Inelastic placenta shears from elastic uterus resulting in abruption key consideration in even minor trauma…assessment of placental integrity
● Blunt versus Penetrating mechanism trauma thoracoabdominal
● Uterine Penatrating trauma 60-90% fetal mortality with 7-9% maternal mortality
Trauma & OB● Must proceed with
diagnostic studies despite radiation exposure to fetus to ensure safe trauma assessment
● Limit Radiation as much as possible for subsequent studies
● Invasive Lines may be required
● GETA if impending respiratory compromise or cardiovascular collapse
● High aspiration risk…precautions in place
● Spine precautions
Amniotic Fluid Embolism● AFE is a rare & life
threatening obstetrical emergency
● Amniotic fluid, fetal cells, hair or other debris enter mothers blood stream via placental bed of uterus/uterine veins
● AFE: results in a severe inflammatory/
immune response, cardiovascular collapse
Pulmonary edema, CV collapse, resulting coagulation disorders (DIC)
Amniotic Fluid Embolism● Risk factors:● Abdominal trauma● Advanced maternal age
(35>)● C/S or instrumented
SVD● Uterine rupture/previa
● Preeclampsia ● Fetal distress● Signs: sudden severe
respiratory distress, tachypnea, tachycardia, arrest
● Suspected bronchial mediators exacerbate AFE
Amniotic Fluid Embolism● Risk factors:● Abdominal trauma● Advanced maternal age
(35>)● C/S or instrumented
SVD● Uterine rupture/previa
● Preeclampsia ● Fetal distress● Signs: sudden severe
respiratory distress, tachypnea, tachycardia, arrest
● Suspected bronchial mediators exacerbate AFE
AFE & Data Deficiency● Due to the limited
information for this rare even few studies exist to provide sufficient evidence for comparative treatment modalities
● 1 in 80,000 delivery● 70% occur during labor● 19% occur during c/s● 11% after SVD● C/S noted often
immediately following delivery
AFE & Anesthesia● Once consistent report in
national registry was tear in the fetal membrane (78%)
● Mortality 61% for AFE● 10% of all maternal
deaths are related to AFE
● AFE Survivors 85% had neurological deficits
● Diagnostics may aid in confirmation of diagnosis but should not delay immediate emergent care
● Rapid delivery of fetus indicated!
AFE Treatment● Treatment: ● Early recognition &
intervention● ABC placement of ETT● PEEP● Fluid resuscitation to avoid
negative pressure gradient ● Epinephrine infusions may be
helpful to limit inflammatory response & provide cardiovascular support
● Dopamine may also be ideal to promote b-adrenergic effects, improve cardiac function
● Dobutamine & Milrinone infusions may be useful
● Theraputic Heparinization to limit coagulopathy development but this is controversial
● May require transfusions if DIC ensues
AFE Treatment● Degree of resuscitation
based on hemorrhage● May require platelet,
FFP and RBC transfusions
● Advanced coagulation studies to guide resuscitation
● Failed response to DIC treatment is associated with higher mortality as high as 75%
● Family support essential as morbidity & mortality high for mother.
Preeclampsia ● Advanced maternal age
& teens● Prior eclampsia Hx● PIH ● Multiple Gestation● Sickle Cell Disease
● Typically BP over 140/90● Usually begins after 20
weeks● Delivery of fetus is
definitive treatment● May lead to HELLPS if
untreated
Preeclampsia & Anesthesia● Preeclampsia:● High blood pressure,
proteinuria, edema,hyperreflexia,
● nausea/vomiting, dyspnea, visual disturbances
● Decreased urine output ● Low platelets, elevate liver
function tests
● Requires medical Treatment of HTN
● May progress to eclampsia is not treated (seizure)
● Untreated can result in maternal CV damage or cardiac morbidities, HELLPS
Preeclampsia Medications● Treatment: ● Labetolol ● Hydralazine● Magnesium Sulfate
(avoid seizures)● Methyldopa● Corticosteroids (improves
LFT’s)● Bed rest
● Definitive treatment is delivery of fetus as appropriate with gestational age
● Admission may be required due to severity of Preeclampsia & treatment response
HELLPS Syndrome● A life threatening
syndrome associated with Preeclampsia
● H –Hemolysis● E – Elevated Liver Enzymes● L – Low Platelets
● Typically begins during 3rd Trimester a few cases reported at 21 weeks
● HELLPS may occur before or after delivery
● May be difficult to diagnose as mother may not “appear” sick
HELLPS● Symptoms may vary:● Epigastric pain● Increased protenuria● Low platelets, elevated
liver enzymes● May progress to DIC,
liver failure, seizures, hepatic Hemmoraghe
● Prompt delivery of fetus in the only definitive treatment
● Medical Treatment until delivery:
● Antihypertensive Meds● Steroids,● Supportive blood
resuscitation FFP, Platelets
HELLPS● Maternal Mortality 1%● Permanent Liver Failure● Liver Hematoma● Acute Renal Failure● Placental Abruption● Retinal Detachment 25%
● Increased perinatal mortality in HELLPS up to 119/1000 deliveries
● Small for gestational age 40%
HELLPS ● Hemolysis: ● High LDH concentration● Unconjugated bilirubin● Low Haptoglobin
concentration
● Further complications: ● IUGR● Maternal/Fetal Death● Preterm Delivery● Neonatal
Thrombocytopenia● Respiratory Distress
Syndrome
HELLPS● No clear evidence
corticosteroids substantially improve outcomes
● Corticosteroids improve rate of recovery of platelet levels
● Platelets under 50-100,000 may have concern for regional for C/S delivery
● Weight risk benefits of low platelets for regional versus GA for C/S
Hellps Syndrome
Maternal Mortality by State
Placental Abruption● Bleeding between uterus
and placenta● Reduction of oxygen
delivery reduced especially
● Signs: bleeding, abdominal pain uterine irritability
● Seal of placenta of uterus weakens resulting in tearing of vessels (abruption)
● Tearing at 25% of placenta impacts fetus
● May fully separate from placenta/emergent delivery
Placenta Abruption● May be partial or
complete abruption● Complete abruption is
an obstetrical emergency requiring immediate delivery C/S (stat)
● www.placentalabruption ● Fetal can be
compromised or risk of fetal death
● Ultrasound or clinical diagnosis based on symptoms
Fetal Demise ● May required delivery is
gestational age 12-16 weeks
● Significant psychological & emotional impact for family
● Labor Epidural ● C/S
● Discussion with OB team on required approach
● Risks remain for mother for aspiration for GA
● Regional SAB for C/S● Pastoral Care Consult
Maternal Emergency: Gaps in Care● Anesthesia providers
must bridge the gap in the interdisciplinary team care approach & processes
● Simulation based interdisciplinary team approach for Massive Transfusion, Trauma, Malignant Hyperthermia
Anesthesia Considerations● Readiness and timeliness
of resources are ESSENTIAL for Obstetrical Emergencies!
● Appropriate anesthesia equipment, labor resources, and advanced invasive line devices
Future of OB Anesthesia Emergencies● Key for anesthesia
providers in assessment of existing resources, care team processes and readiness
● Plan and promote routine simulation, education and collaboration
● Gap Analysis and process improvement in OB emergencies in an ongoing process!
Questions?
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