Management of Obstetric Emergencies

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Management of ObstetricEmergenciesBrendan Dan Connealy MD FACOGMethodist Perinatal AssociatesMethodist Women s Hospital Omaha NE.
Learning Objectives Hypertensive Emergencies in Pregnancy Clinical update on current management guidelinesand diagnostic criteria How to approach the severe hypertensive patient.
Obstetric Hemorrhage Clinical update on current management guidelines Discuss the approach to the massive hemorrhage Learning Objectives Patient Safety Bundles Alliance for.
Innovation on Maternal Health AIM What are patient safety bundles and how can theyimprove outcomes for our patients Review the AIM supported patient safety bundlesfor severe hypertension in pregnancy and.
obstetric hemorrhage Discuss our experience instituting patient safetybundles for severe hypertension November 2013 ACOG Types of Hypertension.
Chronic Hypertension SBP 140 or DBP 90 Pre pregnancy or 20 weeksGestational Hypertension SBP 140 or DBP 90 20 weeks Absence of proteinuria or severe.
Preeclampsia SBP 140 or DBP 90 Presence of proteinuria Severe signs symptoms in absence ofproteinuria Proteinuria no longer required criteria.
Chronic Hypertension superimposed Sudden increase in controlled BPpreeclampsia New onset proteinuria Severe signs symptoms ofpreeclampsia Preeclampsia with Severe Features.
Proteinuria no longer qualifies as a severe feature Surveillance and Obstetric Management Preeclampsia without severe features Less than 37 weeks Weekly labs antenatal testing BP checks fetal growth.
At or beyond 37 weeks Delivery Additional key recommendations Anti hypertensive medications not indicated Universal magnesium sulfate not necessary to prevent.
eclampsia in those without severe features or symptoms Quality of evidence lower than for those listed above Surveillance and Obstetric Management Preeclampsia with severe features Any GA with unstable fetal or maternal conditions.
Delivery At or beyond 34 weeks EGA Delivery Less than 34 weeks see below Magnesium sulfate for eclampsia prophylaxis.
Delivery route by obstetric indications Treat with anti hypertensives for BP 160 110 Managing severe disease at 34wks You got to know when to hold Know when to fold em .
Know when to walk away Know when to run Kenny Rogers Gambler Early 34wks Severe PreeclampsiaManagement.
Previable PreE with with severe features HELLP FOLD EM Viability 33 6 7 weeks Stable fetal and maternal condition HOLD EM Expectant management Appropriate facility.
Corticosteroids Weekly surveillance labs fetal testing growth Viable 33 6 7 weeks Unstable fetal or maternal condition FOLD EM Stabilize while giving steroids but don t delay delivery.
Postpartum Preeclampsia Difficult to diagnose requires index of suspicion Prevalence 1 27 depending on study Differential should include other life threateningconditions.
TTP HUS May present with seizures Assume eclampsia but image to rule out other etiologies Hypertensive Emergency Management Goals of therapy.
Control severe hypertension Stabilize the patient initiate diagnostic tests Prevent recurrent hypertension Seizure prophylaxis Monitor fetal and maternal status.
Hypertensive EmergencyACOG Committee Opinion 692 April 2017 Hypertensive Emergency Oral nifedipine or labetalol effective if no IV Common side effects associated with medications.
Hydralazine maternal hypotension flushing tachycardia Labetalol avoid in asthmatics heart failure bradyarrhythmia Failure of initial acute therapy.
Consult anesthesia MFM ICU Continuous infusion medications labetalol nicardipine AJOG July 2016 Severe intrapartum.
HTN associated withincreased risk forsevere maternal Risk Factors for Eclampsia Previous eclampsia.
Multifetal gestation Chronic hypertension renal disease Collagen vascular disease Molar pregnancy partial mole Gestational hypertension preeclampsia plus.
Severe headache Persistent visual changes Severe epigastric right upper quadrant pain Altered mental status When does it occur .
Antepartum 38 53Intrapartum 18 36Postpartum 11 44 48 hours 7 39 48 hours 5 26.
Summary of 5 series Signs and SymptomsHeadache 30 70Visual Changes 19 32RUQ epigastric pain 12 20.
Altered mental changes 4 5At least one of the above 33 75Hypertension 85Proteinuria 85 Summary of 5 series.
Steps in Managing EclampsiaSupplemental 02Step 1 Prevent maternal hypoxia by supportingPulse oximetryrespiratory and cardiovascular function ABG if acidemia.
Mouth guardStep 2 Prevent maternal injury and aspiration Bed padding1 MgSO4 6gStep 3 Do not try to arrest the first seizure bolus then 2g hr2 Re bolus 2g if.
Pentobarb 250mgStep 4 Prevent subsequent seizures from recurring IV if persist Steps in Managing EclampsiaStep 5 Control severe hypertension to prevent previouslycerebrovascular injury mentioned.
Step 6 Manage complication such as DIC PulmonaryStep 7 Begin induction delivery within 24 hours Obstetric Hemorrhage Hemorrhage incidence 4 6 SVD 500ml.
Cesarean 1000ml Life threatening obstetric hemorrhage 1 1000 Second most common cause of maternal mortality in 0 9 100 000 Most are considered preventable.
ACOG Practice Bulletin 76Drife J BJOG 1997 104 275 7CDC NVSR V 58 19 May 2010 tables Obstetric Hemorrhage93 of deaths due to hemorrhage are.
considered preventable on review Primarily due to delay in treatment Delay is due to lack of recognition andpoor inadequate communication Etiology.
Lacerations Abruption Retained placenta Accreta Percreta Uterine rupture.
Hematoma Hemorrhage Management Activate response team Nurses Physicians OR staff Lab Blood bank Important initial steps.
IV access Hemorrhage cart medications Lab studies Diagnosis etiology of the bleed Massive transfusion protocol if you have one .
Atony Management Bimanual massage Drain the bladder Uterotonics Oxytocin.
Carboprost up to 4 doses 15 min apart Avoid in asthmatics Methylergonovine up to 4 doses 2 4 hours apart Avoid in severe hypertension Misoprostol 800 1000 mcg .
800 mcg Buccal or Rectal Delayed absorption giveearly in rescusitation Tamponade Balloon Placement duration antibiotics Ultrasound guidance.
Vaginal packing Antibiotic usage Duration of usage Tamponade Test pressure volume at which the bleeding.
Georgiou et al Tamponadepressure is not systolic Best for lower uterine segment When conservative measures fail Surgical Treatment.
Retained placenta Manual or sharp curettage Persistent atony Laparotomy B lynch sutures.
O Leary sutures Additional devascularization Hysterectomy Delayed decision increased Hysterectomy.
Subtotal hysterectomy vs Total hysterectomy More rapid completion emergency situations Less beneficial if lower segment previa bleeding Consider pre hysterectomy vascular ligation or occlusionWright Obstet Gynecol 2010 115 6 1187 1193.
Additional Measures Tranexamic Acid Recombinant Factor VII Cell salvage Interventional radiology.
Product Replacement Platelets single vs pooled donor Unit 50 ml increase plts 7500 Most come in 6 10 unit packs Clotting factors Cryoprecipitate FFP .
All plasma proteins and factors Volume 250 ml must be thawed 20 30 min Increase fibrinogen 10 15 mg dL Cryoprecipitate Factor VIII XIII Fibrinogen vWF.
Volume 40 ml increase fibrinogen 10 15 mg dL PRBC s ABO Rh additional Ab Fluid and Product Administration Early administration of clotting factors is key Borgmann et al 2007.
Combat support hospital 1 1 or 1 2 ratio of FFP to PRBC s Decreased mortality Sperry et al 2008 1 1 5 ratio 52 lower mortality compared to lower ratios.
Goal is avoid the bloody vicious cycle Keep warmCoagulopathy Bear hugger Level 1 tranfuser Maintain perfusion.
Transfusion replacement Correct coagulopathyAcidosis Hypothermia Pacheco et al Am J Obstet Gynecol Dec 2011 Post Hemorrhage Management.
Laboratory values will frequently fluctuate Trends are important Vital signs are critical Calcium replacement Maintain uterine tone.
Re dose antibiotics Consider ICU admission if there is significant hemorrhage product replacement or medical comorbidities What is AIM National data driven maternal safety and.
quality improvement initiative Proven approaches to improvement ofmaternal safety and outcomes in the U S Eliminate preventable maternal mortality andsevere morbidity .
Who Is AIM AIM Safety Bundles AIM Safety Bundles Readiness Recognition Prevention.
Response Reporting Systems Learning Severe Hypertension in Pregnancy Severe Hypertension in Pregnancy Obstetric Hemorrhage.
Toolkits are Readily Available No need to reinvent the wheel Our Experience Safe healthcare for every woman 3 Bundles implemented in past 3 years.
Maternal early warning signs Hemorrhage Hypertension Maternal Early Warning Signs Criteria may be individualized by institution.
Above list may not be considered comprehensive Maternal Early Warning Signs Step 1 Immediate action criteria met Step 2 Attending or in house physician will evaluatepatient within 10 minutes.
Step 3 Physician documents evaluation andimmediate care plan Huddle Step 4 If MEWS criteria persists despite correctivemeasures Consultation with MFM Intensivist Rapid Step 5 Advanced measures labs treatments.
Our Experience Our Experience Our Experience Our Experience Our Experience.
Management Plans Stage 0 Everyone Stage 1 Initial responseto hemorrhage Stage 2 Continued and.
escalated response topersistent hemorrhage Stage 3 Severehemorrhage with withoutcoagulopathy.
Challenges Nebraska rural state of population islocated in a single metropolitan area Several low volume delivery centers 50babies year .
Critical access to care Differing levels of obstetric care Challenges 16 50 have obstetricians performing deliveries 7 50 have access to MFM.
Plan to improve outcomes Hospital based approaches supported bystatewide collaborative Rural Outreach Establish referral networks Levels of care.
Provider education Didactic Simulation training Implementation of protocols Data collection and review.
Checklists when designed well implementedthoughtfully and monitored closely offer theopportunity for health care providers to not simply besatisfied with doing most of the right things for mostthe patients most of the time Checklists are tools that.
can help standardize care improve communication andassist teams in optimizing their performance Thank YouConsider ICU admission if there is significant hemorrhage, product replacement or medical comorbidities. Post Hemorrhage Management. AIM. What is AIM? “National data-driven maternal safety and quality improvement initiative” ...

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