Obstetrical Emergencies

1. Obstetrical Emergencies Prepared by Shane Barclay MD

2. Disclaimer There are many causes of pain, bleeding and cardiovascular collapse in pregnancy. This does not address them all and several that are discussed are not covered in detail. But you should be aware of potential causes in you ‘mental differential’ as some scenarios can have specific treatments which you may have available. In a rural setting you may not be able to determine the cause in many cases. However, initial management - resuscitation – is the same.

3. OB ER - Outline This presentation will cover: 1. Shock and critical illness in pregnancy 2. Vaginal bleeding in pregnancy.3. Eclampsia4. Trauma and cardiac arrest in pregnancy.

5. OB Emergencies 1. Shock and critical illness in Pregnancy 2. Vaginal bleeding in pregnancy 3. Eclampsia4. Trauma and cardiac arrest in pregnancy

6. Shock and Critical Illness in Pregnancy Pregnant women who end up in ICU from what ever cause have a high mortality rate. Ranges up to 15%. Role of rural physicians is to recognize, stabilize and transport as soon as possible.

7. Shock and Critical Illness in Pregnancy Several conditions can lead to shock, but this will focus on the following 3 topics: Respiratory Failure Peripartum cardiomyopathy Infection/sepsis

8. Shock and Critical Illness in Pregnancy Other pregnancy related conditions causing shock in pregnancy can include: Thrombotic Thrombocytopenic Purpura Hemolytic uremic syndrome Posterior Reversible Encephalopathy syndrome These are rare, not included in this presentation, but one should be aware of them.

9. Shock and Critical Illness in Pregnancy • Acute Respiratory Failure • Peripartum cardiomyopathy • Infection/sepsis

10. Respiratory Failure in Pregnancy Conditions that cause acute respiratory failure can be pregnancy related or not. • Asthma exacerbation • Pneumonia • Pulmonary embolus (thrombus, amniotic fluid) • Aspiration • Acute pulmonary edema

11. Respiratory Failure in Pregnancy Treatment initially is the same for all conditions. • Oxygen. Delivery depends on need. • Goal is to keep SpO2 > 95% for fetal oxygenation. • Intubate only as last resort. - can be difficult due to laryngeal edema. - target PaCO2 is 30 – 32 mmHg

12. Respiratory Failure in Pregnancy • Asthma exacerbation • Pneumonia • Pulmonary embolus (thrombus, amniotic fluid) • Aspiration • Acute pulmonary edema

13. Asthma in pregnancy can be from this…. …to this.

14. Asthma in Pregnancy Up to 30% of pregnant women with asthma will have exacerbations during pregnancy. Asthma in pregnancy generally is associated with increased risk of: lower birth weight pre-term delivery preeclampsia.

15. Asthma in Pregnancy Management: Is the same as for non pregnant patients: Beta agonists Systemic steroids Theophylline IV Probably NOT Magnesium Sulfate (no safety studies)

16. Respiratory Failure in Pregnancy • Asthma exacerbation • Pneumonia • Pulmonary embolus (thrombus, amniotic fluid) • Aspiration • Acute pulmonary edema

17. Pneumonia in Pregnancy Etiological agents and management are the same as for non pregnant women. However, lowered immunity in late pregnancy can worsen pneumonia and make for even atypical pathogens to be a cause.

18. Respiratory Failure in Pregnancy • Asthma exacerbation • Pneumonia • Pulmonary embolus (venous thrombus, amniotic fluid) • Aspiration • Acute pulmonary edema

19. Pulmonary Embolus in Pregnancy • Venous thrombus Risk of PE is up to 6 times higher than for non pregnant women. Treatment same as for non pregnant women.

20. Pulmonary Embolus in Pregnancy 2. Amniotic fluid embolism

21. Pulmonary Embolus in Pregnancy 2. Amniotic fluid embolism Rare but often fatal. Usually occurs during labor. Onset often with chills, nausea, agitation then sudden development of respiratory failure and shock. Other features can be hemorrhage/DIC, tonic clonic seizures and stroke. Can lead to cardiac arrest. Treatment is CV support, +/- vasopressors (Norepi), inotropes, mechanical ventilation, delivery. Maternal mortalities are up to 90%, neonatal up to 60%.

22. Respiratory Failure in Pregnancy • Asthma exacerbation • Pneumonia • Pulmonary embolus (thrombus, amniotic fluid) • Aspiration • Acute pulmonary edema

23. Aspiration in Pregnancy Usually occurs during delivery and is of stomach contents. Treatment as for non pregnant aspiration pneumonia, which is largely supportive. Aspiration may cause acute bronchospasm, which can be treated as for asthma.

24. Respiratory Failure in Pregnancy • Asthma exacerbation • Pneumonia • Pulmonary embolus (thrombus, amniotic fluid) • Aspiration • Acute pulmonary edema

25. Pulmonary edema in Pregnancy Causes are: - Tocolytic therapy (beta blockers, MgSO4, CCB) to inhibit preterm labor. - Eclampsia - Iatrogenic fluid overload. Treatment is to stop tocolytics and manage as per eclampsia and pulmonary edema protocols.

26. Shock and Critical Illness in Pregnancy • Acute Respiratory Failure • Peripartum cardiomyopathy • Infection/sepsis

29. Peripartum Cardiomyopathy Peripartum cardiomyopathy (PPCM) is a rare condition (fortunately) causing heart failure in late pregnancy or within 5 months post partum. Cause is unknown. Indistinguishable from other causes of heart failure. However, treatment is the same regardless of cause.

30. Assessment of PPCM Clinical presentation: • Dyspnea • Cough • PND and orthopnea • Pedal edema Note: many of these can be seen normally in late pregnancy.

31. Assessment of PPCM 5. ECG – more to rule out other causes. 6. BNP – given time for results, may be of limited value in a rural setting. 7. CXR/pleural ultrasound.

32. Management of PPCM Unless the patient presents in acute pulmonary failure, these patients should be transferred to an urban critical care setting. Consult obstetrics/ICU. If acute, management can be as for pulmonary edema.

33. Video: note hypokinesis of the ventricles.

34. Shock and Critical Illness in Pregnancy • Acute Respiratory Failure • Peripartum cardiomyopathy • Infection/sepsis

35. Sepsis in Pregnancy Although uncommon, has a high mortality. Leading causes: septic abortion chorioamnionitis complicated pyelonephritis pneumonia post partum endometritis other – wound infections, pelvic abscess etc

36. Sepsis in Pregnancy Management is as for sepsis. IV, antibiotics, transfer.

37. Ok, take a breath!

38. OB Emergencies 1. Shock and critical illness in Pregnancy 2. Vaginal bleeding in pregnancy3. Eclampsia4. Trauma and cardiac arrest in pregnancy

39. Vaginal Bleeding in Pregnancy A differential diagnosis can be based on gestational age. Under 20 weeks gestation First trimester spotting Miscarriage Retained products of conception Ectopic pregnancy Trauma Over 20 weeks gestation Miscarriage Abruptio placenta Placenta previa Uterine rupture Trauma

40. First Trimester Bleeding Ultrasound – intrauterine pregnancy? NO Speculum Os closed Os open Ectopic Complete or Miscarriage (RPOC) Very early pregnancy

41. First Trimester Bleeding Ultrasound – intrauterine pregnancy? YES Fetal Activity? No Yes Incomplete Speculum Miscarriage Os closed Os open Threatened Impending Miscarriage Miscarriage or other visible vaginal causes

42. First Trimester Bleeding Ultrasound – intrauterine pregnancy? NO YES Speculum Fetal Activity? Os closed Os open No Yes Ectopic Complete Incomplete Speculum or Miscarriage (RPOC) Miscarriage very early pregnancy Os closed Os open Threatened Impending Miscarriage Miscarriage or other visible vaginal causes

43. Vaginal Bleeding in Pregnancy Under 20 weeks gestation First trimester spotting Miscarriage Retained products of conception Ectopic pregnancy Trauma

44. First Trimester Spotting Common (up to 20% pregnancies) Is spotting, not bleeding (i.e. not requiring a liner or pad) Due to implantation, intercourse, cervical/vaginal pathology. Is usually not associated with adverse outcomes.

45. Miscarriage Can be ‘threatened, inevitable, incomplete, complete’. Management: Assess cardiovascular status – treat as appropriate Obs exam – fundal height, FHR, tenderness Ultrasound – assess for viable fetus Speculum exam – vaginal/cervical pathology Os open or closed? Labs: CBC, hCG levels (rising or falling), Rh status

46. Miscarriage Threatened Miscarriage: Viable fetus on exam and a closed Os. Over 90% do not miscarry. Inevitable Miscarriage: Non-Viable fetus on exam and open Os. Usually heavier bleeding and cramping.

47. Miscarriage Incomplete Miscarriage: Membranes and fetus have passed, but placental tissue can be retained. Most common in late first trimester. Often require obstetrical assessment. Complete Miscarriage: Examination of tissue will reveal fetal contents and chorionic villi on histological examination. Should have falling hCG levels and decreasing bleeding.

48. Retained Products of Conception Retained products of conception usually relate to gestations under 20 weeks. Post partum hemorrhage relates to gestations over 20 weeks. Both can be variable in bleeding, but both can be catastrophic and life threatening.

49. Retained products of conception

50. Post Partum Hemorrhage PPH is defined as bleeding within 24 hours of delivery. Stoppage of blood loss after delivery is usually due to the uterus contracting causing simple mechanical compression of vessels and a series of clotting/hemostatic factors. Most common cause of PPH is lack of uterine contraction (uterine atony)