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Emergencies in Obstetrics

Emergencies in Obstetrics. Paul C. Browne, M.D. Associate Professor Department of Obstetrics and Gynecology USC School of Medicine. Disclosures. Nature of Financial Relationship : Grant/Research Support– USC School of Medicine March of Dimes. Objectives. 1. Define “Emergency

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Emergencies in Obstetrics

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  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 • 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. 2007 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

  23. 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

  24. 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

  25. 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

  26. 2007 SC DHEC Vital Statistics

  27. Bleeding Courtesy thepregnancyzone.com

  28. Triage of Bleeding • Blood from vagina • Labor • Rupture of membranes • Abruption • Blood from anywhere else • Trauma • Epistaxis (nosebleed) • GI bleeding

  29. 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?

  30. 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

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

  32. Most likely incorrect diagnosis in Obstetrics? • DIC-Disseminated Intravascular Coagulation

  33. DIC versus Coagulopathy • DICis a primary diagnosis • Coagulopathy occurs with • Excessive surgical blood loss • Amniotic fluid embolism • Prophylactic anti-coagulation • Pre-eclampsia • Sepsis

  34. 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

  35. Skin manifestations of DIC Courtesy dermaamin.com

  36. Consumption versus DIC • Exhaustion of pro-coagulants from hemorrhage versus inappropriate depletion of pro-coagulants internally • Macro clotting versus microvascular clotting • At 2000-3000 ml, recovery time to replace lost pro-coagulants is exceeded

  37. Consumption-Abruption Courtesy cbbsweb.org

  38. DIC-Amniotic Fluid Embolism Courtesy brown.edu

  39. 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

  40. 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

  41. 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

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

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

  44. 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

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