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Management of Obstetric Emergencies. Brendan “Dan” Connealy, MD FACOG Methodist Perinatal Associates Methodist Women’s Hospital, Omaha NE. Learning Objectives. Hypertensive Emergencies in Pregnancy Clinical update on current management guidelines and diagnostic criteria
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Management of Obstetric Emergencies Brendan “Dan” Connealy, MD FACOG Methodist Perinatal Associates Methodist Women’s Hospital, Omaha NE
Learning Objectives • Hypertensive Emergencies in Pregnancy • Clinical update on current management guidelines and diagnostic criteria • How to approach the severe hypertensive patient • Obstetric Hemorrhage • Clinical update on current management guidelines • Discuss the approach to the massive hemorrhage patient
Learning Objectives • Patient Safety Bundles – Alliance for Innovation on Maternal Health (AIM) • What are patient safety bundles and how can they improve outcomes for our patients • Review the AIM supported patient safety bundles for severe hypertension in pregnancy and obstetric hemorrhage • Discuss our experience instituting patient safety bundles for severe hypertension
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’ em, Know when to fold ’em, Know when to walk away, Know when to run.” Kenny Rogers - Gambler
Early (<34wks) Severe Preeclampsia Management • PreviablePreE 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-threatening conditions • CVA • HELLP • 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 Emergency ACOG 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
Severe intrapartum HTN associated with increased risk for severe maternal morbidity AJOG July 2016
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
Steps in Managing Eclampsia Supplemental 02 Pulse oximetry ABG if acidemia Step 1: Prevent maternal hypoxia by supporting respiratory and cardiovascular function Mouth guard Bed padding Suction Step 2: Prevent maternal injury and aspiration 1. MgSO4 – 6g bolus then 2g/hr 2. Re-bolus 2g if persist 3. Sodium Pentobarb 250mg IV if persist Step 3: Do not try to arrest the first seizure Step 4: Prevent subsequent seizures from recurring
Steps in Managing Eclampsia Reference previously mentioned alorithms Step 5: Control severe hypertension to prevent cerebrovascular injury Step 6: Manage complication such as DIC, Pulmonary Edema Step 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 the US • 0.9/100,000 • Most are considered preventable ACOG Practice Bulletin 76 Drife J. BJOG (1997) 104:275–7 CDC; NVSR, V 58:19, May 2010, tables 33 and 34
Obstetric Hemorrhage 93% of deaths due to hemorrhage are considered preventable on review. Primarily due to delay in treatment. Delay is due to lack of recognition and poor/inadequate communication
Etiology • Atony • 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 – give early in rescusitation
Tamponade Balloon • Placement, duration, antibiotics • Ultrasound guidance • Vaginal packing • Antibiotic usage • Duration of usage • “Tamponade Test” – pressure (volume) at which the bleeding stops • Georgiou et al – Tamponade pressure is not > systolic pressure • Best for lower uterine segment atony
Surgical Treatment • Retained placenta • Manual or sharp curettage • Persistent atony • Laparotomy • B-lynch sutures • O’ Leary sutures • Additional devascularization • Hysterectomy • Delayed decision increased morbidity
Hysterectomy • Subtotal hysterectomy vs Total hysterectomy • More rapid completion – emergency situations • Less beneficial if lower segment (previa) bleeding • Consider pre-hysterectomy vascular ligation or occlusion Wright, ObstetGynecol, 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) • 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 warm • Bear hugger, Level 1 tranfuser • Maintain perfusion • Transfusion/replacement • Correct coagulopathy Coagulopathy Hypothermia Acidosis
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 Post Hemorrhage Management
What is AIM? • “National data-driven maternal safety and quality improvement initiative” • “Proven approaches to improvement of maternal safety and outcomes in the U.S.” • “Eliminate preventable maternal mortality and severe morbidity”
AIM – Safety Bundles • Readiness • Recognition/Prevention • Response • Reporting/Systems Learning