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Suneet P. Chauhan, MD Eastern Virginia Medical School chauhasp@evms

Best Practices in Ob Triage: A to F. Suneet P. Chauhan, MD Eastern Virginia Medical School chauhasp@evms.edu. French, sorting, sifting From trier to sort First use 1918 Sorting of patients (e.g. ER) according to the urgency of their need for care. Triage. Merriam-Webster Dictionary.

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Suneet P. Chauhan, MD Eastern Virginia Medical School chauhasp@evms

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  1. Best Practices in Ob Triage: A to F Suneet P. Chauhan, MD Eastern Virginia Medical School chauhasp@evms.edu

  2. French, sorting, sifting From trier to sort First use 1918 Sorting of patients (e.g. ER) according to the urgency of their need for care Triage Merriam-Webster Dictionary

  3. Outline • ACOG, Amniotic fluid assessment • Bleeding—Abruption / Previa / Unknown • Contractions, preterm • Decreased fetal movement count • Estimate of fetal weight • Fetal acoustic stimulation

  4. ACOG Practice Bulletins

  5. ACOG Practice Bulletins

  6. Pregnancy changes normal laboratory values and physiologic parameters. Approximately 75% of obstetric ICU patients are admitted to the unit postpartum. Hemorrhage and hypertension are the most common causes of admission from obstetric services to intensive care. Critical Care in Pregnancy: Level A Recommendations ACOG PB Number 100; 2009

  7. Cesarean delivery in the ICU should be restricted to cases in which transport to the operating room or delivery room cannot be achieved safely or expeditiously, or to a perimortem procedure. Treatment of sepsis should not await admission to an ICU but should begin as soon as septic shock is diagnosed. Critical Care in Pregnancy: Level B Recommendations ACOG PB Number 100; 2009

  8. Initiate early goal-directed therapy for sepsis ASAP Do NOT delay treatment until admission to the ICU Stabilize, IV access maintained, urine output and fluid volume managed, and antibiotics started Broad-spectrum antibiotic therapy should be started within 1 hour of the diagnosis of severe sepsis or septic shock. Sepsis ACOG PB Critical Care in Pregnancy # 100; 2009

  9. Sepsis: Need > 2 Criteria Soper DE Infectious Disease in Obstetrics and Gynecology 2009

  10. Obtain cultures (blood) but do not delay initiating antibiotics Fetal resuscitation (O2, IV bolus, LLD) Cesarean delivery for NR FHR, after resuscitation Antenatal corticosteroids are not contraindicated even in the setting of sepsis Sepsis ACOG PB Critical Care in Pregnancy # 100; 2009

  11. Abruption / Previa

  12. Abruption Oyelese Y, Ananth CV Obstet Gynecol 2006

  13. Abruption Oyelese Y, Ananth CV Obstet Gynecol 2006

  14. About 1% of pregnancies A leading cause of vaginal bleeding in the latter half The maternal effect of abruption depends primarily on its severity Fetal effect is determined both by its severity and the GA at which it occurs Abruption involving more than 50% of the placenta is frequently associated with fetal death. Abruption Oyelese Y, Ananth CV Obstet Gynecol 2006

  15. Abruption, prior AMA Cocaine Cigarette Hypertension Hydramnios Intrauterine infection Multiple gestation Preeclampsia PROM Thrombophilia Trauma Abruption Oyelese Y, Ananth CV Obstet Gynecol 2006

  16. Diagnosis: Clinically Ultrasound and Kleihauer-Betke test are of limited value If fetal demise has occurred, vaginal delivery is preferable Conservative management with the goal of vaginal delivery Extreme preterm or near term Reassuring maternal status Fetal well-being assured Abruption Oyelese Y, Ananth CV Obstet Gynecol 2006

  17. Suspect Abruption • Vaginal bleeding or abdominal pain or both • Unexplained preterm labor • Unexplained low back pain • History of trauma • History of cocaine Oyelese Y, Ananth CV Obstet Gynecol 2006

  18. Sonographic Findings of Abruption • Preplacental collection under the chorionic plate (between the placenta and amniotic fluid) • Jello-like movement of the chorionic plate with fetal activity. • Retroplacental collection • Marginal or subchorionic hematoma • Increased heterogenous placental thickness (> 5 cm) • Intra-amniotic hematoma Oyelese Y, Ananth CV Obstet Gynecol 2006

  19. Sonographic Accuracy of Detecting Abruption • Ultrasound examination will fail to detect at least ½ of cases of abruption • When ultrasound exam shows an abruption, the likelihood is extremely high • A negative ultrasonogram does not rule out an abruption. Oyelese Y, Ananth CV Obstet Gynecol 2006

  20. Kleihauer-Betke Test • A negative test should not be used to rule out abruption • A positive test does not confirm abruption • Has limited usefulness in the diagnosis of abruption • Allows for quantification of fetomaternal transfusion to guide dosing of Rh-immune globulin in Rh-negative women Oyelese Y, Ananth CV Obstet Gynecol 2006

  21. Placenta Previa Vergani P et al AJOG 2009

  22. Placental Distance

  23. Antepartum Bleeding of Unknown Origin Magann EF et al Ob Gyn Survey 2005

  24. Contractions, Preterm

  25. Empty bladder Guide probe in anterior fornix Sagittal sonographic view of cervix with echogenic endocervical mucosa along the length of the canal Withdraw probe until blurred, then reinsert making sure to avoid excessive pressure Transvaginal Cervical Length

  26. Enlarge image (at least 2/3 of screen) Obtain symmetric image of entire endocervical canal, with internal os at flat or isosceles angle, and symmetric view of external os (anterior lip diameter should be equal to posterior lip diameter) Measure from internal os to external os along entire  cervical canal Transvaginal Cervical Length

  27. Obtain three measurements, use shortest best Apply transfundal pressure for at least 15 seconds Total examination duration: at least 5 minutes Transvaginal Cervical Length

  28. Fetal Fibronectin (fFN)

  29. Fetal fibronectin (fFN) • Obtain before digital exam or transvaginal cervical length • Place speculum and roll Dacron swab in posterior fornix for 10 sec • Place the swab in buffer solution and send to lab

  30. Fetal fibronectin (fFN) • Do NOT obtain fFN if within last 24 hours • Use of lubricant • Digital exam • Sexual intercourse • Bleeding • Do not obtain fFN if cerclage was done within the last 14 days

  31. Management of PTL: Level A Recommendations • No clear "first-line" tocolytic drugs to manage preterm labor. • Antibiotics do not appear to prolong gestation and should be reserved for group B streptococcal prophylaxis in patients in whom delivery is imminent. • Neither maintenance treatment with tocolytic drugs nor repeated acute tocolysis improve perinatal outcome; neither should be undertaken as a general practice. • Tocolytic drugs may prolong pregnancy for 2-7 days, which may allow for administration of steroids to improve fetal lung maturity and the consideration of maternal transport to a tertiary care facility ACOG Practice Bulletin # 43, 2003; Reaffirmed 2011

  32. Management of PTL: Level B Recommendations • “Cervical ultrasound examination and fetal fibronectin testing have good negative predictive value; thus, either approach or both combined may be helpful in determining which patients do not need tocolysis. • Amniocentesis may be used in women in preterm labor to assess fetal lung maturity and intraamniotic infection. • Bed rest, hydration, and pelvic rest do not appear to improve the rate of preterm birth and should not be routinely recommended.” ACOG Practice Bulletin # 43, 2003; Reaffirmed 2011

  33. Management of PTL: Level C Recommendations ACOG Practice Bulletin # 43, 2003; Reaffirmed 2011

  34. GA 24-33 wks Cx < 3cm Cx culture, fFN, TV Cx length Cervix length ≥ 3cm Cervix length 1.6-2.9cm Cervix length <1.5cm Discharge to home Send for fFN Admit for corticosteroid fFN (-) Discharge to home fFN (+): Admit for Corticosteroids Triage Protocol for PTL Rose CH et al Am J Obstet Gynecol 2010

  35. All patients underwent triage evaluation per a standardized protocol Evaluated with combination of cervical length measurement and fetal fibronectin assay Compared to the previous year, the rate of hospital admission was reduced by 56%, Reducing rate of hospitalization by 56% would result in a cost saving of $560 million Triage Protocol for PTL Rose CH et al Am J Obstet Gynecol 2010

  36. Oligohydramnios / Hydramnios

  37. Amniotic Fluid (AF) Assessment Subjective Single Deepest Pocket (SDP) Amniotic Fluid Index (AFI) Amniotic Fluid Assessment

  38. AF Assessment Single Deepest Pocket (SDP) Amniotic Fluid Index (AFI) Hydramnios (> 8 cm) Oligo- hydramnios Hydramnios (> 24 cm) Oligo- hydramnios Amniotic Fluid Assessment

  39. AF Assessment SDP AFI Oligo- hydramnios Oligo- hydramnios < 1 cm < 2 cm Phelan et al < 5.0 cm Moore & Cayle Magann et al Amniotic Fluid Assessment

  40. Antepartum AFI & 3 Criteria of Oligohydramnios Johnson JM et al AJOG 2007 N = 2,046 Data as likelihood ratio & 95% CI

  41. Intrapartum AFI & 3 Criteria of Oligohydramnios Johnson JM et al AJOG 2007 N = 825 No AS < 3 at 5 min Data as likelihood ratio & 95% CI

  42. AFI & Oligohydramnios • Using AFI, all 3 criteria of oligohydramnios are poor predictors of: • Cesarean delivery for non-reassuring fetal heart rate tracing • Low Apgar score at 5 min • Umbilical arterial pH < 7.00 • Birth weight < 5% for gestational age Johnson JM et al AJOG 2007

  43. Cochrane Review: AFI vs. SDP AFI, amniotic fluid index; SDP, single deepest pocket; Oligo, oligohydramnios; CD-NR FHR, cesarean delivery for non-reassuring fetal heart rate; UA, umbilical artery; NICU, neonatal intensive care unit Nabhan AF, Abdelmoula YA Cochrane Database of Systematic Reviews2008

  44. Cochrane Review: AFI vs. SDP • In the assessment of AFV during fetal surveillance, SDP is “better” than AFI. • Compare to SDP, use of AFI: • Significantly increases the diagnosis of oligohydramnios • Significantly increases the rate of induction • Does NOT improve the peripartum outcomes Nabhan AF, Abdelmoula YA Cochrane Database of Systematic Reviews 2008

  45. Decreasing The Rate of Cerebral Palsy P < 0.05 Manning FA et al AJOG 1998

  46. Decreasing The Rate of Cerebral Palsy /1,000 Deliveries (N = 58,657) (N = 26,290) Manning FA et al AJOG 1998

  47. Last Biophysical Profile & Cerebral Palsy /1,000 Deliveries P < 0.001 Manning FA et al AJOG 1998

  48. Oligohydramnios During Biophysical Profile Magann et al Obstet Gynecol 2000

  49. Decreased Fetal Movements • Antepartum fetal monitoring is a valuable approach and can be used to monitor the pregnancies of women with pregestational diabetes mellitus • Fetal movement counting, • Nonstress test, • Biophysical profile, and the • Contraction stress test ACOG Practice Bulletin Pregestational Diabetes # 60, 2005; Reaffirmed 2010

  50. Decreased Fetal Movements • Antepartum fetal surveillance in multiple gestations is recommended in all situations in which surveillance would be performed in a singleton pregnancy: • IUGR, • Maternal disease, • Decreased fetal movement ACOG Practice Bulletin Multiple Gestation # 56, 2004; Reaffirmed 2009

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