High Risk & Critical Care OB

1. High Risk & Critical Care OB

2. LECTURE OVERVIEW • Physiologic Changes of Pregnancy • Risk Factor Identification • OB Assessment • High Risk OB • Trauma/CPR • Emergency Delivery

3. Physiological Changes of Pregnancy • Cardiovascular • Respiratory • Renal • GI

4. Cardiovascular • Blood volume increased by 40-50% • 1500 cc • Uterine vasculature hypertrophied • Adequate tissue perfusion when erect or supine • Reserve to compensate for PP blood loss

5. Cardiovascular • Heart rate increases 10-15 bpm • Cardiac output increased 25-50% • Hgb/Hct decreased • WBC increased • Transient murmurs not uncommon • Dependent edema common

6. Respiratory • Minimal effect from anatomical changes • Oxygen consumption increased 20% • PO 2 slight increase 104-108 • Ph 7.4-7.45 • Decreased basal breath sounds

7. GI • Constipation/heartburn due to increased progesterone • Gallbladder disease not uncommon • Appendix displaced upward and laterally • Nausea/vomiting not uncommon

8. Renal • Frequency/urgency due to many anatomical changes • Glucose present in 20% • Trace to protein acceptable

9. Risk Assessment • OB history • Medical history • Current pregnancy • Psychosocial • Demographics • Lifestyle

10. Obstetric History • Grand multiparity • Incompetent cervix • Previous preterm labor • Previous c-section • Previous fetal loss

11. Medical History • Pre-existing conditions • Family OB history • STD’s • Past surgery

12. Current pregnancy • Prenatal care? • Amniotic fluid status • Placental problems • BP changes • Preterm contractions • Multiple gestations • STD’s

13. Psychosocial • Lack of resources/support • Domestic violence • Psych history • Grieving

14. Demographics/Lifestyle • <16 or >35 • Tobacco use • Substance abuse • Seat belt use

15. OB Assessment • EDC • Contractions • Membranes • Gravidity/Parity • Bleeding

16. EDC • Due Date • LMP: subtract 3 months, add 7 days • Most accurate: early ultrasound • Wheel

17. Contractions • Frequency • Duration • Intensity • Onset

18. Membranes • Has your water broken? • When? What color? • Trickle?Gush?

19. G’s and P’s • G: gravida: number of pregnancies • P: para: number of deliveries > 20 weeks • Preterm deliveries • Living children

20. Vaginal bleeding • Quantity • Duration • Color • Clots

21. High Risk Obstetrical Complications • Placenta previa • Abruptio placenta • Preterm labor • PROM

22. Placenta Previa • Painless vaginal bleeding • Hemodynamically unstable • IV hydration • Oxygen • Unstable: delivery and/or transport

23. Abruptio Placenta • Painful, frequent contractions; uterus tetanic • Can occur with no visible vaginal bleeding • Fetal compromise(15% of neonatal deaths) • Associated with HTN • Risk of DIC • Oxygen/fluid resuscitation • Unstable: delivery/transport

24. Preterm Labor • 12% of all pregnancies • 75% neonatal morbidity • Preterm contractions with cervical change prior to 36 weeks • Treatment: • Bed rest • IV hydration • Medications

25. Preterm labor: medications • Magnesium Sulfate • 4 to 6 gram IV bolus over 20 min • 2 to 4 grams/hour • Decreases respirations • Antidote: calcium gluconate 1 gram IV

26. Hypertension • Chronic hypertension • Pre-eclampsia • Hypertension 140/90 or 30/15 over baseline • Proteinuria • Edema • Gestational hypertension • SIPE(super imposed pre-eclampsia) • Signs of worsening: headache, visual changes, epigastric pain

27. Worsening HTN: treatment • Magnesium sulfate while severity being evaluated, in labor & for 24 hours PP • Maintenance meds: aldomet, apresoline, labetalol • Monitoring of urine output, BP, pulse ox • Hypertensive crisis: apresoline, labetolol,procardia—must be CLOSELY monitored

28. Eclampsia • Significant maternal/neonatal morbidity • Signs of worsening pre-eclampsia: headache, blurred vision, epigastric pain • Stabilize airway • IV access • Magnesium sulfate • Usually self-limiting • Valium if prolonged

29. HTN: complications • Pulmonary edema • DIC • Renal failure • Liver failure/rupture • HELLP

30. Preterm labor medications • Terbutaline 0.25 mg SQ q 15 min x 3 doses • Watch for tachycardia, hypotension • Indomethacin: calcium channel blockers • Steroids to enhance fetal lung maturity • Antibiotics: group B strep reduction

31. PROM: premature rupture of membranes • Prior to 36 weeks • Avoid digital exam • Suppress labor for 24-48 to get antibiotics and steroids in • Conservative management

32. Prolapsed Cord • Ruptured membranes • Umbilical cord visible or palpable • Elevate presenting part • Trendelenburg or knee-chest • IV fluids, oxygen • Rapid transport for c/section

33. CPR in Pregnancy • Rare event • Hemorrhage, thromboembolism, hypertension, domestic violence/trauma, cocaine • Fetal assessment during CPR: not necessary, take time. Personnel better used to resuscitate mother

34. CPR • Uterine displacement with a wedge (vena caval compression decreases circulation blood volume 30%) • Decreased placental perfusion with maternal hypotension/hypoxia • Failed intubation pregnant 1:500 (general population is 1:2000), airway edematous • Increased risk of aspiration (intubate ASAP) • Perimortem C/S within 5 min of arrest

35. CPR Summary • Airway: intubate ASAP • Breathing: control ventilation • Circulation: central access ASAP • Displacement: left uterine • Defibrillate: per ACLS • Drugs: per ACLS

36. CPR Summary • Delivery: within 5 minutes of arrest if resuscitation not successful • Document • Consider: Open chest cardiac massage Cardiopulmonary bypass Adapted from Johnson, Luppi and Over

37. Trauma • More reported in third trimester • Majority MVA’s • Falls, burns, GSW’s, domestic violence • Leading non-OB cause of maternal death • 20% maternal deaths • 70% are MVA’s—half not restrained

38. Trauma physiology • After 1st trimester, uterus abdominal organ • Distended bladder, risk of rupture/injury • Increased risk of acidosis • Avoid supine position • Increased risk of aspiration • Shock: must lose 30% blood volume • Fetal monitor: first signs of hypoxia

39. Blunt abdominal trauma • MVA’s/falls • Maternal morbidity/mortality increased with ejection • Fetal death result of placenta abruption

40. Penetrating Abdominal Trauma • GSW/Stab wounds • 66% with bad prognosis • Fetal direct injury 3rd trimester

41. Thoracic Trauma • 25% trauma deaths • 70% pulmonary contusion

42. Trauma Stabilization • Priorities identical to non-pregnant patient • ACOG: no restriction of usual diagnostic, pharmacologic or resuscitative measures • Fetal survival depends on maternal survival • Stabilization of mother improves fetal survival

43. Emergency Delivery • Signs of imminent delivery • Nausea and vomiting • Increased bloody show • Urge to push or to have bowel movement • “The baby’s coming” • Separation of labia • Bulging of perineum

44. Delivery Essentials • Support perineum • Check for a cord, if loose slip over head; if tight, clamp twice and cut in-between • Suction with bulb syringe • Allow head to turn • Place hands on each side of head • Gentle downward traction

45. Delivery Essentials • Upward traction to deliver posterior shoulder • Deliver body • Cut and clamp cord • Place on mom and dry • Deliver placenta