Annelee Boyle MD FACOG Assistant Professor Department of Obstetrics and Gynecology Division of MaternalFetal Medicine University of Virginia School of Medicine Disclosures Pregnancyrelated mortality in the United States 19872010 ID: 930275
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Slide1
Obstetric Emergencies
Postpartum Hemorrhage and Hypertension
Annelee Boyle, MD, FACOG
Assistant Professor
Department of Obstetrics and Gynecology
Division of Maternal-Fetal Medicine
University of Virginia School of Medicine
Slide2Slide3Slide4Disclosures
Slide5Pregnancy-related mortality in the United States: 1987-2010
Source: CDC Pregnancy Mortality Surveillance System
Slide6Obstetrics and Gynecology, May 2014
Slide7Causes of pregnancy-related death in the United States: 2006 -2010
Source: CDC Pregnancy Mortality Surveillance System
Slide8Maternal mortality is only the tip of the iceberg
Slide9Obstetrics and Gynecology, February 2012
Slide1093% of deaths preventable!
Berg et al. Preventability of pregnancy related deaths: results of a statewide review.
Obstet
Gynecol
2005; 106:1228-34.
Common mistakes:
Under-recognition of blood loss
Under-recognition of hypovolemia
Failure to act decisively
Failure to restore blood volume
Postpartum Hemorrhage
Slide11Recognize the extent of blood loss
Dildy
et al, Estimating
Blood Loss: Can Teaching Significantly Improve Visual Estimation?
Obstetrics
& Gynecology. 104(3):601-606, September 2004.
Slide12Recognize the extent of hypovolemia
Class 1
Class 2
Class 3
Class 4
EBL in ml
< 750ml
750-1500ml
1500-2000ml
>2000ml
EBL in %
Vol.
<15%
15-30%
30-40%
>40%
Pulse
<100
>100
>120
>140
BP
Normal or ↑
↓
↓
↓
RR
14-20
20-30
30-40
>35
UOP
>30ml/h
20-30ml/h
5-15ml/h
negligible
Mental State
Slightly anxious
Mildly anxious
Anxious, confused
Confused, lethargic
Slide13Obstetrics and Gynecology, May 2014
Slide14Systolic BP <90 or >160
Diastolic BP >100
Heart Rate <50 or >120
Resp
Rate <10 or >30
Oxygen Sat <95% on room air
Urine output <35ml/
hr for 2 hoursAgitation, confusion, or unresponsivenessShortness of breath or a non-remitting headache in a patient with pre-eclampsia
Mhyre et al. The maternal early warning criteria: a proposal from the national partnership for maternal safety.
Obstet
Gynecol
2014;124:782-6.
Early warning signs
Slide15Act decisively/
R
estore blood volume
Slide16Rule number one: Postpartum Hemorrhage is a definition, not a diagnosis!
Post-Partum Hemorrhage
Slide17Actively manage the third stage of labor
Pearls for
Atony
Slide18Consider additional utero-tonics for those at highest risk of PPH
Pearls for
Atony
Have a low threshold for going to the OR for repair.
Pearls for Lacerations
Slide20Slide21Source: California Maternal Quality Care Collaborative
Slide2260% of deaths are preventable!
Berg
et al. Preventability of pregnancy related deaths: results of a statewide review.
Obstet
Gynecol
2005; 106:1228-34
.
Common mistakes:
Failure to adequately control blood pressure
Failure to recognize HELLP syndrome
Failure to diagnose and treat pulmonary edema
Preelcampsia
Slide23Systolic BP <90 or >160
Diastolic BP >100
Heart Rate <50 or >120
Resp
Rate <10 or >30
Oxygen Sat <95% on room air
Urine output <35ml/
hr for 2 hoursAgitation, confusion, or unresponsivenessShortness of breath or a non-remitting headache in a patient with pre-eclampsia
Mhyre et al. The maternal early warning criteria: a proposal from the national partnership for maternal safety.
Obstet
Gynecol
2014;124:782-6.
Early warning signs
Slide24Control Blood Pressure
Slide25Control Blood Pressure
Slide26Hi
Annelee
. Hope you’re doing well and liking your new job. It’s 10:30 pm here and for me, that’s the middle of the night so rather than be friendly and “chat”, I’m going to get straight to the point – it’s
business…
So
our hospital protocol essentially regurgitates ACOG, but it doesn’t specify that it is for use only with
preeclamptic
/
eclampic patients. Would you use it for someone with chronic HTN also, barring known renal disease or other cause of the HTN?
Thanks!
Love
, Aunt Crunchy
Slide27Recognize HELLP Syndrome
Slide28The most important paper on HTN in pregnancy in the last year
Slide29SBP >160
DBP >110
Platelets < 100,000)
LFTs >2x normal
Creatinine > 1.1
Pulmonary
edema
New-onset cerebral or visual disturbancesRight upper quadrant pain
American College of Obstetricians and Gynecologists. Hypertension in pregnancy: executive summary. Obstet
Gynecol
2013;122:1122–31.
Severe Features of Preeclampsia
Slide30Recognize and treat pulmonary edema
Slide31Slide32“If you’re going down take everybody else with you.”
Susan
Modesitt
, Gyn Oncologist
The UVA way (or maybe it was UNC)
Slide33David Barker 1938-2013
Slide34The Barker Hypothesis
The Thrifty Phenotype
Fetal Origins Hypothesis
Slide35Intrauterine Growth Restriction
Slide3630 years from now
Slide37Thank you!!!