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Obstetric Emergencies Postpartum Hemorrhage and Hypertension Obstetric Emergencies Postpartum Hemorrhage and Hypertension

Obstetric Emergencies Postpartum Hemorrhage and Hypertension - PowerPoint Presentation

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Obstetric Emergencies Postpartum Hemorrhage and Hypertension - PPT Presentation

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

blood pregnancy 100 maternal pregnancy blood maternal 100 obstetrics gynecol recognize obstet gynecology failure class warning mortality related hemorrhage

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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

Slide2

Slide3

Slide4

Disclosures

Slide5

Pregnancy-related mortality in the United States: 1987-2010

Source: CDC Pregnancy Mortality Surveillance System

Slide6

Obstetrics and Gynecology, May 2014

Slide7

Causes of pregnancy-related death in the United States: 2006 -2010

Source: CDC Pregnancy Mortality Surveillance System

Slide8

Maternal mortality is only the tip of the iceberg

Slide9

Obstetrics and Gynecology, February 2012

Slide10

93% 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

Slide11

Recognize 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.

Slide12

Recognize 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

Slide13

Obstetrics and Gynecology, May 2014

Slide14

Systolic 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

Slide15

Act decisively/

R

estore blood volume

Slide16

Rule number one: Postpartum Hemorrhage is a definition, not a diagnosis!

Post-Partum Hemorrhage

Slide17

Actively manage the third stage of labor

Pearls for

Atony

Slide18

Consider additional utero-tonics for those at highest risk of PPH

Pearls for

Atony

Slide19

Have a low threshold for going to the OR for repair.

Pearls for Lacerations

Slide20

Slide21

Source: California Maternal Quality Care Collaborative

Slide22

60% 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

Slide23

Systolic 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

Slide24

Control Blood Pressure

Slide25

Control Blood Pressure

Slide26

Hi

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

Slide27

Recognize HELLP Syndrome

Slide28

The most important paper on HTN in pregnancy in the last year

Slide29

SBP >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

Slide30

Recognize and treat pulmonary edema

Slide31

Slide32

“If you’re going down take everybody else with you.”

Susan

Modesitt

, Gyn Oncologist

The UVA way (or maybe it was UNC)

Slide33

David Barker 1938-2013

Slide34

The Barker Hypothesis

The Thrifty Phenotype

Fetal Origins Hypothesis

Slide35

Intrauterine Growth Restriction

Slide36

30 years from now

Slide37

Thank you!!!