Management of Obstetric Emergencies - PowerPoint Presentation

Management of Obstetric Emergencies Brendan “Dan” Connealy, MD FACOGMethodist Perinatal AssociatesMethodist Women’s Hospital, Omaha NE

Learning Objectives Hypertensive Emergencies in PregnancyClinical update on current management guidelines and diagnostic criteriaHow 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 patientsReview the AIM supported patient safety bundles for severe hypertension in pregnancy and obstetric hemorrhage Discuss our experience instituting patient safety bundles for severe hypertension

November 2013 - ACOG

Types of Hypertension Chronic Hypertension SBP >140 or DBP >90 Pre-pregnancy or <20 weeks Gestational Hypertension SBP >140 or DBP >90 >20 weeks Absence of proteinuria or severe symptoms Preeclampsia SBP >140 or DBP >90 Presence of proteinuria Severe signs/symptoms in absence of proteinuria Proteinuria no longer required criteria Chronic Hypertension + superimposed preeclampsia Sudden increase in controlled BP New onset proteinuria Severe signs/symptoms of preeclampsia

Preeclampsia with Severe Features Proteinuria no longer qualifies as a severe feature

Surveillance and Obstetric Management Preeclampsia without severe featuresLess than 37 weeksWeekly labs, antenatal testing, BP checks, fetal growthAt 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 featuresAny GA with unstable fetal or maternal conditionsDeliveryAt 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 Previable PreE 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 studyDifferential should include other life-threatening conditionsCVA HELLP TTP/HUS May present with seizures Assume eclampsia but image to rule out other etiologies

Hypertensive Emergency Management Goals of therapyControl severe hypertensionStabilize the patient, initiate diagnostic testsPrevent 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 IVCommon side effects associated with medicationsHydralazine – maternal hypotension, flushing, tachycardiaLabetalol – 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 eclampsiaMultifetal 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

When does it occur? % Antepartum 38 - 53 Intrapartum 18 - 36 Postpartum 11 - 44 ≤ 48 hours > 48 hours 7 - 39 5 - 26 Summary of 5 series

Signs and Symptoms % Headache 30-70 Visual Changes 19-32 RUQ/epigastric pain 12-20 Altered mental changes 4 - 5 At least one of the above Hypertension Proteinuria 33-75 85 85 *Summary of 5 series

Steps in Managing Eclampsia Step 1: Prevent maternal hypoxia by supporting respiratory and cardiovascular function Step 2: Prevent maternal injury and aspiration Step 3: Do not try to arrest the first seizure Supplemental 02 Pulse oximetry ABG if acidemia Mouth guard Bed padding Suction Step 4: Prevent subsequent seizures from recurring 1. MgSO4 – 6g bolus then 2g/ hr 2. Re-bolus 2g if persist 3. Sodium Pentobarb 250mg IV if persist

Steps in Managing Eclampsia Step 5: Control severe hypertension to prevent cerebrovascular injury Reference previously mentioned alorithms Step 6: Manage complication such as DIC, Pulmonary Edema Step 7: Begin induction/delivery within 24 hours

Obstetric Hemorrhage Hemorrhage incidence - 4-6%SVD >500mlCesarean >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 AtonyLacerationsAbruptionRetained placenta Accreta / Percreta Uterine rupture Hematoma

Hemorrhage Management Activate response teamNurses, Physicians, OR staff, Lab, Blood bankImportant initial stepsIV access Hemorrhage cart/medications Lab studies Diagnosis – etiology of the bleed Massive transfusion protocol (if you have one)

Atony ManagementBimanual 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 BalloonPlacement, 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

When conservative measures fail

Surgical Treatment Retained placentaManual or sharp curettagePersistent atony Laparotomy B-lynch sutures O’ Leary sutures Additional devascularization Hysterectomy Delayed decision  increased morbidity

Hysterectomy Subtotal hysterectomy vs Total hysterectomyMore rapid completion – emergency situations Less beneficial if lower segment ( previa ) bleeding Consider pre-hysterectomy vascular ligation or occlusion Wright, Obstet Gynecol , 2010 115;6, 1187-1193

Additional Measures Tranexamic AcidRecombinant Factor VIICell salvageInterventional radiology

Product Replacement Platelets – single vs pooled donorUnit – 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 keyBorgmann 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 Hypothermia Coagulopathy Acidosis

Pacheco et al, Am J Obstet Gynecol Dec 2011

Laboratory values will frequently fluctuate Trends are importantVital 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

AIM

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”

Who Is AIM

AIM – Safety Bundles

AIM – Safety Bundles ReadinessRecognition/PreventionResponseReporting/Systems Learning

Severe Hypertension in Pregnancy

Severe Hypertension in Pregnancy

Obstetric Hemorrhage

Toolkits are Readily Available “No need to reinvent the wheel”

Our Experience Safe healthcare for every woman3 Bundles implemented in past 3 yearsMaternal early warning signsHemorrhageHypertension

Maternal Early Warning Signs Criteria may be individualized by institution Above list may not be considered comprehensive

Maternal Early Warning Signs Step 1: Immediate action criteria metStep 2: Attending or in-house physician will evaluate patient within 10 minutesStep 3: Physician documents evaluation and immediate care plan (Huddle) Step 4: If MEWS criteria persists despite corrective measures – Consultation with MFM/ Intensivist /Rapid Response Step 5: Advanced measures, labs, treatments

Our Experience

Our Experience

Our Experience

Our Experience

Our Experience

Management Plans Stage 0 – EveryoneStage 1 – Initial response to hemorrhageStage 2 – Continued and escalated response to persistent hemorrhage Stage 3 – Severe hemorrhage with/without coagulopathy

Challenges Nebraska – rural state – ½ of population is located in a single metropolitan areaSeveral low volume delivery centers (<50 babies/year)Critical access to care Differing levels of obstetric care

Challenges 16/50 have obstetricians performing deliveries 7/50 have access to MFM

Plan to improve outcomes Hospital based approaches supported by statewide collaborativeRural Outreach Establish referral networks – Levels of careProvider education Didactic Simulation training Implementation of protocols Data collection and review

“Checklists, when designed well, implemented thoughtfully, and monitored closely, offer the opportunity for health care providers to not simply be satisfied with doing most of the right things for most the patients most of the time…..Checklists are tools that can help standardize care, improve communication, and assist teams in optimizing their performance”

Thank You