Postpartum Hemorrhage and Hypertension Annelee Boyle MD FACOG Assistant Professor Department of Obstetrics and Gynecology Division of MaternalFetal Medicine University of Virginia School of Medicine ID: 257359
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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 MedicineSlide2Slide3Slide4
Disclosures Slide5
Pregnancy-related mortality in the United States: 1987-2010
Source: CDC Pregnancy Mortality Surveillance System Slide6
Obstetrics and Gynecology, May 2014Slide7
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 icebergSlide9
Obstetrics and Gynecology, February 2012Slide10
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, lethargicSlide13
Obstetrics and Gynecology, May 2014Slide14
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 volumeSlide16
Rule number one: Postpartum Hemorrhage is a definition, not a diagnosis!
Post-Partum Hemorrhage Slide17
Actively manage the third stage of labor
Pearls for
AtonySlide18
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 Slide20Slide21
Source: California Maternal Quality Care CollaborativeSlide22
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
PreelcampsiaSlide23
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 CrunchySlide27
Recognize HELLP Syndrome Slide28
The most important paper on HTN in pregnancy in the last yearSlide29
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 Slide31Slide32
“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 1938-2013Slide34
The Barker Hypothesis
The Thrifty Phenotype
Fetal Origins Hypothesis Slide35
Intrauterine Growth Restriction Slide36
30 years from now Slide37
Thank you!!!