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High Risk OB Case Studies
Patricia M. Witcher, RNC-OB, MSNNorthside Hospital
Labor and Delivery, High Risk ObstetricsAtlanta, Georgia
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0
3.2
6.4
9.6
12.8
16
Matern
al Death
s per 1
00,0
00 Live B
irths
19791981
19831965
19871989
19911993
19951997
19992001
20032005
Source: http://www.census.gov/compendia/statab/2010/tables/10s0112.pdf. Last accessed 6/7/11
Maternal Mortality Rates in the U.S. 1979 to 2005
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• Preterm labor
• Hypertensive disease
• Anemia / hemorrhage
• Infection-related
• Anesthesia-related complications
• Diabetes
• Embolism-related
Top Reasons for Hospitalization During Pregnancy
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Cause-Specific Pregnancy-Related Mortality in the U.S., 1987 - 2005
0
5
10
15
20
25
30
Hemorrhage Thrombotic PE AFE Infection Hypertension Cardiomyopathy Anesthesia CVA CV Conditions Non CV Medical
Mort
ality
%
1987-1990 1991-1997 1998-2005
Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality in the United States, 1998 to 2005. Obstet Gynecol, 2010; 116(6): 1302-9.
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Case Studies
• Case studies are not provided in handout material in order to protect the confidentiality of the patients and institutions from which they are derived.
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Pregnancy Adaptations that Necessitate Consideration
During Assessment and Interventions
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• Pregnancy does not change the overall therapeutic goal
–Restoring oxygenation is aggressive
–Interventions directed at restoring hemodynamic instability are not withheld out of concern for fetal effects
• Some clinical practices may require adaptation
General Considerations
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• Hemodynamic and laboratory interpretation requires adaptation based upon normal values in pregnancy
– i.e. Septic shock criteria typically requires adaptation
– i.e. Renal insufficiency despite normal nonpregnant values
• Anticipate increased potential for anesthesia-related adverse events
– Difficult or failed airway
– Aspiration
• Pregnant women may deteriorate more rapidly due to changes in pulmonary volumes and mechanics
• Higher risk for complications (i.e. DKA)
• Increased risk for UTI and pyelonephritis
General Considerations
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Decreased Maternal Cardiac Output: Impact Upon Uteroplacental Perfusion
!CO
! uteroplacental perfusion
!PaO2
"PaCO2
Placental vasoconstriction
FHR abnormality
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• Assess according to normal hemodynamic values for pregnancy
• Ensure adequate circulating blood volume whenever possible to maintain uteroplacental perfusion
– Lateral positioning
– Judicious afterload reduction
– “Gental” diuresis in the setting of fluid overload
Hemodynamic Stabilization
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• Uteroplacental perfusion
• Greatly determined by maternal cardiac output and circulating blood volume
• Maternal oxygenation status
Determinant of Fetal Oxygenation