obstetric emergencies dr mohamed abdul hakim kotb,mbbch,msc,md anaesthesia & icu
TRANSCRIPT
Obstetric EmergenciesObstetric Emergencies
Dr Mohamed Abdul Hakim Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD Kotb,MBBCH,MSC,MD
Anaesthesia & ICUAnaesthesia & ICU
Obstetric emergenciesObstetric emergenciesMassive obstetric haemorrhageMassive obstetric haemorrhage
Non-haemorrhagic shock:Non-haemorrhagic shock:– Amniotic fluid embolismAmniotic fluid embolism– Acute uterine inversionAcute uterine inversion
Shoulder dystociaShoulder dystocia
EclampsiaEclampsia
Cord prolapseCord prolapseCardiac ArrestCardiac ArrestAnaphylaxisAnaphylaxisTRAUMATRAUMA
BASIC PRINCIPLES FOR OBSTETRIC BASIC PRINCIPLES FOR OBSTETRIC EMERGENCIES.EMERGENCIES.
Physiological changes in pregnancy modify:Physiological changes in pregnancy modify:• Presentation of the problemPresentation of the problem• Normal physiological variablesNormal physiological variables• Response to treatmentResponse to treatment
Both mother & fetus are affected by the pathology & Both mother & fetus are affected by the pathology & subsequent treatment.subsequent treatment.
Mother’s welfare always takes precedence over fetal Mother’s welfare always takes precedence over fetal concerns ---concerns ---Fetal survival is usually dependant on optimal maternal Fetal survival is usually dependant on optimal maternal management.management.
•
MASSIVE OBSTETRIC MASSIVE OBSTETRIC HAEMORRHAGEHAEMORRHAGE
Major contributor to maternal mortalityMajor contributor to maternal mortalityDefinitionDefinition– Blood loss requiring replacement of patient’s total blood Blood loss requiring replacement of patient’s total blood
volumevolume– Transfusion requiring > 10 u of blood in 24 hsTransfusion requiring > 10 u of blood in 24 hs– 50% replacement of blood vol. <3 hs period50% replacement of blood vol. <3 hs period
Difficult to estimate blood lossDifficult to estimate blood lossProblem of concealed bleedingProblem of concealed bleeding– UterusUterus– Broad lig.Broad lig.– Peritoneal cavityPeritoneal cavity
RECOGNISING SIGNIFICANT RECOGNISING SIGNIFICANT BLOOD LOSSBLOOD LOSS
10 – 15%10 – 15%500-1000ml500-1000ml
Normal BPNormal BP
No signs.No signs.
15-25%15-25%1000-1500ml1000-1500ml
BP ~ 100mmHgBP ~ 100mmHg
Dizziness, Dizziness, tachycardiatachycardia
25-35%25-35%1500-2000ml.1500-2000ml.
BP ~ 70-80mmHg.BP ~ 70-80mmHg.
Restlessness,pallor, Restlessness,pallor, oliguria.oliguria.
35-45%35-45%2000-3000ml2000-3000ml
50-70mmHg50-70mmHg
Collapse, air hunger, Collapse, air hunger, anuriaanuria
Factors contributing to maternal Factors contributing to maternal death from catastrophic PPHdeath from catastrophic PPH
GeneralGeneralIncreased oxygen and Increased oxygen and cardiac output cardiac output requirements of requirements of pregnancy may hamper pregnancy may hamper adequate blood / volume adequate blood / volume replacementreplacement– Placental bed perfusion 600 Placental bed perfusion 600
mls/minmls/min
Blood loss Blood loss underestimatedunderestimatedDelayed or inadequate Delayed or inadequate managementmanagementInadequate resources / Inadequate resources / personnelpersonnel
SpecificSpecificFailure to anticipate Failure to anticipate coagulopathycoagulopathyPET, abruption, sepsis, PET, abruption, sepsis, IUFD, IUFD, AFE.AFE.Abnormal placentationAbnormal placentationPlacenta praevia / accretaPlacenta praevia / accretaJehovah’s witness**Jehovah’s witness**
Mechanism of DICMechanism of DIC1) intravascular infusion of thromboplastic 1) intravascular infusion of thromboplastic substances that initiate the extrinsic substances that initiate the extrinsic coagulation systemcoagulation system– placental abruption, IUFDplacental abruption, IUFD
2) conditions associated with endothelial 2) conditions associated with endothelial cell damage, which activates both the cell damage, which activates both the extrinsic and intrinsic coagulation systemsextrinsic and intrinsic coagulation systems– eclampsia/ PETeclampsia/ PET
3) indirect effects of other disease, such as 3) indirect effects of other disease, such as G- sepsis, AFE etcG- sepsis, AFE etc
Preventative Management PPHPreventative Management PPH Detect and treat antenatal anaemia Detect and treat antenatal anaemia Active Management of Third StageActive Management of Third Stage
Administration of a prophylactic oxytocin Administration of a prophylactic oxytocin Early cord clamping Early cord clamping Controlled cord traction of the umbilical cord. Controlled cord traction of the umbilical cord.
Advantage of active management = reduction in the Advantage of active management = reduction in the incidence of PPH by 40%incidence of PPH by 40%
IV access plus collect blood for grouping IV access plus collect blood for grouping and cross matching if assessed as at risk. and cross matching if assessed as at risk.
Available from Royal Women’s Hospital, Carlton, Clinical Practice Guidelines: http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3333
Management PrinciplesManagement Principles
OrganisationOrganisationrestoration of blood volumerestoration of blood volumecorrection of coagulopathycorrection of coagulopathyevaluating response to treatmentevaluating response to treatment
monitoring PR, BP, CVP, ABG, UOPmonitoring PR, BP, CVP, ABG, UOPIf resuscitation is adequate P & BP should return If resuscitation is adequate P & BP should return to normalto normal
treat the causetreat the causeabruptionabruptionplacenta praeviaplacenta praeviauterine ruptureuterine ruptureplacenta accretaplacenta accreta
Available from Royal Women’s Hospital, Carlton, Clinical Practice Guidelines: http://www.rwh.org.au/rwhcpg/womenshealth.cfm?doc_id=3333
NON-HAEMORRHAGIC NON-HAEMORRHAGIC OBSTETRIC SHOCKOBSTETRIC SHOCK
Uncommon but responsible for Uncommon but responsible for majority of maternal deaths in majority of maternal deaths in developed countries.developed countries.
-Amniotic fluid embolus-Amniotic fluid embolus
-Acute uterine inversion-Acute uterine inversion
Amniotic Fluid EmbolismAmniotic Fluid Embolism
– Passage of amniotic fluid debris into maternal circulation
– Obstructs pulmonary circulation
– Cardio-respiratory arrest
AMNIOTIC FLUID EMBOLISMAMNIOTIC FLUID EMBOLISM
Clinical featuresClinical features– Multiparous womenMultiparous women– Precipitous labourPrecipitous labour– Presence of intact membranesPresence of intact membranes– Sudden dyspneaSudden dyspnea– HypotensionHypotension– Seizure activity not uncommonSeizure activity not uncommon– If survive initial insultIf survive initial insult
70% suffer non-cardiogenic pulmonary oedema70% suffer non-cardiogenic pulmonary oedema
ARDSARDS
AMNIOTIC FLUID EMBOLISMAMNIOTIC FLUID EMBOLISM
DiagnosisDiagnosis– Consider in all obstetric patients with Consider in all obstetric patients with
sudden collapse.sudden collapse.– DifferentialDifferential
PTEPTE
Septic shockSeptic shock
MIMI
Aspiration pneumoniaAspiration pneumonia
Allergy to drugAllergy to drug
ManagementManagement
Secure airwaySecure airway
treat cardiovascular collapsetreat cardiovascular collapse
central venous linecentral venous line
acute left ventricular failure: digoxinacute left ventricular failure: digoxin
dopaminedopamine
correct coagulopathycorrect coagulopathy
treat metabolic/electrolyte treat metabolic/electrolyte abnormalitiesabnormalities
Acute Uterine InversionAcute Uterine Inversion
Most commonly arises from Most commonly arises from mismanaged 3mismanaged 3rdrd stage stage
PresentationPresentation
Sudden collapse in 3Sudden collapse in 3rdrd stage stage
Degree of shock inconsistent with Degree of shock inconsistent with blood lossblood loss
Shock is neurogenic in natureShock is neurogenic in natureTraction on infundibular pelvic ligamentTraction on infundibular pelvic ligament
May be no palpable fundusMay be no palpable fundus
Mass in vagina/introitusMass in vagina/introitus
ManagementManagement
Avoid mismanagement of 3Avoid mismanagement of 3rdrd stage of stage of labourlabour
Once occursOnce occurs– Anti-shock measuresAnti-shock measures– If placenta still attached remove after If placenta still attached remove after
uterus is replaceduterus is replaced– Manual replacement of uterusManual replacement of uterus– O’Sullivans hydrostatic pressureO’Sullivans hydrostatic pressure– Surgical correctionSurgical correction
Shoulder DystociaShoulder Dystocia
Erb’s palsy
‘‘It all comes,’ said Pooh crossly, ‘of not It all comes,’ said Pooh crossly, ‘of not having front doors big enough’having front doors big enough’
‘‘It all comes’, said Rabbit It all comes’, said Rabbit sternly, ‘of eating too much’sternly, ‘of eating too much’
Risk FactorsRisk FactorsMacrosomia (>4kg)Macrosomia (>4kg)– maternal diabetesmaternal diabetes– post datespost dates– maternal obesitymaternal obesity– high maternal wgt high maternal wgt
gain in pregnancygain in pregnancy– advanced maternal advanced maternal
ageage– previous large infantprevious large infant– previous shoulder previous shoulder
dystociadystocia
IntrapartumIntrapartum– protracted late active protracted late active
phasephase– prolonged 2nd stageprolonged 2nd stage– delay in head descent delay in head descent
in 2nd stagein 2nd stage– mid-pelvic operative mid-pelvic operative
deliverydelivery
The combination of macrosomia and delay in 2nd stage predicts 35% of shoulder dystocia
EclampsiaEclampsia
1/15001/1500
ComplicationsComplications
Cerebrovascular injuryCerebrovascular injury
pulmonary oedemapulmonary oedema
coagulopathycoagulopathy
maternal/fetal deathmaternal/fetal death
HELLP syndromeHELLP syndrome
PresentationPresentation
Hypertension, hyperreflexia, clonus, Hypertension, hyperreflexia, clonus, headache, visual changes, seizureheadache, visual changes, seizure
20% have diastolic BP<90, normal 20% have diastolic BP<90, normal reflexes, and urinary protein <2+reflexes, and urinary protein <2+
70% of deaths due to intracerebral 70% of deaths due to intracerebral haemorrhagehaemorrhage
Management Management
• • Goals:Goals:– – Stabilization of the mother/seizure controlStabilization of the mother/seizure control• • MgSO4 therapy: 4-6 g over 20 min MgSO4 therapy: 4-6 g over 20 min
followed byfollowed byinfusion of 1-3 g/hr, ORinfusion of 1-3 g/hr, OR• • Thiopental or diazepam followed by Thiopental or diazepam followed by
MgSO4MgSO4infusioninfusion– – Airway managementAirway management– – Avoiding aspirationAvoiding aspiration
Prolapsed CordProlapsed Cord
1/500 deliveries
Most occur during ARM
PresentationPresentation
Cord visible outside the introitusCord visible outside the introitus
CTG abnormalities appearCTG abnormalities appear– variable decelerationsvariable decelerations– fetal bradycardiafetal bradycardia
Note: fetal or maternal injury due to Note: fetal or maternal injury due to hasty interventionhasty intervention
ManagementManagementKeep cord warm - replacing in vagina Keep cord warm - replacing in vagina may helpmay helpKeep pressure off cord by gloved Keep pressure off cord by gloved hand in vagina lifting fetal part off the hand in vagina lifting fetal part off the cordcord
Positioning,Maternal OPositioning,Maternal O22, IV access, IV accessIf fetus is alive, operative delivery - If fetus is alive, operative delivery - CS if not able to deliver vaginallyCS if not able to deliver vaginallyIf fetus is dead, vaginal delivery if If fetus is dead, vaginal delivery if presentation allowspresentation allows
AnaphylaxisAnaphylaxisvasodilatation, smooth muscle contraction, vasodilatation, smooth muscle contraction, glandular secretion, increased capillary glandular secretion, increased capillary permeabilitypermeabilityManagementManagement: : – oxygenoxygen– colloidcolloid– bronchodilator bronchodilator – adrenaline (despite Ux stimulatory effect)adrenaline (despite Ux stimulatory effect)– anti-histamine (if angioneurotic oedema)anti-histamine (if angioneurotic oedema)– steroid (for refractory bronchospasm)steroid (for refractory bronchospasm)
Maternal cardiac emergencyMaternal cardiac emergency
Acute:Acute:– AMIAMI– Tocolytic therapyTocolytic therapy– Aortic dissecting aneurysmAortic dissecting aneurysm– Peripartum cardiomyopathyPeripartum cardiomyopathy: :
1 in 50000, 50% progress to end-stage 1 in 50000, 50% progress to end-stage heart failure (heart Tx), 50% recurrence.heart failure (heart Tx), 50% recurrence.Suspect if acute SOB, chest pain, abN Suspect if acute SOB, chest pain, abN ECG, signs LVF/RVFECG, signs LVF/RVF
– Traumatic myocardial contusionTraumatic myocardial contusion: ie: : ie: MCAMCA
Drug OverdoseDrug OverdoseIllicit drugsIllicit drugs: heroin, cocaine and : heroin, cocaine and amphetamines (these 2 can cause amphetamines (these 2 can cause hypertension, ^ C.O., decrease Uterine blood hypertension, ^ C.O., decrease Uterine blood flow, APH, cerebral haemorrhage, convulsions, flow, APH, cerebral haemorrhage, convulsions, arrhythmias).arrhythmias).Drug overdoseDrug overdoseDrug errorDrug errorAnaphylaxisAnaphylaxisHypermagnesaemiaHypermagnesaemia::– wide QRS on ECG, 5-6mmol/l lose tendon reflexwide QRS on ECG, 5-6mmol/l lose tendon reflex– resp. paralysis, SA and AV node blockresp. paralysis, SA and AV node block– cardiac arrest. cardiac arrest.
TreatmentTreatment: CaGluconate 10% 10ml slow IV: CaGluconate 10% 10ml slow IV
CARDIO-PULMONARY ARRESTCARDIO-PULMONARY ARRESTCardiac arrest rare in pregnancy (1 in 30000 Cardiac arrest rare in pregnancy (1 in 30000 deliveries)deliveries)
Usually associated with particular obstetric Usually associated with particular obstetric complications like amniotic fluid embolism, drug complications like amniotic fluid embolism, drug toxicity from Magnesium sulphate & local toxicity from Magnesium sulphate & local anesthetics.anesthetics.
Technique for external cardiac massage:Technique for external cardiac massage: External cardiac massage in non-obstetric patient External cardiac massage in non-obstetric patient
provides 30% cardiac output.provides 30% cardiac output. After 20 weeks reduced further due to veno-caval After 20 weeks reduced further due to veno-caval
compression.compression. Relief of aorto-caval compression part of BLS:Relief of aorto-caval compression part of BLS: left lateral tilt --- decreased efficacy of compressionsleft lateral tilt --- decreased efficacy of compressions wedge 27wedge 2700 angle allows 80% of maximal force to be angle allows 80% of maximal force to be
dissipateddissipated rescuer’s thigh as wedge.rescuer’s thigh as wedge.
Sodium bicarbonate controversial as it leads to fetal Sodium bicarbonate controversial as it leads to fetal acidosis but pH has to be kept above 7.30 to prevent acidosis but pH has to be kept above 7.30 to prevent uterine vasoconstriction.uterine vasoconstriction.
International Liaison Committee on Resuscitation International Liaison Committee on Resuscitation (ILCOR) (ILCOR) “ “ if there is no response to ALS, peri-mortem caesarean if there is no response to ALS, peri-mortem caesarean delivery should be made within 5 minutes of arrest”delivery should be made within 5 minutes of arrest”
TRAUMATRAUMAOccurs in 6-7% of all pregnancies.Occurs in 6-7% of all pregnancies.
Hospital admissions only 0.3- 0.4 % of all Hospital admissions only 0.3- 0.4 % of all pregnancies.pregnancies.
1% of all trauma cases are pregnant.1% of all trauma cases are pregnant.
Maternal deaths associated most commonly Maternal deaths associated most commonly with head injuries & severe hemorrhage.with head injuries & severe hemorrhage.
Fetal deaths associated with placental Fetal deaths associated with placental abruption & maternal death.abruption & maternal death.
ManagementManagementInitial resuscitation should follow normal plan of Initial resuscitation should follow normal plan of ABC.ABC.
Hypotension may not be present until 35% or Hypotension may not be present until 35% or more blood volume is lost.more blood volume is lost.
Aorto-caval compression releaseAorto-caval compression release
Rule out pelvic fractures, uterine injury & retro-Rule out pelvic fractures, uterine injury & retro-peritoneal hemorrhageperitoneal hemorrhage
Fetal monitoring with cardio-tocographic monitor Fetal monitoring with cardio-tocographic monitor
Rh immunoglobulin – within 72 hours.Rh immunoglobulin – within 72 hours.
Radiation hazards: Radiation hazards: 11stst trimester >5 rads trimester >5 rads
Chest x-ray < 5 radsChest x-ray < 5 rads
Pelvic film <1 radsPelvic film <1 rads
Abdomino-pelvic CT scan 5-10 radsAbdomino-pelvic CT scan 5-10 rads
BURNSBURNSIncreased levels of prostaglandins predispose to Increased levels of prostaglandins predispose to pre-term labour.pre-term labour.
Replacement of fluids vis-à-vis increased volumes Replacement of fluids vis-à-vis increased volumes in pregnancy.in pregnancy.
Inhalational injury- hypoxia & carbon monoxide Inhalational injury- hypoxia & carbon monoxide poisoningpoisoning
Infections- prophylactic antibiotics controversialInfections- prophylactic antibiotics controversial
Topical Povodine iodine- affects fetal thyroid Topical Povodine iodine- affects fetal thyroid functionsfunctions