Emergencies in Obstetrics

Paul C. Browne, M.D.Associate Professor

Department of Obstetrics and GynecologyUSC School of Medicine

Disclosures

Nature of Financial Relationship:

•Grant/Research Support–•USC School of Medicine•March of Dimes

Objectives• 1. Define “Emergency• 2. Triage for Pregnancy Emergencies• 3. Maternal versus Fetal Emergencies• 4. Change in Mental Status• 5. Hemorrhage• 6. Cardiac/Pulmonary Insufficiency• 8. Trauma• 9. Cardiac Arrest• 10. Appropriate Maternal Evaluation• 11. Appropriate Fetal Evaluation

Definition of Emergency

• “An emergency is the sudden onset of symptoms which, in the opinion of a reasonable and prudent lay person, require immediate medical attention and where lack of treatment would pose a significant health risk to the mother or her unborn child”

Components of Emergency

• Sudden onset

• Symptoms which require immediate attention

• Lack of treatment may cause harm

• Mother and/or fetus

Examples

• Chronic bleeding• Acute bleeding• Sudden-onset is

an emergency

Courtesy mybloodyourblood.org

Examples• Symptoms which require immediate

attention• Preterm labor

Courtesy activebodycare.co.uk

Examples• Lack of Treatment may cause harm

Courtesy topnews.in and statejournal.com

Fetal Emergencies

• No Fetal Movement

• Vaginal Bleeding

• Preterm Labor

• Abdominal Trauma

Viability• World Health Organization/ACOG

– 20 weeks gestation– 350 Grams

• State of South Carolina– Completion of “Second Trimester”

• Your ER– 20 weeks gestation– Positive fetal heart rate

Statement of AAP• Less than 23 weeks gestation

– No mandate to resuscitate secondary to uniformly poor outcomes

• 23-25 weeks– Resuscitation on a case by case basis in

consultation with the parents and NICU professionals

• Greater than 25 weeks– Ethical mandate for resuscitation in absence of

an anomaly incompatible with life

Maternal Emergencies

Altered mental status

Hemorrhage/DIC

Cardiopulmonary insufficiency

Trauma

Cardiopulmonary arrest

Change in Mental Status

• Disorientation• Aphasia• Slurred Speech

Causes of Altered Mental Status

• Recreational Drugs• Hypotension

(internal bleeding)• Diabetes• Seizure (post-ictal

eclampsia)

Triage of Altered Mental Status• Vital signs

– Pulse, Blood Pressure

• IV access

• Fingerstick glucose

• Urine drug screen

• Fetal heart rate by doppler

• Abbreviated EEGJ Clin Neurophysiol. 2007 Feb;24(1):16-21

Mental Status Score

Courtesy Scripps Mercy Hospital

Triage of Altered Mental Status

• Majority of cases will be caused by drug use or metabolic disturbance

• Easily corrected in ER setting

Altered Mental Status Triage

• Hypoglycemia– Treat and release

• Hypotension– Improved without bleeding

• Seizure– Only with known seizure disorder

Treatment• IV Hydration

– D5LR at 125 ml/hr

• Oxygen– 2 liters/minute nasal cannula

• Serial Vital Signs

• Serial Mental Status Checks

• Monitor fetal status

Recreational Drug Use• Observation

admission– DHSS referral– Arrange outpatient

drug rehab– Schedule birth

defect screening

Courtesy pregnancy.about.com

Intracranial Hemorrhage

• Rare cause of altered mental status

• Lateralizing signs

• Often associated with seizures

• Source of medical-legal action

Courtesy casereports.net and catscanman.net

Pearls in management of altered mental status

• Global neurological dysfunction– Drugs, metabolic disturbance, low BP

• Focal neurological dysfunction– Seizure disorder, migraines, CVA

• Parallel workups– Differential diagnosis evolves

Summary-Altered Mental Status

• Usually corrected in ER

• Secure patient

• Start IVF with dextrose/give O2

• Obtain labs/imaging

• Serial neuro checks until resolution

• Admit for substance abuse and eclampsia

Hemorrhage• 2nd leading cause of maternal death

• Unique physiology– Pregnant women are prepared to bleed

• Increased blood volume• Increased blood clotting

– Decompensate with rapid hemorrhage• Abruptio placenta• Severe trauma• Difficult cesarean section

2007 SC DHEC Vital Statistics

Bleeding

Courtesy thepregnancyzone.com

Triage of Bleeding• Blood from vagina

– Labor– Rupture of membranes– Abruption

• Blood from anywhere else– Trauma– Epistaxis (nosebleed)– GI bleeding

Vaginal Bleeding• First Thing

– Confirm fetal heart rate• Important labs

– Baseline hematocrit– Platelet Count– Fibrinogen– Drug screen

• Sterile Speculum Exam– Locate source of bleeding

• Ask the big question– Did you have sex within the past 24 hours?

Blood from Anywhere Else• Stop the bleeding• Need consultants

– Trauma surgeons, hematologists

• Important labs– Baseline hematocrit– Platelet count– Work-up coagulopathy

• Von Willebrand disease• Factor IX Deficiency

Bleeding-What’s the Baseline?

Hct > 30%Platelets >150,000

Fibinogen > 250 mg%Courtesy robetech.com

Most likely incorrect diagnosis in Obstetrics?

• DIC-Disseminated Intravascular Coagulation

DIC versus Coagulopathy

• DIC is a primary diagnosis

• Coagulopathy occurs with – Excessive surgical blood loss– Amniotic fluid embolism– Prophylactic anti-coagulation– Pre-eclampsia– Sepsis

Best Description

• Coagulopathy– “any disorder of blood coagulation”

• DIC– “a serious medical condition that

develops when the normal balance between bleeding and clotting is disturbed”

Thefreemedicaldictionary.com

Skin manifestations of DIC

Courtesy dermaamin.com

Consumption versus DIC• Exhaustion of pro-coagulants from

hemorrhage versus inappropriate depletion of pro-coagulants internally

• Macro clotting versus microvascular clotting

• At 2000-3000 ml, recovery time to replace lost pro-coagulants is exceeded

Consumption-Abruption

Courtesy cbbsweb.org

DIC-Amniotic Fluid Embolism

Courtesy brown.edu

Treatment of DIC• Stop the inciting process

– Sepsis– Surgical blood loss

• Anticoagulation with heparin– Stop intravascular clotting

• Recombinant Factor VIIa– Directly initiate thrombin formation at

sites of abnormal bleeding

Treatment of Coagulopathy

• Replacement of whole blood– PRBC’s and Clotting factors

• Replacement of clotting factors– FFP, dehydrated FFP (cryo)

• Recombinant Factor VII/Fibrin glue– Rapid direct initiation of thrombin

Emergency Release Blood

• Whole Blood not available

• Make Whole Blood from Packed RBC’s and Fresh Frozen Plasma

• Order 2 units of each stat

• Order 2 additional units of PRBC’s and FFP cross-matched

Emergency Release Blood

• Men-Opos PRBC’s

• Women-Oneg PRBC’s

• Both-ABpos FFP

Palmetto Health Baptist Blood Bank

Bleeding-What’s the Baseline?

Hct > 30%Platelets >150,000

Fibinogen > 250 mg%

Courtesy robetech.com

Replacement• Plain IVF work well

– Lactated Ringers– 0.5 normal saline

• PRBC/FFP is OK for emergency

• PRBC’s best for hemorrhage

• FFP at 1:1 units PRBC’s

• Platelets don’t usually help

Factor viia

• 80 patients with postpartum hemorrhage

• 2.5% mortality

• 95% effective

• Majority of patients require 1 dose

Ceska Gynecol 2010;75:297

Clin Obstet Gynecol

2010;53:219

Topical Hemostatics

• Lattice frame for coagulation– Collagen– Potato starch

• Fibrin glue

Lattice for fibrin deposition

Courtesy cardinal.com

Lattice for fibrin deposition

Courtesy policemag.com

Fibrin Glue

Courtesy laparoscopyhospital.com

Treatment of Coagulopathy• Lattice material

– Must have circulating anticoagulants for these to work

– Ineffective in DIC

• Replacement FFP and Factor VIIa– Correct the deficiency of pro-coagulants– Initiate thrombin formation at site of

abnormal bleeding

Summary-Coagulopathy• Not all bleeding disorders are DIC• Chicken versus the egg

– Bleeding then coagulopathy (not DIC)– Coagulopathy then bleeding (DIC)

• Most common clinical situation– Abruption– Difficult cesarean section

• Treat with replacement and Factor VIIa

Cardio-Pulmonary Insufficiency• Rare but serious emergency

• Tachypnea/tachycardia combination

• Presenting symptoms– SOB– Syncopal episode at home

• Best question to ask– Orthopnea

Symptoms

Courtesy answerbag.com

Causes of Cardiopulmonary Insufficiency

• Fluid overload

• Pre-eclampsia

• Tocolysis

• Cardiomyopathy

• Pulmonary Embolism

Triage of SOB/Syncope• Vital signs

– Pulse, respiratory rate, BP

• Oxygen saturation– Normal > 92%

• Oxygen treatment– Cannula is usually sufficient– Humidity

• IV access (Lactated Ringers)

What makes Pregnant Women Unique?

• Respiratory rate higher– Decrease TLC, FRC– Normal less than 26/minute

• Pulse higher– Compensates for increased cardiac

output– Often greater than 100/minute

Helpful Laboratory Studies• Echocardiogram

– Ejection fraction• Renal function tests• Not helpful

– CXR• Typically shows cardiomegaly and poor

pleural demarcation in bases– BNP

• Always elevated– ABG

• Rarely shows CO2 retention

Cardiac Function

Pulmonary Function

Courtesy glowm.com

Treatment for SOB• Diuresis

– Lasix 10-20 mg IV

• Fluid restriction

• Oxygen

• Sedatives– Morphine 5-10 mg IV– Xanax 0.25 mg po

Cardio/Pulmonary Insufficiency

• Automatic admission

• Critical care if available

• Lots of consults– OB, Cardiology, Pulmonary, Renal

Remote Fetal Monitoring

• Only if Viable

• Protocol with OB nursing– Critical care

should not be responsible

Courtesy delphine.latte.com

Summary-Cardio-Pulmonary Insufficiency

• Elevate head

• Tilt pelvis

• Oxygen saturation monitoring

• EKG

• LISTEN!– Rales-Pulmonary Fluid Overload– Wheezes-Allergies or asthma

Trauma• Usual causes

– MVA– Fall– Domestic Violence

• Unusual causes– Gunshot/Shotgun injury– Knife wound

Trauma

Courtesy centralnewyorkinjurylawyer.com

Courtesy Volvo

Courtesy howstuffworks.com

Courtesy coloribus.com

Trauma• Categorize Trauma

– Blunt (most common)• Injury to abdomen• Injury to other areas (head, extremities)

– Sharp (less common)• Injury to abdomen• Injury to other areas

Doumentation

• When OB was first contacted

• When OB responded

• When fetal cardiac activity was confirmed

Laceration Repair• Verbal orders to ER physician

• Local anesthesia– Lidocaine +/- epinephrine

• Oral/IM antibiotic therapy

• Acetominophen

• Narcotics

X-Rays

Courtesy thestir.cafemom.com

X-Rays• Always when medically indicated

– Plain films have less exposure– CT scans without contrast– MRI may be best imaging

• Appropriate to have permission– Disclaimers– Can’t do when unconscious– Establish next-of-kin

Imaging Studies

Courtesy University of Rochester

Priority List• Head/Spine injury work-up

– X-Rays/MRI, neuro checks– Poor anesthesia risk for delivery

• Work-up for occult abdominal hemorrhage– Ruptured liver/spleen

• Extremity injury

Summary-Trauma• Fetus is rarely injured

• Placenta is often injured

• Litigation is frequent– Document fetal events– Document interactions with OB

• Team approach is best

• Have a plan for rapid transfer

Courtesy babble.com

Causes for arrest during pregnancy

• Trauma• Pre-eclampsia• Magnesium toxicity• PE/Amniotic fluid embolism• Anesthesia• Cardiac disease

– Marfan Syndrome Aortic Dissection– Acute coronary syndrome

Why are Pregnant ER Patients Different?

• Less Risky Behavior– Less Alcohol– Less Drugs/Medication

• Less likely to be charged with an MVA– Drive with their children– Wear their seat belts

• Less likely to settle disputes with violence– Suicide attempts are usually overdose– Don’t frequent clubs

Survival from Cardiac Arrest

• Out of hospital– 40% survival

• In-hospital– 25% survival

Arrest in Women• Arrest occurs 1/3 as often as in men

• Lower incidence of ventricular fibrillation

• Lower resuscitation rates after arrest (29 versus 32%)

• Lower survival rates following resuscitation (11 versus 15%)

Circulation 2001;104:2699

Arrest secondary to Anesthesia complications

• 1990-2003 malpractice cases

• 69 patient deaths or severe brain injuries alleged secondary to OB anesthesia

• 18% OB cases versus 7% of non-OB cases related to airway problems

Anesthesiaology 2009;110:131

Courtesy digital02.com

What’s different doing CPR on pregnant women?

• Left lateral decubitus position

• Hands-only bystander

• Airway and CPR for healthcare providers

• Cesarean section in 5 minutes

Courtesy AHA

Year Citation Number of

Cases

Outcome

2011 J Matern Fetal Neo

Med

2 0%

2011 Isreal Med J

1 0%

2011 Anesthes Intensive

Care

1 100%

2011 Transplant Proc

1 0%

Courtesy medgadget.com

Survival Therapeutic Hypothermia

Survival Normothermia

Australia 77 patients

49% 26%

P<0.05

Europe275 patients

55% 39%

P<0.05

N Engl J Med 2010;363:1262

Summary Cardiac Arrest• Rare event during pregnancy

• CPR must be adapted– LLD, rapid cesarean section

• Poor chance for survival

• Brain injury most significant sequela

• Brain cooling for adults improves intact survival

Transfer

Questions?