obstetrics common dilemmas-wfbuys

7/28/2019 Obstetrics Common Dilemmas-WFBuys

1/34

common obstetric

dilemmas and

anaesthesiaWillem Buys

Department of Anesthesiology and Critical Care

Tygerberg Academic Hospital


2/34

Maternal Mortality

Non-pregnancy related infection 45% (HIV, TB,pneumonia)

Hypertensive disease 20% Haemorrhage 15% Sepsis 7% Medical causes 5% Anaesthesia 2%


3/34

Venous

Thromboembolism

First world USA 10.2% deaths UK 10.9% deaths

UK thromboprophylaxis strategy: 1.94 per 100 000 down to 0.79 per 100 000


4/34

Post-partum

Prophylaxis


5/34


6/34

Case presentation

Hypertensive disease - 20% mortality


7/34

Case 1 - History

23 y female Primigravida, 37weeks GA Two seizures at home BP 180/108, GCS 14/15, PEARL RPR-, Rh+, HIV+, CD4 318, not on HAART Booked, 3 visits

Normotensive, urine N,

no oedema


8/34

Case 1 - Examination

BMI 31 BP 160/100, PR 85 CNS:

GCS 10/15, PEARL, no focal signs Chest: crepitations, CVS: sinus tachycardia Abdomen soft


9/34

Case 1

SIDE-ROOM:

Urine: coke coloured +++

Proteinuria: 4+

LABORATORY:

Hb: 11.6 g/dl

Plt: 80

Urea: 5.1 mmol/l

Creatinine: 101 micromol/l


10/34

Case 1

CTG non-reassuring

Eclampsia

HELLPsyndrome

Foetal

distress


11/34

Case 1 - Anaesthetic

ASA 4E Monitors: basic, A-line, CVP Premed: MgSO4 4g, Metoclopramide, Na-Citrate GA: Alfentanil, etomidate, suxmethonium, RSI MgSO4, morphine, isoflurane Labetalol 5mg, phenylephrine prn


12/34

Case 1 -

Haemodynamics

BP: 120/80 to

160/100


13/34

Case 1 Pre-

Extubation

Breathing

Moving all limbs

Pupils: R 6mm, L2mm


14/34

CT scan

Parenchymalhaematoma

Midline shift

Haemorrhagic

contusions

HYPERTENSIVE

ENCEPHALOPATHY

+HAEMORRHAGE


15/34

Case 1 - ICU

ABG

pH 7.27PO2 42.9

PCO2 2.96

Lac 12.4

Hb 4.5

BE -15.6

IPPV

CVS collapse

Adrenaline

RIP


16/34

The dilemma

General anaesthetic?

Spinal?

Platelets?


17/34

Eclampsia and HELLP

Pre-eclampsia 8%

Mortality

eclampsia

10%

Intracranialhaemorrhage

GA fatalities:

Airway

Failed intubation

BP intubationresponse

Low platelets 15%


18/34

Monitoring?

CVP:

Pulmonary oedemaOliguria

A-line:

Refractory HTInfusion


19/34

Eclampsia and HELLP

Spinal:

Eclamptic

Conscious

IV Magnesium

Plt > 75 x 109/l

GA:

Severe coag

HELLP

Pulm oedema

Cerebral oedema


20/34

Dyer et al, SAMJ 2004;94(3)


21/34


22/34


23/34


24/34

Obstetrichaemorrhage

Obstetric


25/34

Obstetric

haemorrhage

Gravid uterus 12% of CO 15% maternal mortality Lethal causes of massive haemorrhage:

Abruptio placentae Post partum haemorrhage Placenta praevia


26/34

Placenta Praevia

Elective CS Regional

No previous CS No demonstrable placenta

accreta

Clinically significanthaemorrhage risk

Major grade of praevia Number of previous

deliveries

Postpartum


27/34

Postpartum

Hemorrhage

PPH on the increase in Canada, Australia and UK Uterine atony in 75% of cases

A well contracted uterus is the treatment for 75% ofPPH!


28/34


29/34

PPH Management

Identify and Recognize Enough hands, enough legs,

highest expertise

Stick to the basics ABC Two 14G cannulas,

appropriate monitoring

Resus aggressively, monitoryour resus

Appropriate high care post-op


30/34

Obstetric


31/34

Obstetric

Haemorrhage

Transfusion protocols stilluncertain

Trauma literature:

RPC: FFP: Plt 1:1:1

Antifibrinolytics Tranexamic acid may reduce

blood loss

Cell salvage widely acceptedin UK

All cases at risk of excessivehaemorrhage


32/34

Lethal Triad

COAGULOPATHY

HYPOTHERMIA ACIDOSIS


33/34

Nutshell

Carry on reading Carry on teaching

Be ready to save lives

Keep your system ready tosave lives


34/34

Thank You

obstetrics common dilemmas-wfbuys

Documents