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Pitfalls in the Second Half of Pregnancy

Charlotte Page Wills, MD Associate Program Director Alameda Health System-Highland Hospital EM Residency, Oakland, CA Associate Clinical Professor of Emergency Medicine University of California, San Francisco School of Medicine

Financial  Disclosures:  None!  

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• The following is NOT meant to replace the expertise and guidance of a skilled Obstetrician and Perinatologist!

• Expert consultation should always be sought in the care of any pregnant patient greater than twenty weeks gestation or other high risk obstetric case.

• This lecture recognizes, however, that the resources of an expert consultant may not always be immediately available, and aims to provide basic guidance in the approach to Emergency Department management of these patients.

Disclaimer!!

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In the next 30 minutes…!

•  Highlight changes in physiology important to managing patients in the second half of pregnancy.!

•  Describe the basic approach to initiate evaluation and management of the gravid patient.!

•  Describe how to evaluate a fetus as viable or nonviable.!

•  Illustrate the pitfalls of pre-eclampsia and preterm labor.!

•  Discuss some of the obstetric emergencies that can arise in the ED precipitous delivery.!

maternal well-being

gestational age

labor status

fetal well-being

maternal well-being

• What’s normal? Know the physiologic changes that occur in pregnancy.

• Where do I start? Perform standard maneuvers for resuscitation in all pregnant patients.

•  Identify underlying disease and treat aggressively.

High Volume, Low Pressure

BP!

Hct!CO!

Vol!

HR!

SVR!

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Second and Third Trimester Resuscitation

•  Dilu8onal  anemia:  replace  volume  loss;  in  sepsis  transfuse!  

• Oxygena8on:  high  oxygen  content,  increased  minute  ven8la8on  and  TV.  

•  Aortocaval  compression:  pelvic  8lt  or  manual  uterine  distrac8on.  

•  Progesterone:  an8cipate  a  difficult  airway  and  aspira8on.  

Aortocaval Compression

• IVC may be completely obstructed in the supine position.

• Uterus receives 30% of cardiac output.

• Compression occurs at 20 weeks.

• CPR only produces about 10% normal CO.

Avoiding Compression!

•  Tilt the backboard!

•  Blanket roll!

•  Manual distraction of the uterus!

labor status

fetal well-being

maternal well-being

gestational age

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gestational age

• Traditional: Last menstrual period, fundal height.

• Difficult in the obese patient.

•  Is inaccurate with multiple gestations.

• Ultrasound:

• Can be learned easily.

• Can be quickly performed.

Rapid Pregnancy Dating by EP’s

•  Sonographers had a wide range of experience. •  Exams had a high degree of correlation with gold standard. •  Measurements of BPD and FL took less than one minute. •  Was more accurate than measuring fundal height.

•  96% ULS versus 80% for FH

Accuracy of emergency physicians using ultrasound to determine gestational age in pregnant women

Sachita Shah, Nathan Teismann, Brita Zaia, Farnaz Vahidnia, Gerin River, Dan Price, Arun Nagdev

American Journal of Emergency Medicine - 29 March 2010 (10.1016/j.ajem.2009.07.024)

BPD Measurement!

labor status

fetal well-being

maternal well-being

gestational age

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labor status

•  Labor: contractions with progression of the cervix •  Requires uterine monitoring. •  Requires examination of the cervix visually and

manually or by ultrasound. •  Bleeding: may be from labor, trauma, or the placenta

•  Requires extreme caution with the vaginal/cervical examination.

•  Membranes: may rupture from labor or infection •  Requires determining presence or absence of

amniotic fluid.

•  Visual inspection: pooling of amniotic fluid on sterile speculum exam. Most sensitive finding.

•  Ferning: arborization of salt crystals in amniotic fluid.

•  Nitrazine Paper: amniotic fluid has a pH of 6.5 or higher.

Evaluating the Membranes!

•  Exams should be sterile.!

•  Minimize digital exams -rates of infection go up with numbers of exams in PROM.!

•  CONTRAINDICATED if you suspect placenta previa.!

Cervical Evaluation!

labor status

maternal well-being

fetal well-being

gestational age

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fetal well-being

•  Fetal heart rate (FHR) and activity: fetal monitor. •  Can use bedside ultrasound to assess both •  For greater than 20 weeks, fetal monitoring

is standard.

•  MUST come with a provider who can interpret fetal strips. •  Fetal distress or intrauterine infection. •  Both are indications to deliver a viable

fetus.

Supplies for Baby!•  Resuscitation surface:

infant warmer, surface with plenty of dry linens near an oxygen source.!

•  Infant mask and anesthesia bag/ambu bag.!

•  Dedicated person to dry, stimulate, warm the infant.!

26 yo woman complaining of headache and abdominal cramping stating she is 6 months pregnant. BP

is 158/98 and HR is 118.!

Pregnant  

HTN   Headache  

Pre-­‐eclampsia  

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Headache

•Hypertensive •No bleeding •Mildly tender uterus

CBC CMP Uric acid, LDH DIC Panel

UA

•Hemolysis •Elevated LFTs •Platelet consumption

•Elevated creatinine •Proteinuria

Damaged Endothelium!

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BP!

Hct!CO!

Vol!

HR!

SVR!

High Volume, Low Pressure High Pressure, Low Volume!

End-Organ Damage!

•  PRES!

•  Renal failure!

•  Placental abruption!

•  DIC !

maternal well-being

gestational age

labor status

fetal well-being

Managing Pre-eclampsia!•  BP control: labetalol, nifedipine, hydralazine.!

•  Magnesium infusion for severe pre-eclampsia.!

•  Avoid lasix - patients are already volume depleted.!

•  Avoid excessive fluids - patients third space because of endothelial damage and proteinuria.!

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labor status

maternal well-being

fetal well-being

gestational age

Preterm Labor in the ED!•  Tocolytics: Still given but not proven!!

•  Calcium channel blockers now popular.!

•  Do not use more than one agent.!

•  Corticosteroids: Proven! Give them!!

•  Dexamethasone or betamethasone.!

•  Fetal lung maturity.!

•  Antibiotics: Proven, but only with ruptured membranes.!

•  Increase the latency period in PPROM.!

24 yo woman complaining of abdominal pain for several hours. She states her last

period was last month. You are summoned to the room and a code is called.!

+ROM   Pushing  

Delivers  

Pregnant  I had no idea!!

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maternal well-being

gestational age

labor status

fetal well-being

Pregnancy for Emergency Providers

week  13   week  27  

weeks  23-­‐24  

3  inches  15  grams  

12  inches  400-­‐600  grams  

15  inches  900  grams  

week  20  

pre-­‐viable  to  viable  

Clinically Determining Viability: Weight!

•  Less than 400 grams is considered nonviable.!

•  Requires quick access to an infant scale.!

Survival By Weight

Weight Survival Mod-Severe Disability

401-500g 11% *

501-600g 27% 29%

601-700g 63% 30%

701-800g 74% 28%

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Clinically Determining Viability: Ballard Score! Non-initiation of a Code!

•  Age less than 23 weeks.!

•  Weight less than 400 grams.!

•  Anencephaly.!

•  Lethal malformation: Trisomy 13 or 18.!

•  Calling a code: asystole greater than 15 minutes.!

30 yo woman is brought to the ED by friends with abdominal cramping and

rupture of membranes. She states she is about 34 weeks pregnant.!

34  weeks  Pregnant  

+ROM   Pushing  

Labor  

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Cord Prolapse!•  To the OR if possible.!

•  Elevate the presenting part.!

•  Kneeling position or steep Trendelenberg.!

•  Infusing the bladder with saline - although not as helpful if a presenting part is visible.!

Breech Delivery!• To the OR if possible!!• DO NOT PULL until the umbilicus is delivered.!

• Infant should deliver face down.!• Preterm infants are more likely to be breech.!

•  http://www.birthingway.com/footling_breech.htm#!

Shoulder Dystocia!•  “Turtle sign”.!

•  Difficult to predict.!

•  Fetal macrosomia!

•  Precipitous delivery!

•  NO fundal pressure/hold pushing until repositioned.!

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Reducing Dystocia!•  McRobert’s Maneuver!

•  Suprapubic pressure!

•  Delivering the posterior shoulder!

•  Rubin, Woods Corkscrew!

•  Zavenelli Maneuver!

Thermal Care!•  The item we are most likely to overlook

and under-manage!

•  Association between hypothermia and mortality: acidosis, respiratory distress, NEC, intraventricular hemorrhage!

•  The smaller you are, the faster you lose heat. BIG problem less than 30 weeks.!

•  Warm blankets, portable warming mattresses, warming tables, hats.!

Quick Trick!•  No blankets?!

•  “micro-preemie”?!

•  Use a 5 gallon freezer bag.!

•  Cut a hole in the top and seal the bottom.!

Post-Partum Care!•  Do not pull on the umbilical

cord.!

•  Gush of blood prior to placental detachment.!

•  Keep the mom warm and dry.!

•  Be vigilant for postpartum hemorrhage.!

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Postpartum Hemorrhage!•  Greater than 500 cc blood.!

•  Leading cause of death worldwide. In the US, second after VTE.!

•  Uterine atony and lacerations.!

•  Risk factors include advanced age, prior hemorrhage, older age, fetal macrosomia.!

Resuscitating PPH!•  Manual Interventions:!

•  Fundal massage, explore for lacerations, manual uterine exploration for retained products.!

•  Medical Interventions:!

•  Oxytocin, methylergonovine (ergot alkaloid), misoprostil.!

•  Resuscitation with fluids and blood.!

•  TXA now second-line.!

What we covered…!

•  Highlight changes in physiology important to managing patients in the second half of pregnancy.!

•  Describe the basic approach to initiate evaluation and management of the gravid patient.!

•  Describe how to evaluate a fetus as viable or nonviable.!

•  Illustrate the pitfalls of pre-eclampsia and preterm labor.!

•  Discuss some of the obstetric emergencies that can arise in the ED precipitous delivery.!

Thanks  

•  Arun  Nagdev,  MD  and  the  Division  of  Emergency  Ultrasound/Department  of  Emergency  Medicine  at  Highland  Hospital  for  ultrasound  exper8se  and  video  images.  

•  Alameda  County  Paramedics  Trevor  Mollenkopf  and  John  Younan,  and  Highland  charge  nurse  Liz  Lynch,  RN  for  their  assistance  with  audio  recordings  of  radio  ring  downs.  

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•Committee Opinion no. 514: emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia. - Committee on Obstetric Practice - Obstet Gynecol - 01-DEC-2011; 118(6): 1465-8 •Caring for women with hypertension in pregnancy. Sibai BM - JAMA - 3-OCT-2007; 298(13): 1566-8 •Abalos E., Duley L., Steyn D.W., et al: Antihypertensive drug therapy for mild to moderate hypertension during pregnancy. Cochrane Database Syst Rev 1. 2007;CD002252 •ACOG Committee on Obstetric Practice : Diagnosis and management of preeclampsia and eclampsia. ACOG practice bulletin no. 33. American College of Obstetricians and Gynecologists. Obstet Gynecol 99. 159-167.2002 •Hypertension and pregnancy. Deak TM - Emerg Med Clin North Am - 01-NOV-2012; 30(4): 903-17 •Nonobstetric abdominal pain and surgical emergencies in pregnancy. Diegelmann L - Emerg Med Clin North Am - 01-NOV-2012; 30(4): 885-901 •Critical obstetric and gynecologic procedures in the emergency department. Mercado J - Emerg Med Clin North Am - 01-FEB-2013; 31(1): 207-36 •Precipitous and difficult deliveries. Silver DW - Emerg Med Clin North Am - 01-NOV-2012; 30(4): 961-75 •GhGherman R.: Shoulder dystocia: prevention and management. Obstet Gynecol Clin North Am 32. 297-305.200 •Serman R.: Shoulder dystocia: an evidence based evaluation of the obstetric nightmare. Clin Obstet Gynecol 45. 345-362.2002; •Complications in late pregnancy. Meguerdichian D - Emerg Med Clin North Am - 01-NOV-2012; 30(4): 919-36 •Complications of second and third trimester pregnancies. K. Abbrescia Emerg Med Clin of N Am Vol 21 Issue 3 August 2003 •Early Goal Directed Therapy for Sepsis During Pregnancy. D Guinn Obstet Gynecol Clin N Am Vol 34 2007 •Accuracy of Emergency Physicians Using Ultrasound to Determine Gestational Age in Pregnant Women. S Shah, N Teismann, B Zaia, F Vahidnia, G River, D Price, A Nagdev Am Journal of Emerg Med March 2010 •The Enigma of Spontaneous Preterm Birth L Muglia, M Katz NEJM Feb 11, 2010

•Complications of second and third trimester pregnancies. K. Abbrescia Emerg Med Clin of N Am Vol 21 Issue 3 August 2003 •Early Goal Directed Therapy for Sepsis During Pregnancy. D Guinn Obstet Gynecol Clin N Am Vol 34 2007 •Accuracy of Emergency Physicians Using Ultrasound to Determine Gestational Age in Pregnant Women. S Shah, N Teismann, B Zaia, F Vahidnia, G River, D Price, A Nagdev Am Journal of Emerg Med March 2010 •The Enigma of Spontaneous Preterm Birth L Muglia, M Katz NEJM Feb 11, 2010 •Infections Related to Pregnancy. D Gorgas Emerg Med Clin N Am Vol 26, Issue 2 May 2008 •Cervical Dilation: Accuracy of Visual and Digital Examinations C Brown. Obstet and Gynecol Vol 81 No 2 Feb 1993 •Antenatal Corticosteroids for Accelerating Fetal Lung Maturation for Women at Risk of Preterm Birth (Review) Roberts D, Dalziel S Cochrane Database of Systematic Reviews 2006, Issue 3 Art No: CD004454 •Cervical Assessment by Ultrasound for Preventing Preterm Delivery (Review) Bergella V Baxter JK Cochrane Database of Systematic Reviews 2009. Issue 3, Art No: CD007235 •Cervical Sonography in Preterm Labor Obstetrics and Gynecology July 1994 Vol 84, no 1. •Magnesium Sulfate: The First-Line Tocolytic. D Lewis. Obstet Gynecol Clin N Am 32(2205) 485-500 •Biochemical Markers for the Prediction of Preterm Labor. J Yeast Obstet Gynecol Clin N Am 32(2205) 369-381 •Prediction and Early Detection of Preterm Labor. J Iams Obstetrics and Gynecology Vol 101. no 2 Feb 2003 •Major Obstetric Hemorrhage. F Mercier et al Anesthesiology Clin 26(2008) 53-66 •Nontraumatic Abdominal Surgical Emergencies in the Pregnant Patient. K Challoner. Emerg Med Clin N Am. 21 (2003) 97-985

•Outcomes of Expectantly Managed Preterm Premature Rupture of Membranes Occurring Before 24 Weeks of Gestation. T Manuck et al Obstetrics and Gynecology Vol. 114 No.1 July 2009 •A Systematic Review of Pregnancy Outcome Following Preterm Premature Rupture of Membranes at a Previable Gestational Age. H Dewan. Aust NZ J Obstet Gynaecol. Nov 2001, Vol 41 Issue 4; 389-94 •Conservative Management of Preterm Premature Rupture of Membranes Between 18 and 23 Weeks of Gestation--Maternal and Neonatal Outcome. U Verma, Eur J Obstet Gynecol Reprod Biol. Sep=Oct 2006; Vol 128(1-2) • Neonatal Outcome in Preterm Deliveries Between 23 and 27 Weeks/ Gestation With and Without Preterm Premature Rupture of Membranes. DE Newman Arc Gynecol Obstet Jul 2009 280(1): 7-11 •Expectant Management in Spontaneous Preterm Premature Rupture of Membranes between and 24 Weeks’ Gestation. S Falk J Perinatol 2004 Oct; 24(10): 611-6 •Clinical Course of Premature Rupture of the Membranes. J Alexander Semin Perinatol Oct 1996; 20(5): 369-74 •Premature Rupture of Membranes:ACOG Practice Bulletin. Number 80 April 2007. Obstet and Gynecol Vol 109, No 4 •Preterm Premature Rupture of the Membranes. B Mercer Obstet and Gynecol Jan 2003 Vol 101 No 1 • Expectant Management of Midtrimester Premature Rupture of the Membranes: A Plea for Limits. S Grisaru-Granovsky J Perinatology 2003; 23:235-239 •Antibiotic Therapy in Preterm Premature Rupture of the Membranes. M Yudin J Obstet Gynaecol Can 2009 Sep 31(9):863-7 •Effects of Digital Vaginal Examinations on Latency Period in Preterm Premature Rupture of Membranes D Lewis Obstetrics and Gynecology Vol 80, No 4 October 1992

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•Antenatal Corticosteroids for Accelerating Fetal Lung Maturation for Women at Risk of Preterm Birth (Review) Roberts D, Dalziel S Cochrane Database of Systematic Reviews 2006, Issue 3 Art No: CD004454 •Cervical Assessment by Ultrasound for Preventing Preterm Delivery (Review) Bergella V Baxter JK Cochrane Database of Systematic Reviews 2009. Issue 3, Art No: CD007235 •Cervical Sonography in Preterm Labor Obstetrics and Gynecology July 1994 Vol 84, no 1. •Magnesium Sulfate: The First-Line Tocolytic. D Lewis. Obstet Gynecol Clin N Am 32(2205) 485-500 •Biochemical Markers for the Prediction of Preterm Labor. J Yeast Obstet Gynecol Clin N Am 32(2205) 369-381 •Prediction and Early Detection of Preterm Labor. J Iams Obstetrics and Gynecology Vol 101. no 2 Feb 2003 •Major Obstetric Hemorrhage. F Mercier et al Anesthesiology Clin 26(2008) 53-66 •Nontraumatic Abdominal Surgical Emergencies in the Pregnant Patient. K Challoner. Emerg Med Clin N Am. 21 (2003) 97-985 • Extreme Preterm Birth: Onset of Delivery and Its Effect on Infant Survival and Morbidity, M Johanzon Obstet Gynecol Jan 2008; 111(1): 42-50 •Perinatal Care at the Threshold of Viability. H MacDonald Pediatric 2002; 110; 1024-1027 •Very Low Birthweight Outcome of the National Institute of Child Health adn Human Development Neonatal Research Network, January 1995-Dec 1996. Pediatric 2000; 107(1) • American Academy of Pediatrics. Special Considerations. In Braner, Kattwinkel et al. Textbook of Neonatal Resuscitation. 4th Ed Elk Grove Village, IL 2000: 7-19 • the Extremely Premature Neonate: Anticipating and Managing Care. N Yeaney. BMJ 11 July 2009 Volume 339 •Medical Legal Issue in the Prevention of Prematurity. D Seubert Clinics in Perinatology Vol 34, Issue 2 (June 2007) •Medical Staff Guidelines for the Periviability Pregnancy Counseling and Medical Treatment of Extremely Premature Infants. J Kaempf. Pediatrics 2006; 117:22-29 •  Clinical Report-Antenatal Counseling regarding Resuscitation at an Extremely Low Gestational Age. D

Batton American Academy of Pediatrics/ Pediatrics vol 124 number 1, july 2009

•Antenatal Corticosteroids for Accelerating Fetal Lung Maturation for Women at Risk of Preterm Birth (Review) Roberts D, Dalziel S Cochrane Database of Systematic Reviews 2006, Issue 3 Art No: CD004454 •Cervical Assessment by Ultrasound for Preventing Preterm Delivery (Review) Bergella V Baxter JK Cochrane Database of Systematic Reviews 2009. Issue 3, Art No: CD007235 •Cervical Sonography in Preterm Labor Obstetrics and Gynecology July 1994 Vol 84, no 1. •Magnesium Sulfate: The First-Line Tocolytic. D Lewis. Obstet Gynecol Clin N Am 32(2205) 485-500 •Biochemical Markers for the Prediction of Preterm Labor. J Yeast Obstet Gynecol Clin N Am 32(2205) 369-381 •Prediction and Early Detection of Preterm Labor. J Iams Obstetrics and Gynecology Vol 101. no 2 Feb 2003 •Major Obstetric Hemorrhage. F Mercier et al Anesthesiology Clin 26(2008) 53-66 •Nontraumatic Abdominal Surgical Emergencies in the Pregnant Patient. K Challoner. Emerg Med Clin N Am. 21 (2003) 97-985 •Cervical Ectopic Pregnancy K. Fyksha Am J Obstet Gyn 2014 •Successful rescue hysteroscopic resection of a cervical ectopic pregnancy previously treated with methotrexate with no combined safety precautions. Mangino FP, Ceccarello M, Di Lorenzo G, D'Ottavio G, Bogatti P, Ricci G. Clin Exp Obstet Gynecol. 2014;41(2):214-6. •Management of a cervical heterotopic pregnancy presenting with first-trimester bleeding: case report and review of the literature. Moragianni VA, Hamar BD, McArdle C, Ryley DA. Fertil Steril. 2012 Jul;98(1):89-94. doi: 10.1016/j.fertnstert.2012.04.003. Epub 2012 May 12. •The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. Am J Obstet Gynecol. 2012 Jul;207(1):44.e1-13. doi: 10.1016/j.ajog.2012.04.018. Epub 2012 Apr 16. •Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Timor-Tritsch IE, Monteagudo A. Am J Obstet Gynecol. 2012 Jul;207(1):14-29. doi: 10.1016/j.ajog.2012.03.007. Epub 2012 Mar 10.