Obstetrical Emergencies

Kimberly Westra DNP, MSN, CRNA, MBA©

Obstetrical Anesthesia Care● United States is one of

developed eight countries in the world where maternal mortality has increased since 1990

● US Parturient are 3x more likely to die from maternal complications than women in Germany, Britain, Japan!

Maternal Death● Most common causes of

maternal death are:● Hemorrhage● Hypertensive Disorders● Thromboembolic events● Infection/Sepsis

Maternal Mortality by State

Maternal Morbidity Risk● Increase mortality has

doubled in 21st Century affecting approximately 50,000 annually

● Higher number of Cesarean Sections in comparison to other countries world wide

● Maternal Obesity has significantly increased

Maternal Death Causes

Cesarean Section ● Emergent versus Non

emergent –communication with OB team essential

● Stat is a true clinical emergency may require general anesthesia if not time for Spinal (SAB)

● Spinal preferred if possible

STAT Cesarean Section● May see transient

elevation in systolic BP due to direct laryngoscopy: consider lidocaine 1-1.5mg/kg, Esmolol 1mg/kg, fentanyl 1mg/kg

● Have adjunct Airway devices & trained assistants at bedside for induction

● Parturient airway edema may require smaller ETT

STAT Cesarean Section● Consider Risk of Cannot

intubate/ventilate scenario due to high risk for airway loss in stat C/S

● Once ETT through cords, OB incision begins!

● Use of BIS indicated for increase risk of recall: no versed, limited narcotic, limited volatile due to risk of newborn respiratory impairment

OB Anesthesia Basics● Regional technique

preferred to GA for C/S or non-obstetrical cases

● Postpone surgery for elective cases until post partum

● Defer to 2nd trimester (viable fetus)

● Left Uterine Displacement routinely

● Appropriate denitrogenation & preoxygenation

● Additional airway tools in immediate access.

● Standard of care consistent

OB & Non Elective Surgery● Trauma● Acute Appendicitis ● Acute Complex

Cholycystitis● Malignancies● Cervical Incompetence

Preterm Labor Risk Factors● Noncaucasian● Advanced Maternal Age

> 35 ● Low Prenatal Weight● Multiple Gestations● H/O cervical

incompetence● H/O previous preterm

labor

Placental Transfer of Substances/Medication● Placental transfer of

medications occurs in:● Bulk flow (water)● Active Transport (amino

acids, ions)● Pinocytosis (large

molecules such as immunoglobulins)

● “Breaks” like blood/RH sensitization

● Diffusion such as respiratory gases and most drugs from anesthesia hence concern for anesthetic impact on fetus

Placenta, Inhalationals, IV Medications● Most inhalationals & IV

medications freely cross the placenta

● Limited respiratory depression if narcotics given within 10 minutes of induction

● Morphine results in the most significant newborn respiratory

● Fentanyl result in least amount of newborn respiratory depression

● Paralytic Agents cross placenta without difficulty as they are quaternary ammonium salts

Teratogenicity Agents● ACE inhibitors● Alcohol● Androgens● Antithyroid● Benzo● Chemotherapy*● Cocaine● Coumadin

● Diethylstibersterol● Lead● Lithium● Mercury● Phenytoin● Streptomycin● Valproic Acid

Tocolytics: Magnesium● Magnesium (b2 smooth

muscles)● Magnesium IV often

6GM over 30-60 minutes then infusion

● Magnesium GTT often 2-4GM/hr

● Magnesium infusions potentiate muscle relaxant effects

● Consider discontinuation if proceed to GA with use of muscle relaxants

Tocolytics: Magnesium● Theraputic Magnesium

levels are monitored and GTT adjusted

● Ideal MG level is 4-8mg/dl

● Magnesium potentiates muscle relaxants…

● Magnesium works on Ca channels inhibiting voltage in muscle cell

● Side effects: dry mouth, nausea, flushing, blurred vision, peripheral muscle fatigue/weakness, dizziness, confusion

Tocolytic Adjuncts● Glucocorticoids may be

used to supplement other tocolytics: inhibition of inflammatory mediators

● Betamethasone aids in promoting surfactant production in fetus

● Calcium Channel Blockers: Nifedipine

● Nifedipine also limits voltage of Ca channels in muscle cell

Obstetrical Emergencies● Maternal Hemmoraghe● Amniotic Fluid

Embolism● Placental Abruption● Impending Maternal

Death● Maternal Trauma

Maternal Trauma● Leading cause of

maternal death!!● Fetal death secondary to

maternal death/ or placenta abruption

● Trauma scenarios:● Maternal death/stat

postmortem C/S● Stable Maternal/Fetal

distress● Trauma to uterus/

rupture

Maternal Trauma● Violence against women:

domestic abuse and homicide

● Lifestyle Risks● Access to care or delays

in treatment due to rural location

● Call for Help early for OB and Neonatologist.

Maternal Trauma● Impending death with

viable fetus● Assess Maternal & Fetal

Trauma scenario● Call OB & NICU team to

Trauma bay● Consider mechanism of

trauma: trajectory, acceleration and deceleration, blunt/penetrating

● Large Bore IV● Massive Transfusion

Protocol blood products available

● Rapid infusion device for resuscitation

● Invasive monitors● Care team resources● Spine precautions● Proximity to Trauma Bay

or OR

Trauma & OB● Consider effect of trauma

of fetus is directly related to mechanism of trauma

● Consider gestational age of fetus and the extent and duration of disruption of fetal blood flow

● Is this a viable fetus? One life or two….

● Fetal tissue & oxygenation disrupted by traumatic injury can result in fetal Bradycardia or death

● FHR may be a 1st sign of fetal compromise in trauma!

Trauma & OB● Maternal physiological

changes of pregnancy may predispose the parpituents to rapid falls in Pa02 during brief apnea periods resulting in maternal and fetal hypoxia

● Increased risk of aspiration to due to anatomical changes & decreased LES tone with increased progesterone levels

● Primary & Secondary Survey in Trauma Bay

● FHR assessment by Trauma preferably OB team

Trauma & OB● Placental abruption

occurs in 2-4% of minor accidents & up to 50% of major trauma

● Inelastic placenta shears from elastic uterus resulting in abruption key consideration in even minor trauma…assessment of placental integrity

● Blunt versus Penetrating mechanism trauma thoracoabdominal

● Uterine Penatrating trauma 60-90% fetal mortality with 7-9% maternal mortality

Trauma & OB● Must proceed with

diagnostic studies despite radiation exposure to fetus to ensure safe trauma assessment

● Limit Radiation as much as possible for subsequent studies

● Invasive Lines may be required

● GETA if impending respiratory compromise or cardiovascular collapse

● High aspiration risk…precautions in place

● Spine precautions

Amniotic Fluid Embolism● AFE is a rare & life

threatening obstetrical emergency

● Amniotic fluid, fetal cells, hair or other debris enter mothers blood stream via placental bed of uterus/uterine veins

● AFE: results in a severe inflammatory/

immune response, cardiovascular collapse

Pulmonary edema, CV collapse, resulting coagulation disorders (DIC)

Amniotic Fluid Embolism● Risk factors:● Abdominal trauma● Advanced maternal age

(35>)● C/S or instrumented

SVD● Uterine rupture/previa

● Preeclampsia ● Fetal distress● Signs: sudden severe

respiratory distress, tachypnea, tachycardia, arrest

● Suspected bronchial mediators exacerbate AFE

Amniotic Fluid Embolism● Risk factors:● Abdominal trauma● Advanced maternal age

(35>)● C/S or instrumented

SVD● Uterine rupture/previa

● Preeclampsia ● Fetal distress● Signs: sudden severe

respiratory distress, tachypnea, tachycardia, arrest

● Suspected bronchial mediators exacerbate AFE

AFE & Data Deficiency● Due to the limited

information for this rare even few studies exist to provide sufficient evidence for comparative treatment modalities

● 1 in 80,000 delivery● 70% occur during labor● 19% occur during c/s● 11% after SVD● C/S noted often

immediately following delivery

AFE & Anesthesia● Once consistent report in

national registry was tear in the fetal membrane (78%)

● Mortality 61% for AFE● 10% of all maternal

deaths are related to AFE

● AFE Survivors 85% had neurological deficits

● Diagnostics may aid in confirmation of diagnosis but should not delay immediate emergent care

● Rapid delivery of fetus indicated!

AFE Treatment● Treatment: ● Early recognition &

intervention● ABC placement of ETT● PEEP● Fluid resuscitation to avoid

negative pressure gradient ● Epinephrine infusions may be

helpful to limit inflammatory response & provide cardiovascular support

● Dopamine may also be ideal to promote b-adrenergic effects, improve cardiac function

● Dobutamine & Milrinone infusions may be useful

● Theraputic Heparinization to limit coagulopathy development but this is controversial

● May require transfusions if DIC ensues

AFE Treatment● Degree of resuscitation

based on hemorrhage● May require platelet,

FFP and RBC transfusions

● Advanced coagulation studies to guide resuscitation

● Failed response to DIC treatment is associated with higher mortality as high as 75%

● Family support essential as morbidity & mortality high for mother.

Preeclampsia ● Advanced maternal age

& teens● Prior eclampsia Hx● PIH ● Multiple Gestation● Sickle Cell Disease

● Typically BP over 140/90● Usually begins after 20

weeks● Delivery of fetus is

definitive treatment● May lead to HELLPS if

untreated

Preeclampsia & Anesthesia● Preeclampsia:● High blood pressure,

proteinuria, edema,hyperreflexia,

● nausea/vomiting, dyspnea, visual disturbances

● Decreased urine output ● Low platelets, elevate liver

function tests

● Requires medical Treatment of HTN

● May progress to eclampsia is not treated (seizure)

● Untreated can result in maternal CV damage or cardiac morbidities, HELLPS

Preeclampsia Medications● Treatment: ● Labetolol ● Hydralazine● Magnesium Sulfate

(avoid seizures)● Methyldopa● Corticosteroids (improves

LFT’s)● Bed rest

● Definitive treatment is delivery of fetus as appropriate with gestational age

● Admission may be required due to severity of Preeclampsia & treatment response

HELLPS Syndrome● A life threatening

syndrome associated with Preeclampsia

● H –Hemolysis● E – Elevated Liver Enzymes● L – Low Platelets

● Typically begins during 3rd Trimester a few cases reported at 21 weeks

● HELLPS may occur before or after delivery

● May be difficult to diagnose as mother may not “appear” sick

HELLPS● Symptoms may vary:● Epigastric pain● Increased protenuria● Low platelets, elevated

liver enzymes● May progress to DIC,

liver failure, seizures, hepatic Hemmoraghe

● Prompt delivery of fetus in the only definitive treatment

● Medical Treatment until delivery:

● Antihypertensive Meds● Steroids,● Supportive blood

resuscitation FFP, Platelets

HELLPS● Maternal Mortality 1%● Permanent Liver Failure● Liver Hematoma● Acute Renal Failure● Placental Abruption● Retinal Detachment 25%

● Increased perinatal mortality in HELLPS up to 119/1000 deliveries

● Small for gestational age 40%

HELLPS ● Hemolysis: ● High LDH concentration● Unconjugated bilirubin● Low Haptoglobin

concentration

● Further complications: ● IUGR● Maternal/Fetal Death● Preterm Delivery● Neonatal

Thrombocytopenia● Respiratory Distress

Syndrome

HELLPS● No clear evidence

corticosteroids substantially improve outcomes

● Corticosteroids improve rate of recovery of platelet levels

● Platelets under 50-100,000 may have concern for regional for C/S delivery

● Weight risk benefits of low platelets for regional versus GA for C/S

Hellps Syndrome

Maternal Mortality by State

Placental Abruption● Bleeding between uterus

and placenta● Reduction of oxygen

delivery reduced especially

● Signs: bleeding, abdominal pain uterine irritability

● Seal of placenta of uterus weakens resulting in tearing of vessels (abruption)

● Tearing at 25% of placenta impacts fetus

● May fully separate from placenta/emergent delivery

Placenta Abruption● May be partial or

complete abruption● Complete abruption is

an obstetrical emergency requiring immediate delivery C/S (stat)

● www.placentalabruption ● Fetal can be

compromised or risk of fetal death

● Ultrasound or clinical diagnosis based on symptoms

Fetal Demise ● May required delivery is

gestational age 12-16 weeks

● Significant psychological & emotional impact for family

● Labor Epidural ● C/S

● Discussion with OB team on required approach

● Risks remain for mother for aspiration for GA

● Regional SAB for C/S● Pastoral Care Consult

Maternal Emergency: Gaps in Care● Anesthesia providers

must bridge the gap in the interdisciplinary team care approach & processes

● Simulation based interdisciplinary team approach for Massive Transfusion, Trauma, Malignant Hyperthermia

Anesthesia Considerations● Readiness and timeliness

of resources are ESSENTIAL for Obstetrical Emergencies!

● Appropriate anesthesia equipment, labor resources, and advanced invasive line devices

Future of OB Anesthesia Emergencies● Key for anesthesia

providers in assessment of existing resources, care team processes and readiness

● Plan and promote routine simulation, education and collaboration

● Gap Analysis and process improvement in OB emergencies in an ongoing process!

Questions?