Pitfalls in the Second Half of Pregnancy

Charlotte Page Wills, MDAssociate Program DirectorAlameda Health System-Highland Hospital EM Residency, Oakland, CAAssociate Clinical Professor of Emergency MedicineUniversity 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!

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.

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

pregnant. BP is 158/98 and HR is 118.

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.

• What’s wrong with her? Identify underlying disease and treat aggressively.

High Volume, Low Pressure

BP

HctCO

Vol

HR

SVR

Second and Third Trimester Resuscitation

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

• Oxygenation: high oxygen content, increased minute ventilation and TV.

• Aortocaval compression: pelvic tilt or manual uterine distraction.

• Progesterone: anticipate a difficult airway and aspiration.

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

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)

labor status

fetal well-being

maternal well-being

gestational age

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 s• Measurements of BPD and FL took less than one m• 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

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

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

Pregnant

HTN Headache

Pre‐eclampsia

Headache

•Hypertensive•No bleeding•Mildly tender uterus

CBCCMPUric acid, LDHDIC Panel

UA

•Hemolysis•Elevated LFTs•Platelet consumption

•Elevated creatinine•Proteinuria

Damaged Endothelium

BP

HctCO

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.

labor status

maternal well-being

fetal well-being

gestational age

Preterm Labor: Corticosteroid Administration

• Accelerates fetal lung maturation.

• Reduces respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis.

• Reduction in overall neonatal death.

• Does NOT increase the risk of maternal or neonatal infection.

• Betamethasone

• Dexamathasone

Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database of Systematic Reviews 2006, Issue 3, Art No CD004454

Tocolytics: An Overview

• Magnesium sulfate

• Beta-mimetics: terbutaline, ritodrine

• Prostaglandin inhibitors: indomethacin, ketorolac, COX

• Calcium channel blockers: nifedipine, nicardipine

• Nitric oxide donors: nitroglycerin and glyceryl trinitrate

• Oxytocin receptor antagonists: atosiban

Stopping Labor

Should Tocolytics Be Used and Which One?

• Proposed approach: use of tocolytics to delay labor for 48 hours to allow steroid administration.

• The ‘best’ tocolytic is controversial.

• ***Terbutaline no longer recommended.***

• Oral nifedipine may be superior prior to 37 weeks.

• Indomethacin may be superior prior to 32 weeks.

• Combinations-77% patients experience adverse side affects

Tocolytic therapy: A Meta-Analysis and Decision Analysis D Haas et al. Obstetrics and Gynecologyvol 113 no 3 March 2009

Magnesium sulfate for Preventing Preterm Birth in Threatened Preterm Labour. Cochrane Database of Systematic Reviews 2006, Issue 4 Art No CD002255

Magnesium sulfate for Preterm Labor and Preterm BirthB Mercer et al. Obsterics and Gynecology vol 114 no 3 Sept 2009

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm243843.htm

But Do Tocolytics Work?

• 2002 Cochrane Review of 23 trials including 2000 pregnancies.

• 2009 Systematic review of 19 trials including 1,281 pregnancies.

• 2009 Meta-analysis and decision analysis of 58 trials.

• 2014 Cochrane Review of 8 trials with 408 pregnancies.

• Author conclusions in all four:

• conflicting results regarding delivery within 48 hours or 7 days.

• no trend in reduction in the outcome of newborn birth weight below 2,500 grams or in neonatal mortality.

Premature Preterm Rupture of Membranes: Consequences of PPROM

• Intra-amniotic infection

• Risk is higher with lower gestational age.

• Avoid the digital cervical exam!

• Fetal malpresentation necessitating cesarean section.

• Placental abruption

• Post-partum hemorrhage

• Complications of bed rest

Managing PPROM: Conservative Management

• Steroids: to accelerate fetal lung maturity.

• Betamethasone: 12mg IM for two doses Q12 hours.

• Dexamethasone: 6mg IM for four doses Q 12 hours.

• Antibiotics: increased the latency period up to 3 weeks.

• Ampicillin and erythromycin IV for 2 days, then amoxicillin and erythromycin for 5 days.

• Avoid amoxicillin-clavulanate-increased risk of NEC.

Premature Rupture of the MembranesB Mercer Obstetrics and Gynecology vol 101 no 1 Jan 2003

+ROM Pushing

Delivers

PregnantI had no idea!

maternal well-being

gestational age

labor status

fetal well-being

Pregnancy for Emergency Providers

week 13 week 27

weeks 23‐24

3 inches15 grams

12 inches400‐600 grams

15 inches900 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 SurvivalMod-Severe Disability

401-500g 11% *

501-600g 27% 29%

601-700g 63% 30%

701-800g 74% 28%

Clinically Determining Viability: Ballard Score

The Threshold of Viability

Gestational age SurvivalModerate-Severe Morbidity

23 11-30% 56%

24 26-52% 53%

25 54-76% 46%

Perinatal Care at the Threshold of ViabilityH MacDonald et al, Pediatrics 2002: 110; 1024-1027

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.

34 weeksPregnant

+ROM Pushing

Labor

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.

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.

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 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.

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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•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.