Mod VIII: Anesthetic Considerations for Obstetric Emergencies Flashcards
Anesthetic Considerations for Obstetric Emergencies
What’s the leading cause of maternal and perinatal morbidity and mortality?
Obstetrical Hemorrhage
4% of vaginal deliveries & 7% of C-section’s
Because of the normal physiologic changes of pregnancy, including increased blood volume, parturient tolerate mild to moderate hemorrhage with little change in VS
Anesthetic Considerations for Obstetric Emergencies
T/F: UNDERERSTIMATION of blood loss by anesthesia contributes to maternal morbidity and mortality
True
Obstetrical Hemorrhage
What clinical signs accompany a Bloss loss of 15% EBV (900 cc)? Which class of Blood loss is it?
No clinical signs
CLASS I
Obstetrical Hemorrhage
What clinical signs accompany a Bloss loss of 20-25% EBV or (1200-1500 cc)? Which class of Blood loss is it?
↑ Heart rate
Orthostatic hypotension
Narrowed pulse pressure
CLASS II
Obstetrical Hemorrhage
What clinical signs accompany a Bloss loss of 30-35% EBV or (1800-2000 cc)? Which class of Blood loss is it?
Hypotension
Marked tachycardia
Cold, clammy skin
CLASS III
Obstetrical Hemorrhage
What clinical signs accompany a Bloss loss of 40% EBV or (> 2000 cc)? Which class of Blood loss is it?
Profound shock…requires immediate & aggressive resuscitations
CLASS IV
Obstetrical Hemorrhage
Which Obstetrical Hemorrhage occur in the ANTEPARTUM phase?
Abruptio placenta
Placenta previa
Placenta accreta
Obstetrical Hemorrhage
Which Obstetrical Hemorrhage occur in the INTRAPARTUM phase?
Uterine Rupture
Obstetrical Hemorrhage
Which Obstetrical Hemorrhage occur in the POSTPARTUM, and are associated with > 500 CC of blood loss for vaginalor delivery or > 1000 cc of blood loss for C-S?
Uterine atony
Retained placenta
Cervical/vaginal lacerations
Obstetrical Hemorrhage
The Premature separation of a normally implanted placenta before delivery of fetus causing acute bleeding behind the placenta is also known as:
Abruptio Placenta
Aslo means that part of the placenta is not attached to the uterus and therefore is not involved in the normal exchanges that occur btw the uteroplacental unit
Abruptio Placenta
What the incidence of Abruptio Placenta? when does is usually occur?
0.2 -2.4% of all pregnancies
Usually occur in the 3rd trimester
(final 10 wks. gestation)
Abruptio Placenta
What are the maternal and perinatal mortality rates of Abruptio Placenta?
Maternal → 1.8 – 11%
Perinatal → > 50%
Abruptio Placenta
What % of ALL perinatal deaths occur due to Abruptio Placenta
15-25%
Abruptio Placenta
Risk Factors of Abruptio Placenta:
Preeclampsia/HTN*
(highest risk!!!)
Advanced maternal age (AMA)
Multiparity
Increased Uterine distention
(DM, multiple gestation, polyhydramnios)
Trauma
Cocaine abuse/Tobacco use
Premature rupture of membranes (PROM)
Previous abruption
Abruptio Placenta
Clinical Presentation of Abruptio Placenta:
Uterine tenderness
Uterine hypertonus
Abdominal pain
Vaginal bleeding (dark, clotted)
Abruptio Placenta
Amount of Vaginal bleeding (dark, clotted) may be concealed if:
Placental margins remain attached to uterus
→ underestimation of actual degree of hemorrhage
(retro-placental hematoma)
Abruptio Placenta
What’s a hepful diagnosis in severe cases or significant collection concealed blood?
Diagnosis by US
Abruptio Placenta
Complications of Abruptio Placenta:
Coagulopathies
DIC**
Abruption most common complication in parturient
Uterine atony
Hemorrhagic shock (hypotension/tachycardia)
Acute renal failure
Fetal distress/demise
↓surface area for O2 delivery → hypoxia
Abruption > placenta previa
Abruptio Placenta
What’s the most common complication of abruption in parturient?
DIC
Abruptio Placenta
What are causes of Fetal distress/demise in Abruptio Placenta?
Decrease surface area for O2 delivery → Fetal hypoxia
Abruptio Placenta
T/F: The risk of Fetal distress/demise is greater with Abruptio Placenta than with Placenta previa
True
Obstetrical Management of Abruptio Placenta
The Definitive treatment for Abruptio Placenta is:
Delivery of fetus/placenta
Obstetrical Management of Abruptio Placenta
How would a Mild abruption w/o evidence of severe hemorrhage or fetal distress be managed?
Attempt induction of labor for vaginal delivery
Obstetrical Management of Abruptio Placenta
How would a Severe abruption, maternal hemorrhage or fetal distress be managed?
Emergency C/S
Obstetrical Management of Abruptio Placenta
In the obstetrical management of Abruptio Placenta, when would Epidural anesthesia be indicated?
Labor, vaginal delivery, & elective C-S
provided that no contraindications exist
(e.g. s/s that they are not stabel?)
Obstetrical Management of Abruptio Placenta
In the obstetrical management of Abruptio Placenta, what are advantages of epidural anesthesia?
Provides a controlled situation
Obstetrical Management of Abruptio Placenta
In the obstetrical management of Abruptio Placenta, what are concerns w/ epidural anesthesia?
Sympathectomy from the epidural could prevent the parturient ability to compensate for the hypovalemia
Obstetrical Management of Abruptio Placenta
When would GETA be indicated?
Emergency C-S,
if Maternal hemorrhage or Fetal distress
Obstetrical Management of Abruptio Placenta
Why would regional anesthesia no be recommended over GETA if Emergency C-S is required d/t Maternal hemorrhage and/or Fetal distress?
Sympathetctomy
Plus, GETA allow to secure airway more quickly
Time is also of an essence if concerns of fetal distress or maternal hemorrhage
Obstetrical Management of Abruptio Placenta
When is it acceptable to use epidural for emergency C-S?
Maternal hemmorraghe not severe
Pt remains hemodynamically stable
Patient is already receiving epidural analgesia for labor
Obstetrical Management of Abruptio Placenta
Why are Ketamine & Etomidate the preferred induction agents vs Propofol or STP for the Obstetrical Management of Abruptio Placenta?
Less likely to produce hypotension
Obstetrical Management of Abruptio Placenta
In the Obstetrical Management of Abruptio Placent which doses of Ketamine should be avoided? and why?
Avoid ketamine (> 2mg/kg) if uterine hypertonus present
Ketamine will further increase uterine tone and can geopardize uterine perfusion pressures
Obstetrical Management of Abruptio Placenta
In the Obstetrical Management of Abruptio Placenta, what should be the minimmum FiO2 delivered to the pt? How long should delivery of this FiO2 concentrations maintained?
Must deliver FIO2 at least 50%
until fetus delivered
Obstetrical Management of Abruptio Placenta
The use of Volatiles is acceptable in the Obstetrical Management of Abruptio Placenta only under which condition?
Hemodynamically stable
Obstetrical Management of Abruptio Placenta
In the Obstetrical Management of Abruptio Placenta, when is the use of Volatiles agenst actually beneficial?
Hypertonus present
Obstetrical Management of Abruptio Placenta
Why should you decrease the MAC of volatile agents to 0.5 MAC
To ensure adequate uterine tone after delivery
Parturient with abruption at increased risk for developing uterine atony after delivery
Obstetrical Management of Abruptio Placenta
Tx of Hypovolemia associated with Abruptio Placenta involves:
Aggressive fluid resuscitation
2 large-bore IV’s
Availability of blood products must be confirmed
Obstetrical Management of Abruptio Placenta
If cross-matched blood not readily available, what’s the alternative?
Type O neg or Type specific
Obstetrical Management of Abruptio Placenta
What’s the Tx for Coagulopathy/DIC?
FFP/PLT transfusions may be required
Obstetrical Hemorrhage
Abnormal implantation of placenta on lower uterine segment
Placenta Previa
Placenta Previa
What are the different types of Placenta Previa?
Complete
complete coverage of cervical os
Partial
covers only part of cervical os
Marginal
lies close but doesn’t cover cervical os
Low lying
Placenta Previa
What’s the incidence of placenta previa?
0.1 – 1.0% of all pregnancies
Placenta Previa
What are maternal and perinatal mortality for Placenta Previa?
Maternal: Rare (0.9%) unlike abruption
Perinatal: 17-26%
Placenta Previa
What are Risk factors for Placenta Previa?
Prior uterine surgery*
(greatest)
Previous C/S
Risk ↑ as number of prior C/S ↑
Advanced maternal age
Multiparity
Previous placenta previa
Placenta Previa
What’s the Clinical presentation of Placenta Previa?
Painless, bright red, vaginal bleeding during 2nd & 3rd trimester
First episode of bleeding typically occurs preterm
Severe hemorrhage can occur however at anytime
Placenta Previa
What are possible Complications of Placenta Previa?
Maternal hemorrhage
Complications of C-section (esp. anterior lying placenta)
Placenta accreta
Preterm delivery/complications prematurity
Abnormal fetal presentation
Placental separation → fetal anemia/hypoxia
Placenta Previa - Diagnosis
T/F: All parturient with vaginal bleeding are assumed to have placenta previa until proven otherwise
True
Placenta Previa
How is the Diagnosis of Placenta Previa made?
Determined by ultrasound
(abdominal → transvaginal)
Vaginal exam sometimes required to confirm
Placenta Previa
What the risk associated w/ vaginal exam w/ suspected Placenta Previa?
Could separate placenta from uterus and cause maternal hemmorrhage
Often requires “Double set-up” conditions
Placenta Previa - Vaginal Exam Double Set-Up
Why does vaginal Exam for Placenta Previa require “Double Set-Up” and is undertaken only in the OR?
OB surgeon & anesthesia present
Prepared to proceed to emergency C/S if acute hemorrhage occurs
(Double Set-Up means that one team ready for emergent cesarean delivery and one team ready for uneventful vaginal delivery)
Placenta Previa - Vaginal Exam Double Set-Up
Preparation for Double Set-Up conditions includes:
Large-bore (14- or 16-ga) IV on blood set
2-4 units PRBC must be in the OR
Abdomen prepped/draped
All preparations for GETA available
Assistance available
Obstetrical Management of Placenta Previa
All parturients with a total or partial placenta previa undergo C-S - Why?
Great risk for massive hemorrhage that can occur with vaginal delivery
Obstetrical Management of Placenta Previa
All parturient with a total or partial placenta previa undergo C-S because of great risk for massive hemorrhage that can occur with vaginal delivery. For which type of placenta previa would vaginal delivery be attempted?
Marginal placenta previa
Vaginal delivery may be attempted with a marginal placenta previa to try for a vaginal birth (RARE!!!)
Obstetrical Management of Placenta Previa
With known placenta previa, at what gestational age would elective C-S be scheduled?
@ gestational age that maximizes fetal lung maturity
This is to minimize the risk of hemorrhage that may result from onset of normal labor & uterine contractions
Obstetrical Management of Placenta Previa
In a case of placenta previa whereby minimal or absent bleeding are noted, and fetal/maternal stability are evident, the expectant management is to allow time for fetal lung maturation. What would this involve?
Bedrest
High corticosteroids
Tocolytics to prevent normal onset of labor/uterine contractions (severe hemorrhage)
When fetal lung maturation is achieved or 37 weeks gestation reached => proceed with delivery
Obstetrical Management of Placenta Previa
In cases of placenta previa where active bleeding with maternal instability & fetal deterioration are present, which intervention would best serve mothers interest?
IMMEDIATE C/S
(regardless of gestational age)
Obstetrical Management of Placenta Previa
If Active bleeding with maternal instability & fetal deterioration, Mothers interest best served by IMMEDIATE C/S regardless of gestational age - H/E must consider interest of the fetus
Fluid/blood resuscitation
Tocolytics
Obstetrical Management of Placenta Previa
If initial episode of bleeding resolves with maternal & fetal stability evident, and fetus is premature, reasonable to delay delivery - why?
Improve newborn outcome
Anesthetic Management of Placenta Previa
Anesthetic Management of Placenta Previa is dependent on:
Maternal/ fetal status
Urgency with which C/S must proceed
Anesthetic Management of Placenta Previa
Anesthetic Management of Placenta Previa when Elective C-S is indicated:
Regional preferred (no active bleeding evident)
Anesthetic Management of Placenta Previa
There is a High risk for intra op bleeding leading to emergent hysterectomy during the Anesthetic Management of Placenta Previa - How do you prepare for this?
Large-bore IV access
T&C blood readily available before proceeding
Anesthetic Management of Placenta Previa
When is Emergency C-S indicated in the Anesthetic Management of Placenta Previa?
Evidence of Maternal hemorrhage, and/or
Evidence of Fetal distress
Anesthetic Management of Placenta Previa
What’s the preferred anesthetic technique for the Management of Emergency C-S d/t Placenta Previa?
GETA preferred
Anesthetic Management of Placenta Previa
Induction of GETA in the Management of Emergency C-S d/t Placenta Previa is similar to abruption - However, unlike abruption, no concerns regarding ketamine use because
No association between placenta previa and hypertonus
Anesthetic Management of Placenta Previa
Maintenance of GETA in the Management of Emergency C-S d/t Placenta Previa is similar to abruption and is determined by
Maternal hemodynamics
Anesthetic Management of Placenta Previa
Maintenance of GETA in the Management of Emergency C-S d/t Placenta Previa is similar to abruption - How could you promote uterine contraction or prevent uterine atony?
Decrease inspired concentration of N2O/Volatile agent
N2O/Volatile agent before delivery
Opioid added after
Anesthetic Considerations for Obstetric Emergencies
The Abnormally firm attachment of placenta to myometrium is also kown as:
Placenta Accreta
Placenta Accreta
Placenta Accreta comes in three different froms, that include:
Placenta Accreta
Most common
Adherent to myometrium w/o invasion
Placenta Increta
Invasion of myometrium
Placenta Percreta
Most serious
Invades entire myometrium, possibly into other pelvic structures (bladder)
Placenta Accreta
What’s the most common form of Placenta Accreta ? How does it manifest?
Accreta
Adherent to myometrium w/o invasion
Placenta Accreta
Which form of placenta accreta invades the myometrium only w/o spreading to other organs?
Placenta Increta
(invades the myometrium only w/o spreading to other organs)
Placenta Accreta
What’s the most serious form of Placenta Accreta ? How does it manifest?
Percreta
Invades entire myometrium, possibly into other pelvic structures (bladder)
Placenta Accreta
Placenta Accreta prevents placental separation at time of delivery - What does this lead to?
MASSIVE HEMORRHAGE!
Placenta Accreta
What’s the reason of the 10-fold increase in the incidence of Placenta Accreta over last 50 yrs? How often do we see it now?
Increase in the rate of C/S
1 in 2500 deliveries
Placenta Accreta
What are the Risk factors for Placenta Accreta?
Prior placenta previa*
(most common)
Prior C-S
(Incidence correlates with number C/S)
Prior uterine surgery
(myomectomy/D&C)
Placenta located over prior uterine scar
Multiparity
Placenta Accreta
What is the Clinical presentation of Placenta Accreta?
Most asymptomatic
High index of suspicion in parturient with placenta previa and history of prior C/S
Vaginal bleeding likely due to previa
Placenta Accreta
Antenatal diagnosis of Placenta Accreta is difficult & non-definitive - When is this diagnosis often made?
At time of surgery
(Oh oh! what do we do now?!)
Obstetrical Management of Placenta Accreta
When is Elective C-S indicated?
If Diagnosis is known
Obstetrical Management of Placenta Accreta
Procedure of choice that’s required to definitively treat most cases of placenta previa is:
Obstetrical hysterectomy
Parturient counceled & informed of all risks
Conservative management may be attempted if future fertility is desired, however hysterectomy remains procedure of choice
SUBSTANTIAL blood loss => Blood transfusions
Obstetrical Management of Placenta Accreta
Which Interventional radiology procedure could be done to ↓blood loss?
Arterial embolization
Obstetrical Management of Placenta Accreta
Why is Obstetrical Management of Placenta Accreta Schedule in main OR vs. Obstetrical OR?
Better resources
Obstetrical Management of Placenta Accreta
When is it most preferred to induce general anesthesia in the Obstetrical Management of Placenta Accreta?
in a controlled situation
before start of surgery rather than during time of crisis
(esp. concerned about airway)
Obstetrical Management of Placenta Accreta
What are Disadvantages of regional in the Obstetrical Management of Placenta Accreta?
Sympathectomy
Sympathectomy does not allow for compensation if massive hemorrhage occurs
conversion to GETA during crisis!!
If hysterectomy necessary → ↑ discomfort caused by surgical manipulation → conversion to GETA during crisis!!
Hemodynamic instability => intubation
Hemodynamic instability due to massive hemorrhage also may necessitate intubation
Obstetrical Management of Placenta Accreta
Which anesthetic plan can significantly improve parturient outcome during the Obstetrical Management of Placenta Accreta?
Thorough preop preparation
Anticipation of potential problems
Obstetrical Management of Placenta Accreta
Thorough preop anesthetic preparation & anticipation of potential problems can significantly improve parturient outcome - How can this be facilitated?
2 large-bore IV’s (consider a-line/CVP)
_T&C PRBC’_s in OR before surgery starts
Coordinate with blood bank availability of other blood products
Cell-saver set-up
Anesthetic Considerations for Obstetric Emergencies
Failure of uterine muscle to contract normally following delivery of fetus/placenta is also known as:
Uterine Atony
Uterine Atony
What’s the Pathophysiology of Uterine Atony?
Shearing of uterine vessels occurs with placental separation
Bleeding normally stopped by contraction of uterus & compression of vessels
Bleeding continues if contraction absent/inadequate
Responsible for 90% of all cases of postpartum hemorrhage
Obstetric Emergencies
Which Obstetric Emergency is Responsible for 90% of all cases of postpartum hemorrhage?
Uterine Atony
Uterine Atony
When and How is the diagnosis of Uterine Atony made?
Often occurs immediately after delivery
May occur several hours later
Relaxed, large postpartum uterus
Excessive vaginal bleeding
Absence of vaginal bleeding however should not exclude atony
Atonic engorged uterus may contain > 1000 cc
Uterine Atony
What volume of blood may Atonic engorged uterus contain (hidden)?
> 1000 cc
Uterine Atony
Which physical examination will be performed to identify cause of bleeding? - What would this exam look for specifically?
OB examination
Will look for Cervical/vaginal laceration, and
Retained placental fragments (more later)
Uterine Atony
What are Predisposing Risk Factors for Uterine Atony?
Prolonged labor
Augmented labor (oxytocin or IV induction)
Preeclampsia - Multiparity - Multiple gestation - Volatile agents
Fetal macrosomia - Chorio-amnionitis - Tocolytic agents
Retained placenta
Obstetrical Management of Uterine Atony
Which interventions can be conducted in the Obstetrical Management of Uterine Atony?
Bimanual compression
Uterine massage
Oxytocics
Emergency exploratory laparotomy
(if Persistent bleeding)
Control bleeding
Ligation of internal iliac (hypogastric) artery
Emergency hysterectomy
Obstetrical Management of Uterine Atony
Which procedures are indicated to Control bleeding from Uterine Atony?
Ligation of internal iliac (hypogastric) artery
Emergency hysterectomy
Obstetrical Management of Uterine Atony
Which drug is used in the treatment of uterine atony and acts on uterine smooth muscle by stimulating the force & frequency of contractions?
Oxytocin
Obstetrical Management of Uterine Atony
What are the Side effects of Oxytocin?
Vasodilation/Hypotension
Tachycardia
Cardiac arrhythmias
Antidiuretic effect at high doses
(which could cause water intoxication, cerebral edema, convulsions)
Obstetrical Management of Uterine Atony
How is Oxytocin dosed and administered?
Oxytocin
10 - 20 Units in 1000 cc bag LR/NS
Obstetrical Management of Uterine Atony
Which drugs are used to increase force & frequency of uterine contraction followed by normal uterine relaxation, and is usually restricted to controlling Post Partum Hemmorrhage?
Methergine
Ergot alkaloids (methylergonovine)
Obstetrical Management of Uterine Atony
How does Methergine controls Post Partum Hemmorrhage?
Contractions more intense/prolonged
Resting tonus increased
Tetanic contractions can occur
Obstetrical Management of Uterine Atony
What are Methergine Side effects?
Vasoconstriction
HTN
Obstetrical Management of Uterine Atony
Methergine must be given IM, NOT IV - What could happen if it was given IV?
Severe HTN
Convulsions
Retinal detachment
PE
Obstetrical Management of Uterine Atony
In which conditions is Methergine contraindicated?
HTN (preeclampsia)
PVD
CAD
Obstetrical Management of Uterine Atony
Which drugs are considered 3rd line of therapy in the Obstetrical Management of Uterine Atony?
Prostaglandins
(Carboprost, Misoprostol, Dinoprostone)
Obstetrical Management of Uterine Atony
What are Prostaglandins Side effects
Transient HTN
Increased pulmonary vascular resistance
(This is why Caution is advised for use in <strong>asthmatic</strong>)
Obstetrical Management of Uterine Atony
Why is the use of Prostaglandins cautioned in asthmatic?
Increased pulmonary vascular resistance
Obstetrical Management of Uterine Atony
Table summarizing common drugs used in the Obstetrical Management of Uterine Atony and their side effects
Table summarizing common drugs used in the Obstetrical Management of Uterine Atony and their side effects
(Slide 75)
Anesthetic Management of Uterine Atony
What’s the overall goal of Anesthetic Management of Uterine Atony?
Blood
Fluid resuscitation
Anesthetic Management of Uterine Atony
Anesthetic techniques indicated in the management of Uterine Atony a/w Minor peripheral lacerations includes:
Local infiltration
Pudendal block
Residual regional analgesia
(Supplement with N20, opioids, or both)
Anesthetic Management of Uterine Atony
Which corrective Uterine Atony procedures require GETA?
Bimanual massage
Manual extraction of retained placenta
Reversion of inverted uterus
Repair of major lacerations
Obstetric Emergencies
The Full thickness separation of uterine wall and visceral peritoneum; associated with substantial bleeding and expulsion/protrusion of fetal &/or placenta into abdominal cavity is also know as:
Uterine Rupture
Rare but catastrophic complication
High incidence of maternal & fetal morbidity
Emergency C/S required
Obstetric Emergencies
Separation of pre-existing scar tissue that does not disrupt overlying visceral peritoneum is known as:
Uterine Dehiscence
Fetus & placenta contained within uterine cavity
Seldom results in complications
C/S not necessarily warranted
Obstetric Emergencies
What are Risk factors for Uterine Rupture?
Presence of uterine scar*
(most common)
Prior C/S
> vertical uterine incision
< low transverse uterine scar
Myomectomy
Labor induction (Oxytocin)
Abdominal trauma
Fetopelvic disproportion
Abnormal fetal presentation
Grand multiparity
Instrument assisted vaginal delivery
Obstetric Emergencies
The most common risk factor for Uterine Rupture is the Presence of uterine scar which could be the result of:
Prior C/S
Myomectomy
Obstetric Emergencies
Which type of uterine incision during C-S is most likely to potentally lead to Uterine rupture down the road?
A. vertical uterine incision
B. low transverse uterine scar
A. vertical uterine incision
B. low transverse uterine scar
Obstetric Emergencies
What’s the clinical Presentation of Uterine Rupture?
Non-specific
Typically non-specific making diagnosis difficult => delay definitive therapy
Fetal bradycardia Abrupt loss of uterine contraction & pressure
Sudden onset abdominal pain
Recession presenting fetal part
Hemorrhage (vaginal bleeding)
Shock
Obstetrical Management of Uterine Rupture
Uterine Rupture is a Life-threatening event for both fetus & mother - What Obstetrical interventions may be require for its management?
Emergency C/S
Post-partum laparotomy
Uterine repair
Hysterectomy
Obstetrical Management of Uterine Rupture
When is Uterine repair Appropriate in the Obstetrical Management of Uterine Rupture? Does uterine repair eliminate the risk of ruputure in future pregnancy?
Uterine repair is appropriate for some cases with old transverse scar
However risk of rupture remains high in future pregnancy
Obstetrical Management of Uterine Rupture
What’s the Preferred, definitive corrective/preventive procedure for most cases of Uterine Rupture?
Hysterectomy
Anesthetic Management of Uterine Rupture
Why is GETA often required in the Anesthetic Management of Uterine Rupture?
Maternal hemodynamic instability
Fetal distress
Epidural anesthesia not achieved by time OB ready to make incision
(especially if you are trying to start the epidural right at the time of diagnosis and they didn’t have it already during labor)
High potential for hysterectomy → more painful and requires GETA
Anesthetic Management of Uterine Rupture
When is it appropriate to use epidural in the Anesthetic Management of Uterine Rupture?
Epidural already in place for labor analgesia
Mother/fetus stable
The LA of choice is 3% 2-chloroprocaine
Anesthetic Management of Uterine Rupture
Why is 3% 2-chloroprocaine the LA of choice for epidural in the Anesthetic Management of Uterine Rupture?
(Short acting?!)
Anesthetic Management of Uterine Rupture
Anesthetic Management of Uterine Rupture requires being aware that Substantial blood loss expected - How is this blood loss replaced?
Significant Blood transfusions
Crystalloid infusions
Obstetric Emergencies
A common cause of uterine rupture is d/t Women being allowed “trial of labor” after previous C/S - This process is also known as
VBAC
(Vaginal Birth After Cesarean)
Vaginal Birth After Cesarean (VBAC)
What are ACOG recommendations for potential VBAC candidates?
One low-transverse C/S & no other contraindications to vaginal delivery
Two previous C/S may also be offered trial of labor
Counseled on risk of rupture ↑ with number of previous uterine incisions
More than Two previous C/S => NOT recommended
Potential complications of VBAC must be thoroughly discussed with patient and documented
Vaginal Birth After Cesarean (VBAC)
Why must you be aware if there’s a VBAC trial of labor on your OB floor?
There is Increased risk for emergency C-section w/ VBAC
Prepare for emergency cesarean!!!
“…facilities and personnel, including an obstetrician, anesthetist, and operating room personnel, must be immediately available to perform an emergency cesarean delivery when VBAC is being attempted”
ACOG practice bulletin & ACOG/ASA joint statement
Vaginal Birth After Cesarean (VBAC)
In the ACOG practice bulletin & ACOG/ASA joint statement
“facilities and personnel, including an obstetrician, anesthetist, and operating room personnel, must be immediately available to perform an emergency cesarean delivery when VBAC is being attempted”, the term immediately available is not defined - Many physicians and hospitals have interpreted this to mean wthat?
in-house presence!!!
The in-house presence of an obstetrician and anesthesia care provider are necessary whenever a patient attempting VBAC is in active labor
Vaginal Birth After Cesarean (VBAC)
Why was Epidural Analgesia withheld in past in Vaginal Birth After Cesarean (VBAC)?
Concern that it would mask abdominal pain
(from uterine rupture?!)
Vaginal Birth After Cesarean (VBAC)
What’s the Current practice regarding epidural analgesia in VBAC?
Preferred/ideal technique
Dilute LA + opioid solution commonly used
(Shown to not obscure pain a/w rupture)
Sudden loss of analgesia actually warning of uterine rupture
(notify OB)
Allows for quick conversion to surgical anesthesia
(provided hemodynamically stability evident)
Umbilical Cord Prolapse
What % of deliveries are complicated by Umbilical Cord Prolapse?
0.2-0.6%
Umbilical Cord Prolapse
Compression of the Umbilical Cord could lead to:
Fetal asphyxia
Umbilical Cord Prolapse
What are predisposing risk factors for Umbilical Cord Prolapse?
Excessive cord length
Abnormal fetal presentation
Low birth weight
Grand parity (>5)
Multiple gestation
Artificial rupture of membrane
Umbilical Cord Prolapse
Diagnosis/Clinical presentation of Umbilical Cord Prolapse:
SUDDEN fetal bradycardia with profound variable decelerations
Umbilical Cord Prolapse
Management of Umbilical Cord Prolapse involves:
Immediate steep T-burg or knee-chest position
Manual pushing of presenting fetal part back up into pelvis until immediate C/S can be done
Nonviable fetus can be delivered vaginally
Obstetric Emergencies
The Entry of amniotic fluid into maternal circulation through break in uteroplacental membrane is called:
Amniotic Fluid Embolism
aka
“Anaphylactoid Syndrome of Pregnancy”
Amniotic Fluid Embolism
What’s the incidence and mortality of Amniotic Fluid Embolism?
Rare (1:20,000 deliveries) but FATAL
10% of all maternal deaths
Mortality exceeds 50% in 1st hour
Amniotic Fluid Embolism
What are Risk Factors for Amniotic Fluid Embolism?
Severe preeclampsia
Risk is ↑ w/ tumultuous labor/multiparity
Placental abruption
Placenta previa
Uterine rupture
Amniotic Fluid Embolism
What are the 3 major pathophysiologic manifestations of Amniotic Fluid Embolism?
Respiratory distress/Acute PE
DIC
Uterine Atony
Amniotic Fluid Embolism
What’s the Clinical presentation of Amniotic Fluid Embolism?
SUDDEN tachypnea
Pulmonary Edema
Shock
CNS changes (seizure, coma)
Cyanosis
Generalized bleeding
Amniotic Fluid Embolism
How is firm Diagnosis of Amniotic Fluid Embolism established?
Presence of fetal elements in maternal blood only
as evidenced by
Aspirate from CVP
Autopsy
Amniotic Fluid Embolism
Which would generate High suspicion of Amniotic Fluid Embolism?
SUDDEN onset respiratory distress
Circulatory collapse
Amniotic Fluid Embolism
Which are possible differential diagnosis for Amniotic Fluid Embolism?
Acute PE/VAE
Aspiration of gastric contents
Local anesthesia toxicity
Hepatic rupture
Cerebral hemorrhage with Preeclampsia
Amniotic Fluid Embolism
Treatment for Amniotic Fluid Embolism includes:
Aggressive CPR
Stabilization
Supportive care
Amniotic Fluid Embolism
Why are closed-chest compressions in a parturient w/ Amniotic Fluid Embolism considered marginal at best?
Aortocaval compression in supine impedes venous return
Increased O2 demands make hypoxia more likely even with adequate perfusion
Closed-chest compressions are less effective in LUD
Amniotic Fluid Embolism
Which intervention improves maternal/fetal outcome if resuscitative measures for Amniotic Fluid Embolism are unsuccessful after 4mins?
Expeditious delivery
Emergent C/S should be carried out IMMEDIATELY
Amniotic Fluid Embolism
Stabilization in the context of Amniotic Fluid Embolism involves:
Immediately secure airway/mechanical ventilation + PEEP
Fluids
Inotropic support
(full invasive monitoring)
Oxytocin, methylergonovine, or PGF2
Treat coagulopathy
(PLT, coagulation factors) based on labs
Amniotic Fluid Embolism
Graphical representation of the Physiologic manifestations of Amniotic Fluid Embolism
Physiologic manifestations of Amniotic Fluid Embolism
