OB and Surgical Complications Flashcards
Describe ultrasound features characteristic for dichorinic twin gestation
Thick intertwin membrane (>2mm)
Sex discordance
Lambda / Twin peak signs
When is ultrasound the most accurate at establishing chorionicity in multiple gestation?
1st trimester
How do you counsel a patient about the maternal risks of pregnancy with dichorionic twins?
Fetal risks?
Maternal: Hyperemesis Gestational diabetes Hypertensive disorders Anemia Hemorrhage C/S Postpartum depression
Fetal:
Preterm delivery
Stillbirth
FGR
How do you follow Di/di twins throughout gestation?
Serial growth ultrasound
Weekly testing at 36 weeks
Do you follow/perform cervical length screening in twins?
No
What are the options for aneuploidy screening in twins?
NT
NIPT
Quad screen, sequential, integrated, etc.
When do you recommend delivery of uncomlicated di-di twins?
38w0d-38w6d
What are the indications for cesarean in a di/di twin pregnancy?
Twin A breech
<32 weeks Twin A cephalic, twin B noncephalic
Usual obstetric indications
Twin A cephalic, twin B noncephalic and OB provider not trained in management of breech 2nd twin
How do you counsel a patient about risk following a dichorionic cotwin demise in the first trimester?
It can happen fairly commonly
Not usually associated with increased morbidity or mortality of the cotwin
How do you counsel a patient about risk following a dichorionic cotwin demise in the second trimester?
3% -22% risk of cotwin death
1% risk of neurologic abnormality
How do you counsel a patient about risk following a dichorionic cotwin demise in the third trimester?
3-22% risk of cotwin death
1% risk of neurologic abnormality
How do you follow a patient following a dichorionic co twin demise in the first trimester?
Routine obstetric care
But would not use cell free-DNA or serum screens for aneuploidy (NT alone or invasive testing)
How do you follow a patient following a dichorionic co twin demise in the second trimester?
Monitor growth of surviving twin
Antenatal testing
Do not deliver surviving twin as it does not decrease brain injury in 2nd twin
How do you follow a patient following a dichorionic co twin demise in the third trimester?
Monitor growth of surviving twin
Antenatal testing
Do not deliver surviving twin as it does not decrease brain injury in 2nd twin
Do di/di twins run in families?
Yes, on the moms side (more likely to release two eggs, for a non-identical twin)
How do you manage a patient with twins and history of a prior spontaneous preterm birth?
Routine obstetric care
What pregnancy complications are unique to monochorionic twins compared to dichorionic twins?
Twin-to-twin transfusion syndrome Twin anemia polycthemia sequence Acardiac twin (TRAP) Conjoined twins Fetal anomalies
Describe ultrasound features characteristic for a mo/di twin pregnancy?
T-sign
Thin intertwin membrane (<2mm)
Sex concordance
How do you follow mo/di twins during pregnancy?
1st trimester US for dating/chorionicity
TTTS Monitoring (Ultrasound every 2 weeks for fluid and growth, if abnormal –> UA Dopplers)
TAPS monitoring (MCA Doppler velocimetry q2 weeks starting at 26 weeks)
Fetal echocardiogram at 18-22 weeks
Serial growth ultrasounds
Weekly antenatal testing at 32 weeks
When do you recommend delivery of uncomplicated monochorionic twin gestation?
Mono/Di : 34w0d-37w6d (but usually say 36-37 weeks)
Mono/Mono: 32w0d-34w0d
How do you counsel a patient about risks follow a monochorionic cotwin demise in the first trimester?
Unclear whether there can be an increased risk of neurologic abnormality
How do you counsel a patient about risks follow a monochorionic cotwin demise in the second trimester?
15%-40% risk of cotwin death
18%-30% risk of neurologic abnormality
Also if previable offer termination due to the increased risk of neurological abnormality
immediate delivery of the co-twin has not been demonstrated to be of benefit
How do you counsel a patient about risks follow a monochorionic cotwin demise in the third trimester?
15%-40% risk of cotwin death
18%-30% risk of neurologic abnornality
immediate delivery of the co-twin has not been demonstrated to be of benefit
How do you follow a patient following a monochorionic cotwin demise in the first trimester?
Routine obstetric care
But would not use cell free-DNA or serum screens for aneuploidy (NT alone or invasive testing)
How do you follow a patient following a monochorionic cotwin demise in the second trimester?
Monitor growth of surviving twin
Antenatal testing
Do not deliver surviving twin as it does not decrease brain injury in 2nd twin
How do you follow a patient following a monochorionic cotwin demise in the third trimester?
If occurs in late 2nd or in 3rd trimester
Admit for steroids, magnesium sulfate and continuous monitoring
Monitor growth of surviving twin
Antenatal testing
Do not deliver surviving twin as it does not decrease brain injury in 2nd twin
If an intertwin dividing membrane cannot be visualized, what is your differential diagnosis?
TTTS with stuck twin
Monochorionic-monoamniotic twin pregnancy
Rupture of membranes
What is the likelihood of developing TTTS in a mo/di twin pregnancy?
10-15%
What is TTTS?
Complication of Mono-di pregnancies where there is unequal balance of blood flow via A-V connections in the placenta that results in one twin donating blood (donor) to the other twin (recipient) resulting in increased morbidity and mortality.
What are the US features leading you to suspect TTTS?
Donor: volume depleted, growth restricted, oligohydramnios
Recipient: polycythemic, heart failure, polyhydramnios, hypervolemic, hydrops
What are the Quintero stages of TTTS?
I: Poly-Oli II: Poly-Oli + Absent bladder in donor III: Absent/reversed UA diastolic flow, reversed ductus venosus, pulsatile UV flow IV: Hydrops fetalis in one or both twins V: Fetal demise
When do you refer a patient for possible laser surgery for TTTS?
II, III, and IV TTTS in continuing pregnancies at <26 weeks
Why do we not perform laser on Stage I TTTS?
> 75% will regress / remain stable
How do you counsel the patient regarding the benefits of laser therapy for TTTS?
Improved survival at 6 months
Improved neurologic outcomes
Later ga at delivery
Single procedure vs. multiple procedures
80% survival of at least 1 twin
50% survival of both twins
How do you follow a patient after laser surgery for TTTS?
Weekly for 2-3 weeks q 2 weeks if stable Growths q 4 Antenatal testing at 28 weeks Delivery at 34-36 weeks
What are the potential comlications that can occur post laser for TTTS?
PPROM Iatrogenic Mono mono twinning Fetal demise (1 or 2) Brain lesions PVLM Persistent cardiac disease (pulmonary valve) TAPS TTTS recurrence TTTS reversal
When do you recommend delivery following laser surgery for TTTS?
Goal of 34-36 weeks
What is TAPS?
Unbalanced blood distribution between twins w/o amniotic fluid discordance; Likely through small (< 1mm) vessels
Unidirectional, unreciprocated artery and vein anastamoses near periphery of placenta
How do you define TAPS?
MCA PSV> 1.5 MoM in one twin and < 1.0 MoM in the other twin
Do you screen for TAPS?
MCA PSV starting at >26 weeks
How is TAPS detected?
MCA PSV> 1.5 MoM in one twin and < 1.0 MoM in the other twin
What is the likelihood of developing TAPS in a mo/di twin gestation?
5%
What is the likelhood of developing TAPS following laser surgery for TTTS?
10-15%
If TAPS is detected, how will you manage the patient?
??Expectant management, delivery (stage I), selective feticide, IUT (may be short duration, may worsen polycythemia hyperviscosity syndrome in the recipient, skin necrosis of LE reported)-donor IV vs IP, partial exchange IUT or laser ???
Describe US features of monoamniotic twin gestation
Cord entanglement
No intertwin membrane
Sex concordance
One placenta
How do you counsel a patient about the pregnancy risks of a monoamniotic twin gestation?
Cord entanglement
TTTS
Congenital malformations
How do you manage a monoamniotic twin gestation?
Offer early inpatient management (beginning at 24–28 weeks of gestation) with daily fetal surveillance
Regular assessment of fetal growth
When do you recommend delivery for a monoamniotic twin gestation?
32-34 weeks
How do you manage cotwin demise with a monoamniotic twin gestation?
Consider delaying delivery to allow steroids
Delivery after 30 weeks, but can consider continued monitoring until 32
What is a placental abruption?
When a normally implanted placenta prematurely separates from the uterus
What are risk factors for a placental abruption?
Prior history Hypertensive disorders Trauma Cocaine / Smoking Polyhydramnios Multiple gestation PPROM Infection Uterine anomalies/fibroids
What would make you suspect an abruption?
Painful vaginal bleeding
Nonreassuring fetal heart tracing with tachysystole
If an abruption is seen on US, describe the US characteristics?
Hyperechoic or isoechoic collections that turn hypoechoic 2 weeks after event
Does a normal US exclude the possibility of abruption?
50% of abruptions are not seen on ultrasound
What is a concealed abruption?
An abruption that doesnt communicate with cervix and therefore you dont see vaginal bleeding
What are the maternal risks if an abruption occurs?
Hemorrhage, hypovolemia, shock
Coagulopathy
Need for hysterectomy
What are the fetal risks if an abruption occurs?
Fetal growth restriction
PPROM
Prematurity and associated morbidity/mortality
Fetal death
What lab tests will you order if you suspect an abruption?
CBC PT/PTT Fibrinogen Type and cross KB if Rh negative
How do you evaluate a patient if you suspect an abruption?
Vital signs Evaluate for bleeding (speculum) CBC PT/PTT Fibrinogen Type and cross KB if Rh negative Ultrasound FHR/Toco
How do you manage a patient if an abruption is diagnosed?
If >2 bleeds or >34 weeks deliver
<34 weeks and hemodynamically stable without further bleeding, surveillance with delivery at 37 weeks
What is a placenta previa?
When the placenta is covering the internal cervical os
How is a placenta previa diagnosed?
Transvaginal ultrasound
If a placenta previa is identified at <20 weeks on ultrasound, how likely is it to resolve?
90%
If a placenta previa is seen on mid trimester US, how will you follow this patient?
Repeat ultrasound at 32 weeks
How do you counsel a patient if a placenta previa is noted on her 32 weeks US?
That it still has the possibility to resolve, though the likelihood is smaller now than before
Reevaluate at 36 weeks, if still previa, recommend delivery by C/section.
When is delivery recommended for placenta previa?
36w0d-37w6d
How do you manage a patient who presents with a bleeding placenta previa?
Assess maternal / fetal status
Consider betamethasone / magnesium sulfate if viable/appropriate
Rhogam if Rh negative
Consider delivery if >34 weeks
When do you recommend hospitalization for patients with a placenta previa?
3+ bleeding episodes
Long distance from hospital
Do you recommend bedrest for patients with a placenta previa?
No
What are the maternal risks with a placenta previa?
Hemorrhage, need for blood transfusion Need for cesarean section Increased hospitalization Need for hysterectomy particularly if associated with history of cesarean section and MAP Maternal death
What are the fetal risks with a placenta previa?
Preterm delivery
Increased neonatal morbidity/mortality due to prematurity
What is the chance of invasive placentation in patients with a previa and 0 prior uterine surgeries? 1 prior c/s? 2 prior c/s? 3 prior c/s?
0: 3%
1: 11%
2: 40%
3: 61%
What is a vasa previa?
Type 1: Velamentous cord insertion with umbilical vessels inserted into the membranes near or directly Over the internal cervical os
Type 2: Umbilical vessels coursing over membranes between a succenturiate lobe and main lobe near or over the cervix
How is a vasa previa diagnosed?
Transvaginal ultrasound: Uumbilical vessels crossing within 1-2cm of the endocervical os with color doppler
What are the maternal risks with a vasa previa?
hemorrhage
need for blood transfusion
need for cesarean section
When do you recommend hospitalization for patients with a vasa previa?
30-34 weeks
Do you recommend bedrest for patients with a vasa previa?
No, but I recommend pelvic rest
When do you recommend delivery for patients with a vasa previa?
34-35 weeks
What is placenta accreta spectrum disorder?
Where the placenta has invaded to/beyond the myometrium
What are the US findings suggestive of placenta accreta spectrum?
(1) Loss of normal hypoechoic retroplacental zone
(2) Multiple vascular lacunae in placenta (swiss cheese placenta)
(3) Blood vessels or placenta tissue bridging uterine-placental margin, myometrial bladder interface or crossing uterine serosa (disruption of serosa/bladder interface)
(4) Retroplacenta myometrial thickness <1mm
(5) bulging of placenta beyond or distorting the uterine contour
What is the role of MRI in the diagnosis of placenta accreta spectrum?
Unable to adequately visualize the uteroplacental interface (obesity)
Suspected percreta
Is MRI superior to US for the diagnosis of placenta accreta spectrum?
Not superior to ultrasound
What are the risk factors for placenta accreta spectrum?
previa
prior c/section
prior myomectomy
If placenta accreta spectrum is suspected, how do you counsel the patient?
Increased risk of: Hemorrhage (life threatening) Preterm birth w/ need for cesarean hysterectomy Morbidity d/t cesarean hysterectomy Risk of mortality
How will you manage the pregnancy if placenta accreta spectrum is diagnosed on US?
Planned cesarean hysterectomy at 34-35 weeks
Describe your delivery plan for a patient with placenta accreta spectrum?
Cesarean hysterectomy at 34-35w
Steroids for fetal lung maturity in week prior
Maximize preop Hb (iron if indicated)
Multidisciplinary approach
Plan for intraoperative hemorrhage / transfusion (cell saver and blood product availability)
Central lines
What are the risks of cesarean hysterectomy?
Hemorrhage
Risk of ICU admission due to hemorrhage
Damage to GI/GU systems/Ovaries
Describe your surgical approach for cesarean hysterectomy for placenta accreta spectrum?
Consult with NICU, Gyn Onc or Gen surgery and anesthesia Blood products on hold Lithotomy position Midline abdominal incision Fundal uterine incision No attempted removal of placenta
What are the risk factors for hypertensive disorders in pregnancy?
High risk factors: Prior Hx CHTN Diabetes Multiple gestation Renal disease Autoimmune disease (SLE, APS) Moderate risk factors: Age, Weight, Nulliparity, Fam hx, Socioeconomic status, Hx of LBW
Who do you consider to be a candidate for baby ASA to prevent preeclampsia?
1 high risk factor or 2+ moderate risk factors
How do you define GHTN?
SBP >= 140 or DBP >= 90 after 20 weeks
two occasions 4 hours apart
without proteinuria or severe features
What is severe GHTN?
SBP >= 160 or DBP >= 110 after 20 weeks on two occasions 4 hours apart without proteinuria
How do you manage a patient with severe GHTN?
The same as preeclampsia WITH severe features
Admit to hospital
Mag / Steroids
BP control (Goal <160/110)
Delivery at 34 weeks or sooner if contraindications arise
What are the pregnancy risks with GHTN?
Abruption Preeclampsia with severe features Stroke Seizure Pulmonary Edema End-organ damage (Kidney, liver, brain)
How do you screen for preeclampsia?
History
Do you perform Uterine Artery Dopplers to assess risk for preeclampsia?
No, low positive predictive value, so I currently use history for screening
What are criteria to diagnose preeclampsia?
SBP >= 140 or DBP >= 90 after 20 weeks on two occasions 4 hours apart
WITH proteinuria
OR WITH severe features
How do you diagnose preeclampsia w/ severe features?
SBP >= 160 or DBP >= 110 after 20 weeks on two occasions 4 hours apart
WITH proteinuria
OR WITH severe features
What are the severe features of preeclampsia?
SBP >=160 or DBP >= 110 after 20 weeks on 2 occasions at least 4 hours apart
Visual changes/Persistent HA not relieved by meds
Creatinine >=1.1 or 2X baseline
LFTs >= 2X ULN, or persistent RUQ/epigastric pain not relieved by conservative management or explained by alternative dx
Pulmonary edema
Platelets < 100
Can a patient have preeclampsia without proteinuria? Example?
Yes, Patient presenting with new hypertension and abnormal lab findings
How do you define proteinuria?
300mg in a 24 hour urine protein collection
Protein creatinine ratio of >0.3
2+ protein on a dipstick if no other testing is available
How do you manage a patient with preeclampsia WITHOUT severe features diagnosed after 24 weeks?
Outpatient management Home BP checks / evaluation for signs/symptoms of preeclampsia Betamethasone Weekly labs Antenatal testing Serial growth ultrasounds Timing of delivery: 37 weeks
How do you manage a patient with preeclampsia WITH severe features diagnosed prior to 24 weeks?
Supportive care, magnesium sulfate and delivery
How do you manage a patient with preeclampsia WITH severe features diagnosed in the third trimester?
Inpatient management: Betamethasone Magnesium sulfate Antihypertensives to keep BP out of severe range Serial labs Antenatal testing Serial growth ultrasounds Timing of delivery: 34 weeks, or earlier if contraindications to expectant management
What preeclamptic patients are a candidate for mag sulfate?
Severe features
How do you administer mag sulfate?
4g bolus / 2g/hr
What is a therapeutic mag level?
4.8 - 9.6mg/dL
What is the role of magnesium levels?
Monitor that magnesium is in therapeutic range, especially in patients at high risk for mag toxicity (elevated creatinine, low urine output, symptoms of mag toxicity)
How do you manage magnesium in a patient with renal insufficiency?
Decrease maintenance from 2g/hr to 1g/hr
Monitor magnesium levels
Monitor for signs/symptoms of mag toxicity
What are signs and symptoms of mangesium toxicity?
At what levels do changes occur?
Flushing Headache Loss of reflexes (9mg/dL) Respiratory depression (12mg/dL) Cardiovascular collapse (at 30mg/dL)
How do you manage mag toxicity?
1g Calcium gluconate 10% IV, 10mL given over 3 minutes
Furosemide to promote renal clearance
Why is Calcium gluconate administered over 3 minutes?
Risk of respiratory depression or acute hypertension if pushed too fast
When are indications for delivery in a patient with preeclampsia w/out severe features?
37 weeks of gestation
The usual obstetric indications
What are the MATERNAL contraindications for expectant management in preeclampsia WITH severe features?
Severe BPs not responsive to meds Persistent headaches, refractory to tx Epigastric/ruq pain unresponsive to tx Visual disturbances, altered sensorium HELLP syndrome New/worse renal dysfunction Pulmonary edema Stroke Myocardial infarction Eclampsia DIC Abruption or VB w/out previa
What are the FETAL contraindications for expectant management in preeclampsia WITH severe features?
Abnormal fetal testing
Fetal death
Fetus without expectation for survival (eg, lethal anomaly, extreme prematurity)
Persistent rEDV in umbilical artery
Is there a role for outpatient management of preeclampsia?
Yes WITHOUT severe features
What blood pressure requires antihypertensive therapy?
> =160/110
Describe your approach to a patient with severe hypertension?
Treat acutely to get BP <160/110
Regimen 1: Labetalol: 20,40,80 Hydralazine: 10
OR
Regimen 2: Hydralazine 10, 10 Labetalol: 20,40
OR
Regimen 3: Oral nifedipine 10, 20, 20 Labetalol: 20
Repeating BP at 10 mins for Labetalol, 20 mins for hydralazine, nifedipine
What is your first line medication for treatment of severe hypertension?
IV labetalol
What is your goal of therapy for treatment of hypertension?
BP <160/110
How will you manage the patient who has not responded to IV labetalol and hydralazine therapy?
ICU transfer - IV infusion with nicardipine or esmolol
Arterial line
What are indications for an arterial line in preeclampsia?
pulmonary edema
requiring antihypertensive drip
What would make you suspect that your preeclamptic patient is developing pulmonary edema?
Shortness of breath
O2 saturation < 95%
Decreased urine output
In preeclampsia, If the patient develops hypoxemia, how will you evaluate her?
Listen to lungs Continuous pulsox CXR Urine output Check for mag toxicity Labs including mag level and creatinine
In preeclampsia, what is your differential diagnosis for hypoxemia?
Pulmonary edema
Mag toxicity
Pulmonary embolism
Pneumonia
How will you manage anesthesia and analgesia in a preeclamptic patient with platelet count of 90,000?
Neuraxial anesthesia
How will you manage anesthesia and analgesia in a preeclamptic patient with platelet count of 60,000?
General anesthesia
How will you manage anesthesia and analgesia in a preeclamptic patient with platelet count of 30,000?
General anesthesia
How do you manage a patient who present within 7 days postpartum with hypertension?
Admission to hospital
Magnesium sulfate x 24 hours
Antihypertensives
How do you follow your patient postpartum if she was delivered for preeclampsia?
Control BP in hospital prior to discharge
Home BP monitoring
Preeclampsia precautions (specifically headache)
BP check in office in 1 week
How do you counsel a patient with preeclampsia about her risk of cardiovascular disease?
Women with a history of preeclampsia continue to have an elevated risk of cardiovascular disease in subsequent years
Hypertension
Myocardial infarction
Congestive heart failure
Cerebrovascular events (stroke)
Peripheral arterial disease
and Cardiovascular mortality later in life
May warrant closer long-term follow-up and lifestyle modifications to better manage risk factors for cardiovascular disease (eg, achieving healthful weight, exercise, diet, smoking cessation)
What is the risk of recurrent hypertensive disorder in a subsequent pregnancy?
Approximately 15% (higher if early and severe, lower if later and non-severe)
What is eclampsia?
Convulsive manifestation of the hypertensive disorders of pregnancy
New onset tonic clonic, focal or multifocal seizure in the absence of other causes (epilepsy, infarction, hemorrhage, drugs)
What are the risks to the patient of having an eclamptic seizure?
Hypoxia
Aspiration pneumonia
Trauma
Describe how you will manage a patient having an eclamptic seizure?
Call for help
Prevent maternal injury (Padding railings)
Prevent aspiration (Lateral decubitus position)
Supplemental oxygen
Monitor vital signs
Magnesium sulfate
Delivery once stable (does not need to be c/s)
What is the risk of seizure in preeclampia?
Severe: 1/50
Non-severe: 1/200
When do you recommend brain imaging in eclampsia?
Refractory Seizure or while on mag
Vision loss
Altered mental status
Focal symptoms
How will you proceed with delivery following an eclamptic seizure?
Cesarean is not required, but at <28 weeks approximately 97% risk, decreases to 65% from 28-32 weeks
How do you manage the patient with an intractable seizure?
A further 2-4g magnesium bolus over 5 minutes
If still seizing at 20 mins after bolus, or >2 recurrences:
Sodium amobarbitol (250mg IV in 3 mins)
Thiopental
Phenytoin (1250mg IV at 50mg/minute)
ICU admission and consider intubation
What are the fetal risks during a seizure?
Hypoxemia
abruption,
fetal demise
When do you recommend head CT vs MRI in eclampsia?
If suspect hemorrhage -> CT
If suspect PRES -> MRI
How is HELLP syndrome defined?
LDH >600 IU/L
AST/ALT >2x ULN
Platelet <100 x 10^9/L
How do you manage a patient with HELLP syndrome?
Delivery regardless of gestational age (consider trying to complete steroids if stable)
Supportive care
Serial labs
What are maternal/fetal risks from HELLP syndrome?
DIC Abruption Acute kidney injury Pulmonary edema subcapsular or intraparenchymal liver hematoma Retinal detachment Small for gestational age Stillbirth / neonatal death Maternal death
Is there a role for steroids in the management of HELLP syndrome?
Only for the usual fetal indications
What would make you suspect a subcapsular hematoma?
Severe RUQ/epigastric pain
Abnormal LFTs
Nausea/vomitting
If a subcapsular hematoma is identified how will you manage the patient?
Obtain CT/MRI
Assess vitals/coags
Transfuse / volume replete
Delivery once hemodynamically stable and anemia / coagulopathy are corrected
Consult ICU / Surgery (liver trauma experienced)
What are the risks of a subcapsular hematoma?
Capsular rupture -> hemorrhage -> Severe anemia
DIC
Maternal death
How do you manage a patient with a ruptured subcapsular hematoma?
Massive transfusion protocol
Consultation for anesthesia and trauma surgery
Delivery via c/s
How do you counsel patient about recurrence risks following a pregnancy complicated by HELLP syndrome?
7%
Differential diagnosis for HELLP?
Acute fatty liver of pregnancy
thrombotic thrombocytopenic purpura
pregnancy-related hemolytic-uremic syndrome
systemic lupus erythematosus
How do you define preterm labor?
Regular contractions with cervical change
What are risk factors for preterm labor?
Prior preterm birth PPROM Short cervix Infection Multiple gestation Polyhydramnios Smoking / Drugs Medical conditions
How do you evaluate a patient presenting with suspected preterm labor?
H&P Assess frequency of contractions and history of preterm delivery Labs: UA, UDS, GBS, GC, wet mount SSE w/ FFN collection Cervical length >3, sent home <2 dont sent FFN, check cervix and admit for PTL management 2-3cm I would send an FFN
How do you manage preterm labor?
Betamethasone
Magnesium sulfate for neuroprotection
FHR / Toco
I consider tocolytics for 48 hours in patients <34 weeks for the purpose of administration of steroids
How do you manage a patient admitted for PTL at 36 weeks?
Admit to hospital UA, Urine culture Antibiotics for GBS prophylaxis if positive or unknown Steroids No tocolytics Expectant management
What tocolytic do you use for PTL treatment?
Indomethacin
Procardia
What is the role of terbutaline in the management of preterm labor?
I do not use it, but it can be used for short duration for the purpose of getting steroids on board
What are the contraindications to tocolysis?
Intrauterine fetal demise Lethal fetal anomaly Nonreassuring fetal status Severe preeclampsia or eclampsia Maternal bleeding w/ hemodynamic instability Chorioamnionitis PPROM Maternal contraindications to specific medications
Specific contraindications for procardia?
Hypotension
Preload depending cardiac lesions (aortic insufficiency)
Specific contraindications for Indomethacin?
Platelet dysfunction / bleeding disorder Hepatic dysfunction GI Ulcer Renal dysfunction Asthma (in women with hypersensitivity to aspirin)
Specific contraindications for terbutaline?
Tachycardia sensitive maternal cardiac disease
Poorly controlled DM
What are potential complications of prolonged terbutaline use in a pregnant woman?
Death Arrhythmias / Tachycardia Hyperglycemia Hypokalemia Pulmonary edema Myocardial ischemia
Who do you consider a candidate for tocolysis?
Women at <34 week receiving corticosteroids due to increaed risk of preterm delivery
Women with uterine tachysystole
Women undergoing cerclage
What are the risks of chronic NSAID use in pregnancy at/or beyond 32 weeks gestation?
In utero constriction of ductus arteriosus (PDA)
Oligohydramnios
Necrotizing enterocolitis in preterm newborns
Will you tocolyze a previable gestation?
Not for preterm labor, though it can be used after a procedure (like abdominal surgery or cerclage placement)
How long do you continue tocolysis?
48 hours
Is there a role for oral tocolysis beyond 48-72 hours?
No
Who is a candidate for corticosteroids for fetal benefit?
Women that are at increased risk of delivery in the next 7 days that are less than 37 weeks
Who is a candidate for “rescue steroids?
<34 weeks of gestation AND at risk of preterm delivery within the next 7 days
AND whose prior course was >14 days prior (but can be considered within 7 days)
Unclear if beneficial in patients with PPROM
Who is a candidate for corticosteroids between 34-36w6d?
Singleton
No prior antenatal steroids
Not in patients likely to deliver in 12 hours
Not in patients with pregestational diabetes
Benefit of late preterm steroids?
Decreased need for respiratory support in 72 hours
Do you give more than 2 courses of steroids for fetal benefit?
No
What is the earliest gestational age you will give steroids for fetal benefit?
22 weeks if neonatal resuscitation is planned as it may help with mortality
What is the latest gestational age you will give steroids for fetal benefit?
36w6d
How does magnesium provide fetal benefit?
reduces the severity and risk of cerebral palsy, possibly via decreased excitotoxicity in the brain
Who is a candidate for magnesium for fetal neuroprotection?
Increased risk of imminent preterm delivery and gestational age>23 weeks but <32 weeks
Describe your regimen for mangesium for fetal neuroprotection.
4-6g loading dose, 1-2g/hour maintenance dose
Who should receive GBS prophylaxis
GBS positive in labor GBS bacteriuria in this pregnancy GBS unknown and preterm GBS unknown and >18 hours ruptured GBS unknown and prior pregnancy with GBS colonization GBS unknown and maternal fever >=100.4
How do you manage a patient with PTL and unknown GBS?
GBS culture
then treat them
How do you manage GBS prophylaxis in a patient with a low-risk allergy to penicillin?
Treat with cephalosporin
Cefazolin 2g iv, 1g q8h
How do you manage GBS prophylaxis in a patient with a high-risk allergy to penicillin?
Clindamycin and erythro susceptible: Clindamycin 900 mg IV every 8 hrs until delivery
Isolate not clindamycin susceptible: Vancomycin 1g q12 hours
When is a patient a candidate for discharge from the hospital following treatment for PTL?
Depends on the clinical picture and distance from hospital
What is the role of bedrest in the management of PTL?
No role, increases risk of thrombosis
Do you manage twin gestation with PTL differently from singletons?
No
How do you counsel a patient about future pregnancy risk and management if she delivers prematurely due to PTL?
This puts her at an increased risk of it happening again (35%)
She can help decrease that risk with IM progesterone or vaginal progesterone
We can perform serial cervical lengths from 16-24 weeks with consideration for cerclage if cervix is <2.5cm
Which patients are candidates for 17 OHPC in pregnancy?
Singleton with history of prior spontaneous preterm birth
How do you manage a patient with asymptomatic preterm cervical dilation found on exam at 18 weeks?
assess for infection (urine cx, vag cx, +/- amnio)
assess for uterine contractions
Offer exam indicated cerclage
How do you manage a patient with asymptomatic preterm cervical dilation found on exam at 22 weeks?
assess for infection (urine cx, vag cx, +/- amnio)
assess for uterine contractions
Offer exam indicated cerclage
How do you manage a patient with asymptomatic preterm cervical dilation found on exam at 25 weeks?
assess for infection
assess for uterine contractions
GBS prophylaxis, betamethasone, magnesium sulfate
What questions will you ask the patient if she is found to have preterm cervical dilation?
Has she felt contractions Any recent fevers / chills Any foul smelling vaginal discharge Abdominal pain Any recent trauma Any bleeding Prior history of preterm delivery? Prior history of cervical procedures
How do you manage a patient with symptomatic (contractions or spotting) preterm cervical dilation found on examination at 18 weeks gestation?
Assess for infection / abruption
Stabilize mom
Supportive care
How do you manage a patient with symptomatic (contractions or spotting) preterm cervical dilation found on examination at 22 weeks gestation?
Assess for infection / abruption Rh status / Rhogam if applicable Stabilize mom Discuss periviable period, can offer steroids Supportive care
How do you manage a patient with symptomatic (contractions or spotting) preterm cervical dilation found on examination at 25 weeks gestation?
Detailed H&P Labs: UA, UDS, GBS, GC swab, wet mount Rh status / Rhogam if applicable Stabilize mom Fetal monitoring / toco Collect FFN, perform cervical length Depending on evaluation +/- Steroids, tocolysis, magnesium sulfate, antibiotics for GBS prophylaxis
How do you use an fFN to guide management in suspected preterm labor?
Collect FFN for anyone with suspected preterm labor <34 weeks
Then perform a cervical length
If >3, I dont send fFN and consider discharge
If <2, I dont send fFN and admit for continue management of PTL
If 2-3, I send fFN, if negative I consider discharge, if positive I consider admitting and continue managment for PTL
In whom do you perform an fFN?
I send an FFN on any patient with symptoms of preterm labor with a cervical length between 2.0cm - 3.0cm.
When do you recommend amniocentesis in the setting of preterm cervical dilation?
If planning for an exam indicated cerclage
What studies do you send on amniotic fluid to evaluate for intra-amniotic infection?
Gram staining
Culture for aerobic and anaerobic bacteria
Glucose
WBC
How do you interpret results of amniotic fluid studies for intrauterine infection?
Gram stain (positive)
Culture (positive)
Glucose <14 : suggestive of infection (high specificity /sensitivity, PPV 62.5%)
WBC: >50 cells/mm^3 (
How common is intra-amniotic infection present in patients with preterm cervical dilation?
10% if no PPROM
Up to 35% if PPROM
Do you screen / treat for BV to prevent PTB?
Not in asymptomatic women, I would test and treat if symptomatic
What is the definition of a short cervix?
Cervical length <2.5 cm at <24w0d
Describe how you measure a cervical length?
Transvaginal ultrasound Empty bladder Cervix occupying 2/3 of the screen Seeing internal and external os Equal thickness of anterior and posterior parts of cervix
Do you perform universal cervical length screening?
Yes
When in gestation do you recommend screening cervical length be performed?
18-22 weeks
What is the role of an abdominal cervical length assessment?
To screen for short cervix, if short –> transvaginal ultrasound
Do you do cervical length screening in TWINS?
Yes as part of the routine assessment of anatomy at 18-22w6d
If on routine it is suspected to be short, I perform transvaginal ultrasound to better assess cervix.
When in gestation should a cervical length surveillance be performed?
16 weeks - 23w6d
How do you manage a patient with a short cervix at 20 weeks and no prior history of preterm birth?
I would review her OB and GYN history in detail
Vaginal progesterone
How do you manage a patient with a short cervix at 20 weeks and a prior history of preterm birth?
I would review her OB and GYN history in detail
Offer cerclage or vaginal progesterone
How do you manage a patient with a short cervix at 20 weeks and no prior history of preterm birth, that was placed on progesterone and now returns with a cervical length of 0.8cm?
I offer cerclage for patients on vaginal progesterone due to short cervix when cervical length is <1.0cm
What are the benefits of treatment with vagibal progesterone in the management of a patient with a SINGLETON and a short cervix?
Decreases neonatal mortality
Decreases neonatal morbidity
Decreases risk of preterm birth by approximately 30%
How do you counsel a patient with a SINGLETON and a history of prior spontaneous preterm delivery?
Increased risk of preterm birth in a future pregnancy
And there are ways to help decrease that risk (progesterone, cerclage if short cervix)
How do you manage a patient with a SINGLETON and a history of a prior spontaneous preterm delivery?
I would review her OB and GYN history in detail
Vaginal progesterone or IM progesterone from 16-36 weeks
Cervical length surveillance (16-23w6d) with plan for cerclage for cervical length <2.5cm
How do you manage a patient with TWINS with a history of a prior spontaneous preterm birth?
No additional management
Do you use 17 OHPC in TWINS with a prior history of spontaneous preterm birth?
No, though some benefit has been shown in limited studies
Do you use vaginal progesterone in TWIN pregnancy with a short cervix?
No, though some benefit has been shown in limited studies (data is of such quality to make definitive recommendations difficult)
How do you manage a patient with TWINS and previable short cervix?
Offer physical exam to assess dilation
If dilated I offer exam indicated cerclage
If not dilated, I manage expectantly
How do you manage a patient with TWINS and previable painless cervical dilation?
I offer exam indicated cerclage
How do you manage a patient with TWINS and a short cervix with a prior history of a spontaneous preterm birth <34 weeks?
I do not offer cerclage or vaginal progesterone
I offer a vaginal exam to assess for cervical dilation and consider cerclage if it I find painless cervical dilation prior to 24 weeks.
How do you evaluate patients for PPROM?
H&P
Sterile speculum exam: ferning, nitrazine, pooling
AFI
Significance of nitrazine?
Amniotic fluid is more basic (7.1-7.3) then vagina, if positive, suspicious for rupture of membranes
False positive for nitrazine?
Blood, semen, BV
How do you manage a pregnant woman with PPROM after 24 weeks gestation?
Admission to hospital
Betamethasone
Antibiotics for latency
Magnesium sulfate for fetal neuroprotection
FHR/Toco
Delivery at 34 weeks, or later with shared decision making
How do you counsel a patient about potential complications of PPROM?
Infection Preterm labor Abruption Cord prolapse Nonreassuring FHR Increased neonatal morbidity (RDS, IVH, NEC, sepsis)
What percent of PPROM patients deliver within 48 hours (previable vs viable)?
Previable: 20% in 48 hrs, 40-50% in 1 week
24-34: 50% in 48 hrs, 70-80% in 1 week
What are the most common complications following PPROM?
Preterm delivery
Infection
Abruption
What is the role of antibiotics in the management of patients following PPROM?
Increase latency (time from rupture to delivery)
What antibiotic regimen fo you utilize to prolong latency following PPROM?
Ampicillin 2g IV q6 x 48 hours -> Amoxicillin 250mg q8h x 5 days
AND
Azithromycin (1g, orally, once)
What antibiotic regimen do you utilize for a patient with a high risk pencillin allergy following PPROM?
Azithromycin (1g, orally, once)
AND
Clinda / Genta
What clinical findings are suspicious for intraamniotic infection ?
Uterine tenderness Foul smelling discharge Fever Maternal tachycardia Fetal tachycardia Leukocytosis
What are the criteria for a presumptive diagnosis of intraamniotic infection?
Fever >39 OR Fever 38-38.9 AND Fetal tachycardia Maternal leukocytosis Purulent fluid from the cervical Os
How is intraamniotic infection diagnosis confirmed?
Positive AF gram stain Low AF glucose <14 mg/dL Positive AF culture High WBC in AF in absence of bloody tap Histopathologic evidence of triple I in placenta, fetal membranes or umbilical cord vessels.
How do you confirm or exclude ruptured membranes in the setting of inconvlusive initial examination?
Indigo carmine amnioinfusion (1ml in 9mL of NS)
Assess for leakage of blue-stained fluid into the vagina 20-30 minutes
What are complications of previable PPROM?
Preterm birth Maternal infection (sepsis in 5% of PPROM between 20-24 weeks) Fetal/neonatal infection Placental abruption Umbilical cord prolapse Fetal/neonatal deformation Fetal/neonatal death Retained placenta Need for C/s via a classical hysterotomy
How do you manage a patient following previable PPROM?
Counsel
Offer induction of labor vs expectant management
Monitor for infection, abruption, PTL
D/c if stable
Plan to readmit when viability is reached
How do you counsel a patient regarding likelihood of fetal pulmonary hypoplasia following PPROM?
There is an increased risk of problems due to oligohydramnios as amniotic fluid is critical to the production and function of the pneumocytes and lungs are still developing in a preterm fetus
How do you define recurrent pregnancy loss?
2 or more failed pregnancies prior to 20 weeks gestation
When should recurrent pregnancy loss be worked up?
> =3 pregnancy failures
or 2 pregnancy failures and (AMA, difficulty in conception, familial history for pregnancy loss/aneuploidy, fetal cardiac activity seen prior to loss)
What percentage of RPL is unexplained? and what percentage of these women go on to achieve a successful pregnancy?
50-75% unexplained
75% achieve a successful pregnancy
What is your differential diagnosis for the causes of recurrent pregnancy loss?
Genetic (balanced translocations, other genetic disorders)
Autoimmune
Anatomic (didelphy / bicornuate / septated uterus)
Maternal Disease
Endocrine
Unexplained
What clues are suggestive of a genetic etiology of RPL?
Repetitive first trimester losses
Anembryonic pregnancies
AMA
Family history of congenital malformations, MR or xlinked conditions
How do you workup products of conception?
Chromosomal microarray (higher yield, no growth of cells needed)
Limitations of microarray?
Cannot see balanced translocations
What are the types of translocations?
Reciprocal (piece of one chromosome switches with a piece of another)
Robertsonian (acrocentric (13,14,15,21,22) chromosomes that merge long arms)
What are the structural causes of RPL?
Congenital uterine anomalies (didelphy / bicornuate / septated uterus)
Leiomyomas
Synechiae (asherman’s)
Uterine polyps
What is a bicornuate uterus?
one cervix, 2 cavities/uterine horns due to lack/incomplete canalization
What is a didelphys uterus?
2 cervices, 2 cavities/uterine horns due to lack merging / fusion
What is a septate uterus?
Lack of septal reabsorption
Most common mullein anomaly 3-7% in general population
What does bicollis mean?
Double cervix
How does a bicornuate uterus differe from a didelphys uterus?
One cervix in bicornuate
2 cervices in didelphys (may also have vaginal septum)
Describe how Mullerian anomalies occur embryologically?
Failure of elongation, fusion and canalization or septal reabsorption occurs around 9 weeks gestation
How do you counsel a patient about pregnancy risks in the presence of a Mullerian anomaly?
Increased risk of malpresentation, miscarriage, growth restriction, preterm birth
What is the incidence of maternal renal anomalies if she has a Mullerian anomaly?
Up to 30%
How do you manage delivery in a patient with a vaginal septum?
Can deliver through it
How can you improve pregnancy chances in patients with Septate uterus?
Hysteroscopic septum resection
What are the endocrine causes of RPL?
Luteal phase defect PCOS HyperPRL Poorly controlled DM Hypothyroidism
How is PCOS treated?
Metformin
What workup do you perform in patients with a history of recurrent pregnancy loss?
H&P (family history of pregnancy loss, history of birth defects/genetic abnormalities, history of thrombosis, comorbidities, toxin exposure)
Parental karyotype
Sonohysterogram or 3D ultrasound
Antiphospholipid antibodies (if criteria met)
TSH / Prolactin
HbA1c
What are the indications for a cerclage?
Exam - indicated
History - indicated
Ultrasound with a history - indicated
How do you define cervical insufficiency?
Inability of the uterine cervix to retain a pregnancy
In the absence of the contractions / labor
In the second trimester (typically before 24 weeks).
How do you counsel a patient with a history of cervical insufficiency?
Increased risk of it happening again
Discuss history indicated cerclage at 13-14 weeks
VS
Cervical length surveillance with cerclage for CL<2.5cm
Who do you consider to be a candidate for an exam indicated cerclage?
Physical exam showing painless cervical dilation in the second trimester
Who do you consider to be a candidate for a history indicated cerclage?
History of 1+ second trimester losses from painless cervical dilation (without abruption or labor) or that had a cerclage placed due to painless cervical dilation in the 2nd trimester.
Who do you consider to be a candidate for an ultrasound indicated cerclage?
Patients with a history of a prior spontaneous preterm delivery at <34 weeks
AND
Cervical length <2.5cm before 24 weeks gestation
Who do you consider to be a candidate for an abdominal cerclage?
Failed cerclage, or history of trachelectomy
Describe how you place a McDonald cerclage?
Empty bladder
Place speculum and retractor
use ring forcep to grab anterior lip of cervix and place clockwise suture in purse string fashion
5mm mersilene
How do you counsel a patient with a history of cervical insufficiency and a short cervix at 18 weeks gestation?
Vaginal progesterone or cerclage
Do you follow cervical length ultrasounds post cerclage placement? If so, how often?
No
What are the risk factors for fetal demise?
Prior fetal demise Prior preeclampsia, abruption, FGR African american race nulliparity advanced maternal age obesity preexisting diabetes chronic hypertension smoking alcohol use ART Multiple gestations
Risk of stillbirth?
Risk of recurrent stillbirth?
- 5% , 1/200
2. 5%, 1/40
What is your differential diagnosis for a fetal demise?
Placental / Umbilical cord issues Infection Genetic causes HTN Antiphospholipid antibodies Hemorrhage Anomalies
What initial workup do you perform following a fetal demise?
Fetal autopsy placental pathology karyotype or microarray antiphospholipid antibody testing Kleihauer betke CBC, type and screen Syphilis screen
What additional findings would make you send other testing on a fetal demise and what tests would you send?
Macrosomia: FBS, HbA1c FGR: APS, CHTN evaluation, autoimmune Drug use/abruption: tox screen Hydrops: Parvovirus, Antibody screen, Hb electrophoresis Viral infection: viral serology
Following a fetal demise in the second or third trimester, which evaluations offer the greatest yield?
Fetal autopsy
Examination of the placenta, cord and membranes
Karyotype / Microarray analysis
Antiphospholipid antibody testing
How would you counsel a patient regarding route of delivery following a second or third trimester fetal demise and prior c/s?
No fetal benefit for hysterotomy
How would you induce labor in a patient with a fetal demise and a prior cesarean section in the second trimester vs third trimester?
2nd trimester: cytotec
3rd trimester: pitocin
How do you counsel a patient about the risks of anesthesia during pregnancy?
No evidence that in-utero exposure to anesthetics has any effect on the developing brain of the fetus
No anesthetic agent with known teratogenic effects in humans when used at standard concentration at any gestational age
Do you perform continuous fetal monitoring during surgery?
Can assist in maternal positioning and cardiopulmonary management
Can be considered if fetus is viable, physically possible during procedure, presence of OB with privileges and personnel able to translate the monitoring result and c-section consent obtained prior to delivery
How do you counsel a patient about whether fetal monitoring should be performed during surgery in pregnancy?
Can be considered if fetus is viable,
However, in most surgery, risks to the fetus are low, ability to interrupt surgery to perform a C/s is limited and monitoring is not always technically possible
testing pre and post procedure is a good option
What are the risks of abdominal surgery during pregnancy?
Damage to surrounding organs, blood loss, infection, preterm contractions
However, usually risk to fetus is minimal
If continuous monitoring is not planned how do you assess the fetus pre and postoperatively during surgery in the first trimester?
Doppler
If continuous monitoring is not planned how do you assess the fetus pre and postoperatively during surgery in the second trimester?
Doppler, NST if viable
If continuous monitoring is not planned how do you assess the fetus pre and postoperatively during surgery in the third trimester?
NST
30 yo G4P3 at 34 weeks presents due to Minor MVA. +spotting, +cramping.
BP 138/84, HR 104, RR 18 , SVE 3/80/-2
How do you evaluate?
IVF
EFM/Toco
CBC, Fibrinogen, Coags, Type and screen
Ultrasound
30 yo G4P3 at 34 weeks presents due to Minor MVA. +spotting, +cramping.
BP 138/84, HR 104, RR 18 , SVE 3/80/-2
Do you tocolyze?
No, you dont tocolyze a suspected abruption
30 yo G4P3 at 34 weeks presents due to Minor MVA. +spotting, +cramping.
BP 138/84, HR 104, RR 18 , SVE 3/80/-2
On monitor you see recurrent decels and prep for c/s
Her BP is now 88/40 p 130 and she is drowsy. What is happening?
What do you do?
Suspect a concealed abruption with massive blood loss Prepare for massive transfusion 2 large bore IVs, Transfusion IV hydration Stat C/s with general anesthesia
“30 yo G4P3 at 34 weeks presents due to Minor MVA. +spotting, +cramping.
BP 138/84, HR 104, RR 18 , SVE 3/80/-2
On monitor you see recurrent decels and prep for c/s
Her BP is now 88/40 p 130 and she is drowsy. And you go for Stat C/s and activate massive transfusion protocol.
Once on the table, the anesthesiologist reports that she is in Cardiac arrest. What do you do?
Call a code
Continue massive transfusion
Perform resuscitative cesarean section (Can do it before 4 minutes if prepared)
How do you counsel the patient about risks to the pregnancy following a minor motor vehicle crash or fall?
Discuss shearing forces and risk of placental abruption and maternal hemorrhage
In a minor crash, the overall risk is low
But we will monitor FHR, contractions and maternal vital signs for a few hours
What labs do you order on the patient following a minor trauma?
CBC, Type and screen
KB if Rh negative
If there is bleeding or a lot of contracting -> Coags/Fibrinogen
How long do you perform continuous fetal monitoring and contraction monitoring on a patient following minor trauma?
4-6 hours post accident if no contractions
24 hours if contracting or direct abdominal trauma
What clinical and laboratory signs would make you suspect placental abruption?
Tachycardia / Hypotension
Recurrent painful contractions
Bleeding
Dropping fibrinogen, CBC
What is the role of Kleihauer Betke screening in the management of a pregnant patient post trauma?
Assess for amount of Rhogam if maternal fetal hemorrhage is present
How often does an abruption occur in a pregnant woman following minor trauma?
How about in major trauma?
<1%
Can be as high in 40% in major trauma
What is the accuracy of ultrasound in detecting placental abruption?
Not very sensitive
Though high positive predictive value if seen with symptoms
Describe your initial assessment of a pregnant woman following major trauma?
(A) airway / cervical spine control (B) breathing (C) circulation (D) disability (E) exposure- consult with trauma team- consult with NICU- displace uterus > 20 weeks
If you are called to the ER for a pregnant woman folloiwng a major traums, what are your initial steps in her evaluation?
Assess to see if she is stable: Vitals, Bleeding
If Fetus viable, monitoring
Ultrasound of pregnancy
FAST scan
CBC, Type and cross, Coags, Fibrinogen
Consider steroids if viable, consider magnesium sulfate if <32 weeks
What fetal monitoring findings would make you suspect abruption in the patient following trauma, minor or major?
Greater than six (6) contractions in an hour
Fetal decelerations
Describe how a fibrinogen level can alart you to a concealed abruption?
Fibrinogen is consumed to make fibrin clot in the setting of acute bleeding. In the event of preplacental bleed, the bleed may not be seen by ultrasound or vaginally but the fibrinogen would be low suggesting an acute bleed that cannot be seen
How can you do a cesarean under local anesthesia?
Lidocaine 4mg/kg of 1% lidocaine without epi (30mL)
What are the most common causes of cardiac arrest in pregnancy?
Bleeding/ DIC Embolism (AFE, PE) Anesthesia complication Uterine atony Cardiac complications (MI, cardiomyopathy, arrhythmia) Hypertension/preeclampsia/eclampsia Other (5Hs and 4Ts) Placenta abruption/Previa Sepsis
When do you perform a perimortem cesarean delivery?
Maternal cardiac arrest
What are the reversible causes of PEA?
Hypovolemia Hypoxemia Hyper/Hypokalemia H+ excess (Acidosis) Hypothermia Tension pneumo Tamponade Thrombosis (PE) Thrombosis (MI) Toxins
Describe how you perform a perimortem cessarean delivery?
Remain in place where arrest occurred (Do not move to an OR)
Uterus will be manually displaced
Chest compressions continue while CD initiated
No anesthesia necessary
No abdominal prep necessary
Vertical or pfannenstiel
Close uterus while ACLS/CPR continues
Continue palpating aorta to confirm pulse
If a pregnant woman develops cardiac arrest at 28 weeks, describe how you will handle the situation?
CABUD Call code and begin resuscitation Circulation Airway and breathing Uterine displacement (LUD) Delivery
How do you monitor the fetus during CPR?
Detach monitors, and prepare for perimortem c/s
WHat is the 4 or 5 minute rule in resuscitation in pregnancy?
Resuscitative cesarean section after 4 minutes
because it relieves aortocaval obstruction
Improves ability to perform CPR
Improves maternal survival
Improves neonatal outcomes
Describe how chest compressions are performed.
100 compressions / minute
30:2 compressions to ventillations (Changing every 2 minutes)
No pause for breaths once intubated
When do you stop chest compressions for a patient in cardiac arrest?
No return of spontaneous circulation after resuscitative hysterotomy
Do you recommend relocating the patient to an OR for perimorterm cesarean delivery. Why or why not?
No, you do not delay, you deliver whereever you are
What are the most common reasons for ICU admission in the pregnant and postpartum patient?
Hypertension Hemorrhage Respiratory Failure Sepsis Cardiac disease
What is preload?
Amount of fluid being returned to heart
Left ventricular EDV
What is afterload?
Resistance to blood flow exiting the heart
What are the determinants of Cardiac Output? And what are they determined by? And how can they be estimated?
HR X SV (amount of blood pumped out in 1 minute)
SV determined by:
Preload (historically measured with wedge pressure and CVP)
Afterload (PVR and SVR)
Contractility (LVSWI - left ventricular stroke work index)
Determinants of BP?
SVR X SV X HR
Physiologic changes to Cardiac output, SVR and Colloid Oncotic pressure in pregnancy?
Cardiac Output increases
SVR decreases
Colloid oncotic pressure decreases
Treatment for preload problems?
If low Expand volume (fluids)
If high Diurese / Vasodilate
Treatment for afterload problems?
If low give vasopressors
If high give vasodilators
Treatment for contractility?
If low give inotropes (digoxin)
Treatment for bradycardia / tachycardia?
bradycardia: atropine
tachycardia: beta blocker, calcium channel blocker
Mnemonic for alpha and beta receptors?
1 Heart, 2 Lungs 1: constrict, 2: dilate
Alpha: arteries
Beta: beats/breaths
What are indications for invasive hemodynamic monitoring?
Unresponsive shock ARDS Cardiac failure Left heart obstruction AFE
What are the indications for an arterial line
ARDS Hypovolemic shock Septic shock with hypotension Severe preeclampsia with pulmonary edema Cardiac failure
What are the types of central lines? And what are they used for?
Arterial line (radial artery) - used for continuous BP and frequent ABG CVP (central access via jugular or subclavian vein) - Assess volume, RV function, give meds, high volume fluids PICC line
Mixed venous saturation?
Mixed venous saturation - (central access via jugular or subclavian vein) - used in sepsis, assess tissue oxygen extraction
If it’s increasing, means body is compensating by extracting more oxygen, which is not a good sign.
PA catheter measures?
PA Catheter (central access via jugular or subclavian) - Measure CVP, PAP, CO, SVR, PCOP and SvO2
What does pulmonary capillary occlusion pressure assess
Left sided preload (not used much anymore)
What does central venous pressure assess?
Right sided preload
What is gapped acidosis?
Acidosis with an increased anion gap
How do you determine if acidosis is gapped or non-gapped?
Measure anion gap (Na - Cl - HCO3)
What are the risk factors for hemorrhage?
Prolonged labor LGA fetus Polyhydramnios Chorioamnionitis Twins Fibroids Multiparity
What is hemorrhagic shock?
Reduced intravascular volume from blood loss
- > inadequate oxygen delivery to meet cellular needs
- > producing cellular and tissue hypoxia
What is the definition of massive transfusion?
10u of blood in 24 hours
3u of blood in 1 hour
What are the goals of massive transfusion?
(1) Hemodynamic stability (fluids)
(2) Oxygenate tissues (red cells)
Hb > 7
Plt > 50,000
Fibrinogen >100 mg/dL
PT/PTT <= 1.5 times control
What are risks of massive transfusion?
Hypothermia
Coagulopathies
Electrolyte imbalances
Transfusion reactions (Acute lung injury)
Pulmonary edema (cardiogenic if from volume, or non cardiogenic if from DIC or TRALI)
What is the lethal triad in management of massive hemorrhage and transfusion? What does it mean when its present?
Hypothermia
Coagulopathy
Acidosis
When all 3 are present mortality is as high as >65%
How does citrate in blood products effect a patient?
Binds calcium -> leading to hypocalcemia -> arrhythmias
Citrate metabolism results in HCO3, which is excreted in urine, if the insulit is enough to decrease removal then the result is Hypokalemia and Alkalosis
If you anticipated high risk for inctraoperative hemorrhage, how will you prepare?
Large bore IVs Type and cross Make sure patient is warmed Hydrate Baseline labs If very high risk, central line
What is dose and potential side effects of misoprostol?
600-1000mcg PO/PR
Fever
Shivering
What is dose and potential side effects of hemabate?
0.25mg IM q 15-90 max dose 2mg
Diarrhea
What is dose and potential side effects of methergine?
0.2mg IM
Hypertension
How does tranexamic acid work?
Reducing bleeding by decreasing fibrinolysis by inhibiting the enzymatic breakdown by plasmin
Dose and when should tranexamic acid be used?
1g IV, within 3 hours of hemorrhage, and after initial attempts of medical management have failed.
Describe how you perform a B-Lynch suture
1) A large Mayo needle with # 1 or 2 chromic catgut is used to enter and exit 3 cm below the anterior uterine incision and exit 3 cm above the uterine incision anteriorly
2) then looped over and around to the posterior uterine segment
3) insert a horizontal suture at the posterior lower segment of the uterus which allows you to cross to the other side of the uterus posteriorly
4) loop the suture over and around the uterus again
5) insert the suture 3 cm above and below the incision and tied securely with uterine compression
Explain how you manage uterine atony?
Uterine massage Bimanual pelvic exam Remove intrauterine clots Empty bladder Oxytocin plus second agent If unsuccessful then: Uterine tamponade Bakri balloon 300-500mL of saline
What are indications for a cesarean hysterectomy?
??Uterine hemorrhage Infection Fibroids Cervical cancer Adnexal disease??
When will you proceed with hysterectomy in a patient who is having active uterine bleeding postpartum?
Abnormal vital signs not responding to transfusion
What is your management for PPH?
Alert OB team
Uterine massage
Bimanual pelvic exam -> remove intrauterine clots
Oxytocin plus second agentIf unsuccessful
Empty bladder
Uterine tamponade Bakri balloon 300-500mL of saline
What are your goals for resuscitation in postpartum hemorrhage?
Correct coagulopathy Correct acidosis SBP>100 Stop bleeding Maintain oxygenation
How do you monitor response to resuscitation in PPH?
BP/Pulse
Pulse pressure
UOP
SpO2
What are triggers for initiating a massive transfusion protocol?
acute blood loss and hemodynamic instability
Describe how you will manage bleeding from the cuff and peritoneal surfaces post hysterectomy?
Topical hemostatics
Packing
Embolization if stable
What is the role of IR in the management of hemorrhage?
Only for stable patients
What is D.I.C?
Consumption of clotting factors so that you cant clot anymore
How is DIC defined?
Acquired complication resulting in widespread formation of clots in the microcirculation
Signs/symptoms of DIC?
Bleeding
Ecchymosis, petechiae and purpura
Hematuria
Shock out of proportion to blood loss
What are some examples of causes of DIC?
Shock Trauma Infections Abruption Fetal death Malignancies
What is the pathology that occurs in DIC?
Endothelial disruption -> Platelet activation (plug formations) ->Intrinsic clotting cascade -> Fibrin mesh work (screen doors to cover holes) -> Plasmin (remodels and trims the meshwork) -> FSP (fibrin split products) fly through circulation and cause damage -> endothelial disruption…
What damage do fibrin split products cause?
RBC damage (hemolysis) Damage to endothelial lining of pulmonary capillary bed (acute lung injury) Plugs microcirculation (Tissue necrosiss / organ injury) Leads to platelet dysfunction -> bleeding
What laboratory workup to you perform?
Fibrinogen PT (prolongs before PTT)
What is your differential diagnosis of a patient in DIC?
Massive blood loss HIT Vitamin K Deficiency Liver Insufficiency Thrombotic microangiopathy
What are fibrin split products?
Pieces of clot from remodeling that can fly thru vasculature and cause problems
What is a normal fibrinogen level in a pregnant patient?
> 300mg
What are complications of DIC?
Hemorrhage
Tissue necrosis / Organ injury
Lung injury
Hemolysis
How do you manage DIC in a patient due to hemorrhage?
Massive transfusion protocol
Control bleeding
What is FFP? Volume?
Plasma (Fibrinogen, clotting factors) 250mL
What is in FFP?
Fibrinogen, plasma, clotting factors
How much will a single unit of FFP raise fibrinogen levels?
10-15
What is cryoprecipitate? Volume?
Distilled FFP, with smaller volume but more concentrated factors 40mL
Whats in cryoprecipitate?
Fibrinogen, Factor 8, Factor XIII, VWF
How much wll a single unit of cryoprecitate raise fibrinogen levels?
10-15
What are the lab targets for massive transfusion?
Hb > 7
Plt > 50,000
Fibrinogen >100 mg/dL
PT/PTT <= 1.5 times control
Why do patient get acidotic and hypothermic in the setting of massive transfusion?
Hypothermia: decreased blood volume and open abdomen allowing escape of warmth
Acidotic: Hypoperfusion
What is transfusion related acute lung injury (TRALI)?
Transfusion related acute lung injury
Fluid build-up in the lungs/acute injury following transfusion with no other explanation
How is TRALI diagnosed?
new acute respiratory distress syndrome (ARDS) within six hours after blood product administration documented by hypoxemia and abnormal chest imaging.
How is TRALI managed?
Stop transfusion
WBC
CXR
Notify blood bank to screen for anti leukocyte antibodies
How is oxygen carried in your blood?
It saturates Hb first, and then whats left over is dissolved in plasma
Attached to Hb (SaO2) - 98-99%
Dissolved in plasma (PaO2) - 1-2% of it
What is the normal PaO2?
80-100mmHg
What is the respiratory alkalosis of pregnancy?
Alkalosis due to changes during pregnancy
Minute ventillation (Tidal volume * RR) goes up due to an increase in TV
As a result, mom Breathes off extra CO2 -> Decreased CO2 levels
This allows for the gradient to be from fetus to mom to get rid of CO2
Decreased maternal PaCO2 leads to chronic alkalosis, and the compensatory process is kidney excreting Bicarbonate
What are the key changes seen on an ABG in pregnancy?
pH increases slightly CO2 decreases (from 35-45 -> 25-30) - SHOULD NEVER BE IN NORMAL RANGE DURING PREGNANCY HCO3 decreases (22-26 -> 18-26)
How does supplemental oxygen affect ABG results in a patient with healthy lungs?
??
What is your differential diagnosis for a patient who presents with hypoxemia?
Asthma
Pneumonia
Pulmonary edema
Pulmonary embolism
If a patient presents with hypoxemia, describe your initial assessment?
H&P (history of asthma, what medications they are, increased risk of clotting, BP or signs of preeclampsia. listen to lungs) Give O2 CXR ABG If asthma (bronchodilators) If PE suspected CTPA or LE Dopplers If Pulmonary edema suspected (Echo) If fetus is viable, evaluate fetus (FHR / Toco)
Describe how you will escalate oxygen supplementation if he patient’s hypoxemia is not improving?
Nasal canula (24-40%) Face mask (45-55%) Nonrebreather (70%) High flow (100%) CPAP BiPap Mechanical Ventillation ECMO
What is your goal of oxygen supplementation?
> =95%
What are in indications for intubation?
Failure to oxygenate (O2 sat<95% or PaO2 <80-100)
Failure to ventillate (High PCO2 on ABG, eg. asthma)
Unable to maintain the work of breathing (High RR, uncooperative, despite O2 is okay)
Unable to protect airway (seizure, trauma)
Goals for Ventillation settings?
Tidal volume increases in pregnancy (6-10mL /kg)
Goal PaO2 >60mmHg
Goal SaO2 >95%
Goal PaCO2 27-32
If the patient is in respiratory failure and pregnant with a viable fetus, how do you assess the fetus?
Continuous FHR until stable
If the patient is in respiratory failure and pregnant with a previable fetus, how do you assess the fetus?
FH check
What are the indications for delivery in the setting of respiratory failure?
Evidence for delivery to improve maternal condition is conflicting and not compelling
Fetal benefit
Individualize care
General management for: Cardiogenic pulmonary edema
Decrease preload / afterload (diuresis, BP control)
Improve contractility
General management for: Noncardiogenic pulmonary edema
Diuresis
Treat primary cause
Targeted therapy for: Asthma
Bronchodilator
Targeted therapy for: Pneumonia
Antibiotics
Targeted therapy for: Pulmonary embolism
Anticoagulation
Targeted therapy for: ARDS
Supportive care
Address the underlying cause
What factors do you take into consideration when deciding whether or not to proceed with delivery in a patient in respiratory failure and pregnant with a viable fetus?
Gestational age of the fetus?
Will delivery improve maternal status?
Is mom stable for delivery?
What factors do you take into consideration when deciding whether or not to proceed with delivery in a patient in respiratory failure and pregnant with a previable fetus?
Will delivery improve maternal status?
Is mom stable for delivery?
What is cardiogenic pulmonary edema?
Hydrostatic pulmonary edema
Heart is not able to keep up with the volume, so overflows into the lungs
Doesnt need to have a primary heart problem, can be increased fluid volume
Examples of cardiogenic pulmonary edema?
CHF Cardiomyopathy Hypertension Arrhythmias Volume overload
What is non-cardiogenic pulmonary edema?
Non-hydrostatic pulmonary edema
Heart is not the problem,
NOT an overflow problem, a leaky vessel problem
Examples of noncardiogenic pulmonary edema?
Pre-eclampsia ARDS Sepsis DIC TRALI Amniotic fluid embolism Aspiration Pneumonia
How do you differentiate between cardiogenic and non-cardiogenic pulmonary edema?
Cardiogenic
Patchy infiltrates at lung bases
BNP elevated
Decreased LV function on Echo
Non-cardiogenic homogenous fluffy shadows BNP <100 High WBC Normal LV function
What clinical signs and symptoms suggest pulmonary edema?
Hypoxemia Dyspnea Tachypnea Tachycardia Crackles Chest pain Cough
What physiologic changes in pregnancy predispose her to cardiogenic pulmonary edema?
Increased intravascular volume
Increased vascular permeability ???
Lower serum colloid osmotic (oncotic) pressure ??
How do you diagnose pulmonary edema?
Clinical suspicion
CXR
Describe your management of pulmonary edema?
Monitor the fetus
O2 (Goal SaO2 >=95%)
Sit patient up to recruit lower alveoli
Diuresis
Assess volume status (Cardiogenic vs. Noncardiogenic)
BNP or Echo
Decrease Afterload (depending on etiology)
How do you gauge appropriate response to your management of pulmonary edema?
Assess oxygenation, ventillation and work of breathing
If the patient continues to have worsening hypoxemia despite diuretic therapy, how will you manage her?
Consider stepping up in oxygen delivery methods
Contine diuresing
Consider intubation
What is the role of positive pressure ventilation in the management of respiratory failure?
CPAP and BiPap
Keeps airways open by hi flow air
What is high flow nasal canula?
Heated/Humidified
Inspiratory demands met better
FRC increases via delivery of PEEP
Lighter than CPAP or BiPap)
Oxygen dilution minimized by meeting flow demands
Washout of dead space due to hihg flow rates
What is ARDS?
Decreased lung compliance and intrapulmonary shunting
What are the risk factors for developing ARDS?
Sepsis Trauma Aspiration Massive transfusion Pneumonia
How do you diagnose ARDS?
Symptoms within 1 week of a clinical insult
B/l opacities
Rule out cardiac failure and fluid overload with echo
P/F < 300
What is the PF ratio?
PaO2 / FiO2, tells us how well oxygen exchange is
Low = poor
High = good
What are the key management principles for ARDS?
Treat underlying cause (sepsis, trauma) and give supportive measures
O2
Vitals & I/Os
Elevat head of bed / prone (recruit the lower alveoli of lung)
Sedation if needed
Monitor for need to intubate
How is sepsis defined?
Life threatening organ dysfunction caused by a dysregulated host reponse to infection
What is septic shock?
Sepsis with persistent hypotension requiring vasopressors to maintain a MAP > 65mmHg
AND
Lactate level >2mmol/L despite adequate fluid resuscitation
How do you assess for septic shock?
BP
lactate level
Assess volume status
Assess urine output
What are the most common sources for sepsis in the pregnant and postpartum patient?
Chorioamnionitis Septic abortion Wound infection Endometritis Pyelonephritis Pneumonia
What are the most common organisms that cause sepsis in the pregnant and postpartum patient?
E.coli
Group A strep
Group B strep
What is your initial antibiotic of choice in the septic pregnant patient?
Depends on the suspected infection Pneumonia: ceftriaxone and azithromycin Chorioamnionitis: amp/gent Endometritis: amp/gent/clinda Pyelonephritis: ceftriaxone
What is a SOFA score?
An objective assesment score for organ dysfunction
Components of SOFA scoore?
PaO2/FiO2 Platelets Bilirubin MAP Glasgow coma scale Creatinine
Components of qSOFA?
SBP <100
RR >22
Altered mental status
Describe the key principles of sepsis management?
Maintain BP (Hydration/pressors) Source control
What is your initial management of a patient suspected to be septic?
Obtain cultures Obtain lactate Administer broad spectrum antibiotics Initiate fluid therapy (30mL/kg of crystalloid) to maintain MAP of >65 mmHg Evaluate fetus Search for localizing features
What are the objective goals of sepsis resuscitation?
MAP >= 65mmHg
Normal lactate
Urine output > 0.5mL / kg / hour
28 week patient in triage with pyelonephritis and suspected sepsis.
She received 4L IV fluid, is getting amp and gent infusion.
Vital signs 90/50, HR 128 T39 O2sat 92%
EFM Cat 2 with baseline tachycardia and moderate variability with occasional decels.
What are your next steps?
Suspicious that she is hypovolemic (4L still hypotensive)
Lactate level
Assess urine output
Assess volume status (discuss how with intensivist, Bedside Cardiovascular ultrasound, passive leg raise)
What should be performed within 1 hour of suspected sepsis diagnosis?
Obtain cultures
Obtain lactate
Administer broad spectrum antibiotics
Initiate fluid therapy (30mL/kg of crystalloid) to maintain MAP of >65 mmHg
What labs do you draw in a septic patient?
Cultures UA Lactate CBC CMP
What vital sign abnormalities are most commonly abnormal in the septic pregnant patient?
Heart rate (tachycardia) BP (hypotension)
What is the role of lactate in the septic patient management? What does it mean when it’s elevated ?
Help assess perfusion, if elevating , means poorly perfusing
Tissue hypoxia
>2 increases risk for ICU admission
>4 increases risk of death
How do you correct an elevated lactate level?
Improve perfusion:
IV fluids, vasopressors
How do you assess response to fluid resuscitation?
Urine output and Blood pressure
What are complications that may develop with a septic patient broken down by systems?
CNS: Altered mental status CV: Hypotension / Heart failure Pulm: ARDS GI: Ileus Hepatic: Hepatic failure Renal: Oliguria/Acute kidney injury Hematologic: Thrombocytopenia / DIC Endocrine: Adrenal dysfunction / Insulin resistance
How can you assess respiratory function in a septic patient?
Using a P/F Ratio
What is the PF ratio?
PaO2 / FiO2, tells us how well oxygen exchange is
Low = poor
High = good
How do you assess renal function in a septic patient?
Creatinine, Urine output
If the patient is in the ICU with sepsis, how will you assess the fetus?
If viable, fetal monitoring
What are indications for delivery in a septic patient?
Intrauterine infection IUFD GA a low risk for neonatal complications DIC (after stabilization) Respiratory failure (ARDS) Hepatic failure Renal failure Cardiac arrest Fails to respond to therapy Maternal condition expected to improve with delivery
Do you recommend tocolysis in a septic pregnant patient who is contracting at 24 weeks?
At 30 weeks?
At 36 weeks?
No
Do you recommend steroids for fetal benefit in a septic patient who is contracting at 24 weeks?
At 30 weeks?
At 36 weeks?
Yes, for the usual obstetric indications
Do you recommend magnesium for neuroprotection in a septic patient who is contracting at 24 weeks?
At 30 weeks?
At 36 weeks?
Yes, if I think she is at high risk of imminent delivery
But not after 32 weeks.
What is severe hypertension?
> = 160 SBP
OR >= 110 DBP
What are your goals of treatment of hypertension?
<160 SBP
<110 DBP
What is your first-line antihypertensive in a patient with severe hypertension?
Labetalol
How will you escalate if she does not respond?
Treat acutely to get BP <160/110
Regimen 1: Labetalol: 20,40,80 Hydralazine: 10
OR
Regimen 2: Hydralazine 10, 10 Labetalol: 20,40
OR
Regimen 3: Oral nifedipine 10, 20, 20 Labetalol: 20
Repeating BP at 10 mins for Labetalol, 20 mins for hydralazine, nifedipine
How do you manage the patient who remains severely hypertensive despite IV labetalol, IV hydralazine and PO nifedipine?
ICU transfer - IV infusion with nicardipine or esmolol
Arterial line
What are the maternal risks of untreated severe hypertension?
Stroke
Heart failure
What are the fetal risks of untreated severe hypertension?
Abruption
Fetal growth restriction
Fetal death
What is posterior reversible encephalopathy syndrome (PRES)?
What are some features of it?
Vasogenic edema in brain leading to clinical findings like: Altered mental status Vision loss / deficit Seizure Headache
How is PRES diagnosed?
MRI of the brain without intravenous (IV) contrast
Shows vasogenic edema in the posterior brain
What is the prognosis for PRES?
Good prognosis
How is PRES managed?
Delivery
Antihypertensives
Seizure meds
What clinical findings are suggestive of intracranial hemorrhage?
sudden severe headaches
focal neurologic deficits
seizures with a prolonged postictal state
or atypical presentation for eclampsia
When do you recommend brain imaging?
Worse headaches
AMS
focal neurologic deficits (vision loss, stroke like symptoms)
unexplained seizures or seizing on mag
When do you recommend Head CT vs MRI?
If my concern is for Intracranial hemorrhage
