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Anesthesia Concepts 4 (Butera) > OB Emergencies > Flashcards

OB Emergencies Flashcards

1
Q

T Reasons for Hemorrhage

A

Tone (uterine)
Trauma (rupture, laceration of cervix)
Tissue (retained products)
Thrombin ( ex, coagulopathy)
Turned inside out (uterine inversion)

TELEPHONE CALL for help MTP!!!

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2
Q

4 risk factors for highest odds of predicting massive transfusion

A

Abnormal Placentation (1.6/10K deliveries)
Placental Abruption (1.0/10K deliveries)
Severe Preeclampsia (.8/10K deliveries)
Intrauterine fetal demise (.7/10K deliveries)

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3
Q

Why do we check a fibrinogen level?

A

Low is MOST predictive variable for EARLY Hemorrhage
Goal is greater than 200mg/dl
GIVE EARLY!!!!

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4
Q

TXA for PPH

A

Tranexamic acid –give within 3 hours
Lysine analogue
Prevents fibrinolysis
Competitively blocks plasminogen and plasmin
TXA half life is 2-3 hours with normal renal fxn
1 gram in 100cc over 10min
1 gram in 250cc over 8hr infusion

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5
Q

OB Emergencies

A

Maternal Hemorrhage:
- Antepartum/Intrapartum
- Placental abruption
- Uterine rupture
- Location of placenta

Fetal Injury
- Prolapsed cord
- Shoulder Dystocia

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6
Q

Umbilical Cord Prolapse

A

Acute fetal bradycardia
ROM+palpated cord in vagina
STAT C/S
May be on all fours

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7
Q

What is placental abruption?

A

Premature separation of normally implanted placenta
1 in 86 deliveries
Blood loss can be concealed
DIC in 4-10% deliveries
15% 3rd trimester still births

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8
Q

Placental Abruption: Risk Factors

A

Multiparity
Age>35
Preeclampsia
Chronic HTN
ETOH abuse
Cocaine use
Smoking/PROM/Abdominal Trauma
Previous history of abruption

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9
Q

Placental Abruption: Clinical Presentation

A

Vaginal bleeding dark blood/clots
Shock with minimal visible blood loss
Abdominal pain
hypertonicity
U/S=clot
Often concealed

Fetal distress

GOOD NEWS:
90% are mild or moderate
SEVERE= Stat C/S

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10
Q

Uterine Rupture Risk Factors

A

1 in 2000-2500 deliveries
3 ruptures in 1000 deliveries in pt with prev c/s
Leading cause is previous uterine scar
VBAC (most common UR- prev C/S)
Multiparity
Previous uterine surgery-myomectomy
Previous uterine rupture
Hx prior c/s and induction of labor
“Classical” c/s with vertical incision
Fetal macrosomia/malposition
Rapid labor
Prolonged labor with CPD
Parity >7 increased incidence of rupture is 20 times that of lower parity women

STAT C/S + Control hemorrhage

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11
Q

Uterine Rupture symptoms

A

INITIAL signs sudden /individualized
Fetal bradycardia /variable decel (70%)
Hypotension (5-10%)
Vaginal bleeding (3-5%)
Uterine atony/ recession fetal head- rarer
severe abdominal/uterine pain
pain that does not decrease with ctx
STAT C/S + MTP

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12
Q

TOLAC and uterine rupture

A

RARE TOLAC with uterine rupture of those:
1 in 4 serious outcome:
hysterectomy /vented/blood transfusion/death/5 min Apgar<4 or vented

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13
Q

Different types of abnormal placentation

A

Placental Previa
Placenta accreta, increta, percreta

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14
Q

Placenta Previa –location r/t OS

A

Implantation over or too close to the cervical os
Dx with Transvaginal U/S
1 in 250 deliveries
Most detected early U/S

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15
Q

Placenta Previa -

A

BRIGHT RED painless bleeding
Usually 3rd trimester
For stable placenta previa elective C/S with blood products available
2 large bore IVs and blood products in room etc

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16
Q

Abnormally Implanted Placenta

A

Accreta = absence of decidua basalis
Increta = invades myometrium
Percreta =thru serosa

U/S and confirmed by MRI

Undiagnosed if placenta does NOT separate at vaginal delivery or C/S

Earlier diagnosis allows plan development/tertiary care center

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17
Q

Abnormal Implantation- PAS

A

Adherent placenta leads to significant hemorrhage
Average EBL for PAS cases 2-5 liters
40% of cases require more than 10 units of blood products
Neuraxial anesthesia pros and cons/ planned conversion to general at time if needed study by Markley has conversion rate of 21%

18
Q

Risk Factors-abnormal implantation

A

Accreta(76%)
Increta(18%)
Percreta(6%)
Multiparity
Previous C/S
Current PL. PREVIA
IVF pregnancy
Elevated 2nd trimester alpha fetal protein and Bhcg
Hx Post partum Hemmorhage,uterine surgery,
AMA

19
Q

Silver RM etal. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology. 2006.107(6):1226-1232……????? why…

A

Red flag: in cases of previa there is INCREASING risk of Accreta w each c/s

1999-2002
30,132 c/sections without labor 19 institutions
Placenta accreta
1st c/s=15(.24%) 4th c/s=31(2.13%)
2nd c/s=49(.31%) 5th c/s=6 (2.33%)
3rd c/s=36(.57%) 6th c/s=6 (6.74%)

Now in those 723 with known PREVIA….
1st c/s risk of accreta 3%
2nd c/s risk of accreta 11%
3rd c/s risk of accreta 40%
4th c/s risk of accreta 61%

20
Q

Placenta Accreta Spectrum Acog consensus no 7

A

Most accepted approach is cesarean hysterectomy with the placenta in situ
Multidiscipinary team- designated maternity centers
Delivery at 34 weeks -35 6/7 weeks is optimal
Corticosteroids for lung maturity
MT planned
?Post delivery MT uterine artery embolization
(rate increasing noted acog 2021 reaffirmed… cites 2016 study as 1 in 272 USA deliveries)

21
Q

Should have how many units ready with PAS?

A

T&C for 6 units is recommended by recent retrospective studies(published Jan 2023)

Designated Maternity Tertiary Care Center

22
Q

AFE: Anaphylactoid Syndrome of Pregnancy

A

1941 1st described by Steiner and Lusbaugh
Limitations… self reporting and limited pts 2 early registries
Change of term Anaphylactoid syndrome of pregnancy

23
Q

Pathophysiology of AFE

A

1st described as presence of amniotic fluid debri,squamous fetal cells in pulmonary circulation of the mother…embolic “theory”
Immune response in mother to fetal antigens
Amniotic fluid contains vasoactive and procoagulant substances(thromboxane, bradykinin,cytokines etc)…immunologic “theory”

24
Q

NEW-2 phase model of AFE

A

1st phase rapid respiratory and cardiac arrest
2nd phase hemorrhagic
Bleeding wound site: placental attachment or cesarean incision
Rapidly DIC
Dx of exclusion

25
AFE diagnostic criteria basics
Sudden onset of cardioresp arrest or hypotension with evidence of respiratory compromise DIC (scoring sxn Plt, INR, fibrinogen low) Clinical onset during labor or within 30 minutes of placental delivery Absence of fever(> 38 degrees c) during labor (1/4 of all cases of AFE are atypical cases)
26
Amniotic Fluid Embolism ? risk factors ?
AMA Preeclampsia/ Placenta Previa C/S Uterine Rupture Manual removal of placenta Endocervical laceration CONSIDER RiaSTAP(IV fibrinogen)2gram
27
Summary AFE clinically seen by
Resp and cardiac arrest PEA, Pulmonary HTN, Right sided heart failure, RV Failure with severe Tricuspid Regurg Seizures Platelet degranulation/Pulmonary HTN due to serotonin/thromboxane DIC
28
AFE-- USA updated: stats
1: 14,000-1:16,000 Majority at time of delivery (can occur <48hr after delivery and others) Could be via labor or c/s- “distress” Mortality rate 20-22% Most babies survive neurologically intact Pulmonary vasoconstrictors lead to right heart failure….hypoxia… tissue factors from amniotic fluid cause DIC
29
AFE update review
Mast cell degranulation/Complement activation *Mast cell degranulation in aternal lunges in fatal AFE cases-serum tryptase levels in fatal cases AFE 7-10 times that of controls * Hypothesis immunologic mechanism-release vasoactive substances-fetal antigens Tx coagulopathy promptly:FFP, cryo, fibrinogen concentrate and antifibrinolytics Serum tryptase levels in fatal cases 7-10 times higher than controls
30
Society for MFM special statement
Cognitive aid checklist /immed CPR/MANUAL LUD/differential dx /ABCs Time keeper one minute intervals No pulse at 4 minutes PMCD resuscitative hysterotomy “splash prep- location” Interosseous line humerus uterotonics /MTP Cryo preferred over FFP Reduce volume overload/ TXA if DIC Manage Pulmonary HTN/ Right Heart failure Consider early TTE or TEE Avoid overload 500cc bolus reassess 1st line pressor is Norepi .05-3.3mcg/kg/min Inotropes(Dobutamine/Milrinone) Then Pulmonary vasodilator…. ECMO
31
A-OK case reports
**A**tropine 1mg atropine **O**ndansetron 8mg **K**etolorac 15mg Others have added Metoclopramide Baylor College of Medicine registry for AFE 307-363-2337 tel support; registry@afesupport.org (Rezai etal Case Rep Obstet Gynecol 2017 Atypical AFE case report .2mg Atropine, Ondansetron 8mg and Ketolorac 15mg)
32
Manual LUD
33
AHA website comments-updated 2015 ACLS
Back board **+Two handed Manual LUD** Emergency Cesarean Delivery in Cardiac Arrest individualized PMCD may be considered part of maternal resuscitation regardless of fetal viability *** Survival of mother has been reported after 15 minutes of cardiac arrest Neonatal survival has been documented with PMCD performed up to 30 minutes after maternal arrest Not recommended to have cricoid pressure in maternal resuscitation-cardiac arrest-no data to support *
34
ACLS goals
High quality CPR AND Relief of aortocaval compression- 2cm Continuous Manual LUD if fundus height at or above level of umbilicus IV access above diaphragm/ remove internal monitors/stop IV Magnesium give Calcium chloride or calcium gluconate NO DELAY Perimortem cesarean delivery considered at 4 minutes after onset of maternal arrest—ie futile maternal trauma
35
AHA updated 2015
Survival of mother has been reported after 15 minutes of cardiac arrest Neonatal survival has been documented with PMCD performed up to 30 minutes after maternal arrest Post arrest care -targeted temp management and multidisciplinary team 32-36 degrees for 1st 24 hours post ROSC// and onward/ focus hemostasis TTM and multidisciplinary team
36
ACLS for Obstetric cardiac/resp arrest: BEAUCHOPS
**B**leeding/DIC **E**mbolism: coronary/pulmonary/AFE **A**nesthetic complications **U**terine atony **C**ardiac disease (MI/aortic diss/cardiomyopathy) **H**TN- PEC with severe features **O**ther-5Hs 5Ts **P**lacenta Abruption/Placenta Previa/PAS **S**epsis
37
Def: Pregnancy –Related Death
Death of a woman during or within one year of pregnancy that was caused by a pregnancy complication, a chain of events initiated by pregnancy, or the agravation of an unrelated condition by the physiologic effects of pregnancy
38
Maternal Mortality
Estimated 25% of maternal deaths are due to hemorrhage/uterine atony Risk of death increases w/maternal age >35 African American race more likely to die Overall Maternal Mortality rates in the USA **17.4 per 100,000 live births** Nonhispanic black 37.1 per 100K live births Nonhispanic white 14.7 per 100k live births Hispanic 11.8 per 100K live births
39
Maternal Mortality Trends
Maternal Mortality rates 2.5 times higher in Non hispanic Blacks Trends 1999-2018 PEC and Eclampsia are declining Chronic HTN increasing Rise and fall with diabetes mellitus AFE is declining
40
Severe Maternal Morbidity
New trends looking at 2012-2014 National Inpatient sample- has 20% of hospitalizations in US Obstetric readmissions racial disparities Of 11 million births 1.8% admitted post partum- most common dx transfusion nonhispanic black women had 80% higher risk of postpartum readmission Pulmonary edema and acute heart failure SUMMARY: Estimated 35-40% cases of maternal mortality or severe maternal mortality are preventable Only 5.5% of anesthetics OB for c/s are GA in US- think regional first Centers for Excellence team approach for AIP abnormal invasive placenta (PAS) Obesity increases the risk of venous thromboembolism, c/s del, endometritis. failed trial of labor

Anesthesia Concepts 4 (Butera) (15 decks)

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