Caring for pregnant women during disasters and evacuations
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Caring for Pregnant Women During Disasters and Evacuations. LCDR John Heusinkveld Chief, OBGYN Northern Navajo Medical Center. Introduction. About 2% of women, or 1% of the population as a whole, is pregnant at any given time

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Caring for Pregnant Women During Disasters and Evacuations

LCDR John Heusinkveld

Chief, OBGYN

Northern Navajo Medical Center


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Introduction

  • About 2% of women, or 1% of the population as a whole, is pregnant at any given time

  • Any population affected by a disaster is likely to contain a significant number of pregnant women


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Objectives

  • Define the problems posed by pregnancy during disasters


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Objectives

  • Define the problems posed by pregnancy during disasters

  • Discuss types of disasters and how they affect pregnant women


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Objectives

  • Define the problems posed by pregnancy during disasters

  • Discuss types of disasters and how they affect pregnant women

  • Focus on some common themes and make some suggestions


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Objectives

  • Define the problems posed by pregnancy during disasters

  • Discuss types of disasters and how they affect pregnant women

  • Focus on some common themes and make some suggestions


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Real Objective

  • Get potential responders thinking about this issue


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My Background

  • Board Certified in OBGYN

  • Participated in Katrina Response


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My Background

  • Board Certified in OBGYN

  • Participated in Katrina Response

  • 2 years training in Internal Medicine


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Defining the Problem

  • Historically, up to 1 in 10 women died as a result of complications of pregnancy or childbirth

  • Today the number is more like 1 in 100,000

  • Modern care has made pregnancy and childbirth 10,000 times safer


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Defining the Problem

  • How do we maintain this level of safety during emergencies, when patients are unable to reach their usual care providers and facilities?


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Types of Emergencies

  • Natural Disasters

  • Warfare

  • Terrorism

  • Epidemics


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Natural Disasters

  • Damage to transportation infrastructure

  • Damage to healthcare infrastructure

  • Physical trauma

  • Exposure to pathogens and toxins


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Warfare and Terrorism

  • Damage to transportation and healthcare infrastructure

  • CBR Agent exposure


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Epidemics

  • Direct pathogen exposure

  • Healthcare facilities may be overwhelmed or closed due to contamination

  • Quarantines


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Common Problems

  • Damage to transportation infrastructure

  • Damage to healthcare infrastructure

  • Physical trauma

  • Displacement

  • Exposures

  • Inectious Diseases


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Damage to Infrastructure and Displacement

  • Patient can’t reach facility or facility is not operating

  • Most pregnant women can go without any care for a few days or even weeks

  • Exceptions:

    • Patients near delivery

    • Patients with pregnancy complications

    • Patients with chronic medical problems


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Physical Trauma

  • May cause intra-uterine fetal demise or precipitate premature delivery

    • No intervention is possible until the age of viability

    • After viability, delivery in a tertiary care facility is vital

    • Ability to rapidly assess gestational age and fetal well-being is essential


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Exposures

  • Chemical

    • Little known about teratogenic effects of most agents

  • Radiological

    • Exposure is cumulative for pregnancy

    • Less than 5 rads: probably no risk

    • Greater than 10 rads: significant risk

    • Risk probably decreases with gestational age

  • No intervention possible except minimize exposure


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Epidemics

  • Most infectious diseases associated with disasters are unlikely to pose specific risk for pregnant women

  • Biggest risk is non-treatment

  • Responders need to know which medications are safe in pregnancy


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The Challenge: Triage

  • How can non-specialists rapidly identify pregnant patients needing immediate care?




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Scenario 1: Earthquake

  • Multiple trauma victims

  • 22 year-old woman who says she is pregnant and is having some bleeding

    • Stable vitals

    • No acute distress

    • Unsure of gestational age


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Scenario 1: Earthquake

  • Ultrasound reveals 16-week gestation


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Scenario 1: Earthquake

  • Ultrasound reveals 16-week gestation

    • Move on to next patient


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Scenario 1: Earthquake

  • Ultrasound reveals 16-week gestation

    • Move on to next patient

  • Ultrasound reveals no fetal cardiac activity


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Scenario 1: Earthquake

  • Ultrasound reveals 16-week gestation

    • Move on to next patient

  • Ultrasound reveals no fetal cardiac activity

    • Move on to next patient


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Scenario 1: Earthquake

  • Ultrasound reveals 16-week gestation

    • Move on to next patient

  • Ultrasound reveals no fetal cardiac activity

    • Move on to next patient

  • Ultrasound reveals 28-week gestation with fetal cardiac activity


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Scenario 1: Earthquake

  • Ultrasound reveals 16-week gestation

    • Move on to next patient

  • Ultrasound reveals no fetal cardiac activity

    • Move on to next patient

  • Ultrasound reveals 28-week gestation with fetal cardiac activity

    • Evacuate by air to tertiary care center


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Scenario 2: Hurricane

  • Large number of patients in Medical Support Shelter

  • 22 year old woman says she is pregnant and has to take shots “for her blood”


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Scenario 2: Hurricane

  • Syringes say: “insulin”


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Scenario 2: Hurricane

  • Syringes say: “insulin”

    • Monitor blood sugar at relief center


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Scenario 2: Hurricane

  • Syringes say: “insulin”

    • Monitor blood sugar at relief center

  • Syringes say: “Lovenox”


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Scenario 2: Hurricane

  • Syringes say: “insulin”

    • Monitor blood sugar at relief center

  • Syringes say: “Lovenox”

    • Evacuate to tertiary care center

  • Responders need quick access to expert advice in order to make these decisions


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What Responders Need

  • Ability to assess gestational age and fetal well-being

  • Ability to evacuate patients at risk

    • Tertiary care hospitals for acute problems

    • Communities with access to care for chronic problems

  • Access to expertise


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Some Suggestions

  • Teams responding to disasters should have doppler and basic ultrasound capability

  • Identify consultants whom responders can easily reach with questions

  • Coordinate with tertiary care centers and communities to which patients can be dispersed


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