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Obstetric Anesthesiology

Obstetric Anesthesiology. Tammy Y. Euliano , MD Associate Professor of Anesthesiology and Obstetrics & Gynecology University of Florida College of Medicine. Defining the problem in Honduras. 2008 MMR: 110/100K live births Lifetime risk of maternal death 1:240

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Obstetric Anesthesiology

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  1. Obstetric Anesthesiology Tammy Y. Euliano, MD Associate Professor of Anesthesiology and Obstetrics & Gynecology University of Florida College of Medicine

  2. Defining the problem in Honduras • 2008 MMR: 110/100K live births • Lifetime risk of maternal death 1:240 • 8% of female deaths during child-bearing years are pregnancy-related • Progress MMR over time Trends in Maternal Mortality: 1990-2008. WHO

  3. MMR Data 2008

  4. Causes of Maternal Death: Latin America & the Caribbean Hemorrhage Unclassified HTN disorders Obstructed labor Sepsis/infection Abortion The Lancet 2006; 367: 1066-74

  5. Hypertensive Disorders

  6. Case • 20yo AA woman presents at 38w gestation for induction of labor for “preeclampsia” • h/o chronic HTN on aldomet • h/o gestational DM • BMI 36

  7. Hypertensive Disorders • Preeclampsia in up to 15% of Pg

  8. Preeclampsia: Definition • After 20 weeks gestation • Hypertension (BP > 140/90) • Proteinuria (>300 mg/24h; 1-2+ dipstick) • Usually also hyperreflexic • Risk for eclampsia • Labs: CBC+PLT, Liver enzymes, BUN, Cr, uric acid, 24h urine for protein & CrCl • Bleeding or ?HELLP add fibrinogen, PT, aPTT

  9. Preeclampsia: Pathophysiology • Vasoconstriction  hypertension and decreased blood volume • Increased vascular permeability  proteinuria  decreased colloid oncotic pressure  edema (cerebral, pulmonary)

  10. Preeclampsia: Treatment • Prevent seizures • Magnesium sulfate • Renally excreted!!! • Goal 4-6 mEq/L • Monitor with DTR • Stabilize BP • Antihypertensives for BP > 160/105 • Deliver

  11. Preeclampsia: Delivery • The only cure is delivery of the placenta • 38+ weeks, deliver • <38 weeks and mild: bedrest, monitoring • <32 weeks and severe: caution & inpatient • Eclamptic: deliver! • Dexamethasone may reduce the risk/severity of HELLP

  12. Case • 20yo AA undergoing induction • cHTN, gDm • BMI 36 BP 140/90 HR 105 • Magnesium infusion • Desires epidural

  13. Before placing epidural, who would want… • To decline epidural placement • Platelet count • PT/PTT • Fluid bolus

  14. HELLP Syndrome • 15% of severe preeclamptics • Dx: 2/3 antepartum, 1/3 postpartum • Maternal mortality 1.1% • Morbidity: • DIC 21% • Abruption 16% • ARF 8% • Pulmonary edema 6% • Subcapsular liver hematoma 1% • Retinal detachment 1%

  15. Case…4h later • 20yo AA undergoing induction • cHTN, gDm • Epidural placed – now 4h later • BP 200/110 HR 105 RR 55 • c/o dyspnea • LLD with clear BS Right; rales Left; spitting up frothy fluid • SpO2 75%

  16. Severe Preeclampsia • BP > 160/110 • Proteinuria > 5g/24h • Oliguria < 500 mL/24h • CNS Symptoms: HA, visual disturbance • Pulmonary edema • RUQ pain (hepatic swelling) • HELLP Syndrome • Oligohydramnios and/or IUGR

  17. Preeclampsia: Morbidity • HELLP syndrome • Placental abruption • Preterm delivery • Pulmonary edema Preeclampsia: Mortality • ICH

  18. OB’s want to perform C/S. She cannot lie flat and requests general anesthesia. Would you treat her BP before induction?

  19. Critical HTN Treatment • Consider invasive arterial monitoring • Hydralazine / labetalol • Nitroglycerine • Nitroprusside • Nicardipine • Get BP down before laryngoscopy

  20. Case: c/s • 20yo AA undergoing induction • cHTN, gDm • BP 200/110 HR 105 RR 55 SpO2 75% • Frank pulmonary edema • BP Rx to 140/90 • PreO2 with elevated HOB • RSI +/- narcotics • Avoid NDMR

  21. Delayed Awakening • Twitch if NDMR • Blood sugar • Magnesium level (reflexes?) • ICH

  22. Magnesium • Prevents eclamptic seizures • DRAMATICALLY prolongs NDMR • Overdose treated with IV Ca

  23. Eclampsia • Generalized convulsions up to 7d postpartum w/o epilepsy • Complications • Abruption 10% • HELLP 11% • DIC 6% • Neurologic deficit 6% • Aspiration 7% • Pulmonary edema 5% • Cardiopulmonary arrest 4% • Renal failure 4% • Death 1%; higher if no preeclampsia (13%)

  24. Preeclampsia: Anesthetic Implications • Regional may be therapeutic • Cautious preloading • Check platelet count prior to regional anesthesia! • Use tiny doses of ephedrine; phenylephrine may be better • Control BP and consider opioids before GETA • Avoid NDMR or use minute doses • Caution with methergine or hemabate

  25. Hemorrhage

  26. Postpartum Hemorrhage:Definition • Blood loss • >500cc (2 cups) in vaginal birth • >1L in cesarean delivery • Causes ~30% of direct maternal deaths worldwide

  27. Postpartum Hemorrhage: 4T’s • Tone: uterine atony, distended bladder • Trauma: uterine, cervical or vaginal injury • Tissue: retained placenta or clots; accreta • Thrombin: pre-existing or acquired coagulopathy

  28. Postpartum Hemorrhage: Prevention • Active Mgmt of 3rd Stage of Labor • Oxytocin within 1’ of birth • Controlled cord traction • Uterine massage after placenta delivery

  29. Post-partum Hemorrhage • Uterotonics / uterine massage • IV access and fluids • Trendelenberg position • Consider 1:1 PRBC:FFP ± PLT • Fibrinogen or cryo may be needed • Consider airway management • Manual removal of retained products • Examine for lacerations

  30. Non-pneumatic Anti-Shock Garment

  31. Uterine/Aortic Compression

  32. BJOG. Online 13 August 2012

  33. Uterine Artery Embolization

  34. B-Lynch stitch

  35. Hysterectomy

  36. Massive Transfusion Protocol

  37. Massive Transfusion Protocol

  38. Cardiac Arrest

  39. ACLS Modifications • Avoid aortocaval compression • Compression position slightly cephalad • Airway device early • Smaller ETT • Prefer venous access above diaphragm • Consider emergent delivery 12.3 Cardiac Arrest Associated With Pregnancy. Circulation. 2010;122suppl:S833-8

  40. Peri-mortem Cesarean Delivery • Old data: 4 min • New data: up to 10-15 min • Improved fetal survival with • In-hospital, witnessed arrest • >35w gestation • Absence of maternal chronic disease • Shorter arrest-delivery interval • Dedicated perimortem c/s pack on unit • Educational training/simulation/regular drills Einav S, et al. Maternal cardiac arrest and perimortem caesarean delivery: Evidence or expert-based? Resuscitation (2012) Ramsay, et al. When the Heart Stops: A Review of Cardiac Arrest in Pregnancy. JlCM 2011

  41. Emergency Scenario 1 • Fetal bradycardia for emergent c/s • Maternal morbid obesity and concerning airway exam • Plan?

  42. Emergency Scenario 2 • In recovery room after uneventful 3rd c/s • Vaginal bleeding, hypotension, tachycardia

  43. Emergency Scenario 3 • Unresponsive patient immediately after vaginal delivery

  44. RescateLipidicoLipidRescue.org TRATAMIENTO PARA LA PARADA CARDIACA INDUCIDA POR ANESTESICO LOCALEn caso de paradacardiacaprecipitadaporanestesico local que no respondeal tratamiento standard, a parte de la reanimacion cardiopulmonar, Intralipid 20% debe ser administrado de acuerdo con el siguiente regimen: • Intralipid 20% 1.5 mL/kg inyeccionrapidadurante 1 minuto • Seguido inmediatamente por una infusion a 0.25 mL/kg/min, • Continue el masaje cardiaco (el lipido tiene que circular) • Repetir una inyeccionrapida cada 3-5 minutos llegando a los 3 mL/kg dosis total en inyeccionrapida hasta que la circulacion recomience • Continuar la infusion hasta que se establezca estabilidadhemodinamica. Aumentar la velocidad a 0.5 mL/kg/min si la presion arterial baja • La dosis total maxima recomendada es 8 mL/kg

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