Management of Obstetric Emergencies

1. Management of Obstetric Emergencies Brendan “Dan” Connealy, MD FACOG Methodist Perinatal Associates Methodist Women’s Hospital, Omaha NE

2. Learning Objectives • Hypertensive Emergencies in Pregnancy • Clinical update on current management guidelines and diagnostic criteria • How to approach the severe hypertensive patient • Obstetric Hemorrhage • Clinical update on current management guidelines • Discuss the approach to the massive hemorrhage patient

3. Learning Objectives • Patient Safety Bundles – Alliance for Innovation on Maternal Health (AIM) • What are patient safety bundles and how can they improve outcomes for our patients • Review the AIM supported patient safety bundles for severe hypertension in pregnancy and obstetric hemorrhage • Discuss our experience instituting patient safety bundles for severe hypertension

4. November 2013 - ACOG

5. Types of Hypertension

6. Preeclampsia with Severe Features • Proteinuria no longer qualifies as a severe feature

7. Surveillance and Obstetric Management • Preeclampsia without severe features • Less than 37 weeks • Weekly labs, antenatal testing, BP checks, fetal growth • At or beyond 37 weeks • Delivery • Additional key recommendations: • Anti-hypertensive medications not indicated • Universal magnesium sulfate not necessary to prevent eclampsia in those without severe features or symptoms ** Quality of evidence lower than for those listed above **

8. Surveillance and Obstetric Management • Preeclampsia with severe features • Any GA with unstable fetal or maternal conditions • Delivery • At or beyond 34 weeks EGA • Delivery • Less than 34 weeks – see below • Magnesium sulfate for eclampsia prophylaxis • Delivery route by obstetric indications • Treat with anti-hypertensives for BP >160/110

9. Managing severe disease at <34wks “You got to know when to hold’ em, Know when to fold ’em, Know when to walk away, Know when to run.” Kenny Rogers - Gambler

10. Early (<34wks) Severe Preeclampsia Management • PreviablePreE with with severe features/HELLP– FOLD’ EM • Viability – 33 6/7 weeks • Stable fetal and maternal condition – HOLD’ EM • Expectant management - Appropriate facility • Corticosteroids • Weekly surveillance (labs, fetal testing, growth) • Viable – 33 6/7 weeks • Unstable fetal or maternal condition – FOLD’ EM • Stabilize while giving steroids but don’t delay delivery

13. Postpartum Preeclampsia • Difficult to diagnose – requires index of suspicion • Prevalence 1-27% depending on study • Differential should include other life-threatening conditions • CVA • HELLP • TTP/HUS • May present with seizures • Assume eclampsia but image to rule out other etiologies

16. Hypertensive Emergency Management • Goals of therapy • Control severe hypertension • Stabilize the patient, initiate diagnostic tests • Prevent recurrent hypertension • Seizure prophylaxis • Monitor fetal and maternal status

17. Hypertensive Emergency ACOG Committee Opinion #692; April 2017

18. Hypertensive Emergency • Oral nifedipine or labetalol effective if no IV • Common side effects associated with medications • Hydralazine – maternal hypotension, flushing, tachycardia • Labetalol – avoid in asthmatics, heart failure, bradyarrhythmia • Failure of initial acute therapy • Consult anesthesia/MFM/ICU • Continuous infusion medications – labetalol, nicardipine

19. Severe intrapartum HTN associated with increased risk for severe maternal morbidity AJOG July 2016

21. Risk Factors for Eclampsia • Previous eclampsia • Multifetal gestation • Chronic hypertension/renal disease • Collagen vascular disease • Molar pregnancy/partial mole • Gestational hypertension-preeclampsia plus • Severe headache • Persistent visual changes • Severe epigastric/right upper quadrant pain • Altered mental status

22. When does it occur?

23. Signs and Symptoms

24. Steps in Managing Eclampsia Supplemental 02 Pulse oximetry ABG if acidemia Step 1: Prevent maternal hypoxia by supporting respiratory and cardiovascular function Mouth guard Bed padding Suction Step 2: Prevent maternal injury and aspiration 1. MgSO4 – 6g bolus then 2g/hr 2. Re-bolus 2g if persist 3. Sodium Pentobarb 250mg IV if persist Step 3: Do not try to arrest the first seizure Step 4: Prevent subsequent seizures from recurring

25. Steps in Managing Eclampsia Reference previously mentioned alorithms Step 5: Control severe hypertension to prevent cerebrovascular injury Step 6: Manage complication such as DIC, Pulmonary Edema Step 7: Begin induction/delivery within 24 hours

26. Obstetric Hemorrhage • Hemorrhage incidence - 4-6% • SVD >500ml • Cesarean >1000ml • Life threatening obstetric hemorrhage 1:1000 • Second most common cause of maternal mortality in the US • 0.9/100,000 • Most are considered preventable ACOG Practice Bulletin 76 Drife J. BJOG (1997) 104:275–7 CDC; NVSR, V 58:19, May 2010, tables 33 and 34

27. Obstetric Hemorrhage 93% of deaths due to hemorrhage are considered preventable on review. Primarily due to delay in treatment. Delay is due to lack of recognition and poor/inadequate communication

28. Etiology • Atony • Lacerations • Abruption • Retained placenta • Accreta/Percreta • Uterine rupture • Hematoma

29. Hemorrhage Management • Activate response team • Nurses, Physicians, OR staff, Lab, Blood bank • Important initial steps • IV access • Hemorrhage cart/medications • Lab studies • Diagnosis – etiology of the bleed • Massive transfusion protocol (if you have one)

30. Atony Management • Bimanual massage • Drain the bladder • Uterotonics • Oxytocin • Carboprost (up to 4 doses 15 min apart) • Avoid in asthmatics • Methylergonovine (up to 4 doses 2-4 hours apart) • Avoid in severe hypertension • Misoprostol (800-1000 mcg) • 800 mcg Buccal or Rectal - Delayed absorption – give early in rescusitation

31. Tamponade Balloon • Placement, duration, antibiotics • Ultrasound guidance • Vaginal packing • Antibiotic usage • Duration of usage • “Tamponade Test” – pressure (volume) at which the bleeding stops • Georgiou et al – Tamponade pressure is not > systolic pressure • Best for lower uterine segment atony

32. When conservative measures fail

33. Surgical Treatment • Retained placenta • Manual or sharp curettage • Persistent atony • Laparotomy • B-lynch sutures • O’ Leary sutures • Additional devascularization • Hysterectomy • Delayed decision  increased morbidity

34. Hysterectomy • Subtotal hysterectomy vs Total hysterectomy • More rapid completion – emergency situations • Less beneficial if lower segment (previa) bleeding • Consider pre-hysterectomy vascular ligation or occlusion Wright, ObstetGynecol, 2010 115;6, 1187-1193

35. Additional Measures • Tranexamic Acid • Recombinant Factor VII • Cell salvage • Interventional radiology

37. Product Replacement • Platelets – single vs pooled donor • Unit – 50 ml – increase plts 7500 • Most come in 6-10 unit packs • Clotting factors (Cryoprecipitate & FFP) • FFP • All plasma proteins and factors • Volume 250 ml – must be thawed (20-30 min) • Increase fibrinogen 10-15 mg/dL • Cryoprecipitate • Factor VIII, XIII, Fibrinogen, vWF • Volume 40 ml – increase fibrinogen 10 – 15 mg/dL • PRBC’s (ABO, Rh, additional Ab)

38. Fluid and Product Administration • Early administration of clotting factors is key • Borgmann et al 2007 • Combat support hospital • 1:1 or 1:2 ratio of FFP to PRBC’s • Decreased mortality • Sperry et al 2008 • 1:1.5 ratio = 52% lower mortality compared to lower ratios • Goal is avoid the “bloody vicious cycle” • Keep warm • Bear hugger, Level 1 tranfuser • Maintain perfusion • Transfusion/replacement • Correct coagulopathy Coagulopathy Hypothermia Acidosis

39. Pacheco et al, Am J ObstetGynecol Dec 2011

40. Laboratory values will frequently fluctuate Trends are important Vital signs are critical Calcium replacement Maintain uterine tone Re-dose antibiotics Consider ICU admission if there is significant hemorrhage, product replacement or medical comorbidities Post Hemorrhage Management

41. AIM

42. What is AIM? • “National data-driven maternal safety and quality improvement initiative” • “Proven approaches to improvement of maternal safety and outcomes in the U.S.” • “Eliminate preventable maternal mortality and severe morbidity”

43. Who Is AIM

46. AIM – Safety Bundles

47. AIM – Safety Bundles • Readiness • Recognition/Prevention • Response • Reporting/Systems Learning

48. Severe Hypertension in Pregnancy

49. Severe Hypertension in Pregnancy

50. Obstetric Hemorrhage