Maternal morbidity€¦ · •Correct reversible causes Hypoxia Tension puemothorax Hypovolaemia...

transcript

Maternal morbidityDR JAMES ELDRIDGE

QUEEN ALEXANDRA HOSPITAL PORTSMOUTH

Maternal Morbidity One

Maternal Morbidity Two

MBRRACE UPDATE

PRE-ECLAMPSIA

OBESITY

MATERNAL COLLAPSE

CARDIAC DISEASE

Maternal Morbidity One

Maternal Morbidity Two

MBRRACE UPDATE

CARDIAC DISEASE

AMNIOTIC FLUID EMBOLISM

THROMBOPROPHYLAXIS

MATERNAL COLLAPSE

PRE-ECLAMPSIA

ANAESTHESIA

OBESITY

Maternal

Mortality

2015Estimates by WHO,

UNICEF, UNFPA, World

Bank Group and the

United Nations Population

Division

Millennium Development Goal region

Range of MMR uncertainty(80% UI)

Lower estimate Upper estimate

World 216 207 249

Developed regions 12 11 14

Developing regions 239 229 275

Northern Africa 70 56 92

Sub-Saharan Africa 546 511 652

Eastern Asia 27 23 33

Eastern Asia excluding China 43 24 86

Southern Asia 176 153 216

Southern Asia excluding India 180 147 249

South-eastern Asia 110 95 142

Western Asia 91 73 125

Caucasus and Central Asia 33 27 45

Latin America and the Caribbean 67 64 77

Latin America 60 57 66

Caribbean 175 130 265

Oceania 187 95 381

Millennium Development Goal region

Range of MMR uncertainty(80% UI)

Lower estimate Upper estimate

World 216 207 249

Developed regions 12 11 14

Developing regions 239 229 275

Northern Africa 70 56 92

Sub-Saharan Africa 546 511 652

Eastern Asia 27 23 33

Eastern Asia excluding China 43 24 86

Southern Asia 176 153 216

Southern Asia excluding India 180 147 249

South-eastern Asia 110 95 142

Western Asia 91 73 125

Caucasus and Central Asia 33 27 45

Latin America and the Caribbean 67 64 77

Latin America 60 57 66

Caribbean 175 130 265

Oceania 187 95 381

Maternity and Child Welfare Annual Report of the Chief Medical Officer 1920

Maternal Mortality 430 /100,000 live births

No Deaths

Puerperal fever 1730

Puerperal albuminuria and convulsions 749

Haemorrhage 521

Puerperal phlegmasia alba dolens, embolism 347

Accidents of pregnancy 329

Puerperal insanity 40

1850 1900 1950 2000

rnal M

Sulphonamides

Penicillin

Ergotamine

Transfusion service

Safe Caesarean Section

Safer induction for PET

The Transformation of Maternal MortalityLoudon

BMJ 1992

Confidential Enquiries in to Maternal Deaths

Trends in Maternal Deaths 1985 - 2014

Indirect

Direct

Trends in Maternal Mortality

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

rnitie

Mid-year for each three year period

Total deaths

Direct deaths

Indirect deaths

MBRRACE 2018

Direct deaths associated with substandard care

1952-54 2014-16

Improvements to care may have made a difference to outcome

Improvements to care identified but no difference in outcome

Good care

Common◦ Failure of referral

◦ Failure of seniors to attend

◦ Protocols

◦ Communication between specialities

◦ Failure of early identification or severity of disease

CEMD 1955-2018

Thrombosis14%

Haemorrhage8%

Sepsis5%

(Pre)Eclampsia3%

Anaesthesia1%

Other Direct Causes9%

Indirect Causes56%

UK maternal deaths 2014-16

MBRRACE 2018

Thrombosis14%

Haemorrhage8%

(Pre)Eclampsia3%

Indirect Causes56%

MBRRACE 2018

Thrombosis14%

Haemorrhage8%

Sepsis5%

Indirect Causes56%

MBRRACE 2018

“I can’t breath!”

27 year old fitness instructor

38/40 Primip

Cat 2 CS for failure to progress

BMI 24. Previously fit and well – “spinning” the previous day

Uneventful spinal CS

Syntocinon bolus and syntocinon infusion

Noted SaO2 94% in recovery

Sent back to ward

1 hour later anaesthetist called to review –◦ SaO2 88%

◦ Tachypnoea

◦ Struggling to breath

Direct44%

Indirect56%

MBRRACE 2018

Direct44%

Cardiac24%

Indirect32%

Florid pulmonary oedemaRequired rapid intubation and diuretics and inotropesEcho showed mitral valve prolapse and mitral regurgitationTransferred to cardiac surgery centre

Slow recoveryExtubated after 3 days

Mitral valve repair semi-electively 3 weeks laterGood recovery

Lulled by exceptional fitnessConfessed after event that she had felt breathless, but presumed it was normal in pregnancy

Classic timing of presentation – 1-2 hours post delivery.

Year Surveillance data Enquiry Topic Reports Morbidity

Year 32016

2012 -2014

CardiacPreeclampsia & EclampsiaEarly pregnancyCritical Care

Cardiac diseases

Year 42017

2013-2015

AnaesthesiaHaemorrhage, AFE & SepsisEpilepsyRespiratoryStroke, endocrine and other indirect causes

Severe epilepsy

Year 52018

2014-2016

Thrombosis and thromboembolismPsychiatric causesHomicidesMalignancy

Massive obstetric haemorrhage including peripartum hysterectomy

Cardiac disease 09-14SADS/MNH n = 47

(Sudden Arrhythmic Cardiac deaths with morphologically normal heart)

Ischaemic deaths n = 34Atherosclerosis (n = 16)Coronary artery dissection (n = 11)

Myocardial disease / cardiomyopathy n = 27Dilated cardiomyopathy (n = 4)Left ventricular hypertrophy (n = 5)Peripartum cardiomyopathy (n = 9)

Aortic dissection n = 21Valvular heart disease n = 11Essential hypertension n = 6Pulmonary artery hypertension n = 6

Congenital heart disease (included in above) n = 11

MBRRACE 2016

Cardiac disease and pregnancyThink “Is she symptomatic?”

Pre-pregnancy counselling◦ Transition from paediatric to adult care is a recognised risk

HYHA Class Symptoms

I No Symptoms and no limitations in ordinary activity

II Mild symptoms and slight limitations

III Marked limitations even in day to day activity

IV Severe limitations, even at rest – often bed bound.

MBRRACE 2016

Cardiac Disease in Pregnancy

0 20 40 60 80 100

Percentage Mortality

Rheumatic heart disease

Tetralogy of Fallot

Eisenmenger's

Pulmonary hypertension

Cardiac disease and pregnancyMDT meeting and senior involvement

Consider need for and method of anticoagulation for antepartum, peripartum and postpartum periods

Consider place of antenatal care and delivery◦ Home / DGH / Tertiary centre / Cardiac theatre

Consider timing of delivery

Consider method of delivery

MBRRACE 2016

Cardiac disease and peripartum careMake sure relevant teams are aware when labour starts

Minimise cardiovascular stress◦ Slow incremental onset epidural analgesia◦ Limited pushing in 2nd stage / assisted vaginal

delivery◦ Rarely indication for CS◦ Be aware of CVS effects of uterotonics◦ Be wary of fluid shifts and changes in CO at delivery

Post partum consider whether level 2/3 care required

Remember advice on contraception

Haemodynamic Effects of Syntocinon

0 15 30 45 60 75 90 105 120 135 150 165 180 195 210 225 240 255 270 285 300

Time (s)

Bolus Mean

Infusion Mean

28 Women

5 iu syntocinon bolus or infusion

BJA 2007

Cardiac disease and pregnancyMDT meeting and senior involvement

Consider need for and method of anticoagulation for antepartum, peripartum and postpartum periods

Consider place of delivery◦ Home / DGH / Tertiary centre / Cardiac theatre

Consider timing of delivery

Consider method of delivery

Consider effects of preload / afterload / contractility

Consider uterotonics

Have a written plan in notes

MBRRACE 2016

MBRRACE Cardiac deaths:Key Points & recommendations

Symptoms such as ↑Resp rate, chest pain, persistent ↑HR and orthopnoeashould be fully investigated. Pulmonary oedema can present as wheeze◦ Aim to make a diagnosis not just exclude a diagnosis

◦ A normal ECG and/or a negative troponin does not exclude acute coronary syndrome

Remember women with prosthetic heart valves are at extremely high risk. Beware absence of valve clicks

Investigate family following SADs/MNH death

MBRRACE 2016

39 year old, BMI 50, Weight 141kgP2 at 38/40. Elective CS

CSE anaesthetic, block a little high – tingly fingers

Uterine incision - difficult delivery

Patient coughs and says “I cant breath”

Diagnosis?

Hand grip still present

Saturations start to fall

GA induced and intubated

EMD, CPR commenced

Baby delivered

Output re-established with 1mg adrenaline

Echo shows grossly dilated right ventricle

Patient “oozy” – FFP, TXA and cryoprecipitate given

Clotting at zero and 2 hours mildly deranged

Echo at 24 hours normal

Thrombosis14%

Haemorrhage8%

Sepsis5%

(Pre)Eclampsia3%

Anaesthesia1%

Other Direct Causes9%

Indirect Causes56%

MBRRACE 2018

Principally diagnosis of exclusion

Rare and potentially catastrophic

Incidence of 1:8000 – 1:30,000

Mechanismmechanical and/or immune mediated

Commonly right heart failure

13-86% mortality

Most (>80%) develop DIC

20-40% neonatal mortality

Amniotic Fluid Embolism

UKOSS Criteria for diagnosis of AFE

Test Possible findings

Non-specific tests

Full blood count Low haemoglobin

Coagulation Low platelets, increased PT and APTT, low fibrinogen

Arterial blood gas Hypoxaemia, raised PaCO2

Chest X-ray Normal, cardiomegaly, pulmonary oedema

ECG Right heart strain, rhythm abnormalities

V/Q scans V/Q mismatch

Echocardiogram Right or left ventricular dysfunction, low ejection fraction

More specific tests (but still not very specific or sensitive) None are established tests

Pulmonary blood sample Presence of squamous cells coated with neutrophils and presence of fetal debris

Sialyl Tn antigen Raised

Zinc coproporphyrin Raised

Serum tryptase levels Normal or raised

Metodiev, BJA Education , August 2018

AFE : Presenting signs & symptomsSymptoms Signs

Dyspnoea Hypotension

Cough Fetal distress

Headache Pulmonary oedema/ARDS

Chest pain Cardiopulmonary arrest

Cyanosis

Coagulopathy

Seizures

Uterine atony

Bronchospasm

Transient hypertension

AFE : Differential diagnosisOther embolismn - Thrombotic or air

Anaphylaxis

Eclampsia

Acute myocardial infarction

Septic shock

Anaesthetic complications – high block, local anaesthetic toxicity, aspiration

Cerebrovascular accident

Haemorrhage

AFE : TreatmentSupportive• A - early protection of airway

• B – High FiO2, PEEP

• C (& lateral tilt) – Fluid and ionotropes

• Early blood gases and clotting (including fibrinogen)

• Rapid delivery of fetus (expect uterine atony)

• Blood products (early liaison with haematologist)

• CVP / Art line / Urine output

AFE : TreatmentGet help!

• Senior obstetrician

• Senior anaesthetist

• Intensivists

• Cardiologists (bedside - echo)

• Haematologists

May require prolonged CPR

UKOSS Amniotic fluid embolism register

http://www.npeu.ox.ac.uk/ukoss.

AFE Key messagesPerimortem caesarean section should be carried out within five minutes of cardiac arrest.

It is prudent to trigger the massive obstetric haemorrhage protocol.

It is important to replace major blood loss with red cells, plasma and platelets as soon as possible to avoid the dilutional effects of volume expanders.

The effectiveness of replacement and supportive therapy should be continuously monitored (including measures of adequate perfusion ie lactate)

MBRRACE 2014

32 year old midwifery sister

38/40 Primip

Epidural for labour

2nd Top-up

Cardio-Pulmonary Resuscitation (CPR) for “obviously pregnant” mothers

Follow normal BLS

Follow normal ALS

◦ Think of obstetric causes

and get baby off inferior vena cava

Non Pregnant 32 Week Gestation

BJA 1996; 77: 150

Basic Life Support

Can achieve 30% of the normal cardiac output

Think• Rate • Depth• Recoil

Basic Life Support

Can achieve 3% of the normal cardiac output

Displacement of the uterus

Peri-mortem deliveryIf after 4 minutes no return of circulation deliver fetus either vaginally or by perimortem caesarean section

o Improves venous return

o Removes IVC obstruction

o Autologous transfusion with uterine contraction

o Improves chest compliance

o Reduces oxygen demand

o Improves maternal fetal survival (case reports)

o Reported good outcomes for both mother and baby after 30 minutes arrest!

Basic Life Support

I shock150 J -360 J Biphasic

360 J Monophasic

Assess rhythm

CPR for 2 min

Non VF/VT

Assess rhythm

CPR for 2 min

During CPR• Ensure high quality CPR – rate, depth, recoil• Minimise interruptions to CPR• Consider advanced airway and capnography• Continuous chest compresssions once airway in

place• Vascular access• Give adrenaline every 3 mins• Correct reversible causes

Hypoxia Tension puemothoraxHypovolaemia Tamponade (cardiac)Hypo/hyperkalaemia ToxinsHypothermia Thrombosis (coronary or pulmonary)

Reversible causes4 Hs 4 Ts

Specific maternal causes of cardiac arrest - BEAUCHOPS:

Bleeding/DIC

Embolism: coronary, pulmonary,

amniotic fluid embolism

Anaesthetic complications

Uterine atony

Cardiac disease: MI, ischemia, aortic

dissection, cardiomyopathy

Hypertension: preeclampsia/eclampsia

Other: differential diagnosis of

standard ACLS guidelines.

Placenta abruptio or previa

Sepsis

Perimortem Caesarean Delivery

Call the right teams◦ Adult cardiac arrest + Obstetric crisis team + Neonatal crisis team

Remove fetal monitoring if possible

If possible deliver fetus vaginally, if not possible and in hospital perform CD at site of arrest

Performing a PMCD◦ Most senior surgical individual available

◦ Preferably caesarean delivery pack (ED and delivery suite)

◦ Gloves, scalpel, two forceps and packs

◦ Midline or Pfannenstiel incision – depending on surgical experience

◦ ?Uterotonics

◦ Expect bleeding even before ROSC

If ROSC occurs: ◦ think anaesthesia/sedation

◦ Think antibiotic prophylaxis

◦ Think about transfer to an operating theatre for abdominal closure

After a woman with known substance dependence had surgical management of an ectopic pregnancy …

she presented with shortness of breath and tachycardia.

After a woman with known substance dependence had surgical management of an ectopic pregnancy no risk assessment for VTE was carried out.

When she presented with shortness of breath and tachycardia the focus was on concern about possible withdrawal symptoms though the cause of her symptoms was the pulmonary embolism from which she died.

Thrombosis and Thromboembolism

MBRRACE 2018

Reassessment of VTE risk after miscarriage and ectopic pregnancy … is as important as reassessment … after giving birth.

Antenatal deaths due toThromboembolism 1997-2016

1st trimester 2nd and 3rd trimesters

CEMD 1997-2014

• Clear pathways for women who need thromboprophylaxis as soon as they become pregnant

• Reassessment of VTE risk after miscarriage and ectopic pregnancy

• Any surgical procedure in pregnancy or puerperium should have 10 days of postnatal thromboprophylaxis.

(RCOG Green-top Guideline 37a 2015)

CEMD 1990-2018

Thrombosis and Thromboembolism

2011 2012 2013 2014 2015

rnitie

Mid-year for each three year period

Deaths due to thrombosis and thromboembolism

MBRRACE 2018

Lessons -Thrombosis and Thromboembolism:

Women at risk in early pregnancy

Re-assess risk after miscarriage or ectopic pregnancy

Obesity substantial risk. Women with a raised BMI should be given information about symptoms of VTE

Give LMWH asap - at end of surgery after GA or 4 hrs after neuro-axial

Prescriptions for entire postnatal course should be issued in secondary care.

MBRRACE 2015 & 2018

Leading Causes of Maternal Deaths2014-16

Direct Indirect

MBRRACE 2018

Admitted in labour with BP 170/90

No Urine analysis

3 hours later she had a neurological event

Given magnesium

She was transferred to theatre for caesarean section under general anaesthesia. No antihypertensives were given prior to intubation nor was fentanyl given until after delivery of the baby.

She did not recover from her general anaesthetic and was found to have had a large intracranial bleed.

MBRRACE 2016

Key Messages for Preeclampsia / eclampsia

Early onset threat to mother and fetus (< 34 weeks)

Aggressive treatment of (systolic) BP◦ BP > 180mmHg medical emergency

◦ Maintain BP < 150 mmHg

◦ Care with intubation and extubation

Care with fluid

Magnesium sulphate is treatment for eclampsia and pre-eclampsia

Preeclampsia

Liver dysfunction

Thrombocytopenia

HELLPHaemolysis

HUS/TTP

Acute Fatty Liver

GT / ITP

Overlapping circles

Pulmonary

Treatment of Hypertensive Disease of PregnancyPrimary treatment

◦ Aspirin◦ Calcium supplements◦ LMWH (Meta-analysis Carrier 2014)

Secondary prevention◦ Early detection◦ Prevent progression

Tertiary prevention◦ Treat dangerous symptoms & deliver placenta at appropriate time◦ Trade “risk to mother” vs “fetal development”

◦ < 34/40 Wait if possible; >37/40 deliver; 34-37/40 remains uncertain

Treatment of Hypertensive Disease of Pregnancy

Treat hypertension aiming for BP < 150/100◦ Oral Labetalol

◦ Oral nifedipine

Treat severe hypertension (BP > 160/110 despite above)◦ IV labetalol

◦ Oral nifedipine

◦ IV hydralazine

Fluid restriction◦ 80 ml/hr (or 1ml/kg/hr)

1997-2002

2003-2008

2009-2014

Mode of Death

Treatment of Hypertensive Disease of PregnancyTreat Hypertension aiming for BP < 150/100

◦ Oral Labetalol

◦ Oral nifedipine

Treat Severe hypertension (BP > 160/110 despite above)◦ IV labetalol

◦ Oral nifedipine

◦ IV hydralazine

Fluid restriction

Reduce risk of fits

Deliver

MagnesiumPET/eclampsia

Arrhythmias

Asthma

Anaesthesia / analgesia

Reduced cerebral palsy

(Reduce response to intubation)

Mechanism of action

vasodilator relieving vasoconstriction.

may protect the blood-brain barrier and limit cerebral oedema formation

NMDA receptor antagonist

may have a central anticonvulsant action

Magnesium

Complications • Reduced muscle strength

• Uterine relaxation

• Hypotension

• Arrhythmias

Treat overdose with iv calcium

Dose • 4g iv Loading dose

• 1g/hr infusion for 24 hours

Anaesthesia and Preeclampsia Care with hypertensive agents

◦ Phenylepdrine / ephedrine

◦ Ergometrine

Care with NSAIDs

Fluid management (including infusions!)

Spinal or Epidural◦ Dependent on platelets and clotting

◦ Reduced incidence of hypotension

Hypotension

Hypo-Perfusion

of Placental Bed

Sympathectomy

Intracranial

HaemorrhagePulmonary

Oedema

Hypertension

Aorto-caval

Occlusion

GA and Severe pre-eclampsia

Diastolic > 110 mmHg◦ Arterial line

Obtund intubation response◦ Opiate (alfentanil or remifentanil)

◦ Labetalol / esmolol

◦ Not magnesium or lidocaine

More opiate before extubation

Learning pointsEarly involvement of senior obstetricians and anaesthetists

Communication

Beware epigastric pain◦ HELLP / Intrahepatic bleed / Hepatic rupture

Adequacy of non-invasive BP measurement? ◦ A’line for GAs in severe disease

Sepsis

Maternal sepsis definition WHO 2017

“A life threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or the postpartum period”

Sepsis in pregnancyPregnancy causes modulation of immune system to accept foreign proteins.

Can appear well, despite widespread inflammation.

Usually heart rate, blood pressure, temperature and/or respiratory rate give an indication of early stages of sepsis.

Genital Tract Sepsis:

Deaths from Direct Sepsis 2013-20157 deaths from genital tract sepsis

4 deaths from urinary tract or wound infections

1 death from influenza (H1N1)◦ Decrease probably because of prevalence of less virulent strains

Symptoms of Genital Tract Sepsis

GENERAL

Sore throat

Influenza-like illness

Diarrhoea

Vomiting

Shortness of breath

Wound infection

SPECIFIC

Premature contractions

Abdominal pain

Sickle cell crisis

Atonic uterus causing PPH

Mastitis

Vaginal discharge – profuse and malodorous

Genital Tract Sepsis:

sAll causes sepsis

Maternal Mortality Rate due to Sepsis 2009-2015

2009-11 2010-12 2011-13 2012-14 2013-15

Direct Sepsis - pregnancy related infections

Indirect Sepsis - Inflenza

Indirect sepsis - pneumonia/others

Organisms

Prevent delays in diagnosis

Pregnant women/recently delivered should be given information about signs and symptoms

Healthcare professionals regular training

MEOWS charts

Sepsis Screening Tools

Signs of SIRS

UK SEPSIS TRUST 2014

ANY TWO of

Confusion / altered mental state

Pyrexia (or hypothermia) >38.3oC or < 36oC

Persistent tachycardia > 100* bpm

Tachypnoea > 20 bpm

WBC > 12 or < 4 x 109/L

Glucose > 7.7mmmol/L

ALSO CONSIDER

↑CRP

Fetal loss

Lactic acidosis

Abdo pain requiring opiate

Organ de-compensation including confusion

*Note the guidelines are not specific for pregnancy and these observations should be interpreted in the context of the normal physiology for the pregnant woman. RCOG guidance suggests using a threshold of 100 beats per minute in pregnancy

Signs of SIRS + organ de-compensation

Systolic BP < 90 mmHg

Heart Rate > 130 bpm

Oxygen Sats < 91%

Resp Rate > 25

AVPU “V”, “P” or “U”

Act immediately if presence of any one of:

Lactate > 4 mmol/l

Creatinine > 175 μmol/l

Platelets < 100 x 109/l

Bilirubin > 34 μmol/l

INR >1.5

Urine Output < 0.5 ml/kg/hr

Treatment of Sepsis: Care Bundles

RESUSCITATION BUNDLE

SEPSIS SIX

Maintain saturation with facial oxygen

Obtain cultures

Give antibiotics

Measure serum lactate

Give intravenous fluid

Commence accurate urine output measurement

FURTHER MANAGEMENT BUNDLE

With hypotension (or ↑ lactate)

◦ Use vasopressors

◦ CVP > 8mmHg

◦ Consider steroids

Consider transfusion if Hb < 7g/dl

Surgical source control

Key Messages: Think sepsis

Timely recognition

Fast administration of antibiotics

Quick involvement of experts andsenior review

◦ Obstetric team

◦ Anaesthetics and critical care

◦ Microbiology

◦ Radiology

◦ Infectious disease physicians

Influenza vaccination

MBRRACE 2014

LessonsImportance of thromboprophylaxis

Importance of recognising PDPH

Communication with GP

Arranging follow-up until resolution

Serious neurological symptoms require urgent referral and/or imaging

If reduced LOC, transfer must be with appropriate medical (anaesthetic) involvement

MBRRACE 2014

Key points5% PDPH are not postural

Incidence of PDPH ◦ >50% after 16/18G Tuohy

◦ 1/3 dural puncture was not recognised

◦ 1.5-11.2% after spinal anaesthesia

Rare but serious complications include cerebral vein thrombosis and intracranial haemorrhage, cranial nerve palsies (VI & VII), seizures

Bed rest may provide temporary relief (DVT prophylaxis)

Simple analgesics should be used

Caffeine may be tried, but treatment limited to 24 hours. Benefit limited to 4 hours. Possible ↑risk of seizures.

No or insufficient evidence for all other treatments apart from blood patch.

This includes: other theophyllines, ACTH and analogues, steroids, triptans, gabapentinoids, DDAVP, methylergonovine, ondansetron, acupuncture, greater occipital nerve block, spenopalatine ganglion block, epidural morpine, epidural crystalloids, dextrans, HES, gelatin, or fibrin glue.

Key pointsBlood patch success rates

◦ Early studies suggested >90%

◦ Recent studies suggest ◦ complete success 30%

◦ Complete or partial success 50-80%

Timing◦ EBP <48 hours has reduced success

Volume – 20ml max

Routine imaging is not required if history and symptoms are typical

Written information should be provided and systemic and “red-flag” symptoms suggesting alternative diagnosis should be excluded

Complications of EBP includes◦ Repeat dural puncture

◦ Back pain -80% at 24 hours. No evidence for chronic backpain

Case reports of:◦ Arachnoiditis (4 cases) – possible associated with

large volumes of blodd – use <20 ml

◦ Isolated reports of spinal-subdural haematomas

◦ Seizures (4 obs cases)

◦ Venous sinus thrombosis (5 cases)

MBRRACE 2018

Anaesthesia1%

Lessons for Anaesthesia

◦ Total number of deaths is small.

◦ Focused on prevention and lessons.

Key messages for Anaesthesia 2013-15Ability to palpate a pulse may not indicate adequate cardiac output.

Pulmonary aspiration risk remains prevalent.

CEMD: Cause of Anaesthetic Deaths 1988-2014Failed Airway Management

1988-90 1991-93 1994-96 1997-99 2000-02 2003-05 2006-08 2009-11 2012-14

Deaths not related to airway Deaths associated with failed airway

Key messages for Anaesthesia 2013-15

Ability to palpate a pulse may not indicate adequate cardiac output

Pulmonary aspiration risk remains prevalent.

In cases of MOH, before extubation ensure that patient is warm, adequately resuscitated, bleeding stopped and lactate normalised.

Beware aortocaval compression.

Prophylactic vasopressors should be used for spinal anaesthesia.

Use 7.0mm for intubation and smaller tubes should be immediately available.

Blood transfusion should not be delayed by false reassurance from a single haemoglobin result.*

Obesity39 year old

P2 – two normal deliveries in 2008 and 2011

Otherwise fit and well!

Quetelet formulaBelgian statistician

Compare populations

1800ish Norwegian fishing village data

Body Mass Index

BMINormal Distribution

Obesity defined as 2 standard deviations from mean

UKOSS Comparison Women

Knight Obstet &Gynecol 2010

BMISkewed “normal” distribution

Obesity defined by WHO

BMIBMI WHO 2000

RGOG and CMACE 2010

NHSIC*

< 18 Underweight Underweight

18-25 Normal Normal

25-30 Overweight Overweight

30-35 ObeseClass 1

Obese Class 1

35-40 ObeseClass 2

ObeseClass 2

>40 ObeseClass 3

Morbidly Obese

>50 Super-Morbidly Obese

Extreme Obesity

*NHS Information Centre

BMISkewed “normal” distribution

Obesity defined by WHO

Limitations ◦ Definitions may need to change for different populations

◦ Lean body mass

◦ Pregnancy etc

BMI and maternal deaths

<20 20-24 25-29 30-34 35-39 >40

UKOSS study of635 pregnantwomen

Maternal deaths2009-12

Knight Obstet &Gynecol 2010

Over weight and ObeseCMED 2006-08

Risks related to obesity in pregnancyFor the Mother

Spontaneous 1st trimester and recurrent miscarriage

Maternal death or severe morbidity

Cardiac disease

Preeclampsia

Dysfunctional labour

Gestational diabetes

Thromboembolism

Caesarean section

Wound infection post CS

Post partum haemorrhage

Low breastfeeding rates

For the Baby

Still birth

Congenital abnormalities

Prematurity

Shoulder dystocia

CMACE 2006-08

Thyroid Function

Immune system

Cancers

Arthropathies

Increased intraabdominal pressure

Diabetes

Idiopathic Intracranial Hypertension

Fertility

Respiratory disease

and hypoxia and OSA

Cardiovascular disease

Labour, delivery,

analgesia and anaesthesia

Obesity and DeliveryBMI > 35 - Consultant lead unit•NICE Guideline No.55 2007

BMI > 30

Slow labour progression

↑ Difficulty of fetal monitoring

↑Emergency caesarean section ◦ Bonnesen 2013 BMI> 50 doubles EmCS◦ UKOSS 2010 BMI> 50 = 50% CS

↑Difficulty of caesarean section

↑Post partum haemorrhage

Obesity and DeliveryDifficulty in monitoring fetus

Macrosomia – (BMI> 50 - 5 x risk of NICU admission1)

1 Bonnesen 2013

Antenatal discussion, decisions and

planning

Antenatal AssessmentFor whom?

BMI > 40 (?35- ?50)

1. Airway

–Neck circumference

• 35% difficult if NC > 60 cm (23")

–Mallampati

– Tongue size

2. Lumbar spinous processes

3. Obstructive Sleep Apnoea

4. Venous access

Can a GA be performed safely by labour ward anaesthetists?

If No:

• Inform mother, midwives and obstetricians that an urgent Cat 1 in < 30 minutes may not be possible.

• Careful discussion with mother about implications of requiring senior anaesthetic presence.

• Early epidural in labour (? which anaesthetist)

• Must be flagged to anaesthetist on admission in labour

Can a GA be performed safely by labour ward anaesthetists?

If Yes:

• Discuss advantages of early epidural in labour

• Must be flagged to anaesthetist on admission in labour

Planning: EquipmentTheatres

◦ BP cuffs, long epidural / spinal needles

◦ Airway devices

◦ Hover mattresses

◦ Oxford wedge

◦ Foot retainers

◦ Ultrasound

◦ Lateral supports

Labour Analgesia

Labour analgesia and obesityEpidural – early and by senior epiduralist◦ “Get Out of Jail Free”

◦ More difficult◦ ↑failure rate

◦ ↑intravenous cannulation rate

◦ ↑dural puncture rate

◦ Epidural fixation◦ Be aware catheter movement at

skin with movement (upto 4 cm!)

If it fails – resite it!

Epidural Space and BMI

Clinkscales IJOA 2007

Anaesthesia

Regional AnaesthesiaHave a selection of regional block needles

Use usual doses

Expect high blocks (esp. epidurals)

? CSE◦ Technically harder

◦ Higher failure of spinal

◦ Able to rescue poor analgesia, prolonged surgery

General AnaestheticsAntacids in labour

Right anaesthetist and right surgeon(s)

Plan B and C discussed for failed intubation

Positioning

Pre-oxygenation◦ Mask + nasal cannulae

◦ 3L/min pre-induction

◦ 5-15L/min if problem at intubation

General AnaestheticsCalm room

Induction

Drugs dosage:◦ Lean body mass for thiopentone and propofol (induction dose), fentanyl

atracurium and rocuronium.

◦ Adjusted body weight: Sugammadex, alfentanil, neostigmine, antibiotics

ABW = LBM + 40% excess weight.

General AnaestheticsBeware extubation

Beware recovery◦ Night time

◦ General anaesthetic

◦ Busy labour ward

◦ Untrained midwife

◦ Obesity and OSA

HypoventilationPatient was obese.

Prolonged hypoventilation post extubation.

Inadequate monitoring.

Lessons

Recovery must be the same standard as non-obstetric patients including documentation.

Monitoring should include pulseoximetry

Consider capnography

Consider arterial blood gases

MBRRACE 2014

Questions?

Maternal morbidity€¦ · •Correct reversible causes Hypoxia Tension puemothorax Hypovolaemia...

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