7/25/2019 15. Obstetric Emergencies-Bates[1]

1/17

5/8/20

ObstetricEmergencies

forEveryProvider

JamesBates,PhD,MDAssociateProfessor

DirectorofthedivisionofOBanesthesia

ClinicalcoordinatorMOR

DepartmentofAnesthesia

Universityof

Iowa

College

of

Medicine

Disclosure

Ihavenofinancialrelationshipswith

manufacturersofpharmaceuticalsordevices.

7/25/2019 15. Obstetric Emergencies-Bates[1]

2/17

5/8/20

OBEmergencies

Non

Hemorrhagic

Emergencies Fetaldistress

Impendingfetaldistress(2nd twinisbreech,etc)

HemorrhagicEmergencies

Placentalabruption

Placentaprevia

Placentaacreta(increta,percreta)

Retainedplacenta

Uterinerupture Uterineatony

Indicationsfor

ImmediateCesareanDelivery

PersistentFHR

7/25/2019 15. Obstetric Emergencies-Bates[1]

3/17

5/8/20

AnesthesiaforEmergencyCesareanSection

Choiceusuallybasedon

UrgencyofsituationSpeedofonset:

GA>existingepidural>spinal>newepidural

MaternalintravascularvolumestatusHypovolemia isusuallyconsideredgreaterproblemfor

regionalanesthesia

Coagulationstatus

Coagulopathyandthrombocytopeniacanbecontraindicationstoneuraxial blockplacement.

Epidural

for

Emergency

Cesarean

Section Extensionofanexistingepiduralthatisworkingwell

Dosingcanbeginbeforetransporttothedeliveryroom

increaseschancesofachievingsufficientblockintime

riskshypotensionorotherregionalanesthesia

complicationsintransit.

Inveryurgentcasesprepareforgeneralanesthesiaand

assessqualityofblockwhensurgeryabouttobegin

7/25/2019 15. Obstetric Emergencies-Bates[1]

4/17

5/8/20

LocalAnestheticsforEpiduralAnesthesia

2%lidocainewithorwithoutepinephrine

Withoutepinephrine:higherpH,fasteronset

Withepinephrine:longerduration,easiertodetect

intravascularinjection

3%2chloroprocaine

Fastonsetbutshortdurationoften

7/25/2019 15. Obstetric Emergencies-Bates[1]

5/17

5/8/20

GeneralAnesthesiaforCS

Advantages:Fast

Fewcontraindications

Indefiniteduration

Patientnotawake

Disadvantages

Airwayrisks

Aspirationrisks

Patientnotawake

FetaluptakeofanestheticsUterinerelaxationfromvolatileagents

Druginteractions(e.g.neuromuscularblockers&MgSO4)

Risksof

General

vs Regional

Anesthesia

Generalanesthesiaisgenerallyassociated

withmorebadanesthesiaoutcomes

increasedriskfactorsinobstetricpatients

increaseduseofGAinhighriskOBpatientsand

emergentsituations

7/25/2019 15. Obstetric Emergencies-Bates[1]

6/17

5/8/20

HawkinsJL,Koonin LM,PalmerSK,GibbsCP.Anesthesiarelated

DeathsduringObstetricDeliveryintheUnitedStates,19791990.Anesthesiology1997;86:277284.

1st nationalstudyinUSA,performedbytheCDCandNationalPregnancyMortalitySurveillanceSystem

Reviewed,whereavailable:Deathcertificates(19791990)forallpregnancyrelateddeaths.

Pregnancyoutcomedataforrelationtoanesthesia.(89%avail.)

NumberoflivebirthsfromNationalFilesofHealthStatistics.

EstimatesofC/Srates,RAandGAratesfromothersurveys.

4097deaths; 129associatedwithanesthesia

OBAnesthesiaDeathsinUS

NumberofDeaths(N=129)

Hawkins etal.,1997

7/25/2019 15. Obstetric Emergencies-Bates[1]

7/17

5/8/20

CI=confidenceinterval

*Permilliongeneralanestheticsforcesareansection

Permillionregionalanestheticsforcesareansection

95%CI

1.82.0

95%CI

1.89.4

ReferentReferent1.98.6919Regional

95%CI

12.921.8

95%CI

1.92.9

95%CI

25.949.9

95%CI

17.722.7

16.72.332.3*20.0*3233General

198519901979198419851990197919841985

1990

1979

1984

RiskRatioCaseFatalityRateNumberofDeaths

Numbers,CaseFatalityRates,andRiskRatiosofAnesthesiarelatedDeathsduringCesarean

SectionDeliverybyTypeofAnesthesia:UnitedStates,19791984and19851990

Hawkins etal.,1997

AnesthesiaforCesarean

0

10

20

30

40

50

60

70

80

90

%

General Epidural Spinal CSE

1981 1992 2001Elective

Bucklin et al., 2005, Anesthesiology 103:64

2001Emergent

S 100500

M

5001499

L >1500SML

GA41%

RA55%

GA16%

RA84%

7/25/2019 15. Obstetric Emergencies-Bates[1]

8/17

5/8/20

Limitations

LimitationsoftheHawkinsstudy:

Numbersareestimates

Typesofanesthesiafromindependentsurveys

Dataonwhoprovidedanesthesiaislacking

Detailsontheactualeventsoftensparse

Nonetheless:

MaternalAnestheticMortalityinUK

0

10

20

30

40

50

60

1961 1964 1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003

Triennium Beginning

GA

RA

Lyons and Akerman 2005, Minerva Anestesiol 71:27

7/25/2019 15. Obstetric Emergencies-Bates[1]

9/17

5/8/20

AnesthesiaforFetalStress/Distress

Regionalanesthesiasafeinchronicfetalstress.

Generalanesthesiausuallypreferredindiredistressplacentalabruption,severefetalbradycardia,uterinerupture.

Intermediate degreesofdistressoftenmanagedwellwithregionalanesthesia.

Considerearlyuseofepiduralanesthesiainpatientsathighriskofoperativedelivery

Peripartum Hemorrhage

Hemorrhagehasbeenoneoftheleadingcausesof

maternalmortalitysincerecordshavebeenkept

#1causeofmaternaldeathworldwide

Amajorcauseofmaternaldeathindevelopedand

developingcountries

~125,000deathsperyear

Affects515%ofwomengivingbirth

Increasesmorbidityin~20,000,000women

7/25/2019 15. Obstetric Emergencies-Bates[1]

10/17

5/8/20

PlacentalAbruption

Akaabruptio placentae,accidentalhemorrhage(UK)

Prematureseparationofthenormallyimplantedplacenta. Differentfromplacentaprevia inthatplacentaisimplantedsomedistancebeyondthecervicalinternalos.

Frequency 1in100200deliveries

10 12%ofallthirdtrimesterstillbirths

RequiresemergentCSiffetusviableandvaginal

deliverynotimminent Mayrequirematernaltransfusion&resuscitation

PlacentaPrevia

Placentaimplantedoverorverynearinternalcervicalos.

Riskofmajorantepartumbleed

Cervicalos edgeofplacenta:

7/25/2019 15. Obstetric Emergencies-Bates[1]

11/17

5/8/20

PlacentaPrevia,PriorCesareanSectionandPlacentaAccreta

# Patients with # Patients with# Prior C/S placenta previa placenta accreta %

0 238 12 5

1 25 6 24

2 15 7 47

3 5 2 40

4 3 2 67

Clark,etal. 1985,Obstet Gynecol 66:89

PlacentaAccreta

Normaldecidua

Accreta

78%

Increta 17%

Percreta

5%

Abnormallyadherentplacenta

7/25/2019 15. Obstetric Emergencies-Bates[1]

12/17

5/8/20

PlacentaAccreta

Incidence: ~1/500~35%notconfirmedatthetimeofsurgeryorpathology

RiskFactors:

Previouscesarean (1CS:0.3%,2CS:0.6%,3CS:2.4%)

Lowlyingplacenta/placentaprevia Maternalage>35years

Highparitygravidity

Historyofuterinecurettage

High2ndtrimesterAFPandhCG

Previousuterinesurgery

Uterinefibroids IVFpregnancy

PlacentaAccretaMaternalComplications:

Postpartumhemorrhage

Maternalmortality(04.25%inWesternnations)

Increasedrateofrequireduterinecurettage

Treatment:

Cesareanhysterectomyat34 37weeksDecreasedbloodlossandmorbidityifplanned

Preoperativeballooncathetersintotheinternaliliacarteriesmaydecreasebloodlossandshortensurgery

Conservativetreatmentshouldonlybeattemptedinhighriskcenterspreparedforsuddenseverehemorrhage

7/25/2019 15. Obstetric Emergencies-Bates[1]

13/17

5/8/20

Uterinerupture

Rarewhennohistoryofuterinesurgery ortrauma

Associatedwith

Directorblunttrauma

Excessivefundalpressure,version

Forceps,curettageor otherintrauterineinjury

Inappropriateoxytocin

Uterineanomaly

Placentapercreta

Tumors Fetalmacrosomia,malposition,anomaly

RetainedPlacenta

~1%ofdeliveries

Bleedingusuallyslowbutpersistent

Usuallyrequiresmanualextractionofremaining

placenta

Anesthesiaoftenneededforextraction

Goodreasontodelayremovaloflaborepiduralfor3060

minutesafterdelivery

Uterinerelaxationsometimesneeded

Inhalationanesthesiagivesexcellentrelaxation

Nitroglycerine50150givgivesgoodrelaxation

7/25/2019 15. Obstetric Emergencies-Bates[1]

14/17

5/8/20

Uterineatony

Drugstotreathemorrhagefromuterineatony Oxytocin (Pitocin)

Pituitaryhormone

10 40units/litercontinuousinfusion

Directbolusinjection(>5units)associatedwithmaternalhypotensionandpossibledeath

Methylergonovine (Methergine)Ergotalkaloid; smoothmuscleconstrictoractivealsoon

vascularsmoothmuscle. Cancausevasospasm,severehypertensionifoverdoseorgiveni.v. Avoidin

hypertension.0.2mgIMrepeatuptoevery2hrs

Uterineatony

15methylPGF2(Carboprost,Hemabate)

ProstaglandinF2analog,smoothmuscleconstrictoractivealsoonbronchialsmoothmuscle. Cancause/exacerbate bronchospasm. Avoidinasthma.

0.25mgIM. Mayrepeatevery15 90minutesupto8doses.

Dinoprostone (Cervidil,Prepidil,Prostin E2)

ProstaglandinE2.Cancause/exacerbate hypotension.

Fevercommon.20mgvaginalorrectalsuppository,mayrepeatevery2

hours.

Storedfrozen,mustbethawed.

7/25/2019 15. Obstetric Emergencies-Bates[1]

15/17

5/8/20

Uterineatony

Misoprostol (Cytotec)ProstaglandinE1analog

8001000mcgrectallyorsublingually,singledose

Theonlyprostaglandinforuterineatony thatcanbe

storedatroomtemperature

CautiongivingsublinguallyinpatientsunderGA

(aspirationrisk)

Uterineatony:Surgicaloptions

Uterinetamponade

Gauzepacking soakedinsaline/thrombin5000units/5ml

Foleycatheter;oneormore,inflated

SengstakenBlakemoretube

SOSBakri tamponade tube

Uterinecurretage

Uterinearteryligation BLynchsuture(uterinecorpuscompression)

Hysterectomy

7/25/2019 15. Obstetric Emergencies-Bates[1]

16/17

5/8/20

UterineTamponade Devices

SengstakenBlakemoretube

SOSBakri tamponade tube

MassiveTransfusion

Protocol

Onceinitiated,Anesthesia,OB,Nursing,BloodBank,Pathology,etc.allworkingfromawrittenprotocol.

Protocolreadilyavailable(i.e.bycomputer).

Presetamountsofbloodproductsarepreparedautomatically

Bloodproductspreparedautomatically,laboratorypreparedtoprocesssamplesquickly,ancillarypersonnelmadeavailable.

7/25/2019 15. Obstetric Emergencies-Bates[1]

17/17

5/8/20

MassiveTransfusionProtocol

UniversityofIowaHospitalsandClinics

Summary

Fetaldistressand/ormaternalhemorrhageoftenrequire

immediatecesareandelivery.

Generalanesthesiaoffersgreatestspeedbutmaybe

associatedwithgreatermaternalrisk.

Epiduralanesthesiausingalreadyinplacecatheteris

oftenagoodalternative.

Iftimeallows,spinalanesthesiaismostcommonlyused.

Hypovolemia,ongoinghemorrhagefavortheuseof

generalanesthesia.

Bepreparedformassivehemorrhage. Establisha

massivetransfusionprotocol.