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5/24/14 ¡ Charlotte Page Wills, MD Associate Program Director Alameda Health System-Highland Hospital EM Residency, Oakland, CA Pitfalls in the Associate Clinical Professor of Emergency Medicine University of California, San Francisco School of Medicine Second Half of Pregnancy Disclaimer! � Financial ¡Disclosures: ¡None! ¡ • The following is NOT meant to replace the expertise and guidance of a skilled Obstetrician and Perinatologist! • Expert consultation should always be sought in the care of any pregnant patient greater than twenty weeks gestation or other high risk obstetric case. • This lecture recognizes, however, that the resources of an expert consultant may not always be immediately available, and aims to provide basic guidance in the approach to Emergency Department management of these patients. 3 ¡ 1 ¡

5/24/14 ¡ maternal well-being In the next 30 minutes… � • Highlight changes in physiology important to managing gestational age patients in the second half of pregnancy. � • Describe the basic approach to initiate evaluation and management of the gravid patient. � labor status • Describe how to evaluate a fetus as viable or nonviable. � • Illustrate the pitfalls of pre-eclampsia and preterm labor. � • Discuss some of the obstetric emergencies that can fetal well-being arise in the ED precipitous delivery. � maternal well-being High Volume, Low Pressure • What’s normal? Know the physiologic changes that occur in pregnancy. HR � HR BP � BP SVR SVR � • Where do I start? Perform standard maneuvers for resuscitation in all pregnant patients. • Identify underlying disease and treat Vol Vol � aggressively. CO CO � Hct Hct � 2 ¡

5/24/14 ¡ Second and Third Trimester Aortocaval Compression Resuscitation • IVC may be completely • Dilu8onal ¡anemia: ¡replace ¡volume ¡loss; ¡in ¡sepsis ¡ obstructed in the supine position. transfuse! ¡ • Uterus receives 30% of cardiac • Oxygena8on: ¡high ¡oxygen ¡content, ¡increased ¡ output. minute ¡ven8la8on ¡and ¡TV. ¡ • Aortocaval ¡compression: ¡pelvic ¡8lt ¡or ¡manual ¡ • Compression occurs at 20 weeks. uterine ¡distrac8on. ¡ • Progesterone: ¡an8cipate ¡a ¡difficult ¡airway ¡and ¡ • CPR only produces about 10% normal CO. aspira8on. ¡ Avoiding Compression � maternal well-being gestational age • Tilt the backboard � • Blanket roll � labor status • Manual distraction of the uterus � fetal well-being 3 ¡

5/24/14 ¡ Rapid Pregnancy Dating by EP’s gestational age • Traditional: Last menstrual period, • Sonographers had a wide range of experience. fundal height. • Exams had a high degree of correlation with gold standard. • Di ffi cult in the obese patient. • Measurements of BPD and FL took less than one minute. • Is inaccurate with multiple • Was more accurate than measuring fundal height. gestations. • 96% ULS versus 80% for FH • Ultrasound: • Can be learned easily. Accuracy of emergency physicians using ultrasound to determine gestational age in pregnant women 
 Sachita Shah, Nathan Teismann, Brita Zaia, Farnaz Vahidnia, Gerin • Can be quickly performed. River, Dan Price, Arun Nagdev 
 American Journal of Emergency Medicine - 29 March 2010 (10.1016/ j.ajem.2009.07.024) maternal well-being BPD Measurement � gestational age labor status fetal well-being 4 ¡

5/24/14 ¡ Evaluating the Membranes � labor status • Visual inspection: pooling • Labor: contractions with progression of the cervix of amniotic fluid on sterile speculum exam. Most • Requires uterine monitoring. sensitive finding. • Requires examination of the cervix visually and manually or by ultrasound. • Bleeding: may be from labor, trauma, or the placenta • Ferning: arborization of salt crystals in amniotic • Requires extreme caution with the vaginal/cervical fluid. examination. • Membranes: may rupture from labor or infection • Requires determining presence or absence of • Nitrazine Paper: amniotic amniotic fluid. fluid has a pH of 6.5 or higher. Cervical Evaluation � maternal well-being • Exams should be gestational age sterile. � • Minimize digital exams -rates of infection go up labor status with numbers of exams in PROM. � • CONTRAINDICATED if you suspect placenta fetal well-being previa. � 5 ¡

5/24/14 ¡ fetal well-being Supplies for Baby � • Fetal heart rate (FHR) and activity: fetal monitor. • Resuscitation surface: infant warmer, surface with • Can use bedside ultrasound to assess both plenty of dry linens near an • For greater than 20 weeks, fetal monitoring oxygen source. � is standard. • Infant mask and anesthesia bag/ambu bag. � • MUST come with a provider who can interpret fetal strips. • Dedicated person to dry, • Fetal distress or intrauterine infection. stimulate, warm the infant. � • Both are indications to deliver a viable fetus. Pregnant ¡ HTN ¡ Headache ¡ 26 yo woman complaining of headache and abdominal cramping stating she is 6 months pregnant. BP Pre-­‑eclampsia ¡ is 158/98 and HR is 118. � 6 ¡

5/24/14 ¡ • Hypertensive • No bleeding • Mildly tender uterus Headache CBC UA CMP Uric acid, LDH DIC Panel Damaged Endothelium � • Hemolysis • Elevated LFTs • Platelet consumption • Elevated creatinine • Proteinuria 7 ¡

5/24/14 ¡ High Pressure, Low Volume � High Volume, Low Pressure End-Organ Damage � HR HR � • PRES � BP � BP SVR SVR � • Renal failure � • Placental abruption � Vol Vol � • DIC � CO CO � Hct Hct � Managing Pre-eclampsia � maternal well-being • BP control: labetalol, nifedipine, hydralazine. � gestational age • Magnesium infusion for severe pre-eclampsia. � labor status • Avoid lasix - patients are already volume depleted. � • Avoid excessive fluids - patients third space fetal well-being because of endothelial damage and proteinuria. � 8 ¡

5/24/14 ¡ Preterm Labor in the ED � maternal well-being • Tocolytics: Still given but not proven! � gestational age • Calcium channel blockers now popular. � • Do not use more than one agent. � • Corticosteroids: Proven! Give them! � labor status • Dexamethasone or betamethasone. � • Fetal lung maturity. � fetal well-being • Antibiotics: Proven, but only with ruptured membranes. � • Increase the latency period in PPROM. � I had no idea! � Pregnant ¡ +ROM ¡ Pushing ¡ 24 yo woman complaining of abdominal pain for several hours. She states her last period was last month. You are summoned Delivers ¡ to the room and a code is called. � 9 ¡

5/24/14 ¡ Pregnancy for Emergency Providers maternal well-being pre-­‑viable ¡to ¡viable ¡ gestational age weeks ¡23-­‑24 ¡ week ¡20 ¡ week ¡27 ¡ week ¡13 ¡ labor status fetal well-being 12 ¡inches ¡ 15 ¡inches ¡ 400-­‑600 ¡grams ¡ 900 ¡grams ¡ 3 ¡inches ¡ 15 ¡grams ¡ Clinically Determining Survival By Weight Viability: Weight � Mod-Severe Weight Survival Disability 401-500g 11% * • Less than 400 grams is considered nonviable. � 501-600g 27% 29% • Requires quick access to an 601-700g 63% 30% infant scale. � 701-800g 74% 28% 10 ¡

5/24/14 ¡ Clinically Determining Non-initiation of a Code � Viability: Ballard Score � • Age less than 23 weeks. � • Weight less than 400 grams. � • Anencephaly. � • Lethal malformation: Trisomy 13 or 18. � • Calling a code: asystole greater than 15 minutes. � 34 ¡weeks ¡ Pregnant ¡ +ROM ¡ Pushing ¡ 30 yo woman is brought to the ED by friends with abdominal cramping and rupture of membranes. She states she is Labor ¡ about 34 weeks pregnant. � 11 ¡

5/24/14 ¡ Cord Prolapse � • To the OR if possible. � • Elevate the presenting part. � • Kneeling position or steep Trendelenberg. � • Infusing the bladder with saline - although not as helpful if a presenting part is visible. � Breech Delivery � Shoulder Dystocia � • “Turtle sign”. � • To the OR if possible! � • DO NOT PULL until the umbilicus is • Difficult to predict. � delivered. � • Fetal macrosomia � • Infant should deliver face down. � • Preterm infants are more likely to be • Precipitous delivery � breech. � • NO fundal pressure/hold pushing until repositioned. � • http://www.birthingway.com/footling_breech.htm# � 12 ¡

5/24/14 ¡ Reducing Dystocia � Thermal Care � • McRobert’s Maneuver � • The item we are most likely to overlook and under-manage � • Suprapubic pressure � • Association between hypothermia and mortality: acidosis, respiratory distress, NEC, intraventricular hemorrhage � • Delivering the posterior shoulder � • The smaller you are, the faster you lose heat. BIG problem less than 30 weeks. � • Rubin, Woods Corkscrew � • Warm blankets, portable warming • Zavenelli Maneuver � mattresses, warming tables, hats. � Quick Trick � Post-Partum Care � • No blankets? � • Do not pull on the umbilical cord. � • “micro-preemie”? � • Gush of blood prior to • Use a 5 gallon placental detachment. � freezer bag. � • Keep the mom warm and • Cut a hole in the top dry. � and seal the bottom. � • Be vigilant for postpartum hemorrhage. � 13 ¡