Disclaimer! Financial Disclosures: None! The following is NOT - - PDF document

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Pitfalls in the Second Half

• f Pregnancy

Charlotte Page Wills, MD

Associate Program Director Alameda Health System-Highland Hospital EM Residency, Oakland, CA Associate Clinical Professor of Emergency Medicine University of California, San Francisco School of Medicine

Financial ¡Disclosures: ¡None! ¡

3 ¡

• 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.

Disclaimer!

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In the next 30 minutes…

• Highlight changes in physiology important to managing

patients in the second half of pregnancy.

• Describe the basic approach to initiate evaluation and

management of the gravid patient.

• 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

arise in the ED precipitous delivery.

maternal well-being gestational age labor status fetal well-being maternal well-being

• What’s normal? Know the physiologic

changes that occur in pregnancy.

• Where do I start? Perform standard

maneuvers for resuscitation in all pregnant patients.

• Identify underlying disease and treat

aggressively.

High Volume, Low Pressure

BP BP Hct Hct CO CO Vol Vol HR HR SVR SVR

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Second and Third Trimester Resuscitation

• Dilu8onal ¡anemia: ¡replace ¡volume ¡loss; ¡in ¡sepsis ¡

transfuse! ¡

• Oxygena8on: ¡high ¡oxygen ¡content, ¡increased ¡

minute ¡ven8la8on ¡and ¡TV. ¡

• Aortocaval ¡compression: ¡pelvic ¡8lt ¡or ¡manual ¡

uterine ¡distrac8on. ¡

• Progesterone: ¡an8cipate ¡a ¡difficult ¡airway ¡and ¡
• aspira8on. ¡

Aortocaval Compression

• IVC may be completely
• bstructed in the supine position.
• Uterus receives 30% of cardiac
• utput.
• Compression occurs at 20 weeks.
• CPR only produces about 10%

normal CO.

Avoiding Compression

• Tilt the backboard
• Blanket roll
• Manual distraction of the

uterus

labor status fetal well-being maternal well-being gestational age

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gestational age

• Traditional: Last menstrual period,

fundal height.

• Difficult in the obese patient.
• Is inaccurate with multiple

gestations.

• Ultrasound:
• Can be learned easily.
• Can be quickly performed.

Rapid Pregnancy Dating by EP’s

• Sonographers had a wide range of experience.
• Exams had a high degree of correlation with gold standard.
• Measurements of BPD and FL took less than one minute.
• Was more accurate than measuring fundal height.
• 96% ULS versus 80% for FH

Accuracy of emergency physicians using ultrasound to determine gestational age in pregnant women 
 Sachita Shah, Nathan Teismann, Brita Zaia, Farnaz Vahidnia, Gerin River, Dan Price, Arun Nagdev 
 American Journal of Emergency Medicine - 29 March 2010 (10.1016/ j.ajem.2009.07.024)

BPD Measurement

labor status fetal well-being maternal well-being gestational age

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labor status

• Labor: contractions with progression of the cervix
• Requires uterine monitoring.
• Requires examination of the cervix visually and

manually or by ultrasound.

• Bleeding: may be from labor, trauma, or the placenta
• Requires extreme caution with the vaginal/cervical

examination.

• Membranes: may rupture from labor or infection
• Requires determining presence or absence of

amniotic fluid.

• Visual inspection: pooling
• f amniotic fluid on sterile

speculum exam. Most sensitive finding.

• Ferning: arborization of

salt crystals in amniotic fluid.

• Nitrazine Paper: amniotic

fluid has a pH of 6.5 or higher.

Evaluating the Membranes

• Exams should be

sterile.

• Minimize digital exams
• rates of infection go up

with numbers of exams in PROM.

• CONTRAINDICATED if

you suspect placenta previa.

Cervical Evaluation

labor status maternal well-being fetal well-being gestational age

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fetal well-being

• Fetal heart rate (FHR) and activity: fetal

monitor.

• Can use bedside ultrasound to assess both
• For greater than 20 weeks, fetal monitoring

is standard.

• MUST come with a provider who can interpret

fetal strips.

• Fetal distress or intrauterine infection.
• Both are indications to deliver a viable

fetus.

Supplies for Baby

• Resuscitation surface:

infant warmer, surface with plenty of dry linens near an

• xygen source.
• Infant mask and anesthesia

bag/ambu bag.

• Dedicated person to dry,

stimulate, warm the infant.

26 yo woman complaining of headache and abdominal cramping stating she is 6 months pregnant. BP is 158/98 and HR is 118.

Pregnant ¡ HTN ¡ Headache ¡

Pre-­‑eclampsia ¡

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Headache

• Hypertensive
• No bleeding
• Mildly tender uterus

CBC CMP Uric acid, LDH DIC Panel

UA

• Hemolysis
• Elevated LFTs
• Platelet consumption
• Elevated creatinine
• Proteinuria

Damaged Endothelium

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BP BP Hct Hct CO CO Vol Vol HR HR SVR SVR

High Volume, Low Pressure

High Pressure, Low Volume

End-Organ Damage

• PRES
• Renal failure
• Placental abruption
• DIC

maternal well-being gestational age labor status fetal well-being

Managing Pre-eclampsia

• BP control: labetalol, nifedipine, hydralazine.
• Magnesium infusion for severe pre-eclampsia.
• Avoid lasix - patients are already volume

depleted.

• Avoid excessive fluids - patients third space

because of endothelial damage and proteinuria.

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labor status maternal well-being fetal well-being gestational age

Preterm Labor in the ED

• Tocolytics: Still given but not proven!
• Calcium channel blockers now popular.
• Do not use more than one agent.
• Corticosteroids: Proven! Give them!
• Dexamethasone or betamethasone.
• Fetal lung maturity.
• Antibiotics: Proven, but only with ruptured membranes.
• Increase the latency period in PPROM.

24 yo woman complaining of abdominal pain for several hours. She states her last period was last month. You are summoned to the room and a code is called.

+ROM ¡ Pushing ¡

Delivers ¡

Pregnant ¡

I had no idea!

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maternal well-being gestational age labor status fetal well-being

Pregnancy for Emergency Providers

week ¡13 ¡ week ¡27 ¡ weeks ¡23-­‑24 ¡

3 ¡inches ¡ 15 ¡grams ¡ 12 ¡inches ¡ 400-­‑600 ¡grams ¡ 15 ¡inches ¡ 900 ¡grams ¡

week ¡20 ¡

pre-­‑viable ¡to ¡viable ¡

Clinically Determining Viability: Weight

• Less than 400 grams is

considered nonviable.

• Requires quick access to an

infant scale.

Survival By Weight

Weight Survival Mod-Severe Disability 401-500g 11% * 501-600g 27% 29% 601-700g 63% 30% 701-800g 74% 28%

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Clinically Determining Viability: Ballard Score

Non-initiation of a Code

• 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.

30 yo woman is brought to the ED by friends with abdominal cramping and rupture of membranes. She states she is about 34 weeks pregnant.

34 ¡weeks ¡ Pregnant ¡ +ROM ¡ Pushing ¡

Labor ¡

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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

• To the OR if possible!
• DO NOT PULL until the umbilicus is

delivered.

• Infant should deliver face down.
• Preterm infants are more likely to be

breech.

• http://www.birthingway.com/footling_breech.htm#

Shoulder Dystocia

• “Turtle sign”.
• Difficult to predict.
• Fetal macrosomia
• Precipitous delivery
• NO fundal pressure/hold

pushing until repositioned.

SLIDE 13

5/24/14 ¡ 13 ¡

Reducing Dystocia

• McRobert’s Maneuver
• Suprapubic pressure
• Delivering the posterior shoulder
• Rubin, Woods Corkscrew
• Zavenelli Maneuver

Thermal Care

• The item we are most likely to overlook

and under-manage

• Association between hypothermia and

mortality: acidosis, respiratory distress, NEC, intraventricular hemorrhage

• The smaller you are, the faster you lose
• heat. BIG problem less than 30 weeks.
• Warm blankets, portable warming

mattresses, warming tables, hats.

Quick Trick

• No blankets?
• “micro-preemie”?
• Use a 5 gallon

freezer bag.

• Cut a hole in the top

and seal the bottom.

Post-Partum Care

• Do not pull on the umbilical

cord.

• Gush of blood prior to

placental detachment.

• Keep the mom warm and

dry.

• Be vigilant for postpartum

hemorrhage.

SLIDE 14

5/24/14 ¡ 14 ¡

Postpartum Hemorrhage

• Greater than 500 cc blood.
• Leading cause of death
• worldwide. In the US, second

after VTE.

• Uterine atony and lacerations.
• Risk factors include advanced

age, prior hemorrhage, older age, fetal macrosomia.

Resuscitating PPH

• Manual Interventions:
• Fundal massage, explore for

lacerations, manual uterine exploration for retained products.

• Medical Interventions:
• Oxytocin, methylergonovine

(ergot alkaloid), misoprostil.

• Resuscitation with fluids and

blood.

• TXA now second-line.

What we covered…

• Highlight changes in physiology important to managing

patients in the second half of pregnancy.

• Describe the basic approach to initiate evaluation and

management of the gravid patient.

• 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

arise in the ED precipitous delivery.

Thanks ¡

• Arun ¡Nagdev, ¡MD ¡and ¡the ¡Division ¡of ¡Emergency ¡

Ultrasound/Department ¡of ¡Emergency ¡Medicine ¡ at ¡Highland ¡Hospital ¡for ¡ultrasound ¡exper8se ¡ and ¡video ¡images. ¡

• Alameda ¡County ¡Paramedics ¡Trevor ¡Mollenkopf ¡

and ¡John ¡Younan, ¡and ¡Highland ¡charge ¡nurse ¡Liz ¡ Lynch, ¡RN ¡for ¡their ¡assistance ¡with ¡audio ¡ recordings ¡of ¡radio ¡ring ¡downs. ¡

56 ¡

SLIDE 15

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SLIDE 16

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(Review) Roberts D, Dalziel S Cochrane Database of Systematic Reviews 2006, Issue 3 Art No: CD004454

• Cervical Assessment by Ultrasound for Preventing Preterm Delivery (Review) Bergella V Baxter JK

Cochrane Database of Systematic Reviews 2009. Issue 3, Art No: CD007235

• Cervical Sonography in Preterm Labor Obstetrics and Gynecology July 1994 Vol 84, no 1.
• Magnesium Sulfate: The First-Line Tocolytic. D Lewis. Obstet Gynecol Clin N Am 32(2205) 485-500
• Biochemical Markers for the Prediction of Preterm Labor. J Yeast Obstet Gynecol Clin N Am 32(2205)

369-381

• Prediction and Early Detection of Preterm Labor. J Iams Obstetrics and Gynecology Vol 101. no 2 Feb

2003

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• Nontraumatic Abdominal Surgical Emergencies in the Pregnant Patient. K Challoner. Emerg Med Clin N
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• Cervical Assessment by Ultrasound for Preventing Preterm Delivery (Review) Bergella V Baxter JK

Cochrane Database of Systematic Reviews 2009. Issue 3, Art No: CD007235

• Cervical Sonography in Preterm Labor Obstetrics and Gynecology July 1994 Vol 84, no 1.
• Magnesium Sulfate: The First-Line Tocolytic. D Lewis. Obstet Gynecol Clin N Am 32(2205) 485-500
• Biochemical Markers for the Prediction of Preterm Labor. J Yeast Obstet Gynecol Clin N Am 32(2205)

369-381

• Prediction and Early Detection of Preterm Labor. J Iams Obstetrics and Gynecology Vol 101. no 2 Feb

2003

• Major Obstetric Hemorrhage. F Mercier et al Anesthesiology Clin 26(2008) 53-66
• Nontraumatic Abdominal Surgical Emergencies in the Pregnant Patient. K Challoner. Emerg Med Clin N
• Am. 21 (2003) 97-985
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