Obstetric Emergencies respect to my current presentation. William - - PowerPoint PPT Presentation

Obstetric Emergencies

William M. Gilbert, MD Regional Medical Director, Women’s Services Sutter Health Valley Region & Clinical Professor OB/GYN University of California, Davis

I have no financial conflicts of interest with

respect to my current presentation.

Introduction

Update on Obstetrical Emergencies Increasing Maternal Mortality rates Most common

Hemorrhage, Hypertension, Sepsis

Rare Obstetrical Emergencies

Life threatening due to rarity

What can we do to prepare

Case report # 1

25 year old G1 women at 37 weeks goes to ED

for:

Whole body swelling for 1-2 weeks Headache for 3 days Mid-epigastric pain x 2 days

In ED:

Blood pressure 160/100 3 + proteinuria, CBC and LFTs are normal Given a GI cocktail Told to follow up with OB/GYN in the next week

Case report # 1

3 days later:

Seizure at home. Taken to OB hospital with Dx of

Eclampsia

Recurrent seizures starting MgSO4 CVA occurs

Post Op day 2:

Mother died

Case report # 1

Massive failure on multiple levels:

ED missed the Dx of preeclampsia Patient uneducated on S/S of preeclampsia Did not contact OB provider Did not follow up with OB provider Much more common in the postpartum period Patient presents to ED with headache ED doesn’t know she is postpartum

16 18 16 13 9 10 8 10 11 14 9 12 7 8 8 15 15 9 9 10 11 10 6 6 6 6 10 9 11 11 11 11 8 7 10 11 15 12 17 12 21

5 10 15 20 25 1970 1975 1980 1985 1990 1995 2000 2005 2010 HP Objectives – Maternal Deaths (<42days postpartum) per 100,000 Live Births

Maternal Deaths per 100,000 Live Births ICD-10 codes ICD-8 codes ICD-9 codes

Maternal Mortality Rate, California Residents; 1970-2010

SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1970-2010. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using the ICD-8 cause of death classification for 1970-1978, ICD-9 classification for 1979-1998 and ICD-10 classification for 1999-2010. Healthy People Objectives: HP2000: 5.0 deaths per 100,000 live births; HP2010: 3.3 deaths, later revised to 4.3 deaths per 100,000 live births, and; HP2020: 11.4 deaths per 100,000 live births. Produced by California Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, December, 2012.

5

Question #1

What is the leading cause of Maternal mortality according to the CA-PAMR Report?

• A. Hypertensive disorders of

pregnancy

• B. Obstetrical hemorrhage
• C. Sepsis/infection
• D. Maternal Cardiac disease

H y p e r t e n s i v e d i s

• r

d e r s

• f

. . . O b s t e t r i c a l h e m

• r

r h a g e S e p s i s / i n f e c t i

• n

M a t e r n a l C a r d i a c d i s e a s e

49% 12% 1% 39%

Training in Obstetrical Emergencies

History of well intended biologically plausible

interventions which turned out to be wrong

X-Ray pelvimetry to Dx pre-labor CPD High dose Vitamin C and E to prevent preeclampsia

Robust data shows:

Some training helpful Others detrimental to outcome One reports show a worsening fund of knowledge

at 6 weeks with loss of confidence

Effective training is not cheap but can be cost

effective

Training in Obstetrical Emergencies

Evidence for effective and sustainable training

does show:

Local unit based and multi-professional training Use of Mannequins and practice based tools

Much Research is still needed

Why different programs are associated with different

• utcomes

Data to harness financial support

Rare Obstetrical Emergencies

Often seen once in a life time Untreated – can have a high maternal mortality

rate

If diagnosed – Survival markedly improved

Case Report # 2

31 y.o. female G2 P 1001 prior C/S 36 weeks with Severe PIH, Repeat C/S BP 160/100, 3+ proteinuria Underwent Repeat C/S with cystotomy POD # 3 BP 135/86 Patient wants to go home Blood tinged urine Pl ct 38K, Repeat 18 K Platelet transfusion - 40K pl ct

Case Report # 2

POD # 4 The patient continues to feel fine without

any S/S of severe preeclampsia.

Platelet count 18 K POD #5

The patient’s pl ct 13 K without S/S of severe

preeclampsia

Question # 2

Diagnosis?

• A. Severe Preeclampsia
• B. Immune thrombocytopenia (ITP)
• C. Thrombotic thrombocytopenia purpura

(TTP)

• D. Systemic Lupus Erythematosus (SLE)

Flare

S e v e r e P r e e c l a m p s i a I m m u n e t h r

• m

b

• c

y t

• p

e n i a . . . T h r

• m

b

• t

i c t h r

• m

b

• c

y t

• p

e n . . S y s t e m i c L u p u s E r y t h e m a t

• s

. .

35% 1% 47% 17%

Case Report # 2

POD #6

CNS changes, the patient becomes confused. The patient develops shortness of breath,

Cardio-respiratory distress

Question of pulmonary embolism Sent to Radiology for a VQ scan

Patient Died

Thrombotic Thrombocytopenia Purpura (TTP)

Severe multisystem disease.

Similar to severe preeclampsia

Diagnosis

Micro angiopathic hemolytic anemia Thrombocytopenia 5-100K Fever most cases CNS abnormalities: Confusion, delirium, coma,

seizures, hemiparesis, aphasia, and visual field changes

Occur in over 90% of cases with mortality Renal dysfunction

TTP

Mortality rate in past 90% Etiology:

Severe Acquired ADAMTS13 deficiency Inherited ADAMTS13 deficiency Cleaves large VWF molecules Blocked by IGG auto antibodies

Peak incidence age 20 - 40 yrs More Common in women

TTP

Associated with no illness or

Infections Pregnancy, 10-25 % of cases Autoimmune disease, 10 % SLE, + ANA 20% of

time

Surgery, Hysterectomy, Chole, C/S, Angiograms Past history increase risk of relapse 7.5%, 84% within 1 month

TTP

Treatment

No randomized controlled studies Corticosteroids Splenectomy Plasma-pheresis, Plasma infusions With Treatment Survival as high as 90% CNS changes most sensitive to treatment LDH sensitive indicator to disease activity Platelet count, renal f(x) slow to recover

Future pregnancies

Jiang Y et al 2014 Pregnancy Outcomes

following recovery from acquired TTP

Oklahoma TTP-HUS Registry 1995 – 2012 10 women had 16 pregnancies 1999-2013

2 recurrent TTP post partum 5 of 16 (31%) had preeclampsia 13 of 16 normal pregnancies (81%)

Re-occurrence of TTP uncommon but increase

in preeclampsia

Future pregnancies

Inherited ADAMTS13 deficiency

Invariably get TTP in pregnancy Require plasma transfusion, immunosuppressive

medications or Plasma-pheresis

Severe acquired ADAMTS13 deficiency

Measurement of ADAMTS13 activity in severe

acquired ADAMTS 13 deficiency.

May be helpful for following disease

Case Report # 3

24 year old G2 P1001 at term in labor

Normal first delivery and this pregnancy Epidural with bolus given at 9 cm While pushing suddenly sits up and passes out.

Unresponsive – “Code Blue” called Anesthesia intubated patient OB/GYN performed a forceps delivery

Question # 3

Diagnosis in Case # 3?

• A. High spinal
• B. Amniotic fluid embolism
• C. Eclamptic Seizure

H i g h s p i n a l A m n i

• t

i c f l u i d e m b

• l

i s m E c l a m p t i c S e i z u r e

12% 0% 88%

Case Report # 3

Despite rapid intubation and ICU

management

DIC and cardiac failure develops The patient is transfused multiple units of

blood products.

Patient recovers but in ICU for 3 weeks

Amniotic Fluid Embolism

Historically close to 100% mortality

Intrapartum or Postpartum Sudden onset hemodynamic collapse Hypoxia, hypotension, DIC, Fetal distress

Mechanisms

Amniotic fluid, fetal cells enter maternal sinuses Pulmonary embolism, vasospasm Hypoxia, Heart failure DIC, tissue factor

Amniotic Fluid Embolism

Treatment

Oxygen Intubation IV fluids and blood products ICU setting

Outcome

Prior outcome 60-80% maternal mortality Significant morbidity, but decreasing Recent data 15-25% mortality

Amniotic Fluid Embolism

May 2017 Green Journal: What is new in

AFE?

IGF binding protein -1 increased

Only effective test for AFE

Cases without CV collapse

3 case reports of DIC requiring multiple

transfusions and hysterectomy

1:1 transfusion with FFP to PRBCs

< 1:1 40% survival 1:1 90% survival

Summary

Maternal Mortality is increasing nationwide:

Many/most related to Obstetrical Emergencies Hypertension, Hemorrhage, AFE

Many toolkits are available to prepare us for

when they might occur.

When training, must make sure effective and

beneficial.

Rare obstetrical emergencies may be missed if

not identified.

References

• www.CMQCC.org
• Draycott TJ. Myths and realities of training in obstetrical
• emergencies. Best Practices and Research in clinical
• bstetrics and gynecology. 2015 29(8) 1067-76.
• Gilbert et al. Amniotic Fluid Embolism: Decreased Mortality

in a population-Based Study. O&G 93:973-7, 1999.

• Benson MD. What is new in AFE? O&G 2017
• Clark et al. Amniotic fluid embolism: Analysis of the national
• registry. Am J O&G 172:1158-69, 1995.
• Lockwood et al. Amniotic fluid contains tissue factor, a

potent initiator of coagulation. Am J O&G 165:1335-41, 1991.

• Jiang Y et al. Pregnancy outcomes following recovery

from acquired TTP. Blood. 123(11) 1674-1680, 2014

• Bosch and Wendler. Extracorpeal plasma treatment in

TTP and UUS: a review. Ther Apher 5:182-5, 2001.

• Bell et al. Improved survival in TTP-HUS Syndrome.

NEJM 325:398-403, 1991.

• Castro et al. DIC and antithrombin III depression in AFL of
• pregnancy. Am J O&G 174:211-7, 1996.

Tyni et al. Pregnancy complications are frequent in long-

chain 3-hydroxyacyl-coenzyme A dehydrogenase

• deficiency. Am J O&G 178:603-7, 1998.

Castro et al. Radiologic studies in AFL of pregnancy. A

review of the literature and 19 new cases. J Reprod Med 41:839-44, 1996.