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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.
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OBEmergencies
Non
Hemorrhagic
Emergencies Fetaldistress
Impendingfetaldistress(2nd twinisbreech,etc)
HemorrhagicEmergencies
Placentalabruption
Placentaprevia
Placentaacreta(increta,percreta)
Retainedplacenta
Uterinerupture Uterineatony
Indicationsfor
ImmediateCesareanDelivery
PersistentFHR
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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
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LocalAnestheticsforEpiduralAnesthesia
2%lidocainewithorwithoutepinephrine
Withoutepinephrine:higherpH,fasteronset
Withepinephrine:longerduration,easiertodetect
intravascularinjection
3%2chloroprocaine
Fastonsetbutshortdurationoften
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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
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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
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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%
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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
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AnesthesiaforFetalStress/Distress
Regionalanesthesiasafeinchronicfetalstress.
Generalanesthesiausuallypreferredindiredistressplacentalabruption,severefetalbradycardia,uterinerupture.
Intermediate degreesofdistressoftenmanagedwellwithregionalanesthesia.
Considerearlyuseofepiduralanesthesiainpatientsathighriskofoperativedelivery
Peripartum Hemorrhage
Hemorrhagehasbeenoneoftheleadingcausesof
maternalmortalitysincerecordshavebeenkept
#1causeofmaternaldeathworldwide
Amajorcauseofmaternaldeathindevelopedand
developingcountries
~125,000deathsperyear
Affects515%ofwomengivingbirth
Increasesmorbidityin~20,000,000women
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PlacentalAbruption
Akaabruptio placentae,accidentalhemorrhage(UK)
Prematureseparationofthenormallyimplantedplacenta. Differentfromplacentaprevia inthatplacentaisimplantedsomedistancebeyondthecervicalinternalos.
Frequency 1in100200deliveries
10 12%ofallthirdtrimesterstillbirths
RequiresemergentCSiffetusviableandvaginal
deliverynotimminent Mayrequirematernaltransfusion&resuscitation
PlacentaPrevia
Placentaimplantedoverorverynearinternalcervicalos.
Riskofmajorantepartumbleed
Cervicalos edgeofplacenta:
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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
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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
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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
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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.
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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
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UterineTamponade Devices
SengstakenBlakemoretube
SOSBakri tamponade tube
MassiveTransfusion
Protocol
Onceinitiated,Anesthesia,OB,Nursing,BloodBank,Pathology,etc.allworkingfromawrittenprotocol.
Protocolreadilyavailable(i.e.bycomputer).
Presetamountsofbloodproductsarepreparedautomatically
Bloodproductspreparedautomatically,laboratorypreparedtoprocesssamplesquickly,ancillarypersonnelmadeavailable.
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MassiveTransfusionProtocol
UniversityofIowaHospitalsandClinics
Summary
Fetaldistressand/ormaternalhemorrhageoftenrequire
immediatecesareandelivery.
Generalanesthesiaoffersgreatestspeedbutmaybe
associatedwithgreatermaternalrisk.
Epiduralanesthesiausingalreadyinplacecatheteris
oftenagoodalternative.
Iftimeallows,spinalanesthesiaismostcommonlyused.
Hypovolemia,ongoinghemorrhagefavortheuseof
generalanesthesia.
Bepreparedformassivehemorrhage. Establisha
massivetransfusionprotocol.