Obstetrical crisis in the PACU

Dr. Jagdeep UbhiRoyal Columbian Hospital

Gestational Hypertension Postpartum Hemorrhage

Outline

25 year old G1P1 admitted to PACU post operatively from a caesarean section for an abnormal heart tracing.

Intraoperative blood loss 1500 ml Vital signs: BP 160/100, HR 72, RR 12, T

36.6 One 18 ga IV Indwelling foley catheter 5 minutes after arrival patient has a tonic

clonic seizure What is the appropriate management

Case One

Incidence◦ 5 to 10% of pregnancies◦ Pre-eclampsia syndrome most serious (3.9%)

WHO review of maternal mortality◦ Hypertensive disorders 16%◦ Hemorrhage 13%◦ Abortion 8%◦ Sepsis 2%

Berg et al. (2003)◦ 1991-1997: 16% of 3201 related to hypertensive

disorders of pregnancy◦ Over half preventable

Hypertensive disorders of pregnancy (HDP)

Diagnosis◦ Diastolic blood pressure>90mmHg◦ Severe hypertension

>160 mmHg systolic >110 mmHg diastolic

◦ Proteinuria 0.3g/24 hour urine collection >2+ on dipstick Sign of systemic endothelial dysfunction

HDP

Pregnancy specific syndrome that can affect every organ system in the body

Headaches or visual symptoms Epigastric or right upper quadrant pain Thrombocytopenia Renal or cardiac involvement Fetal growth restriction Eclampsia

◦ 10% postpartum◦ 1:2000 births

Pre-eclampsia

Placental implantation◦ Abnormal

trophoblastic proliferation

Immunologic factors Endothelial cell

activation Genetic factors

ETIOPATHOGENESIS

Abnormal trophoblastic invasion

Semiallogenic fetal graft Intolerance or dysregulation

◦ Maternal-Placental interface Acute graft rejection

Inferential data◦ First pregnancy increased incidence◦ New partner = new antigentic load◦ Immunized against pre-eclampsia

Immunologic factors

Placental factors lead to ischemic changes◦ Activated state of leukocytes in maternal circulation◦ Increased oxidative stress

Increased cytokines e.g. interleukin 1 and TNF Generation of free oxygen radicals

Modify nitrous oxide and prostaglandin balance

Atherosis Activation of coagulation cascade

◦ Thrombocytopenia Increased permeability

◦ edema, proteinuria

Endothelial cell activation

Multifactorial and polygenetic Incident risk

◦ 20-40% for daughters of pre-eclamptic mothers◦ 11-37% for sisters◦ 22-47% of twin studies◦ 60% of identical twins

Genetic factors

Vasospasm◦ Vascular constriction leading to hypertension◦ Endothelial cell damage leading to interstitial

leakage Endothelial cell activation

◦ Placental factors secreted into maternal circulation

◦ Promotes dysfunction of vascular endothelium◦ Widespread endothelial cell dysfunction◦ Intact epithelium has anticoagulant properties

and blunts response to smooth muscle agonists by secreting nitric oxide

pathogenesis

Cardiovascular system◦ Hemodynamic changes◦ Blood volume changes

Blood and coagulation◦ Thrombocytopenia, Hemolysis, HELLP Syndrome

Kidney Liver Brain

Pathophysiology

Posterior reversible encephalopathy syndrome

Termination of pregnancy Birth of an infant Restoration of health to the mother

Management

Tonic clonic convulsions Immediate management

◦ Protect airway◦ Short acting◦ Post ictal state◦ Visual changes◦ Magnesium sulfate

Eclampsia

Loading dose 4 grams over 20 minutes then 1 gram per hour infusion

Renal excretion Risk for respiratory depression

◦ Loss of patellar reflexes by 5mmol/L◦ Respiratory depression > 5-6 mmol/L◦ Treatment is calcium gluconate 1gram IV

Magnesium sulfate is now also used for neuroprotection in preterm pregnancies

Magnesium sulfate

Calcium channel blockers◦ Nifedipine capsules 5–10 mg to be bitten and

swallowed, or just swallowed, every 30 min◦ Hydralazine IV - Start with 5 mg IV; repeat 5–10

mg IV every 30 min, or 0.5–10mg/hr IV, to a maximum of 20mg IV (or 30 mg IM)

Beta blocade◦ Labetalol IV◦ Labetalol Start with 20 mg IV; repeat 20–80 mg IV

q 30min, or 1–2 mg/min, max 300 mg

Management of severe hypertension

High risk for development of pulmonary edema

Fluid restrict to 80 mls/h Tolerate oliguria and elevated creatinine

Fluid management

Protect the airway Padded bed Magnesium sulfate Frequent vital signs One to one nursing Laboratory evaluation Maintain blood pressure less than 160/110

Case One

Definition DBP > 90 mmHg If proteinuria or adverse features, think pre-

eclampsia Treatment is delivery, but not out of the

woods yet Magnesium sulfate prophylaxis to reduce

mortality Antihypertensives to reduce the risk of

stroke Run the patient dry

Summary of hypertension

Hemorrhage is a leading cause of maternal morbidity.

Worldwide it results in half the cases of maternal mortality

Hospital delivery is one of the main reasons for a decline in mortality due to availability of blood products

Postpartum Hemorrhage

Postpartum Hemorrhage Leading cause of death in the world

◦140,000 cases/year◦Maternal mortality 386/100,000 Sierra Leone 2000/100,000 Canada 5/100,000

Worldwide impact

Postpartum Hemorrhage BC Perinatal database 2000-2009

27% increase in PPH [6.3 to 8%]1

Transfusion rate 17.8/10,000 to 25.5/10,000

Surgical/angiographic intervention 1.8/10,000 to 5.6/10,000

Perinatal Services BC, Dec 16, 2011

Definition◦ Loss of 500 mls of blood or more

Postpartum hemorrhage

4 T’s of PPH Tone Tissue Trauma Thrombin

Etiology

Etiology Process Clinical Risk factors

Abnormalities of uterine contraction [Tone]

over distended uterus multiple gestation

uterine muscle exhaustion

prolonged labour

intra amniotic infection chorioamnionitis

functional/anatomic distortion of the uterus

fibroid uterus

Retained Products of conception [Tissue]

retained products incomplete placenta at delivery

abnormal placenta abnormal placenta U/S

retained blood clots atonic uterus

Genital Tract Trauma lacerations of the cervix, vagina or vulva

operative delivery

uterine rupture previous uterine surgery

uterine inversion

Abnormalities of Coagulation [Thrombin]

von Willebrand’s Disease

thrombocytopenia with pre-eclampsia

600 ml/min flow thorough the intervillous spaced

Flow carried by spiral arteries approximately 120, and their veins

These vessels are avulsed with delivery of the placenta

Hemostasis at the placental site

Oxytocin - Synthetic hormone◦ In small doses increases tone and frequency of contractions.

In large doses can cause tetany◦ Very few side effects◦ In large doses rarely can cause water intoxication◦ 20 units per liter infusion for PPH IV

Methylergonovine maleate◦ Ergot produces tetany◦ 0.25 mg IM q 5 min to max of 1.25 mg◦ Can cause vasospam so contraindicated in hypertensive

patients Carboprost – 15 methyl analog of PGF2alph

◦ 0.25 mg q15 min to max of 2 mg◦ Smooth muscle contraction

Uterine atony

Definition Placenta accreta is the abnormal attachment

of chorionic villi to the myometrium Absence of an intervening decidua basalis

(Nitabuch’s layer)

Placenta Accreta75-78%

Attachment of chorionic villi to myometrium

Placenta Increta17%

Invasion of villi into myometrium

Placenta Percreta5%

Penetration to or through uterine serosa+/- adjacent

organs

Miller DA, Chollett JA, Goodwin TM. Clinical risk factors for placenta previa–placenta accreta. Am J Obstet Gynecol 1997;177:210-4

Miller D et al, AJOG 1997.

Increasing incidence?

Breen et al Obstet Gynecol 1977 - 1:7000

Miller et al AJOG 1997 - 1:2500 Wu et al AJOG 2005 - 1:533

Epidemiology Incidence

◦ 1:530 – 1:2500 1-3 ◦ 10 fold increase in the last 30 years1

Risk Factors◦ Previous C-section◦ Other uterine surgery

D&C/Asherman’s, myomectomy◦ Advanced maternal age and parity◦ Smoking◦ Placenta previa

10% - element of accreta4

40% - anterior previa and >=2 previous c-sections1

1. Committee on Obstetric Practice. ACOG committee opinion no. 266. Placenta accreta. Int J Obstet Gynecol 2002;77:77-8.

2. Usta IM, Hobeika EM, Musa AA, Gabriel GE, Nassar AH. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol

2005;193:1045-9.3. Miller DA, Chollett JA, Goodwin TM. Clinical risk factors for placenta previa–

placenta accreta. Am J Obstet Gynecol 1997;177:210-4.4. Angstmann T, Gard G, Harrington T, et al. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet

Gynecol 2010;202:38.e1-9.5. STERGIOS K. DOUMOUCHTSIS & SABARATNAM ARULKUMARAN. The morbidly adherent placenta: an overview of management options. Acta

Obstetricia et Gynecologica. 2010; 89: 1126–1133

Rate of Placenta Accreta with Rising C/S

1.9

15.6

23.5

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Number of Caesarean Sections

Usta IM, Hobeika EM, Musa AA, Gabriel GE, Nassar AH. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol

2005;193:1045-9.

http://www.perinatalservicesbc.ca//sites/bcrcp/files/Optimal_Birth/OptimalBirth_BC_for_BCPHP.pdf

Location of Previa and risk of Placenta Accreta (with> 1 prior CD)

Anterior/central previa: 29% (36/124) Posterior previa 6.5% (4/62)

RR 4.5

Miller D et al AJOG 1997

Complications Post-partum hemorrhage (3000 mL to 5500 mL)1-2

Placenta increta (3630 ± 2216 mL)3

Placenta percreta (12,140 ± 8343 mL)3

Massive transfusion (21%)5

Transfusion-related complications (DIC, TRALI, Hemolytic rxn, infection)

Surgical complications6

Ureteric/bladder/bowel injury Fistula formation Thrombosis Limb ischemia

Infection/Sepsis1-6

Increased length of stay / ICU admission5

Maternal death (7%)5

1. Angstmann T, Gard G, Harrington T, et al. Surgical management of placenta accreta: a cohort series and suggested approach. Am J Obstet

Gynecol 2010;202:38.e1-9.2. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year

analysis. Am J Obstet Gynecol 2005;192:1458-61.3. Sumigama S, Itakura A, Ota T, et al. Placenta previa increta/percreta in

Japan: a retrospective study of ultrasound findings, management and clinical course. J Obstet Gynaecol Res 2007;33:606-11.

4. Usta IM, Hobeika EM, Musa AA, Gabriel GE, Nassar AH. Placenta previa-accreta: risk factors and complications. Am J Obstet Gynecol 2005;193:1045-

9.5. DOUMOUCHTSIS SK & ARULKUMARAN S. The morbidly adherent placenta:

an overview of management options. Acta Obstetricia et Gynecologica. 2010; 89: 1126–1133

6. O’Brien JM, Barton JR, Donaldson ES. Obstetrics: the management of placenta percreta: conservative and operative strategies. Am J Obstet

Gynecol 1996;175:1632-8.

Estimated blood loss in Placenta Accreta>2000 ml – 66%>5000 ml – 15%>10,000 ml - 6.5%>20,000 ml – 3%

90.5%

62 histologically confirmed cases among 155,670 deliveries

Miller D et al AJOG 1997

Management Options◦ Caesarean Hysterectomy

Following delivery of the baby after leaving placenta intact

Adjuncts Interventional Radiology

Balloon Catheter occlusion Embolization

Ureteric stents Proceed to Hysterectomy

Conclusion Recognition of clinical risk factors Importance of early diagnosis PPH is a symptom, make a diagnosis Targeted treatment

Questions?