laura fitzmaurice, md, facog assistant clinical professor ...som.uci.edu/hospitalist/pdfs...

Laura Fitzmaurice, MD, FACOG Assistant Clinical Professor Division of OB/GYN Hospitalists Department of Obstetrics and Gynecology

No conflicts of interest No financial contributors to disclose Will touch on Betamethasone use to promote

fetal lung maturity.

Off-label use

Also a HVBPP quality metric

I am not an internist, intensivist or MFM

Review maternal mortality statistics Describe cardiopulmonary changes in pregnancy Identify how CPR is different in pregnancy In pregnant patients, recognize and initially

manage:

Hypertensive emergencies

Eclamptic seizures

Hypoxia

Sepsis

Maternal morbidity and mortality.

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Annual maternal mortality estimates per 100,000 live births Source: Trends in Maternal Mortality: 1990-2013. Estimates by WHO, UNICEF, UNFPP, The World Bank and United Nations Population Division: Executive Summary. 2014.

Source: The California Pregnancy-Associated Mortality Review. Report from 2002 and 2003 Maternal Death Reviews. Sacramento: California Department of Public Health, Maternal Child and Adolescent Health Division; 2011.

Source: The California Pregnancy-Associated Mortality Review. Report from 2002 and 2003 Maternal Death Reviews. Sacramento: California Department of Public Health, Maternal Child and Adolescent Health Division; 2011.

Source: The California Pregnancy-Associated Mortality Review. Report from 2002 and 2003 Maternal Death Reviews. Sacramento: California Department of Public Health, Maternal Child and Adolescent Health Division; 2011.

Cause Mortality (1-2 per 10,000)

ICU Admission (1-2 per 1,000)

Severe morbidity (1-2 per 100)

VTE/AFE 15% 5% 2%

Infection 10% 5% 5%

Hemorrhage 15% 30% 45%

Preeclampsia 15% 30% 30%

Cardiac disease 25% 20% 10%

Percentage of the total

Source: Main, Elliott, “Maternal Mortality” lecture slides, Society of OB/GYN Hospitalists Annual Meeting, 9/2014

You have just received ICU to ICU transport of a critically ill patient from a local community hospital. She is a 38 year old G5P4 at 24 weeks gestational age with urosepsis and severe ARDS. Shortly after her arrival, telemetry monitors alarm, showing polymorphic ventricular tachycardia.

Cardiopulmonary changes in pregnancy

Parameter Change

Cardiac output ~40% increase

Blood volume ~50% increase

Heart rate ~10 bpm increase

Blood pressure Nadir at ~22 wks

Image: thepregnancyzone.com

HIGHEST CARDIOVASCULAR RISKS • 20-24 weeks • Labor • Postpartum

Source: Cunningham FG, et al, ed. Williams Obstetrics, 22nd ed. McGraw-Hill; 2005

Parameter Change

O2 consumption increased

Minute ventilation increased

Tidal Volume increased

FRC decreased

PaCO2 decreased

PREGNANT WOMEN COMPLAIN OF: • Shortness of breath at rest • Dyspnea on exertion

Source: Cunningham FG, et al, ed. Williams Obstetrics, 22nd ed. McGraw-Hill; 2005

Source: Baggish et al. Atlas of Pelvic Anatomy

Avoid supine position Give 100% oxygen IV access above the diaphragm Differential diagnosis accounting for pregnancy

Cardiac disease more likely

Aggressive treatment of pre-arrest scenarios

Hemorrhage and preeclampsia protocols

Sepsis bundles

Six [additional] steps to improve outcomes

In-hospital arrest: pregnancy and gestational age typically already known

Found down?

Check for “obviously gravid” abdomen

When in doubt, palpate for mass (uterine fundus) reaching from pelvis to above umbilicus.

If fundus > umbilicus, call Code White AND Code Blue

Get a knife (and a surgeon)

Image: Jeejeebhoy FM and Morrison LJ. Maternal Cardiac Arrest: A Practical and Comprehensive Review. Emergency Medicine International 2013; 6: 1-8

Rhythm interpretation, defibrillation and all drugs and dosages same as in non-pregnant patient

If patient is on magnesium sulfate:

STOP

Give IV/IO calcium chloride 10mL in 10% solution

Anesthetic complications

Bleeding Cardiovascular Drugs Embolic Fever General non-obstetric

causes of arrest Hypertension

A.k.a. Anaphylactoid syndrome of pregnancy Fulminant cardiovascular collapse DIC 1 in 40,000 pregnancies

1 in 7 pregnancy-related deaths

Maternal mortality at least 40% Neonatal mortality up to 68%

Early activation of aggressive transfusion protocol.

afesupport.org, marchofdimes.org

A-OK • Atropine 1mg • Ondansetron 8mg • Ketorlac 30 mg

Why perimortem cesarean delivery is good for everyone

Possibility of saving the baby Possibility of saving the mother

Uteroplacental blood flow can consume as much as 30% of CO

Aortocaval compression no longer a concern

▪ Better cardiac return

▪ Better CPR

Auto-transfusion post-partum

▪ CO can increase by 80% after placenta is delivered

IT CAN’T MAKE THINGS WORSE!

Maternal cardiac arrest Uterine fundus at umbilicus or higher

Do NOT need to know

▪ Gestational age

▪ Number of fetuses

▪ Fetal viability or heart rate

Code ongoing >= 4 minutes, OR Initial assessment of maternal rhythm is NOT

shockable

Call for help

Code Blue

Code White

Uterine displacement Start CPR NO fetal monitoring NO anesthesia NO abdominal prep Do it where you are Continue ACLS after

baby delivered.

1. Code Blue AND Code White 2. Left uterine displacement 3. Perimortem cesarean delivery is a potentially life-

saving intervention for both mother and baby, both of whom will almost certainly die without it.

You have been asked by the OB team to consult on a 26 year old G1P0 at 26 weeks gestational age with no prenatal care and symptoms suspicious for an SLE flare. During your interview, she becomes distracted by a severe headache.

Blood Pressure

>= 140 mmHg systolic OR 90 mmHg diastolic

Two measurements >= 4 hours apart

After 20 weeks gestation

BP previously normal, returns to normal by 6 weeks post-partum

Proteinuria

>= 300 mg/day in 24 hour urine collection

Urine protein/creatinine ration >= 0.3

Dipstick >= 1+ (last resort)

Severe features

Platelets < 100,000

Cr > 1.1 or doubled

AST/ALT >= 2x normal

Pulmonary edema

Cerebral or visual symptoms

AND OR

Severe range blood pressures (>= 160 systolic or 110 diastolic) should be treated immediately, so you can’t count on the “on two occasions four hours apart”

Severe range blood pressures may be a severe feature in a patient with preeclampsia, BUT

Are NOT a severe feature in superimposed preeclampsia*

Do NOT make the diagnosis of preeclampsia (vs. gestational hypertension)

HELLP syndrome

Hemolysis, Elevated Liver enzymes, Low Platelets

1/3 will have NORMAL blood pressures!

½ will have normal or MILD range blood pressures

Acute onset, severe hypertension (defined as >= 160 SBP or >= 110 DBP*)

accurately measured using standard technique

Persistent > = 15 minutes * = starting page 60 of the task force report, concern noted

for adverse outcomes at lower diastolic BP

Task force recommends treatment threshold of

DBP >= 105

Drug Dose Interval Maximum total dose

Adverse effects and contra-indications

Labetalol IV 20 40 80 mg over 2 min

10 min 220 - 300 mg Neonatal bradycardia Asthma CHD/CHF

Hydralazine IV 5 10 mg over 2 min

20 min 25 mg vs. None

Maternal hypotension

Nifedipine PO (Immediate Release)

10 20 mg 20 min 50 mg Maternal tachycardia and hypotension

CMQCC Protocol for Labetalol Treatment

LABETALOL:

ThresholdBloodPressure:Systolic160ORDiastolic105-110

TargetBloodPressure:140-150-90-100

AdaptedfromACOGCommi eeOpinion#514;(1)MFM,Cri calCare,Anesthesia,InternalMedicine;(2)RaheemI,SaaidR,OmarS,TanP.Oralnifedipineversusintravenouslabetalolforacutebloodpressurecontrolinhypertensiveemergenciesofpregnancy:arandomisedtrial.BJOG.2012;119:78-85.

SwitchTO:

IfNoIVAccess:GiveOralLabetalol

200mg

CheckBPin30minutes;ifabove

threshold,labetalol200mg

dose

SeekConsulta on(1)(Maternal-FetalMedicine,Cri cal

Care,Anesthesia,InternalMedicine)

IfNoIVaccess:GivePONifedipine

10mg

CheckBPin30minutes;ifabove

threshold,repeatPOnifedipine10mg(2)

OR

CMQCC Protocol for Labetalol Treatment

4-6 g load over 20 minutes OR 2 x 5 g IM of 50% sol’n

1-2 g/hr on infusion pump (10% in 100 mL)

Probably works by raising the seizure threshold

Also causes peripheral vasodilation

May help BP a little

Side effects: diaphoresis, n/v, warmth, HA, palpitations

Important side effect (rare) = pulmonary edema

Contraindicated in pulm edema, myasthenia gravis

Causes decreased, even absent variability in FHR

Does NOT cause loss of reactivity OR decels

Seconds after the nurse leaves the room to procure the labetalol you ordered, the patient has a generalized tonic-clonic seizure.

A 30 year old G3P2 at 34 weeks gestational age presents to labor and delivery complaining of fevers/chills and malaise. She is found to be febrile to 102.7 deg F, BP 145/95, pulse 120. On ROS she also endorses a productive cough. Labs are notable for WBC 3.2, Hgb 8.0, Hct 24, Plts 60, AST 145, ALT 102, Cr 0.5. U pr/cr = 0.25.

Aarvold ABR et al. Multiple Organ Dysfunction Score is Superior to the Obstetric-Specific Sepsis in Obstetrics Score in Predicting Mortality in Septic Obstetrics Patients. Critical Care Medicine. Jan 2017; 45(1), e49-57.

Chorioamnionitis

Polymicrobial

▪ Atypicals (Ureaplasma, Mycoplasma)

▪ Anaerobes (vaginal and enteric)

▪ Gram-negatives

▪ Group B Strep

Typical treatment in labor

▪ Ampicillin and gentamicin

https://www.mdcalc.com/sirs-sepsis-septic-shock-criteria

Survivingsepsis.org

Goal directed therapy: • CVP 8-12 mmHg • MAP > 65 mmHg • ScvO2 > 70%

http://reference.medscape.com/calculator/mods-score-multiple-organ-dysfunction

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Intact Survival (%)

Intact Survival (%)

Estimates based on NICHD NRN data

The patient is delivered by urgent cesarean section for fetal indications. On post-operative day#2, she remains in the ICU with high spiking fevers (despite A/G/C). Her hepatitis and pancytopenia have worsened. Her pulse is in the 110s (higher with high fevers), her O2 sats are 96% on RA and her BPs are in the 80s/50s. You are now called to consult.

29 year old G1P0 at 38 weeks gestational age presents complaining of dyspnea, progressive x 1 week. She appears anxious. VS: BP 156/88, P 90, R 20, O2 sat 85% RA 95% on 2L N/C.

Hypoventilation CNS

▪ Pain meds, Mag Sulfate

PNS

Muscular

Chest Wall V/Q mismatch Asthma/COPD

Pulmonary Vascular Dz ▪ PE

Interstitial disease

R to L shunt Anatomic

Physiologic ▪ PNA

▪ ARDS

Pulmonary edema CHF

Severe hypovolemia/anemia

Occurs in late pregnancy or within weeks to months postpartum

Almost always 36 weeks gestation to 4 weeks postpartum

Need to rule out other causes of heart failure

Ddx = unmasking of previously undiagnosed heart disease by demands of pregnancy

EF < 45%

Parameter Non-pregnant normal range

Pregnant Normal Range

pH 7.38-7.42 7.4-7.46

PaCO2 (mmHg) 38-42 26-32

PaO2 (mmHg) 75-100 85-105

Bicarb 22-28 18-22

Sources: medlineplus.gov; Hankins et al, ObstetGynecol, 1996

Perinatology.com