laura fitzmaurice, md, facog assistant clinical professor ...som.uci.edu/hospitalist/pdfs...
TRANSCRIPT
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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Germany Sweden U.S. Russia
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2008
2015
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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28-31wks
32-33wks
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37-39wks
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