Anaesthetic management of obstetric emergencies


Published on

anaesthetic management of obstetric emergencies

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Anaesthetic management of obstetric emergencies

  1. 1. Dr sheeba hakak Waterford regional hospital
  2. 2. Definition <ul><li>Obstetrical emergencies are life-threatening medical conditions that occur in pregnancy or during or after labor and delivery. </li></ul>
  3. 3. .
  4. 4. Massive obstetric haemorrhage <ul><li>MOH is a major cause of maternal death and morbidity </li></ul><ul><li>Variably defined as; </li></ul><ul><li>. blood loss >1500ml </li></ul><ul><li>. decrease in hb >4g/dl or </li></ul><ul><li>.acute transfusion requirements </li></ul><ul><li>>4 units </li></ul><ul><li>3. The gravid uterus receives up to 12% of cardiac output ,thus OH can be un expected and rapidly become life threatening. </li></ul>
  5. 5. Classification <ul><li>Antepartum placenta previa/accreta </li></ul><ul><li>placental abruption </li></ul><ul><li>uterine rupture </li></ul><ul><li>Post partum uterine inversion </li></ul><ul><li>uterine atony </li></ul><ul><li>birth trauma or laceration </li></ul>
  6. 6. ANTEPARTUM HEMORRHAGE <ul><li>Per vagina blood loss after 20 weeks’ gestation. </li></ul><ul><li>Complicates close to 4% of all pregnancies and is a MEDICAL EMERGENCY ! </li></ul><ul><li>Is one of the leading causes of antepartum hospitalization, maternal morbidity, and operative intervention. </li></ul>
  7. 7. Placenta Previa <ul><li>Defined as a placenta implanted in the lower segment of the uterus, presenting ahead of the leading pole of the fetus. </li></ul><ul><ul><li>Total placenta previa . The internal cervical os is covered completely by placenta. </li></ul></ul><ul><ul><li>Partial placenta previa . The internal os is partially covered by placenta. </li></ul></ul><ul><ul><li>Marginal placenta previa . The edge of the placenta is at the margin of the internal os. </li></ul></ul><ul><ul><li>Low-lying placenta . The placenta is implanted in the lower uterine segment such that the placenta edge actually does not reach the internal os but is in close proximity to it </li></ul></ul>
  8. 9. Placenta Previa <ul><li>Incidence about 1 in 300 </li></ul><ul><li>Perinatal morbidity and mortality are primarily related to the complications of prematurity, because the hemorrhage is maternal. </li></ul>
  9. 10. Etiology <ul><ul><li>Advancing maternal age </li></ul></ul><ul><ul><li>Multiparity </li></ul></ul><ul><ul><li>Multifetal gestations </li></ul></ul><ul><ul><li>Prior cesarean delivery </li></ul></ul><ul><ul><li>Smoking </li></ul></ul><ul><ul><li>Prior placenta previa </li></ul></ul>
  10. 11. Placenta Previa <ul><li>The most characteristic event in placenta previa is painless hemorrhage. </li></ul><ul><li>This usually occurs near the end of or after the second trimester. </li></ul><ul><li>The initial bleeding is rarely so profuse as to prove fatal. </li></ul><ul><li>It usually ceases spontaneously, only to recur. </li></ul>
  11. 12. Placenta Previa <ul><li>Placenta previa may be associated with placenta accreta , placenta increta or percreta. </li></ul><ul><li>Coagulopathy is rare with placenta previa. </li></ul>
  12. 14. . <ul><li>Diagnosis. </li></ul><ul><ul><li>Placenta previa or abruption should always be suspected in women with uterine bleeding during the latter half of pregnancy. </li></ul></ul><ul><ul><li>The possibility of placenta previa should not be dismissed until appropriate evaluation, including sonography, has clearly proved its absence. </li></ul></ul><ul><ul><li>The diagnosis of placenta previa can seldom be established firmly by clinical examination. Such examination of the cervix is never permissible unless the woman is in an operating room with all the preparations for immediate cesarean delivery, because even the gentlest examination of this sort can cause torrential hemorrhage. </li></ul></ul>
  13. 15. . <ul><li>The simplest and safest method of placental localization is provided by transabdominal sonography. </li></ul><ul><li>Transvaginal ultrasonography has substantively improved diagnostic accuracy of placenta previa. </li></ul><ul><li>MRI </li></ul><ul><li>At 18 weeks, 5-10% of placentas are low lying. Most ‘migrate’ with development of the lower uterine segment </li></ul>
  14. 16. Placenta Previa Management <ul><li>Admit to hospital </li></ul><ul><li>NO VAGINAL EXAMINATION </li></ul><ul><li>IV access </li></ul><ul><li>Placental localization </li></ul>
  15. 17. Placenta Previa Management Severe bleeding Caesarean section Moderate bleeding Gestation >34/52 <34/52 Resuscitate Steroids Unstable Stable Resuscitate Mild bleeding Gestation <36/52 Conservative care >36/52
  16. 18. Anaesthetic management for previa <ul><li>Examine the airway in case emergency G/A is required and provide aspiration prophylaxis </li></ul><ul><li>Ask OB about involvement with any previous cesarean scar on ultrasound [risk of accreta] </li></ul><ul><li>Place two large bore IV lines and have warmers available. </li></ul><ul><li>Assure that blood is type and cross matched. </li></ul><ul><li>What type of anaesthetic? </li></ul>
  17. 19. Anaesthetic management of previa <ul><li>A review of 514 women with placenta prtevia found: </li></ul><ul><li>No difference between G/A or regional anaesthesia in anaesthetic or operative complications. </li></ul><ul><li>G/A was associated with increased EBL and transfusions and decreased post op Hgb. </li></ul><ul><li>Am J Obstet Gyn 1999;180:1432 </li></ul>
  18. 20. Anaesthetic management for previa <ul><li>A retros pective review 350 consective cases of plcenta previa [ 60% using regional anaesthesia, 40% using G/A found: </li></ul><ul><li>. decreased EBL with regional vs G/A </li></ul><ul><li>. decreased transfusion with regional. </li></ul><ul><li>. no diff in incidence of hypotension. </li></ul><ul><li>.two spinals were converted to G/A secondry to c-hyst. </li></ul><ul><li>Br J Anaesth 2000;84;725 </li></ul>
  19. 21. Interventional radiology <ul><li>Prenatal diagnosis of palcenta accreta/percreta is now becoming more common[vs diagnosis at delivery] </li></ul><ul><li>Have a care conference in advance with anaesthesiology ,OB,nursing and interventional radiology present. </li></ul>
  20. 22. Placental Abruption <ul><li>Defined as the premature separation of the normally implanted placenta. </li></ul><ul><li>Occurs in 1-2% of all pregnancies </li></ul><ul><li>Perinatal mortality rate associated with placental abruption was 119 per 1000 births compared with 8.2 per 1000 for all others. </li></ul>
  21. 23. Placental Abruption <ul><li>external hemorrhage </li></ul><ul><li>concealed hemorrhage </li></ul><ul><li>Total </li></ul><ul><li>Partial </li></ul>
  22. 24. Risk factors for abruption <ul><li>Hypertension,chronic or pregnancy-induced </li></ul><ul><li>Age>35yrs </li></ul><ul><li>Multiparity </li></ul><ul><li>Smoking </li></ul><ul><li>Cocaine use </li></ul><ul><li>Abdominal trauma </li></ul><ul><li>Premature rupture of membranes </li></ul><ul><li>Hx of previous abruption </li></ul>
  23. 25. Diagnosis of abruption <ul><li>Vaginal bleeding with abdominal pain </li></ul><ul><li>Uterine hypertonicity </li></ul><ul><li>Fetal distress </li></ul><ul><li>Retroplacental clot </li></ul><ul><li>The presentation can be quite variable and difficult to diagnose </li></ul>
  24. 26. OB management of abruption <ul><li>Evaluate maternal stability[vital signs,coagulation studies] </li></ul><ul><li>Evaluate fetal well-being and maturity </li></ul><ul><li>If severe fetal distress and/or maternal instability ...........urgent C/S </li></ul><ul><li>If stable mother and fetus......induction of labor and vaginal delivery </li></ul>
  25. 27. Anaesthetic management of abruption <ul><li>Assure good IV access and availability. </li></ul><ul><li>Regional techniques are appropriate if maternal volume staus and coags normal </li></ul><ul><li>If G/A is indicated,consider induction with etomidate or ketamine </li></ul><ul><li>Have several oxytocics available for treatment of uterine atony. </li></ul>
  26. 28. Uterine rupture <ul><li>Risk factors for uterine rupture </li></ul><ul><li>Previous uterine surgery </li></ul><ul><li>Abdominal trauma </li></ul><ul><li>Uterine trauma </li></ul><ul><li>Grand multiparity </li></ul><ul><li>Fetal macrosomia </li></ul><ul><li>Fetal malposition </li></ul>
  27. 29. Diagnosis of uterine rupture <ul><li>Fetal distress </li></ul><ul><li>Cessation of uterine contraction [ in labor] </li></ul><ul><li>Vaginal bleeding </li></ul><ul><li>Abdominal pain </li></ul>
  28. 30. OB management of uterine rupture <ul><li>Uterine repair. </li></ul><ul><li>Hysterectomy </li></ul><ul><li>ANAESTHETIC MANAGEMENT </li></ul><ul><li>. Depends on ease of repair ,but be prepared for G/A and volume replacement. </li></ul>
  29. 31. PPH <ul><li>The mean blood loss in a vaginal delivery is 500 ml & 1000 ml for cesarean section. </li></ul><ul><li>Definition: </li></ul><ul><ul><li>Blood loss greater than 500 ml for vaginal and 1000 ml for cesarean delivery. </li></ul></ul><ul><ul><li>However, clinical estimation of the amount of blood loss is notoriously inaccurate. </li></ul></ul><ul><ul><li>Another proposed definition for PPH is a 10% drop in haematocrit. </li></ul></ul>
  30. 33. PPH Risk Factors
  31. 34. PPH Risk Factors
  32. 35. PPH Risk Factors
  33. 36. PREVENTION OF PPH <ul><li>Although any woman can experience a PPH, the presence of risk factors makes it more likely. </li></ul><ul><li>For women with such risk factors, consideration should be given to extra precautions such as: </li></ul><ul><ul><li>IV access </li></ul></ul><ul><ul><li>Coagulation studies </li></ul></ul><ul><ul><li>Crossmatching of blood </li></ul></ul><ul><ul><li>Anaesthesia backup </li></ul></ul><ul><ul><li>Referral to a tertiary centre </li></ul></ul>
  34. 37. OB MANAGEMENT OF PPH <ul><li>Bimanual uterine compression and massage </li></ul><ul><li>Infusion of oxytocin </li></ul><ul><li>Evaluation for retained placenta </li></ul><ul><li>Use of other oxytocics </li></ul>
  35. 39. ANAESTHETIC MANAGEMENT OF PPH <ul><li>Volume resuscitation </li></ul><ul><li>large bore IVs ,monitors,warmers </li></ul><ul><li>Analgesia </li></ul><ul><li>pre existing epidural,ketamine,G/A </li></ul><ul><li>Oxytocics </li></ul><ul><li>Move to OT sooner rather than later. </li></ul><ul><li>Consider notifying interventional radiology. </li></ul>
  36. 40. Oxytocic drugs <ul><li>Drug/dose </li></ul><ul><li>Oxytocin 20-80u/l </li></ul><ul><li>Methergine 0.2mg IM </li></ul><ul><li>Hemabate ..prostagladin F2alpha 250 mcg IM </li></ul><ul><li>Side effects </li></ul><ul><li>vasodialation with IV bolus,hyponatremia </li></ul><ul><li>Diffuse vasoconstriction,pulmonary and systemic htn,coronary vasospasm,nausea </li></ul><ul><li>Broncho spasm,pul htn,hypoxia,nausea,diarrhoea. </li></ul>
  37. 41. PRE ECLAMPSIA <ul><li>. </li></ul>
  38. 42. Definitions of Hypertensive Disorders in Pregnancy [1,2,4,5] <ul><li>Preeclampsia </li></ul><ul><ul><li>Blood pressure elevation with proteinuria </li></ul></ul><ul><ul><li>Occurs after 20 weeks of gestation </li></ul></ul><ul><ul><li>Proteinuria </li></ul></ul><ul><ul><ul><li>urinary excretion of 300 mg or greater of protein in 24 hr </li></ul></ul></ul><ul><ul><li>Edema no longer diagnostic for poor specificity </li></ul></ul><ul><li>Eclampsia </li></ul><ul><ul><li>seizures </li></ul></ul>
  39. 43. Definitions of Hypertensive Disorders in Pregnancy [1,2,4,9] <ul><li>HELLP syndrome </li></ul><ul><ul><li>defined by the presence of all 3 criteria: </li></ul></ul><ul><ul><ul><li>Hemolysis (abnormal peripheral smear, bilirubin 1.2 mg/dL [20.5 µmol/L], or lactate dehydrogenase 600 IU/L) </li></ul></ul></ul><ul><ul><ul><li>Elevated liver enzymes (aspartate aminotransferase 2 x normal) </li></ul></ul></ul><ul><ul><ul><li>Thrombocytopenia (platelets <100 x 10 3 /µL) </li></ul></ul></ul>
  40. 44. Aetiology <ul><li>Exact aetiology unknown </li></ul><ul><li>Possible causes </li></ul><ul><li>1. widespread endothelial dysfunction leading to placental ischemia and multi organ dysfunction </li></ul><ul><li>2. synthesis of many substances like NO and PGI2 may be decreased in pre ecclampsia which leads to smooth muscle reactivity and platelet adhesion </li></ul>
  41. 45. Complications <ul><li>Neurological </li></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Visual disturbances </li></ul></ul><ul><ul><li>Hyperexcitability </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Intracranial hemorrhage </li></ul></ul><ul><ul><li>Cerebral edema </li></ul></ul><ul><li>Pulmonary  </li></ul><ul><ul><li>Upper airway edema </li></ul></ul><ul><ul><li>Pulmonary edema </li></ul></ul><ul><li>Cardiovascular  </li></ul><ul><ul><li>Decreased intravascular volume </li></ul></ul><ul><ul><li>Increased arteriolar resistance </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Heart failure </li></ul></ul>
  42. 46. Complications <ul><li>Hepatic  </li></ul><ul><ul><li>Impaired function </li></ul></ul><ul><ul><li>Elevated enzymes </li></ul></ul><ul><ul><li>Hematoma </li></ul></ul><ul><ul><li>Rupture </li></ul></ul><ul><li>Renal  </li></ul><ul><ul><li>Proteinuria </li></ul></ul><ul><ul><li>Sodium retention </li></ul></ul><ul><ul><li>Decreased glomerular filtration </li></ul></ul><ul><ul><li>Renal failure </li></ul></ul><ul><li>Hematological  </li></ul><ul><ul><li>Coagulopathy </li></ul></ul><ul><ul><ul><li>     Thrombocytopenia </li></ul></ul></ul><ul><ul><ul><li>     Platelet dysfunction </li></ul></ul></ul><ul><ul><ul><li>     Prolonged partial thromboplastin time </li></ul></ul></ul><ul><ul><li>Microangiopathic hemolysis </li></ul></ul>
  43. 47. Risk Factors [10] <ul><li>Obesity </li></ul><ul><li>Black race </li></ul><ul><li>Chronic hypertension </li></ul><ul><li>Diabetes or insulin resistance </li></ul><ul><li>Collagen vascular disease </li></ul><ul><li>Thrombophilias </li></ul><ul><li>Increased circulating testosterone </li></ul><ul><li>Multiple gestation </li></ul><ul><li>Previous preeclampsia </li></ul>
  44. 48. Management <ul><li>Definitive treatment of preeclampsia is delivery </li></ul><ul><li>Whether or not to deliver the fetus </li></ul><ul><ul><li>gestational age </li></ul></ul><ul><ul><li>maternal and fetal condition </li></ul></ul><ul><ul><li>severity of preeclampsia </li></ul></ul><ul><li>Patients at term  delivered </li></ul><ul><li>Remote from term  Conservative approach </li></ul><ul><li>Delivery at any gestational age </li></ul><ul><ul><li>Maternal end-organ dysfunction </li></ul></ul><ul><ul><li>Nonreassuring tests of fetal well-being </li></ul></ul>
  45. 49. .
  46. 50. Mgso4 <ul><li>Anticonvulsant of choice in preventing and treating fits. </li></ul><ul><li>Iv bolus 4 to 6 gms and then </li></ul><ul><li>Infusion 1 to 2 gms/hr to keep sr mg in therapeutic range [2-3 mmol/lt] </li></ul><ul><li>Indicators of mgso4 toxicity...... </li></ul><ul><li>ECG changes [3-5mmol/lt] </li></ul><ul><li>loss of deep TR [5 mmlol/lt] </li></ul><ul><li>resp dep [6-7.5 mmol/lt] </li></ul><ul><li>cardiac arrest [12 mmol/lt] </li></ul>
  47. 51. Anaesthetic considerations <ul><li>Pre anaesthetic assessment </li></ul><ul><li>Fluid balance and hemodynamics </li></ul><ul><li>.hypo albuminaemia,increased cap permeability,high hydrostatic pressure leads to risk of pul and pharyngolaryngeal oedema </li></ul><ul><li>2. Estimation of cardiac out put ......if .....oliguria ,pul oedema,htn resistant to initial therapy. </li></ul><ul><li>Coagulation </li></ul><ul><li>Assessment of coag status is essential before reg anaesthesia . </li></ul>
  48. 52. Epidural analgesia <ul><li>Early epidural is an ideal form of pain relief in preceelamptic pts. </li></ul><ul><li>It helps to control the exaggerated hypertensive response to pain and can improve placental blood flow. </li></ul><ul><li>A functioning epidural may safely be etended for C/S. </li></ul>
  49. 53. Anaesthesia for c/s <ul><li>Regional vs G/A </li></ul><ul><li>1 Avoidance of hypertensive response to laryngoscopy [more in preecclamptics] </li></ul><ul><li>Blunting of neuro endocrine response to surgery </li></ul><ul><li>Prevention of transient neonatal depression associated vth G/A. </li></ul>
  50. 54. Spinal vs epidural <ul><li>Advantages </li></ul><ul><li>1. quicker and more reliable in on set </li></ul><ul><li>2. less potential trauma in the epidural space. </li></ul><ul><li>Dis advantages </li></ul><ul><li>theoretical risk of more abrupt hypotension in a pt who may be relatively hypovolumic and with a fetus who may be compromosed by palcental insufficiency. </li></ul><ul><li>Aternatively CSE used small dose of L/A in SA and option of utilizing the epidural as necessary. </li></ul>
  51. 55. General anaesthesia <ul><li>G/A may be necessary </li></ul><ul><li>Main concerns; </li></ul><ul><li>1.mucosal oedema of upper airway </li></ul><ul><li>2.severe hypertensive responses to laryngoscopy and surgery </li></ul><ul><li>3.pts on mgso4 may be very sensitive to effects of NDMRs </li></ul><ul><li>Difficult obstetric intubation trolley ready. </li></ul>
  52. 56. Feotal distress <ul><li>. </li></ul>
  53. 57. DEFINITION <ul><li>Foetal distress is defined as depletion of oxygen and accumulation of carbon dioxide,leading to a state of hypoxia and acidosis during intra uterine life. </li></ul>
  54. 58. causes <ul><li>During labor; umblical cord prolapse </li></ul><ul><li>umblical cord compression </li></ul><ul><li>[variable deceleration] </li></ul><ul><li>uteroplacental insufficency </li></ul><ul><li>[late deceleration] </li></ul><ul><li>At delivery; shoulder dystocia </li></ul>
  55. 59. management <ul><li>Change maternal position </li></ul><ul><li>Administer supplemental oxygen </li></ul><ul><li>Maintain/improve maternal circulation </li></ul><ul><li>Give a tocolytic for hypertonicity </li></ul><ul><li>Deliver ......forceps </li></ul><ul><li>C/S </li></ul>
  56. 60. CLASSIFICATION OF C/S ACCORDING TO URGENCY <ul><li>Catagory 1 .requiring immediate delivery [a threat to maternal and foetal life] </li></ul><ul><li>Catagory 2.requiring urgent delivery </li></ul><ul><li>[maternal and foetal compromise </li></ul><ul><li>that is not immediately life threatening] </li></ul><ul><li>Catagory 3.requiring early delivery </li></ul><ul><li>[no maternal or foetal compromise] </li></ul><ul><li>Catagory 4.elective delivery </li></ul><ul><li>[at a time suited to the women and maternity staff] </li></ul>
  57. 61. . <ul><li>Thank you </li></ul>