Obstetrical crisis in the PACU

1. Obstetrical crisis in the PACU Dr. Jagdeep Ubhi Royal Columbian Hospital

2. Outline • Gestational Hypertension • Postpartum Hemorrhage

4. Case One • 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

5. Hypertensive disorders of pregnancy (HDP) • 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

6. 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

8. Pre-eclampsia • 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

9. ETIOPATHOGENESIS • Placental implantation • Abnormal trophoblastic proliferation • Immunologic factors • Endothelial cell activation • Genetic factors

11. Abnormal trophoblastic invasion

12. Immunologic factors • 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

13. Endothelial cell activation • 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

14. Genetic factors • 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

15. pathogenesis • 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

16. Pathophysiology • Cardiovascular system • Hemodynamic changes • Blood volume changes • Blood and coagulation • Thrombocytopenia, Hemolysis, HELLP Syndrome • Kidney • Liver • Brain

21. Posterior reversible encephalopathy syndrome

22. Management • Termination of pregnancy • Birth of an infant • Restoration of health to the mother

23. Eclampsia • Tonic clonic convulsions • Immediate management • Protect airway • Short acting • Post ictal state • Visual changes • Magnesium sulfate

24. Magnesium sulfate • 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

25. Management of severe hypertension • 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

26. Fluid management • High risk for development of pulmonary edema • Fluid restrict to 80 mls/h • Tolerate oliguria and elevated creatinine

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

28. Summary of hypertension • 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

29. Postpartum Hemorrhage • 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

30. 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

31. Worldwide impact

32. 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

33. Postpartum hemorrhage • Definition • Loss of 500 mls of blood or more

35. Etiology • 4 T’s of PPH • Tone • Tissue • Trauma • Thrombin

37. Hemostasis at the placental site • 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

42. Uterine atony • 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

45. Definition • Placenta accreta is the abnormal attachment of chorionic villi to the myometrium • Absence of an intervening decidua basalis (Nitabuch’s layer) Miller DA, Chollett JA, Goodwin TM. Clinical risk factors for placenta previa–placenta accreta. Am J Obstet Gynecol 1997;177:210-4

46. Miller D et al, AJOG 1997 .

48. Increasing incidence? • Breen et al Obstet Gynecol 1977 - 1:7000 • Miller et al AJOG 1997 - 1:2500 • Wu et al AJOG 2005 - 1:533

49. 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

50. 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.