Intrapartum

Medical Emergencies
Raymond O. Powrie, MD
Professor, Medicine and Obstetrics & Gynecology
Alpert School of Medicine at Brown University
Care New England Chief Medical Quality Officer
The Big Five
The Big Four
• Hypoxia
• Hypotension
• Change in
Neurologic
Status
• Arrhythmias
Hypotension
 HYPOTENSION

Sinus Abnormal
Rhythm Rhythm

FLUID BOLUSES
Hypoxia Signs of Medication
Hypoxia Other Call
with Infection Bleeding Effects
Bleeding
Get a CXR a Code

Amniotic Pneumo-
Sepsis Tamponade thorax
Hemorrhage Fluid
Embolism
protocol Narrow Pulse Assymetric
Pressure Breath sounds
Change in Neuro Status
 Change in
mental status

Ensure Airway is protected

IV Magnesium Load if >20 weeks
Assess for PIH Check Na K Ca Mg CBC
Check glucose and consider D50W
Neuroimaging Urgently
Drug screen and consider naloxone
(Consider pseudoseizures /conversion)

Evidence of PIH and

Infarct or
Normal Head CT or changes No evidence PIH
bleed on head CT
consistent with edema from PIH

Early involvement of Continued Mg Urgent neurology

Neurosurgery (bleed) and Delivery
Neurology (infarction) Keep BP <160/100 consultation
but not <140/90
Abnormal Rhythm
 Worrisome
Tachycardia

Unstable
Stable Pulseless
with Pulse

Immediate 200 J biphasic or

Get an EKG and
Synchronized 300 J monophasic
a Cardiologist
Cardioversion Immediate CPR

Probable SVT Possible VT

Adenosine iv Amiodarone
PUSH 6 MG 150 mg IV
 Intrapartum
Respiratory
Emergencies
Dyspnea and Hypoxia
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
 Establish adequate
oxygen delivery
• Oxygen delivery
– Nasal prongs
• 1 lpm = 24% FiO2 with each additional lpm
increasing it by 4%
• Maximum flow rate 5 LPM (40% FiO2)
– Venturi mask
• FiO2 24%, 28%, 31%, 35%, 40%, 50%.
– Non re-breather mask
• Up to 80-90% FiO2
– Non-invasive positive pressure ventilation
• CPAP and BiPAP
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
Endotracheal Intubation

• Get the most experienced hand

available and involve them early
– the incidence of failed ELECTIVE
intubation in pregnancy is 1 in 250
cases (95% CI 187-370)
• ~10 times that for non-pregnant
patients
• often emergencies, off hours and
trainees
• a decreasing but still significant
cause of maternal mortality
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
Causes of Pregnancy Associated
Pulmonary Edema
Siscione AC et al. Obstet Gynecol 2003 (n=51)
infection
4%
other
3%
PIH tocolytic
18% 27%

fluid
overload cardiac
22% 26%
 Pulmonary Edema

• Consider pulmonary edema secondary to

tocolytics, infection, or pre-eclampsia and
look carefully for the latter two
– Discontinue any tocolytics
– Watch temp, consider blood and urine cultures
– Check PIH labs… and while you are at it get a
DIC screen (INR, PTT, FDP and fibrinogen)
– Review and minimize fluids unless
hemodynamically unstable
– Follow urine output
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
New or previously occult
cardiac disease is an
increasingly important cause
of morbidity and mortality in
pregnancy
Cardiac causes (per million maternities) UK
maternal mortality 1952-2002

60 Total cardiac

Congenital
50
Pulmonary
hypertension
40
Ischaemic

30 Rheumatic

20

10

0
1954 1960 1966 1972 1978 1984 1990 1996 2002
• To diagnose it you have to think of it
• Be suspicious of dyspnea with cough
or orthopnea, especially if a woman
is not doing things she normally
might because of them
• Measure pulse and respiratory rate
and get an EKG
Be willing to get some normal
echocardiograms
Order a serum troponin

Myocardial infarctions happen

rarely in women with no
identified cardiac risk factors.
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
 Pulmonary Embolism

Pulmonary embolism is the number

one preventable killer of pregnant
women in the US

To diagnose it, you have to think of it

and investigate for it
Testing for Pulmonary Embolism
in Pregnancy
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history or present features
to suggest pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen
 Acute Treatment of Asthma

• Short acting bronchodilator by inhaler or

nebulizer Q20 minutes X 3
Albuterol/ipratropium combination by neb
• Oxygen administered to get O2 saturation
>95%
• Oral or systemic steroids if patient does
not respond immediately or has been on
steroids recently
Methylprednisolone 110 mg IV
 Empiric antibiotic regimens for community
acquired pneumonia in pregnancy

• Start with
– ceftriaxone 2 g IV once daily with erythromycin 500
mg IV every six hours
• azithromycin 500 mg IV daily may be used as an alternative to
erythromycin if erythromycin is poorly tolerated
• Once patient is afebrile and stable switch to
– erythromycin 250-500 mg PO QID with cefuroxime
axetil 500 mg PO BID for a total antibiotic course of
14 days
• if patient has been treated with azithromycin instead of
erythromycin, this antibiotic can be administered for a 5 day
course only
 Acute management
• Provide adequate oxygenation and check ABG
• Make sure you are ready for intubation
• Get a Chest X-ray
• Consider pulmonary edema secondary to
tocolytics, infection, or pre-eclampsia and look
carefully for the latter two
• Examine patient for evidence of cardiac disease
• Consider diagnostic imaging for diagnosis of
pulmonary embolism
• Consider aspiration if recent meal or sedation
• Look for antecedent history to suggest
pneumonia, asthma
• Review medications and recent transfusions
• Obtain a drug screen