Management of Obstetric

Emergencies
Brendan “Dan” Connealy, MD FACOG
Methodist Perinatal Associates
Methodist Women’s Hospital, Omaha NE
 Learning Objectives
• Hypertensive Emergencies in Pregnancy
– Clinical update on current management guidelines
and diagnostic criteria
– How to approach the severe hypertensive patient
• Obstetric Hemorrhage
– Clinical update on current management guidelines
– Discuss the approach to the massive hemorrhage
patient
 Learning Objectives
• Patient Safety Bundles – Alliance for
Innovation on Maternal Health (AIM)
– What are patient safety bundles and how can they
improve outcomes for our patients
– Review the AIM supported patient safety bundles
for severe hypertension in pregnancy and
obstetric hemorrhage
– Discuss our experience instituting patient safety
bundles for severe hypertension
• November 2013 - ACOG
 Types of Hypertension
Chronic Hypertension • SBP >140 or DBP >90
• Pre-pregnancy or <20 weeks

Gestational Hypertension • SBP >140 or DBP >90

• >20 weeks
• Absence of proteinuria or severe
symptoms
Preeclampsia • SBP >140 or DBP >90
• Presence of proteinuria
• Severe signs/symptoms in absence of
proteinuria
• Proteinuria no longer required criteria

Chronic Hypertension + superimposed • Sudden increase in controlled BP

preeclampsia • New onset proteinuria
• Severe signs/symptoms of
preeclampsia
Preeclampsia with Severe Features

• Proteinuria no longer qualifies as a severe feature

 Surveillance and Obstetric Management

• Preeclampsia without severe features

– Less than 37 weeks
• Weekly labs, antenatal testing, BP checks, fetal growth
– At or beyond 37 weeks
• Delivery
• Additional key recommendations:
– Anti-hypertensive medications not indicated
– Universal magnesium sulfate not necessary to prevent
eclampsia in those without severe features or symptoms

** Quality of evidence lower than for those listed above **

 Surveillance and Obstetric Management

• Preeclampsia with severe features

– Any GA with unstable fetal or maternal conditions
• Delivery
– At or beyond 34 weeks EGA
• Delivery
– Less than 34 weeks – see below
• Magnesium sulfate for eclampsia prophylaxis
• Delivery route by obstetric indications
• Treat with anti-hypertensives for BP >160/110
 Managing severe disease at <34wks
“You got to know when to hold’
em,
Know when to fold ’em,
Know when to walk away,
Know when to run.”
Kenny Rogers - Gambler
 Early (<34wks) Severe Preeclampsia
Management
• Previable PreE with with severe features/HELLP–
FOLD’ EM
• Viability – 33 6/7 weeks
– Stable fetal and maternal condition – HOLD’ EM
• Expectant management - Appropriate facility
• Corticosteroids
• Weekly surveillance (labs, fetal testing, growth)
• Viable – 33 6/7 weeks
– Unstable fetal or maternal condition – FOLD’ EM
• Stabilize while giving steroids but don’t delay delivery
 Postpartum Preeclampsia
• Difficult to diagnose – requires index of suspicion
• Prevalence 1-27% depending on study
• Differential should include other life-threatening
conditions
– CVA
– HELLP
– TTP/HUS
• May present with seizures
– Assume eclampsia but image to rule out other etiologies
Hypertensive Emergency Management

• Goals of therapy
– Control severe hypertension
– Stabilize the patient, initiate diagnostic tests
– Prevent recurrent hypertension
– Seizure prophylaxis
– Monitor fetal and maternal status
 Hypertensive Emergency

ACOG Committee Opinion #692; April 2017

 Hypertensive Emergency
• Oral nifedipine or labetalol effective if no IV
• Common side effects associated with medications
– Hydralazine – maternal hypotension, flushing,
tachycardia
– Labetalol – avoid in asthmatics, heart failure,
bradyarrhythmia
• Failure of initial acute therapy
– Consult anesthesia/MFM/ICU
– Continuous infusion medications – labetalol,
nicardipine
 AJOG July 2016

• Severe intrapartum
HTN associated with
increased risk for
severe maternal
morbidity
 Risk Factors for Eclampsia
 Previous eclampsia
 Multifetal gestation
 Chronic hypertension/renal disease
 Collagen vascular disease
 Molar pregnancy/partial mole
 Gestational hypertension-preeclampsia plus
• Severe headache
• Persistent visual changes
• Severe epigastric/right upper quadrant pain
• Altered mental status
 When does it occur?
%
Antepartum 38 - 53
Intrapartum 18 - 36
Postpartum 11 - 44
≤ 48 hours 7 - 39
> 48 hours 5 - 26

Summary of 5 series
 Signs and Symptoms
%
Headache 30-70
Visual Changes 19-32
RUQ/epigastric pain 12-20
Altered mental changes 4-5
At least one of the above 33-75
Hypertension 85
Proteinuria 85
*Summary of 5 series
Steps in Managing Eclampsia

Supplemental 02
Step 1: Prevent maternal hypoxia by supporting
Pulse oximetry
respiratory and cardiovascular function ABG if acidemia

Mouth guard
Step 2: Prevent maternal injury and aspiration Bed padding
Suction

1. MgSO4 – 6g
Step 3: Do not try to arrest the first seizure bolus then 2g/hr
2. Re-bolus 2g if
persist
3. Sodium
Pentobarb 250mg
Step 4: Prevent subsequent seizures from recurring IV if persist
 Steps in Managing Eclampsia

Reference
Step 5: Control severe hypertension to prevent previously
cerebrovascular injury mentioned
alorithms

Step 6: Manage complication such as DIC, Pulmonary

Edema

Step 7: Begin induction/delivery within 24 hours

 Obstetric Hemorrhage
• Hemorrhage incidence - 4-6%
– SVD >500ml
– Cesarean >1000ml

• Life threatening obstetric hemorrhage 1:1000

• Second most common cause of maternal mortality in

the US
– 0.9/100,000
– Most are considered preventable

ACOG Practice Bulletin 76

Drife J. BJOG (1997) 104:275–7
CDC; NVSR, V 58:19, May 2010, tables 33 and 34
 Obstetric Hemorrhage
93% of deaths due to hemorrhage are
considered preventable on review.

Primarily due to delay in treatment.

Delay is due to lack of recognition and

poor/inadequate communication
 Etiology
• Atony
• Lacerations
• Abruption
• Retained placenta
– Accreta/Percreta
• Uterine rupture
• Hematoma
 Hemorrhage Management
• Activate response team
– Nurses, Physicians, OR staff, Lab, Blood bank
• Important initial steps
– IV access
– Hemorrhage cart/medications
– Lab studies
– Diagnosis – etiology of the bleed
• Massive transfusion protocol (if you have one)
 Atony Management
• Bimanual massage

• Drain the bladder

• Uterotonics
– Oxytocin
– Carboprost (up to 4 doses 15 min apart)
• Avoid in asthmatics
– Methylergonovine (up to 4 doses 2-4 hours apart)
• Avoid in severe hypertension
– Misoprostol (800-1000 mcg)
• 800 mcg Buccal or Rectal - Delayed absorption – give
early in rescusitation
 Tamponade Balloon
• Placement, duration, antibiotics
– Ultrasound guidance
– Vaginal packing
– Antibiotic usage
– Duration of usage
– “Tamponade Test” – pressure
(volume) at which the bleeding
stops
• Georgiou et al – Tamponade
pressure is not > systolic
pressure
– Best for lower uterine segment
atony
When conservative measures fail
 Surgical Treatment

• Retained placenta
– Manual or sharp curettage
• Persistent atony
– Laparotomy
• B-lynch sutures
• O’ Leary sutures
• Additional devascularization
– Hysterectomy
• Delayed decision  increased
morbidity
 Hysterectomy
• Subtotal hysterectomy vs Total hysterectomy
– More rapid completion – emergency situations
– Less beneficial if lower segment (previa) bleeding
• Consider pre-hysterectomy vascular ligation or occlusion

Wright, Obstet Gynecol, 2010 115;6, 1187-1193

 Additional Measures
• Tranexamic Acid
• Recombinant Factor VII
• Cell salvage
• Interventional radiology
 Product Replacement
• Platelets – single vs pooled donor
– Unit – 50 ml – increase plts 7500
• Most come in 6-10 unit packs
• Clotting factors (Cryoprecipitate & FFP)
– FFP
• All plasma proteins and factors
• Volume 250 ml – must be thawed (20-30 min)
• Increase fibrinogen 10-15 mg/dL
– Cryoprecipitate
• Factor VIII, XIII, Fibrinogen, vWF
• Volume 40 ml – increase fibrinogen 10 – 15 mg/dL
• PRBC’s (ABO, Rh, additional Ab)
 Fluid and Product Administration
• Early administration of clotting factors is key
– Borgmann et al 2007
• Combat support hospital
• 1:1 or 1:2 ratio of FFP to PRBC’s
– Decreased mortality
– Sperry et al 2008
• 1:1.5 ratio = 52% lower mortality compared to lower ratios
• Goal is avoid the “bloody vicious cycle”
– Keep warm
Coagulopathy
• Bear hugger, Level 1 tranfuser
– Maintain perfusion
• Transfusion/replacement
– Correct coagulopathy

Acidosis Hypothermia
Pacheco et al, Am J Obstet Gynecol Dec 2011
 Post Hemorrhage Management
• Laboratory values will frequently fluctuate
– Trends are important
– Vital signs are critical
– Calcium replacement

• Maintain uterine tone

• Re-dose antibiotics

• Consider ICU admission if there is significant hemorrhage,

product replacement or medical comorbidities
AIM
 What is AIM?
• “National data-driven maternal safety and
quality improvement initiative”
• “Proven approaches to improvement of
maternal safety and outcomes in the U.S.”
• “Eliminate preventable maternal mortality and
severe morbidity”
Who Is AIM
AIM – Safety Bundles
 AIM – Safety Bundles
• Readiness
• Recognition/Prevention
• Response
• Reporting/Systems Learning
Severe Hypertension in Pregnancy
Severe Hypertension in Pregnancy
Obstetric Hemorrhage
Toolkits are Readily Available
“No need to reinvent the wheel”
 Our Experience
• Safe healthcare for every woman
• 3 Bundles implemented in past 3 years
– Maternal early warning signs
– Hemorrhage
– Hypertension
 Maternal Early Warning Signs

• Criteria may be individualized by institution

• Above list may not be considered comprehensive
 Maternal Early Warning Signs
• Step 1: Immediate action criteria met
• Step 2: Attending or in-house physician will evaluate
patient within 10 minutes
• Step 3: Physician documents evaluation and
immediate care plan (Huddle)
• Step 4: If MEWS criteria persists despite corrective
measures – Consultation with MFM/Intensivist/Rapid
Response
• Step 5: Advanced measures, labs, treatments
Our Experience
Our Experience
Our Experience
Our Experience
Our Experience
 Management Plans
• Stage 0 – Everyone
• Stage 1 – Initial response
to hemorrhage
• Stage 2 – Continued and
escalated response to
persistent hemorrhage
• Stage 3 – Severe
hemorrhage with/without
coagulopathy
 Challenges
• Nebraska – rural state – ½ of population is
located in a single metropolitan area
• Several low volume delivery centers (<50
babies/year)
• Critical access to care
• Differing levels of obstetric care
 Challenges

• 16/50 have obstetricians performing deliveries

• 7/50 have access to MFM
 Plan to improve outcomes
• Hospital based approaches supported by
statewide collaborative
• Rural Outreach
– Establish referral networks – Levels of care
• Provider education
– Didactic
– Simulation training
• Implementation of protocols
• Data collection and review
“Checklists, when designed well, implemented
thoughtfully, and monitored closely, offer the
opportunity for health care providers to not simply be
satisfied with doing most of the right things for most
the patients most of the time…..Checklists are tools that
can help standardize care, improve communication, and
assist teams in optimizing their performance”
Thank You