Anaesthetic management of obstetric emergencies

anaesthetic managment of obstetric emergencies

1. Dr sheeba hakak
Waterford regional hospital

2. Definition
Obstetrical emergencies are life-threatening
medical conditions that occur in pregnancy or
during or after labor and delivery.

3. .

4. Massive obstetric haemorrhage
1.MOH is a major cause of maternal death and morbidity
2.Variably defined as;
. blood loss >1500ml
. decrease in hb >4g/dl or
.acute transfusion requirements
>4 units
3. The gravid uterus receives up to 12% of cardiac output ,thus
OH can be un expected and rapidly become life
threatening.

5. Classification
Antepartum placenta previa/accreta
placental abruption
uterine rupture
Post partum uterine inversion
uterine atony
birth trauma or laceration

6. ANTEPARTUM HEMORRHAGE
Per vagina blood loss after 20 weeks’
gestation.
Complicates close to 4% of all pregnancies
and is a MEDICAL EMERGENCY!
Is one of the leading causes of antepartum
hospitalization, maternal morbidity, and
operative intervention.

7. Placenta Previa
Defined as a placenta implanted in the lower segment of
the uterus, presenting ahead of the leading pole of the
fetus.
eTotal placenta previa. The internal cervical os is covered
completely by placenta.
aPartial placenta previa. The internal os is partially covered by
placenta.
sMarginal placenta previa. The edge of the placenta is at the
margin of the internal os.
tLow-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

9. Placenta Previa
Incidence about 1 in 300
Perinatal morbidity and mortality are primarily
related to the complications of prematurity,
because the hemorrhage is maternal.

10. Etiology
Advancing maternal age
Multiparity
Multifetal gestations
Prior cesarean delivery
Smoking
Prior placenta previa

11. Placenta Previa
The most characteristic event in placenta
previa is painless hemorrhage.
This usually occurs near the end of or after
the second trimester.
The initial bleeding is rarely so profuse as to
prove fatal.
It usually ceases spontaneously, only to recur.

12. Placenta Previa
Placenta previa may be associated with
placenta accreta, placenta increta or percreta.
Coagulopathy is rare with placenta previa.

14. .
Diagnosis.
Placenta previa or abruption should always be suspected in
women with uterine bleeding during the latter half of pregnancy.
The possibility of placenta previa should not be dismissed until
appropriate evaluation, including sonography, has clearly proved
its absence.
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.

15. .
The simplest and safest method of placental
localization is provided by transabdominal
sonography.
Transvaginal ultrasonography has substantively
improved diagnostic accuracy of placenta previa.
MRI
At 18 weeks, 5-10% of placentas are low lying.
Most ‘migrate’ with development of the lower
uterine segment

16. Placenta Previa
Management
Admit to hospital
NO VAGINAL EXAMINATIONNO VAGINAL EXAMINATION
IV access
Placental localization

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

18. Anaesthetic management for
previa
Examine the airway in case emergency G/A is
required and provide aspiration prophylaxis
Ask OB about involvement with any previous
cesarean scar on ultrasound [risk of accreta]
Place two large bore IV lines and have
warmers available.
Assure that blood is type and cross matched.
What type of anaesthetic?

19. Anaesthetic management of
previa
A review of 514 women with placenta prtevia
found:
No difference between G/A or regional
anaesthesia in anaesthetic or operative
complications.
G/A was associated with increased EBL and
transfusions and decreased post op Hgb.
 Am J Obstet Gyn 1999;180:1432

20. Anaesthetic management for
previa
A retros pective review 350 consective cases of
plcenta previa [ 60% using regional anaesthesia,
40% using G/A found:
. decreased EBL with regional vs G/A
. decreased transfusion with regional.
. no diff in incidence of hypotension.
.two spinals were converted to G/A
secondry to c-hyst.
Br J Anaesth 2000;84;725

21. Interventional radiology
Prenatal diagnosis of palcenta
accreta/percreta is now becoming more
common[vs diagnosis at delivery]
Have a care conference in advance with
anaesthesiology ,OB,nursing and
interventional radiology present.

22. Placental Abruption
Defined as the premature separation of the
normally implanted placenta.
Occurs in 1-2% of all pregnancies
Perinatal mortality rate associated with
placental abruption was 119 per 1000 births
compared with 8.2 per 1000 for all others.

23. Placental Abruption
external hemorrhage
concealed hemorrhage
Total
Partial

24. Risk factors for abruption
Hypertension,chronic or pregnancy-induced
Age>35yrs
Multiparity
Smoking
Cocaine use
Abdominal trauma
Premature rupture of membranes
Hx of previous abruption

25. Diagnosis of abruption
Vaginal bleeding with abdominal pain
Uterine hypertonicity
Fetal distress
Retroplacental clot
The presentation can be quite variable and
difficult to diagnose

26. OB management of abruption
Evaluate maternal stability[vital
signs,coagulation studies]
Evaluate fetal well-being and maturity
If severe fetal distress and/or maternal
instability ...........urgent C/S
If stable mother and fetus......induction of
labor and vaginal delivery

27. Anaesthetic management of
abruption
Assure good IV access and availability.
Regional techniques are appropriate if
maternal volume staus and coags normal
If G/A is indicated,consider induction with
etomidate or ketamine
Have several oxytocics available for
treatment of uterine atony.

28. Uterine rupture
Risk factors for uterine rupture
Previous uterine surgery
Abdominal trauma
Uterine trauma
Grand multiparity
Fetal macrosomia
Fetal malposition

29. Diagnosis of uterine
rupture
Fetal distress
Cessation of uterine contraction [ in labor]
Vaginal bleeding
Abdominal pain

30. OB management of uterine
rupture
Uterine repair.
Hysterectomy
ANAESTHETIC MANAGEMENT
. Depends on ease of repair ,but be prepared
for G/A and volume replacement.

31. PPH
The mean blood loss in a vaginal delivery is 500 ml
& 1000 ml for cesarean section.
Definition:
Blood loss greater than 500 ml for vaginal and 1000 ml
for cesarean delivery.
However, clinical estimation of the amount of blood loss
is notoriously inaccurate.
Another proposed definition for PPH is a 10% drop in
haematocrit.

33. PPH Risk Factors

34. PPH Risk Factors

35. PPH Risk Factors

36. PREVENTION OF PPH
Although any woman can experience a PPH, the
presence of risk factors makes it more likely.
For women with such risk factors, consideration
should be given to extra precautions such as:
IV access
Coagulation studies
Crossmatching of blood
Anaesthesia backup
Referral to a tertiary centre

37. OB MANAGEMENT OF PPH
Bimanual uterine compression and massage
Infusion of oxytocin
Evaluation for retained placenta
Use of other oxytocics

39. ANAESTHETIC MANAGEMENT OF
PPH
1.Volume resuscitation
large bore IVs ,monitors,warmers
3.Analgesia
pre existing epidural,ketamine,G/A
5.Oxytocics
6.Move to OT sooner rather than later.
7.Consider notifying interventional radiology.

40. Oxytocic drugs
Drug/dose
Oxytocin 20-80u/l


Methergine 0.2mg IM

Hemabate ..prostagladin
F2alpha 250 mcg IM
Side effects
vasodialation with IV
bolus,hyponatremia
Diffuse
vasoconstriction,pulmon
ary and systemic
htn,coronary
vasospasm,nausea
Broncho spasm,pul
htn,hypoxia,nausea,diarr
hoea.

41. PRE ECLAMPSIA
.

42. Definitions of Hypertensive
Disorders in Pregnancy [1,2,4,5]
Preeclampsia
Blood pressure elevation

with proteinuria
Occurs after 20 weeks of gestation
Proteinuria
urinary excretion of 300 mg or

greater of protein in
24 hr
Edema no longer

diagnostic for poor specificity
Eclampsia
seizures

43. Definitions of Hypertensive
Disorders in Pregnancy [1,2,4,9]
HELLP syndrome
defined by the presence

of all 3 criteria:
Hemolysis (abnormal peripheral smear,
bilirubin

1.2 mg/dL [20.5 µmol/L], or lactate
dehydrogenase 600 IU/L)
Elevated liver enzymes (aspartate
aminotransferase 2 x normal)

Thrombocytopenia (platelets <100 x 10
3
/µL)

44. Aetiology
Exact aetiology unknown
Possible causes
1. widespread endothelial dysfunction
leading to placental ischemia and multi organ
dysfunction
2. synthesis of many substances like NO
and PGI2 may be decreased in pre
ecclampsia which leads to smooth muscle
reactivity and platelet adhesion

45. Complications
Neurological
Headache
Visual disturbances
Hyperexcitability
Seizures
Intracranial hemorrhage
Cerebral edema
Pulmonary
Upper airway edema
Pulmonary edema
Cardiovascular
Decreased intravascular volume
Increased arteriolar resistance
Hypertension
Heart failure

46. Complications
Hepatic
Impaired function
Elevated enzymes
Hematoma
Rupture
Renal
Proteinuria
Sodium retention
Decreased glomerular filtration
Renal failure
Hematological
Coagulopathy
 Thrombocytopenia
 Platelet dysfunction
 Prolonged partial thromboplastin time
Microangiopathic hemolysis

47. Risk Factors [10]
Obesity
Black race
Chronic hypertension

Diabetes or insulin resistance
Collagen vascular disease
Thrombophilias
Increased circulating testosterone
Multiple

gestation
Previous preeclampsia

48. Management
Definitive treatment of preeclampsia is delivery
Whether or not to deliver the fetus
gestational age
maternal and fetal condition
severity of preeclampsia
Patients at term  delivered
Remote from term  Conservative approach
Delivery at any gestational age
Maternal end-organ dysfunction
Nonreassuring tests of fetal well-being

49. .

50. Mgso4
Anticonvulsant of choice in preventing and
treating fits.
Iv bolus 4 to 6 gms and then
Infusion 1 to 2 gms/hr to keep sr mg in
therapeutic range [2-3 mmol/lt]
Indicators of mgso4 toxicity......
 ECG changes [3-5mmol/lt]
 loss of deep TR [5 mmlol/lt]
 resp dep [6-7.5 mmol/lt]
 cardiac arrest [12 mmol/lt]

51. Anaesthetic considerations
Pre anaesthetic assessment
2Fluid balance and hemodynamics
.hypo albuminaemia,increased cap
permeability,high hydrostatic pressure leads to
risk of pul and pharyngolaryngeal oedema
2. Estimation of cardiac out put ......if
.....oliguria ,pul oedema,htn resistant to initial
therapy.
Coagulation
Assessment of coag status is essential
before reg anaesthesia .

52. Epidural analgesia
Early epidural is an ideal form of pain relief in
preceelamptic pts.
It helps to control the exaggerated
hypertensive response to pain and can
improve placental blood flow.
A functioning epidural may safely be etended
for C/S.

53. Anaesthesia for c/s
Regional vs G/A
1 Avoidance of hypertensive response to
laryngoscopy [more in preecclamptics]
3Blunting of neuro endocrine response to
surgery
4Prevention of transient neonatal depression
associated vth G/A.

54. Spinal vs epidural
Advantages
1. quicker and more reliable in on set
2. less potential trauma in the epidural space.
Dis advantages
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.
Aternatively CSE used .....giving small dose
of L/A in SA and option of utilizing the
epidural as necessary.

55. General anaesthesia
G/A may be necessary
Main concerns;
1.mucosal oedema of upper airway
2.severe hypertensive responses to
laryngoscopy and surgery
3.pts on mgso4 may be very sensitive to
effects of NDMRs
Difficult obstetric intubation trolley ready.

56. Feotal distress
.

57. DEFINITION
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.

58. causes
During labor; umblical cord prolapse
 umblical cord compression

 [variable deceleration]
 uteroplacental insufficency
 [late deceleration]
At delivery; shoulder dystocia

59. management
Change maternal position
Administer supplemental oxygen
Maintain/improve maternal circulation
Give a tocolytic for hypertonicity
Deliver ......forceps
 C/S

60. CLASSIFICATION OF C/S
ACCORDING TO URGENCY
Catagory 1 .requiring immediate delivery
[a threat to maternal and foetal life]
Catagory 2.requiring urgent delivery
[maternal and foetal compromise
that is not immediately life threatening]
Catagory 3.requiring early delivery
[no maternal or foetal compromise]
Catagory 4.elective delivery
[at a time suited to the women and maternity
staff]

61. .
Thank you