Obstetric Emergencies Postpartum Hemorrhage and Hypertension Annelee Boyle
Obstetric Emergencies Postpartum Hemorrhage and Hypertension Annelee Boyle, MD, FACOG Assistant Professor Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine University of Virginia School of Medicine
Disclosures
Pregnancy-related mortality in the United States: 1987 -2010 Source: CDC Pregnancy Mortality Surveillance System
Obstetrics and Gynecology, May 2014
Causes of pregnancy-related death in the United States: 2006 -2010 Source: CDC Pregnancy Mortality Surveillance System
Maternal mortality is only the tip of the iceberg
Obstetrics and Gynecology, February 2012
Postpartum Hemorrhage • 93% of deaths preventable! – • Berg et al. Preventability of pregnancy related deaths: results of a statewide review. Obstet Gynecol 2005; 106: 1228 -34. Common mistakes: – Under-recognition of blood loss – Under-recognition of hypovolemia – Failure to act decisively – Failure to restore blood volume
Recognize the extent of blood loss Dildy et al, Estimating Blood Loss: Can Teaching Significantly Improve Visual Estimation? Obstetrics & Gynecology. 104(3): 601 -606, September 2004.
Recognize the extent of hypovolemia EBL in ml Class 1 < 750 ml Class 2 Class 3 750 -1500 ml 15002000 ml EBL in % Vol. <15% 15 -30% 30 -40% Pulse <100 >120 BP Normal or ↑ ↓ ↓ RR 14 -20 20 -30 30 -40 UOP >30 ml/h 20 -30 ml/h 5 -15 ml/h Mental Slightly Mildly Anxious, State anxious confused Class 4 >2000 ml >40% >140 ↓ >35 negligible Confused, lethargic
Obstetrics and Gynecology, May 2014
Early warning signs • • Systolic BP <90 or >160 Diastolic BP >100 Heart Rate <50 or >120 Resp Rate <10 or >30 Oxygen Sat <95% on room air Urine output <35 ml/hr for 2 hours Agitation, confusion, or unresponsiveness Shortness of breath or a non-remitting headache in a patient with pre-eclampsia – Mhyre et al. The maternal early warning criteria: a proposal from the national partnership for maternal safety. Obstet Gynecol 2014; 124: 782 -6.
Act decisively/Restore blood volume
Post-Partum Hemorrhage • Rule number one: Postpartum Hemorrhage is a definition, not a diagnosis!
Pearls for Atony • Actively manage third stage of labor
Pearls for Atony • Consider additional utero-tonics for those at highest risk of PPH
Pearls for Lacerations • Have a low threshold for going to the OR for repair.
Risk of accreta in the setting of placenta previa by number of prior cesareans 80% 70% 60% 50% 40% 30% 20% 10% 0% No prior CD 1 2 3 4 or more
Source: California Maternal Quality Care Collaborative
Preelcampsia • 60% of deaths are preventable! – • Berg et al. Preventability of pregnancy related deaths: results of a statewide review. Obstet Gynecol 2005; 106: 1228 -34. Common mistakes: – Failure to adequately control blood pressure – Failure to recognize HELLP syndrome – Failure to diagnose and treat pulmonary edema
Early warning signs • • Systolic BP <90 or >160 Diastolic BP >100 Heart Rate <50 or >120 Resp Rate <10 or >30 Oxygen Sat <95% on room air Urine output <35 ml/hr for 2 hours Agitation, confusion, or unresponsiveness Shortness of breath or a non-remitting headache in a patient with pre-eclampsia – Mhyre et al. The maternal early warning criteria: a proposal from the national partnership for maternal safety. Obstet Gynecol 2014; 124: 782 -6.
Control Blood Pressure
Control Blood Pressure
Hi Annelee. Hope you’re doing well and liking your new job. It’s 10: 30 pm here and for me, that’s the middle of the night so rather than be friendly and “chat”, I’m going to get straight to the point – it’s business… So our hospital protocol essentially regurgitates ACOG, but it doesn’t specify that it is for use only with preeclamptic/eclampic patients. Would you use it for someone with chronic HTN also, barring known renal disease or other cause of the HTN? Thanks! Love, Aunt Crunchy
Recognize HELLP Syndrome
The most important paper on HTN in pregnancy in the last year
Severe Features of Preeclampsia • • SBP >160 DBP >110 Platelets < 100, 000) LFTs >2 x normal Creatinine > 1. 1 Pulmonary edema New-onset cerebral or visual disturbances Right upper quadrant pain American College of Obstetricians and Gynecologists. Hypertension in pregnancy: executive summary. Obstet Gynecol 2013; 122: 1122– 31.
Recognize and treat pulmonary edema
The UVA way (or maybe it was UNC) “If you’re going down take everybody else with you. ” – Susan Modesitt, Gyn Oncologist
David Barker 1938 -2013
The Barker Hypothesis The Thrifty Phenotype Fetal Origins Hypothesis
Intrauterine Growth Restriction
30 years from now
Thank you!!!
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