Obstetric Emergencies respect to my current presentation. William - PowerPoint PPT Presentation

� I have no financial conflicts of interest with Obstetric Emergencies respect to my current presentation. William M. Gilbert, MD Regional Medical Director, Women’s Services Sutter Health Valley Region & Clinical Professor OB/GYN University of California, Davis Introduction Case report # 1 � 25 year old G1 women at 37 weeks goes to ED � Update on Obstetrical Emergencies for: � Increasing Maternal Mortality rates � Whole body swelling for 1-2 weeks � Headache for 3 days � Most common � Mid-epigastric pain x 2 days � Hemorrhage, Hypertension, Sepsis � In ED: � Rare Obstetrical Emergencies � Blood pressure 160/100 � Life threatening due to rarity � 3 + proteinuria, CBC and LFTs are normal � What can we do to prepare � Given a GI cocktail � Told to follow up with OB/GYN in the next week

Case report # 1 Case report # 1 � 3 days later: � Massive failure on multiple levels: � Seizure at home. Taken to OB hospital with Dx of � ED missed the Dx of preeclampsia Eclampsia � Patient uneducated on S/S of preeclampsia � Recurrent seizures starting MgSO4 � Did not contact OB provider � CVA occurs � Did not follow up with OB provider � Much more common in the postpartum period � Post Op day 2: � Patient presents to ED with headache � Mother died � ED doesn’t know she is postpartum Maternal Mortality Rate, California Residents; 1970-2010 25 ICD-10 ICD-8 ICD-9 21 codes codes codes Maternal Deaths per 100,000 Live Births 20 18 17 16 16 15 15 14 15 15 13 11 11 12 11 10 10 10 12 11 12 10 9 11 11 11 10 9 10 9 8 10 8 9 9 7 8 8 7 5 6 6 6 6 HP Objectives – Maternal Deaths (<42days postpartum) per 100,000 Live Births 0 1970 1975 1980 1985 1990 1995 2000 2005 2010 SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1970-2010. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using the ICD-8 cause of death classification for 1970-1978, ICD-9 classification for 1979-1998 and ICD-10 classification for 1999-2010. Healthy People Objectives: HP2000: 5.0 deaths per 100,000 live births; HP2010: 3.3 deaths, later revised to 4.3 deaths per 100,000 live births, and; HP2020: 11.4 deaths per 100,000 live births. Produced by California 5 Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, December, 2012.

Question #1 What is the leading cause of Maternal mortality according to the CA-PAMR Report? 49% A. Hypertensive disorders of 39% pregnancy B. Obstetrical hemorrhage C. Sepsis/infection 12% D. Maternal Cardiac disease 1% n e e o g i s . . a t a . c e h e f r s o r f d i o n s i c r m / e s a d e i i h s d o r p r l e a s a C i c S d i l r a e t v e n i t r s s e n b t a e O t M r e p y H

Training in Obstetrical Emergencies � History of well intended biologically plausible interventions which turned out to be wrong � X-Ray pelvimetry to Dx pre-labor CPD � High dose Vitamin C and E to prevent preeclampsia � Robust data shows: � Some training helpful � Others detrimental to outcome � One reports show a worsening fund of knowledge at 6 weeks with loss of confidence � Effective training is not cheap but can be cost effective

Training in Obstetrical Emergencies Rare Obstetrical Emergencies � Evidence for effective and sustainable training � Often seen once in a life time does show: � Untreated – can have a high maternal mortality � Local unit based and multi-professional training rate � Use of Mannequins and practice based tools � If diagnosed – Survival markedly improved � Much Research is still needed � Why different programs are associated with different outcomes � Data to harness financial support Case Report # 2 Case Report # 2 � 31 y.o. female G2 P 1001 prior C/S � POD # 4 � 36 weeks with Severe PIH, Repeat C/S � The patient continues to feel fine without � BP 160/100, 3+ proteinuria any S/S of severe preeclampsia. � Underwent Repeat C/S with cystotomy � Platelet count 18 K � POD # 3 � POD #5 � BP 135/86 � The patient’s pl ct 13 K without S/S of severe � Patient wants to go home preeclampsia � Blood tinged urine � Pl ct 38K, Repeat 18 K � Platelet transfusion - 40K pl ct

Question # 2 Case Report # 2 Diagnosis? � POD #6 � CNS changes, the patient becomes confused. A. Severe Preeclampsia 47% � The patient develops shortness of breath, B. Immune thrombocytopenia (ITP) 35% Cardio-respiratory distress C. Thrombotic thrombocytopenia purpura � Question of pulmonary embolism (TTP) 17% � Sent to Radiology for a VQ scan D. Systemic Lupus Erythematosus (SLE) Flare � Patient Died 1% a s i . . . . . . p . n s m a o e a n i p t a l e o m c t e p y e o e c h r t o P y b t c y e o m r r E b o e m s v r u e h o t p S r u h c i L t t o c e i n b m m u e m o t m r s h y S I T Thrombotic Thrombocytopenia TTP Purpura (TTP) � Severe multisystem disease. � Mortality rate in past 90% � Similar to severe preeclampsia � Etiology: � Diagnosis � Severe Acquired ADAMTS13 deficiency � Micro angiopathic hemolytic anemia � Inherited ADAMTS13 deficiency � Thrombocytopenia 5-100K � Cleaves large VWF molecules � Fever most cases � Blocked by IGG auto antibodies � CNS abnormalities: Confusion, delirium, coma, � Peak incidence age 20 - 40 yrs seizures, hemiparesis, aphasia, and visual field changes � More Common in women � Occur in over 90% of cases with mortality � Renal dysfunction

TTP TTP � Associated with no illness or � Treatment � Infections � No randomized controlled studies � Pregnancy, 10-25 % of cases � Corticosteroids � Autoimmune disease, 10 % SLE, + ANA 20% of � Splenectomy time � Plasma-pheresis, Plasma infusions � Surgery, Hysterectomy, Chole, C/S, � With Treatment Survival as high as 90% � Angiograms � CNS changes most sensitive to treatment � Past history increase risk of relapse � LDH sensitive indicator to disease activity � 7.5%, 84% within 1 month � Platelet count, renal f(x) slow to recover Future pregnancies Future pregnancies � Jiang Y et al 2014 Pregnancy Outcomes � Inherited ADAMTS13 deficiency following recovery from acquired TTP � Invariably get TTP in pregnancy � Require plasma transfusion, immunosuppressive � Oklahoma TTP-HUS Registry 1995 – 2012 medications or Plasma-pheresis � 10 women had 16 pregnancies 1999-2013 � Severe acquired ADAMTS13 deficiency � 2 recurrent TTP post partum � Measurement of ADAMTS13 activity in severe � 5 of 16 (31%) had preeclampsia acquired ADAMTS 13 deficiency. � 13 of 16 normal pregnancies (81%) � May be helpful for following disease � Re-occurrence of TTP uncommon but increase in preeclampsia

Question # 3 Case Report # 3 Diagnosis in Case # 3? � 24 year old G2 P1001 at term in labor 88% � Normal first delivery and this pregnancy A. High spinal � Epidural with bolus given at 9 cm B. Amniotic fluid embolism � While pushing suddenly sits up and passes out. C. Eclamptic Seizure � Unresponsive – “Code Blue” called 12% � Anesthesia intubated patient 0% � OB/GYN performed a forceps delivery l a e m n r i u p s i z s l i o e h S b g m i c H i e t p d m i u l a f l c c E t i o i n m A Case Report # 3 Amniotic Fluid Embolism � Despite rapid intubation and ICU � Historically close to 100% mortality management � Intrapartum or Postpartum � Sudden onset hemodynamic collapse � DIC and cardiac failure develops � Hypoxia, hypotension, DIC, Fetal distress � The patient is transfused multiple units of � Mechanisms blood products. � Amniotic fluid, fetal cells enter maternal sinuses � Patient recovers but in ICU for 3 weeks � Pulmonary embolism, vasospasm � Hypoxia, Heart failure � DIC, tissue factor

Amniotic Fluid Embolism Amniotic Fluid Embolism � Treatment � May 2017 Green Journal: What is new in AFE? � Oxygen � Intubation � IGF binding protein -1 increased � IV fluids and blood products � Only effective test for AFE � ICU setting � Cases without CV collapse � Outcome � 3 case reports of DIC requiring multiple � Prior outcome 60-80% maternal mortality transfusions and hysterectomy � Significant morbidity, but decreasing � 1:1 transfusion with FFP to PRBCs � Recent data 15-25% mortality � < 1:1 40% survival � 1:1 90% survival References Summary • www.CMQCC.org � Maternal Mortality is increasing nationwide: • Draycott TJ. Myths and realities of training in obstetrical emergencies. Best Practices and Research in clinical � Many/most related to Obstetrical Emergencies obstetrics and gynecology. 2015 29(8) 1067-76. � Hypertension, Hemorrhage, AFE • Gilbert et al. Amniotic Fluid Embolism: Decreased Mortality � Many toolkits are available to prepare us for in a population-Based Study. O&G 93:973-7, 1999. when they might occur. • Benson MD. What is new in AFE? O&G 2017 � When training, must make sure effective and • Clark et al. Amniotic fluid embolism: Analysis of the national registry. Am J O&G 172:1158-69, 1995. beneficial. • Lockwood et al. Amniotic fluid contains tissue factor, a � Rare obstetrical emergencies may be missed if potent initiator of coagulation. Am J O&G 165:1335-41, 1991. not identified.