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Case Conference: Respiratory Failure in Term Pregnancy

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42yo woman - G6P6 (with twins this pregnancy) with hx HTN DM presents ... Treat uterine atony. Fetal monitoring/delivery. Alameda County EMS. AFE: Prognosis ... – PowerPoint PPT presentation

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Title: Case Conference: Respiratory Failure in Term Pregnancy


1
Case Conference Respiratory Failure in Term
Pregnancy
  • James Pointer, MD, FACEP
  • Medical Director
  • Alameda County EMS

2
The Call…
  • 2/16/01 0232 CC SOB
  • Pt. was Cambodian-speaking only, 42y/o woman
    c/o SOB since yesterday, worsening tonight.
  • Thru a translator described chest tightness,
    pain coming from abdomen (pt. 9 mos. pregnant)
    and
  • cough (unproductive).
  • Pt. progressively and noticeably
  • worsened en route.

3
0313 Room 21
  • CC SOB
  • HPI
  • 42yo woman - G6P6 (with twins this pregnancy)
    with hx HTN DM presents with acute SOB tonight.
  • 9 mos. preg. -- EDD 2/22. Saw Ob yesterday, EDD
    moved to March. Ø SZ.
  • PMH GDM, PIH, amniocentesis x 2 normal
  • Meds Insulin, PNVs, Robitussin
  • NKDA

4
History (cont.)
  • Social history
  • Married, six children ages 14 and up.
  • Unplanned pregnancy, husband wanted to keep, pt.
    did not.
  • Hx domestic violence, resolved.
  • Review of systems
  • Nonproductive cough since 30wk EGA
  • chest tightness
  • abdominal pain

5
Physical exam
  • Vital signs
  • T 99.4 pr, BP 230/130, HR 130s, RR 30s SpO2 92
    on 10L by FM
  • General
  • Very distressed, grasping companions, asking for
    help, breathing as if drowning
  • Resp
  • Sitting straight up, rales 1/2way up bilaterally
  • CVS
  • tachy, reg, 2 pitting edema bilaterally, ø
    JVD

6
Physical exam (cont.)
  • GI
  • distended, full belly
  • GU
  • ø crowning
  • Skin
  • cool, wet skin (diaphoretic)
  • Neuro
  • moving all 4s, very distressed

7
Labs Studies
ALT 27 AST 35 Alk ø 187 Ca 8.0 Tbili
0.8 Alb 3.2 Tprot 6.9
PT 9.3 INR 0.79 aPTT 25.5 Fibrinogen
601 D-dimer 12 ßhCG 18,600
CXR small lung fields, pulm edema
UA 1.010/6.0/100 protein/sm blood
8
ED Course
  • 0315
  • Vital signs B/P-210/130, P-155, RR- 36
    Pulse Ox-88 with 100 mask
  • 0318
  • pCXR
  • 0320
  • IV pulled out
  • 0321
  • NTG 1 tab SL, 18ga. IV placed
  • 0327
  • MSO4 4mg

9
ED Course (cont.)
  • 0322
  • Alb/Atro via HHN
  • 0323
  • 220/138, 160
  • Ultrasound in progress
  • 0325
  • Lasix 40mg, second IV placed
  • 0330
  • 130/90 82, labs drawn sent,
  • Etomidate 10mg, succinylcholine 120mg

10
ED Course (cont.)
  • 0332
  • Intubated with 7.5 ETT.
  • 161/98 150 100
  • 0336
  • Dr. Neblett, Ob, arrives. FHR 74.
  • 172/120 133 99.4 AC 15/450/100
  • Packaging pt. to OR, Foley placed.
  • 0345
  • Mg 4g IVP over 15min.
  • 0347
  • Pt. to OR on monitor.

11
OR Course
  • 0350
  • Pt. in room, shaking head, rocuronium 30mg IV.
    Monitor applied.
  • HR 20s, SpO2 10.
  • Idioventricular rhythm, no pulse,
  • CPR with chest comp started.
  • Defib 250J, epi 1.0 mg.
  • 0359
  • I.V. rhythm. Midline abd incision.
  • Defib 300J, epi 1.0mg, NaHCO3 1 amp.

12
OR Course (cont.)
  • 0403
  • Baby boy A Apgars 2/5/8. Pt. defib 350J, epi
    1.0mg. Asystole.
  • 0404
  • Baby boy B Apgars 1/3/5.
  • 0410 Pt. pronounced dead.

13
Pulmonary Edema in Term Pregnancy Differential
Diagnosis
  • Severe preeclampsia
  • Amniotic fluid embolism
  • Peripartum cardiomyopathy
  • Pulmonary embolism
  • CHF -- other etiology

14
Preeclampsia
  • Common complication of term pregnancy
  • Pathophysiology poorly understood
  • Criteria
  • hypertension
  • proteinuria
  • edema
  • Eclampsia seizures
  • More common at extremes of age/parity

15
Pulmonary Edema in Preeclampsia
  • 2.9 of severe preeclamptics
  • Not an isolated complication
  • Age, parity increase risk
  • Associated with fluid administration
  • High maternal/perinatal MM

16
Preeclampsia Treatment
  • Magnesium sulfate IV
  • 4-6g IVP, then drip
  • Blood pressure management
  • Prompt delivery of the baby

17
Amniotic Fluid Embolism (AFE)
  • Rare 1/8000 - 1/80,000 deliveries
  • 10-15 of 1st world perinatal mortality
  • Usually during labor
  • Abruption, membrane rupture predispose
  • Maternal mortality 60-80

18
AFE Presentation
  • Hypoxia
  • Hypotension
  • Fetal bradycardia
  • Seizure (50)
  • DIC (later)

Rapid onset 50 dead in 1hour
19
AFE Pathogenesis
  • Anaphylactoid syndrome of pregnancy
  • Pulmonary vasospasm?
  • Myocardial depression
  • Procoagulant effects of fetal antigens
  • Evil humors
  • endothelin, ?PGF2,
  • histamine, ? bradykinins,
  • leukotrienes, ? thromboxane

20
AFE Diagnosis
  • Microscopic slides neither specific/sensitive
  • Clinical (4/5)
  • Hypotension or cardiac arrest
  • Hypoxia
  • Coagulopathy
  • Absence of other explanation
  • Peripartum onset

21
AFE Management
  • Supportive only
  • Maintain SpO2 and BP
  • Correct DIC
  • Treat uterine atony
  • Fetal monitoring/delivery

22
AFE Prognosis
  • Maternal survival 20-40
  • 15 survived neurologically intact
  • Maternal cardiac arrest
  • 68 babies survive
  • 50 of these neurologically normal

23
Peripartum Cardiomyopathy
  • Dilated cardiomyopathy ? CHF
  • Onset last trimester - 6 mo. postpartum
  • Cause unknown
  • High risk patients
  • African-American
  • Multiparous
  • Age gt30

24
Peripartum Cardiomyopathy (cont.)
  • Treat like regular CHF
  • Mortality 25-50
  • May recover completely
  • Avoid future pregnancies

25
Perimortem Cesarean Section
  • 52 fetal survival (case series of 72)
  • 15 discharged home
  • Survival decreases with longer delivery time
  • Fetal survival gt25 min. after moms death?
  • Indicated when uterus above umbilicus

26
Perimortem Cesarean
  • Midline, xyphoid to pubis, incision
  • Vertical uterine incision (avoid bladder)
  • Cut through placenta if necessary
  • Deliver baby(ies) and placenta
  • Clamp cord ASAP

27
Take-home Points
  • ABCs always useful
  • Always think of magnesium
  • Mom comes first
  • Perimortem C-section is an option
  • Rapid transport

28
(No Transcript)
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