Obstetric Emergencies and Anesthetic Management - PowerPoint PPT Presentation

Loading...

PPT – Obstetric Emergencies and Anesthetic Management PowerPoint presentation | free to view - id: 4329e6-ZTcwZ



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Obstetric Emergencies and Anesthetic Management

Description:

OBSTETRIC EMERGENCIES AND ANESTHETIC MANAGEMENT ... regional anesthesia for C-section can be employed following careful assessment of maternal volume status ... – PowerPoint PPT presentation

Number of Views:1089
Avg rating:3.0/5.0
Slides: 35
Provided by: M20
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Obstetric Emergencies and Anesthetic Management


1
Obstetric Emergencies and Anesthetic Management
  • Clerk ??? ??? CR??? VS???

2
  • Non-Hemorrhagic Emergencies
  • Maternal Hemorrhages
  • Pre-Partum
  • Intra-Partum
  • Post-Partum

3
Non-Hemorrhagic Emergencies
4
Non-Hemorrhagic Emergencies
  • Most common fetal distress
  • Fluctuations and variations in the FHR are normal
  • Tachycardia FHRgt160 BPM, associated with
    maternal fever or infection, medications
    (terbutaline, atropine), or hyperthyroidism
  • Bradycardia FHRlt110, and may be a fetal
    autonomic reflex response to chemoreceptor or
    baroreceptor activation

5
Variability
  • Most reliable index of fetal well-being
  • Definition fluctuations in the baseline FHR of
    two cycles per minute or more, and is quantified
    as absent, minimal (lt5 bpm), moderate (6-25 bpm),
    or marked (gt25 bpm)
  • Presence of FHR variability an intact,
    well-oxygenated neuraxis
  • Variability may be decreased by maternal
    medications, but fetal hypoxemia is the factor of
    greatest concern

6
Decelerations
  • Early decelerations synchronized with the
    contraction ascribed to fetal head compression
  • Variable decelerations not related temporally to
    contractions, more irregular in appearance due
    to umbilical cord compression.
  • Late decelerations begin after the uterine
    contraction associated with utero-placental
    insufficiency, and if repetitive, are a cause for
    major concern
  • -change the maternal position, give IV fluids,
    administer oxygen (by facemask), and stop uterine
    contractions (turning off the oxytocin infusion )

7
FPO vs. FHR
  • Fetal pulse oximetry and cesarean delivery
  • N Engl J Med. 2006 Nov 23 355(21)2195-202
  • use of FPO had no significant effect on the
    overall rate of cesarean delivery or on the rate
    of any maternal or infant outcome evaluated
  • low oxygen saturation was present almost as often
    in fetuses with reassuring and nonreassuring FHR

8
(No Transcript)
9
Maternal Hemorrhage
  • Pre-partum
  • Placental abruption
  • Placenta previa

10
Placental abruption
  • Definition premature separation of a normally
    implanted placenta
  • Frequency 1 in 77 1 in 86 deliveries
  • Cocaine use, hypertension, and heavy maternal
    alcohol use had been linked to increased
    incidence
  • Normal separation of the placenta blood loss is
    limited by constriction of the spiral arteries
    (contraction of the myometrium)
  • Most abruptions are partial - uterus cant
    selectively constrict only the abrupted area?
    on-going maternal blood loss.

11
(No Transcript)
12
Placental abruption
  • Decrease in placental surface area?fetal
    asphyxia.
  • - fetal death( 1 in 750 deliveries )
  • -severe neurologic damage in surviving neonates
  • 90 of abruptions will be mild or moderate,
    without fetal distress, maternal hypotension or
    coagulopathy
  • Vaginal blood loss is misleading
  • - On-going blood loss ? coagulopathy (a low
    platelet count, and low fibrinogen and Factors V
    and VIII)
  • -severe cases ? DIC

13
Placental abruption
  • If abruption is suspected
  • -blood should be drawn immediately for hgb/hct,
    platelet count, fibrinogen, fibrin-split
    products, and blood type
  • - Regional anesthesia employed if 1. FHR
    tracing is reassuring 2. no on-going blood loss
    3. no maternal hypovolemia 4. No coagulopathy
  • -Severe abruption emergent c/s GA

14
Placental abruption
  • If cesarean delivery is necessary
  • be prepared for massive blood loss
  • Careful assessment of maternal circulating blood
    volume
  • large-bore IV
  • Blood infiltrating the myometrium may result in a
    Couvelaire uterus
  • In addition to oxytocin, other uterotonic agents
    may be necessary.
  • In rare situations, internal iliac artery
    ligation or hysterectomy may be necessary to stop
    hemorrhage

15
Placenta Previa
  • Initial control of bleeding may require
    aggressive treatment
  • PRBC
  • Fresh-frozen plasma
  • platelet concentrates
  • cryoprecipitate

16
Placenta Previa
  • Definition abnormal implantation of the
    placenta, over or close to the cervical os, and
    occurs in about 1 in 200250 deliveries
  • Mostly identified in early gestation on routine
    prenatal ultrasonography
  • resolve by the 3rd trimester enlargement of the
    uterus carries the implantation site away from
    the cervical os
  • All vaginal bleeding in the 3rd trimester should
    be considered placenta previa until proven
    otherwise

17
Placenta Previa
  • With on-going bleeding, cesarean delivery is
    indicated.
  • fastest way to deliver the infant and stabilize
    the mother is general anesthesia
  • If bleeding has stopped spontaneously, regional
    anesthesia for C-section can be employed
    following careful assessment of maternal volume
    status (heart rate, blood pressure, urine output)
  • Prior to 32 weeks gestation bed rest
  • Elective cesarean delivery
  • gt32 weeks gestation
  • fetal maturity is assessed (usually by
    amniocentesis)

18
MATERNAL HEMORRHAGE INTRAPARTUM
19
Placenta Accreta
  • Definition abnormal development and implantation
    of the placenta
  • Incidence 1 in 2000 deliveries but higher in
  • placenta previa
  • prior C-section

20
Number of prior cesarean deliveries Number of parturient with placenta previa ( N268) Number with placenta accreta
0 238 12 (5)
1 25 6 (24)
2 15 7 (47)
3 5 2 (40)
4 3 2 (67)
21
Placenta Accreta
  • Treatment
  • Curettage (rare useful)
  • Surgical intervention (usually hysterectomy)
  • Pre-operative placement of balloon catheters in
    the internal iliac arteries

22
Uterine Rupture
  • Uterine rupture most commonly occurs in
    intrapartum
  • Predisposing factor
  • Previous uterine scar, especially a vertical
    uterine incision
  • Rupture of a myomectomy scar
  • Rapid tumultuous labor
  • Prolonged labor with cephalopelvic disproportion
  • Excessive oxytocin stimulation
  • Traumatic or iatrogenic rupture

23
(No Transcript)
24
Uterine Rupture in VBAC Patients
  • VBAC (vaginal birth after cesarean) patients
  • Incidence rate 1
  • Serious maternal or fetal morbidity and
    mortality 10 - 25
  • Regional anesthesia may increase the chance of
    successful vaginal delivery

25
Uterine Rupture
  • Symptoms
  • Vaginal bleeding, severe uterine or abdominal
    pain, shoulder pain, disappearance of fetal heart
    tones, hypotension
  • Management emergency laparotomy with general
    anesthesia

26
Amniotic Fluid Embolism
  • AFE occurs most often intrapartum (65)
  • Symptoms
  • respiratory distress
  • cyanosis
  • cardiovascular collapse (cardiogenic shock)
  • hemorrhage
  • coma

27
Amniotic Fluid Embolism
  • Treatment
  • Goal
  • Restore cardiovascular and pulmonary equilibrium
    (SBPgt90, U/O gt25ml/hr, PaO2 gt60mmHg)
  • Re-establish uterine tone
  • Correct coagulation abnormalities
  • Resuscitation and monitoring
  • Set IV infusion, O2 administration,
  • Airway control

28
MATERNAL HEMORRHAGE POSTPARTUM
29
Retained Placenta
  • Retained placenta occurs in 1 of deliveries
  • Mechanism Retained placenta ? not fully contract
    ? arteries of the decidua basalis continue to
    bleed
  • Treatment uterine manual exploration
  • Uterine relaxation
  • Analgesia

30
Retained Placenta
  • Uterine relaxation
  • Assess maternal volume status first!
  • Inhalation agent (halothane and isoflurane) over
    1MAC
  • Nitroglycerin (100 µg, IV)

31
Uterine Atony
  • Definition Ineffective uterine muscle
    contraction in postpartum period
  • Uterine atony occurs in 2 to 5 of deliveries
  • Predisposing factor
  • Multiparity, polyhydramnios, multiple gestation,
    retained placenta, excessive oxytocin use during
    labor, operative interventions

32
Uterine Atony
  • Initial therapy
  • Fluid resuscitation
  • Oxygen supplementation
  • Uterine massage
  • Uterotonics
  • Oxytocin
  • Methylergonovine
  • Prostaglandin

33
Uterine Atony
Medication Class Administration Dosing Side effect Comments
Oxytocin Neurohypophyseal hormone Infusion Up to 40 IU/l Hypotension with rapid infusion Initial therapy
Methylergonovine Ergot alkaloid Intramuscular 0.4 mg IM repeat once Hypertension Sustained increase in uterine tone
Carboprost Prostaglandin Intramuscular intramyometrial 0.25mg IM repeat up to 1.0mg total Systemic and pulmonary hypertension, bronchospasm Never administer intravenously
34
THANKS FOR YOUR ATTENTION!!
About PowerShow.com