anesthetic considerations in obstetric emergencies

7/30/2019 Anesthetic Considerations in Obstetric Emergencies

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Anesthetic Considerations in

Obstetric EmergenciesAn Update

Arvind Palanisamy, MD, FRCA

Department of Anesthesiology, Perioperative and Pain Medicine

Brigham and Womens Hospital

Harvard Medical School


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Causes of Maternal Death

Cardiac disease

Psychiatric disorders

Hypertensive disorders of pregnancy Thrombo-embolic disorders

Hemorrhage

OBESITY


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Maternal Deaths Are Preventable

40% of maternal deaths

are preventable

Hemorrhage related

deaths completely

preventable

Berg CJ et al.Obstet Gynecol 2005 Dec 106 (6): 1228-34


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Preoperative Planning

Communication

Davies JM et.al, Anesthesiology 2009 Jan;110(1):131-9


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Improving Communication

Systematic review

8 studies 4 randomized, 4 cohort studies

Improvement: KnowledgeCommunication

Practical skills

Team performanceSimulation center vs. training in local hospital?

Merien AE et.al, Obstet Gynecol 2010 May;115(5):1021-31


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Number of Prior CS Risk of Placenta Accreta (%)

0 3.3

1 11

2 40

3 614+ 67

Placenta Previa/Accreta

Silver RM et.al, Obstet Gynecol 2006; 107:1226


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Placenta Accreta

Mean estimated blood

loss > 2.5 L

> 25% require ICU

admission1

Risk of hysterectomy2

- previa + scar (11%)

- previa + accreta (66%)

1.Eller J et.al, BJOG 2009; 116: 648-54

2.Chattopadhyay SK et. al, Eur J Obstet Gynecol Reprod Biol. 1993; 52:151-6


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Team

Resources

Planning

Maternal-fetal medicine

Anesthesia

Gynecologic Oncology

Urology/Surgery

Interventional Radiology

NeonatologyOR

IR suite

L&D

SICU

Blood Bank

Cell Saver

Timed elective delivery

Contingency plan

Multidisciplinary Approach


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Preoperative Planning

Planned between 34-36 weeks

Betamethasone course

Antenatal anesthesia consultation 4 PRBC, 4 FFP, 2 Platelets

Teams notified including ICU

Usually booked as first case


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Surgical Management

Radical approach

- Cesarean hysterectomy prophylactic IR

Conservative approach

- Myometrial resection + Bakri balloon

- Placenta in situ (mostly European practice)


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Anesthetic Management

GETA vs. Regional technique1

- 350 consecutive cases of placenta previa

- decreased EBL with regional- decreased transfusion rate with regional

CSE + A-line

Baseline coagulation UBBH/ Fluid warmers/ DVT prophylaxis

1. Parekh N et. al, Br J Anaesth 2000; 84 (6): 725-30


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Prophylactic

Therapeutic


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Which artery?

- uterine or vaginal artery

- empiric uterine artery embolotherapy if nodye extravasation

What material?

- platinum coils (dated)- particle embolization (gelatin, PVA)


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Efficacy1: 78-100%

re-intervention rate 7-25%

internal iliac, internal pudendal, uterineComparison2:

- efficacy 90% ( uterine compression sutures)

- slightly better than balloon tamponade andpelvic devascularization

1. Badawy SZ et. Al, Clin Imaging 2001; 25: 288-295

2. Doumouchtsis SK, Obstet Gynecol Surv 2007; 62: 542-47


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Transfusion Strategies

- fixed number of PRBC

FFP, platelets, cryoppt

- repeated assessment ofcoagulation

- stat hemorrhage

protocol forunanticipated bleeding


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Transfusion Strategies

In vitro TEG evidencesupports 1:1:1 ratio

Sadana N et.al, Gertie Marx symposium, SOAP 2010


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Recombinant Factor VII a

Licensed for use in hemophilia

Important adjunct

Reported efficacy 78-98% Improved coagulation, fewer RBC transfusion,

lower mortality

Disadvantages: Prohibitive costs, thrombosisNo standard dosing regimen

Priya VR et. al, Clinic Obstet Gynecol 2010; 53(1): 165-81


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Intraoperative Cell Salvage (IOCS)

Ashworth A, BJA 2010 Aug;105(4):401-16


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No differences in:

infectious complications need for ventilatory

support

DIC length of postoperative

stay

Multicenter cohort study

Rebarber A et al, Am J Obstet Gynecol 1998;179:71520


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Randomized Controlled

Trial

Reduced incidence ofhomologous transfusion

(1/34 vs. 8/34)

23.5% backgroundtransfusion rate

Rainaldi MP et. al, Br J Anaesth1998 Feb;80(2):195-8


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Retrospective cohort, case-control study of

12000 patients undergoing cesarean delivery

Theoretical use of cell salvage

- reduced exposure to allogeneic blood in 48%

- eliminated exposure in 14-25%

Fong J et.al, Anesth Analg 2007; 104:666-672


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Maternal Venous Blood

TissueFactor

FetalCells

AmnioticFluid Proteins

Geoghegan J, BJOG 2009 May;116(6):743-7


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high-risk obstetric

patients

pre-existing cell savage

services cell washing + leucocyte

depletion filter

post-transfusion

Kleihauer testing1

cost saving $ 110.542

1. McDonnell NJ et.al, Anaesth Intensive Care. 2010 May;38(3):492-9

2. Waters JR et. al, Anesth Analg 2007; 104: 869-75


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Conservative Management of

Placenta Accreta

Reduced hysterectomy incidence to 15%, DIC

to 5%, and transfusion by 50% 1

20% need hysterectomy, 75% had

spontaneous resorption of the placenta with a

median delay from delivery of 13.5 weeks 2

Infection, risk of recurrent placenta accreta

1.Kayem G et. al, Obstet Gynecol 2004 Sep;104(3):531-6

2. Sentilhes L et. al, Obstet Gynecol 2010 Mar;115(3):526-34


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Postoperative Care

Most cases typically managed in L&D

ICU admission

Inadequate hemostasisMassive fluid shifts

DIC

Pulmonary edema


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Retained Placenta

IVGA

GETA

Neuraxial techniques Intra-umbilical oxytocin injection

NITROGLYCERIN


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Retained Placenta

IV 100 to 200 mcg

Dilution 50-100 mcg/ml

SL 500 to 1000 mcg

Mechanism of action?

Release of NO

placental tissue for

uterine relaxation


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Retained Placenta

Double-blind, multi-

center, randomized,

placebo-controlled trial

Hemodynamically stable

patients

Umbilical oxytocin (50

IU) was ineffective

Weeks AD et.al, Lancet 2010 Jan 9;375(9709):141-7

RELEASE trial


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Airway Management

Traditional Mallampatti

assessment (N = 61)

Acoustic reflectometry

(N = 21) 33% -one MP grade

5% -two MP grades

Decreased oropharyngealvolume

Kodali BS et. al, Anesthesiology 2008 Mar;108(3):357-62


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Airway Management

Superior illumination

High resolution

Favorable viewing angle

Simulated difficult

airways

Morbidly obese

Pregnancy??


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Airway Management

Video laryngoscopy in obstetrics?

- No randomized studies

- Case series of 27 patients

Gray K et. Al, O 13, OAA Annual Meeting Abstract, 2009, Jersey, UK

C+L 1 C+L 2 C+L 3

Standard view 14 (52) 12 (44) 1 (4)

Video laryngoscope view 27 (100) 0 (0) 0 (0)


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Thrombocytopenia in Preeclampsia

Quality vs. Quantity

Spinal vs. Epidural

Rate of platelet decline

TEG vs. PFA


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Intrauterine Resuscitation

IV fluids 1 L fluid bolus

Maternal oxygenation

Positioning lateral

Simpson KR et.al, Obstet Gynecol 2005 Jun;105(6):1362-8


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Anesthetic Neurotoxicity


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GABA agonism

NMDA antagonism


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Fetal Risk of Critical Care Drugs

Remodeling

Synaptogenesis

Differentiation

Migration

Neurogenesis

Birth

GABA


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No differences in learning disabilities irrespective of

the type of anesthesia for cesarean delivery


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Susceptible

Dose-dependent

Developmental stage

dependent

Avoidable with bettermaintenance of

physiology?


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Case for Dexmedetomidine?

Adrenergic mechanisms poorly developed

Minimal transplacental transfer

Inhibits myometrial contractions

Not FDA approved

Long term effects unknown


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Summary

Multi-disciplinary management

Cesarean hysterectomy - mainstay

Use of cell saver, factor VII a

Airway changes dramatically during labor

Video laryngoscopes

Developmental neurotoxicity of anesthetics


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The single biggest problem in communication is the

illusion that it has taken place

http://nobelprize.org/nobel_prizes/literature/laureates/1925/shaw-bio.html

anesthetic considerations in obstetric emergencies

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