obstetrical emergencies · 2021. 2. 4. · umbilical cord prolapse • the umbilical cord lies...
TRANSCRIPT
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ObstetricalEmergencies
by: Kathleen Coble, RNC, BSN
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• Kathy Coble RNC, BSN, has no real orperceived conflicts of interest for thispresentation.
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Physiologic Goals
• Support maternal coping and labor progress
• Maximize uterine blood flow
• Maximize umbilical circulation
• Maximize oxygenation• Maintain appropriate
uterine activity
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Umbilical Cord Prolapse
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• The umbilical cord lies beside or below the presenting part– Funic– Occult– Complete
Defined as:
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• 1.4 and 6.2/ 1000 births = 0.14 – 0.62% (Koonings PP, Campell K., 1990)(Lin, Mg. 2006)(Phelan & Holbrook, 2013)
• 0.16 to 0.18% of liveborn deliveries(Bush, Eddleman, Belogolovkin,2016)Quebec
• No significant change over time. (Stable over last century.)
Incidence:
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• Abnormal placentation (low lying)• Long umbilical cord• Polyhydraminos• Uterine malformations/ tumors• Small or preterm fetus• Malpresentations• Multiple gestation (2nd twin)• Unengaged presenting part• High parity
Risk factors - Preexisting:
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• Cervical Ripening with balloon catheter• Induction of labor• Amniotomy• Fetal scalp electrode placement• IUPC placement• Manual rotation of fetal head• Forceps application• External cephalic version
Risk factors - Iatrogenic:
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• Most obviously ??
Differential Diagnosis:
Diagnosis:
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• Repetitive variable decelerations late in the contraction cycle may indicate a prolapse of the umbilical cord through a dehiscence of the uterine scar.
Remember -
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• Following ROM may rule out through vaginal exam
• If prolapse, relieve compression of the cord(minimize manipulation)
• Continuously elevate the presenting part until delivery of the neonate, either through manual elevation or patient repositioning (knee chest or trendelenburg)
• Fill the woman’s bladder with 500 – 700 mls of sterile saline to elevate presenting part (Katz, 1988)
Management:
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Other Supportive Measures to Prepare for Delivery
• O2 at 10L/min by face mask• IV fluid hydration bolus• DC oxytocin• Continuous fetal assessment• Administration of tocolytic agent to decrease
uterine activity• Anticipate compromised neonate and the need
for neonatal resuscitation
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Outcome:within or out of the perinatal setting
Anticipation/ Prevention:anticipating and managing risk
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Amniotic Fluid Embolism
Anaphylactoid Syndrome of Pregnancy
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Historically --• Amniotic fluid enters the maternal
circulation, resulting in blockage of the pulmonary vasculature and tissue destruction.
???Lone cause???• Criteria (4)
Defined:
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• Varies from 1/ 8000 to 1/ 80,000 pregnancies worldwide
(Clark et,al., 1995)• 1/8000 to 1/30,000 in US (Tuffnell, D.J. 2005)• California Study (1994-1995) – 1 million
deliveries: 1/20,000
Incidence:
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True Incidence….
AFE is rare ranging from 1.9 to 6.1 cases per 100,000 deliveries in a review of reports from Australia, Canada, the Netherlands, the United Kingdom and the United States.
(National Registries)
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Mortality/ Morbidity:
• Accounts for approximately 10% of all maternal deaths
• Maternal mortality is 20-30%• Survivors: 85% suffer long-term neurological
sequelae(15% neurologically intact)
Fetal mortality: 21%Survivors: 50% neurologic injury
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Time from onset of signs/symptoms to maternal death:
Risk factors:
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• Abrupt / catastrophic• Rapidly progressive• Cardiorespiratory compromise• Sudden hypoxia/ hypotension• Development of profound shock – cardiovascular
collapse associated with severe respiratory distress or DIC
Clinical Manifestations
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• Disorientation, decreased level of consciousness
• Sudden dyspnea, cyanosis, respiratory distress
Presenting Signs & Symptoms:
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Pathophysiology:
--incompletely understood
Intense reaction to amniotic fluid?Benign?
--Leong AS, Reprod Sci 2008
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3 Phases1. Amniotic fluid enters maternal
pulmonary vasculature.2. Release of inflammatory
mediators Myocardial depressionLung injuryNeurologic compromise
3. Immunologic activation of coagulation pathway
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Differential Diagnosis
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• Development of coagulopathy• Noncardiogenic pulmonary edema• Acute respiratory distress syndrome• Acute tubular necrosis (Clark, 1990)
Survival – but…
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• Maintain maternal central hemodynamic stability.
Management
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• 35 y.o. G2P1• Uncomplicated antepartum course• EDC 4/8 dates, 4/9 US• Previous 9#15oz• Admitted for induction 4/9 since EFW 4300
grams
Case Study:
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• 2nd IV line started• Blood readied• Hespan• Dopamine infusion• Uterine massage
Management:
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• BP remained 70 systolic• Uterus continued to bleed heavily
Massive Transfusion Protocol
Patient:
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Management
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Emboli• Respiratory• Cardiovascular system• Uterus – within deep myometrial vessels• Cervix
Pathology:
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Pathogenesis
• Embolism• Platelet activation and degranulation• Pulmonary hypertension due to serotonin
and thromboxane• Systemic hypotension and bradycardia due
to reflex vagal stimulation• Death
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A-OK Protocol (BAOK)
• Atropine 1 mg for vagolysis• Ondansetron 8 mgs to block serotonin
receptors and for vagolysis• Ketorolac 30 mg to block thromboxane
production• Benadryl 50 mg antihistamine• Off-label recommendations
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Multidisciplinary Team-Based Approach
• United States National Registry of AFE• United Kingdom--analysis of data for further understanding
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DICDisseminated Intravascular Coagulation
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• Pathogenesis
• Procoagulant Exposure
• Coagulation
• Fibrinolysis
• End Organ Damage
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• Anaphylactoid syndrome of pregnancy (AFE)• Abruptio placentae (most common cause)• Severe preeclampsia• HELLP• Septicemia• Severe hemorrhage• Retained IUFD• Additional pregnancy complications
Predisposing Conditions:
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• Unusual bleeding• Tachycardia• Diaphoresis• Symptoms of shock (late finding)
Clinical Manifestations & Diagnosis:
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Assess and monitor…
+ Management
Nursing Assessment & Care
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Laboratory:• Decreased platelets, fibrinogen, proaccelerin,
antihemophilic factor, prothrombin
(factors consumed during coagulation)
• Fibrinolysis increases initially (later severely depressed)
• Degradation of fibrin leads to accumulation of FDPs in blood
• FDPs – anticoagulant properties – prolong PT, PTT time
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“Massive Transfusion Protocol”• Packed RBCs through one IV line• FF Plasma through a second IV line• Platelets• Recheck serum fibrinogen level and platelet
count every 30 – 60 minutes
Blood Components &
Fluid Volume:
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• Cryoprecipitateeach 40-50 ml bag contains approximately the same amount of fibrinogen as a unit of FFP, plus some other clotting factors (including Factor VIII)
• Fresh Frozen PlasmaRegular: 200-250 ml bag contains fibrinogen + all other clotting factors ( higher level of Factor VIII)Prepared by plasmapheresis: 400-600 ml bag
• Platelets 5-10 units
Blood Components / Clotting Factors:
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R= ResuscitationE= EvaluationA= Arrest HemorrhageC= ConsultT= Treat Complications
(Knuppel & Hatangadi, 1995)
REACT
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Uterine Rupture
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Defined:
• The separation of the uterine myometrium or previous uterine scar, with rupture of the membranes and extrusion of the fetus or fetal parts into the peritoneal cavity.
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• Complete: laceration directly into the peritoneal cavity
• Incomplete: laceration is separated from the peritoneal cavity by the visceral peritoneum
Dehiscence: previous scar begins to separate
Classified as complete or incomplete
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Complete uterine rupture:
• Perimetrium and myometrium are involved
• Clinical signs immediate
• Uterine contractions cease and fetal parts are palpable through the abdominal wall
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• Risk of rupture is 0.2% to 1.5% with prior low transverse Cesarean scar(ACOG, 1999b)
• 0.32% overall0.02% elective repeat C.S 0.12% indicated repeat C.S (OB/GYN 2007)
Regardless of mode of delivery– with Prior C.Sec. 0. 3% 468/100,000 - TOLAC 26/100,000 - RPT C. Sec.( Landon, Frey 2010)
• A normal uterus with no prior surgery contracting spontaneously is
unlikely to rupture unless …..
Incidence:
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Type of Scar:
Low transverse:
Classical incision:
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• Prior uterine surgery• Previous cesarean delivery – (or myomectomy)
Conditions associated with uterine rupture:
• Short inter-delivery interval (<18 months)• Oxytocin use (risk 1.1%)• Prostaglandin preparations• Parity greater than 4• Abruptio placentae
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• Midforceps delivery• Breech version and extraction• Trauma• CPD
Differential Diagnosis
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• Depends on specific type and timing of rupture
• Dehiscence of a prior low-segment cesarean scar is initially asymptomatic
• Prolapse of the umbilical cord can occur through the scar tissue
Presentation:
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Clinical Findings• Abnormal FHR
• Abdominal Pain
• Vaginal Bleeding
• Loss of station
• Hematuria
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• Contractions ???• Significant association between dysfunctional
labor and arrest of dilatation (causality is unclear)
• Hypotension and shock
As rupture continues:
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Remember:Signs and symptoms:
• Sudden fetal distress is the mostcommon sign/ symptom even prior tothe onset of abdominal pain or vaginalbleeding.
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• Previous C. Section at 37 weeks gestation, with c/o ?early labor
• Irregular contractions per EFM• FHR reactive• SVE by nurse: cervix closed, intact
membranes
Case Study:
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Perinatal Mortality and Morbidity
Nursing Diagnoses
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Interventions:
1.Maternal shock related to blood loss secondary to uterine rupture.
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Interventions:
2. Fetal distress related to impaired uteroplacental blood flow.
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Interventions:
3. Fear related to life-threateningcomplication and threatened loss of babe.
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• Maternal stabilization and immediate cesarean birth
• Repair uterine defect (if possible)
Management:
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Uterine Inversion
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May occur immediately after partial placental separation or during the immediate postpartum period
• Incomplete: fundus is not through the cervical ring
• Complete: prolapse of the uterus and the vagina
Defined as:“turning inside out”
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Incidence:
• 1/ 2500 births (You & Zahn, 2006)
• 2.9/ 10,000 births (Coad, Dahlgren, Hutchen, 2017 –Nation Wide Sample 2004-2013)
Risk Factors:Two conditions are prerequisites:
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• Fundal pressure and traction applied to the cord
• Uterine atony• Leiomyomas and abnormally adherent
placental tissue• Occurs most frequently in multiparous
women and with placenta accreta andincreta
Other contributing factors:
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• Hemorrhage• Shock• Pain• Attempts to massage the fundus are
unsuccessful.• The fundus has inverted into the uterus,
the vaginal vault, or the introitus.
Presentation:
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• Combat shock (out of proportion to blood loss)• Withhold oxytocin until the uterus has been repositioned• Attempt to manually replace the uterus (tocolytic or
general anesthesia)Nitroglycerin 50 mcg IV (x4)Terbutaline: 0.25 mg IVMagnesium sulfate: 4-6 Gm IV over 5-10 minutes
Management:
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• Prepare for Surgery:
• Begin blood volume expansion
• If placenta is still attached, do not remove it until blood volume expansion fluids are being given
• If manual replacement fails, be prepared for abdominal or vaginal surgery to reposition the uterus
• Blood replacement therapy as indicated
• Broad spectrum antibiotic therapy
• Nasogastric tube to minimize paralytic ileus
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• Nursing assessments and interventions for uterine inversion are the same as for any obstetrical hemorrhage
• Suspect an incomplete inversion ???
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SEPSISIn OB?…
...think about it!
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Part 1:SIRS – Systemic Inflammatory Response
The body’s response to severe clinical insult manifested by 2 or more symptoms listed below:
• Temperature > 38 degrees C or < 36 degrees C>100.4 x 24 hrs
• HR > 90 BPM (>110 if laboring or recently delivered)• Respiratory rate > 20/ minute or PaCO2 < 32 mmHg
(1st sign – Count for full 60 secs.)
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• WBC > 12,000, < 4000, or > 10% immature (band) forms (non-pregnant value)
• Preg: 5 K – 12 KLabor: up to 14 – 16 KLate labor and PP: up to 25 KPost C/S: up to 30 K• Acute change in LOC• Glucose > 120mg/ dl in non-diabetic
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Part 2:Infection suspected or confirmed
Most Common:
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Part 3:Acute (new) Organ Dysfunction
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Part 4:Severe/ Septic Shock 50 / 50 Life or Death.Multiorgan DysfunctionPresence of altered organ function requiring medical intervention to maintain hemostasis.
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Management:Early Goal Directed Therapy
To be completed within 3 hours1. Measure lactate level2. Obtain blood cultures prior to administration
of antibiotics* 7.6% increase in mortality for every hour delay in Abx. Administration (Kumar, 2006)
3. Administer broad spectrum antibiotics4. Administer 30 ml/kg crystalloid for
hypotension or lactate ≥4mmol/L
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Don’t forget to complete your evaluation athttp://opqic.org/opnf/bootcamp/