placenta previa

placental abruption

uterine rupture

What % of pregnancies does postpartum hemorrhage occur in?

most common causes? (5)

What anesthetic can cause decreased uterine tone?

~10%

uterine atony

vaginal tears

retained placenta

placenta accreta

uterine inversion

Volatile anesthetics

Placental abruption is ____ or ____ separation of the placenta before delivery of the fetus.

Risk factors: (6)

partial or complete

Cocaine Use

HTN

Alcohol use

Preeclampsia

Previous hx of abruption

Smoking

CHAPPS

Delivery 

Restoration of blood volume

management of accompanying DIC

vaginal bleeding+/-

uterine tenderness

increasd uterine activity

hemorrhagic shock

renal failure

fetal distress or demise
(~20% of all perinatal deaths)

coagulopathy

(~10% incidence with abruption)

*What is the most common cause of DIC in pregnancy?

*Abruption sufficient to cause fetal death results in a ~___% incidence of DIC?

placental abruption - DIC

(incidence with abruption is 10%)

~30% incidence of DIC

placenta implanted in advance of the presenting fetal part

"the placenta is between the baby and the escape hatch" --Ron Anderson

total - placenta completely covers the cervical os

partial - placenta partially covers the cervical os

marginal - placenta lies close to, but does not cover the cervical os

What is the incidence of placenta previa?

Associated conditions? (4)

~1/200 pregnancies

associated conditions:

multiparity

advanced maternal age

previous placenta previa

previous C/S or other uterine surgery

MAPP

acute

uteroplacental insufficiency from placental separation

preterm delivery

chronic

 IUGR from decreased placental blood supply

assessment of fluid volume

risk of increased intraop blood loss

type of anesthetic dependent on patient condition

-- GETA probably necessary for significant hemorrhage or hypotension per Ron

~1% in patients with a previously scarred uterus

ie. VBAC

rare complication in an unscarred uterus

grand multiparity

overaggressive use of oxytocin

previous uterine surgery

uterine manipulation

ie. external version = trying to turn the baby by manipulating pts belly

trauma

GO PUT

What are the s/sx of uterine rupture? (5)

Which sign is most reliable? Inconsistent?

vaginal bleeding

hypotension

cessation of labor

fetal distress = most reliable sign

abdominal pain is an inconsistent sign

 Definitive treatment for uterine rupture is ____.

Definitive procedure is hysterectomy

Some patients can have uterine repair

if pt has a uterine repair they will not be able to labor again; no VBAC

GA typically preferred with uterine rupture except with a stable patient having a pre-existing epidural

What is vasa previa?

What is this configuration susceptible to?

velamentous insertion of the cord where the blood vessels traverse the membranes ahead of the presenting part

basically cord vessels are across os so the baby may rupture them when being birthed

susceptible to tearing of vessel with rupture of membranes 

Incidence of vasa previa?

fetal mortality?

blood volume of preterm fetus?

incidence = 1/2000-3000

fetal mortality rate = 50-75%

blood volume = about 250ml (80ml/kg)

What is postpartum hemorrhage defined as?

Incidence?

>500ml of blood after delivery

up to ~10% incidence

What is primary postpartum hemorrhage?

Secondary?

primary - within 24 hours of delivery -- carries higher M&M

secondary - between 24 hours and 6 wks postpartum

uterine atony

An atonic, engorged uterus may hold __mL of blood?

*Management of pp hemorrhage is with 2 main drugs, list 2 others less used?

1000ml

#1 - oxytocin

(stimulates uterine tone)

#2 - Hemabate

 (15-methylprostaglandin F2alpha -- PGF2 = stimulations of uterine tone)

misoprostol 

(PGE1 a cervical ripening agent)

orgonovine & methylergonovine

Methylergometrine is a blood vessel constrictor and smooth muscle agonist most commonly used to prevent or control excessive bleeding following childbirth and spontaneous or elective abortion.

lacerations & hematomas (perineal, vaginal, or cervical)

retained placenta

placenta accreta

uterine inversion

placenta accreta vera

placenta increta

placenta percreta

What is placenta percreta?

Is this type easy to remove?

invasion of the uterine serosa or other pelvic structures by the placenta

most difficult to remove & usually requires total hysterectomy with possibility of severe hemorrhage

 epidemiology of placenta accreta

increased incidence of this with _______?

another big red flag for this issue is _____ in a pt with prior ______.

Increased incidence of placenta acreta is directly proportional to increased number of _____; per graph on slide 19.

increased incidence with prior uterine trauma

placenta previa in a patient with prior C/S should raise suspicion (placenta likes to implant in area of scaring - per Ron)

C-Sections

INCREASED VENOUS STASIS in pelvis & LE's due to vena caval compression by uterus

HYPERCOAGULABLE STATE - particularly in the immediate pp period as fibrinolytic activity↓ with coagulation activity remaining elevated

VASCULAR INJURY ASSOCIATED WITH DELIVERY - leads to an increase in coagulation activity

dyspnea

palpitations

anxiety

pleuritic chest pain

cough

tachycardia

JVD

What % of people will die within the first hour following a PE?

Treatment?

~10%

TX: adequate oxygenation

support of maternal circulation & uterine BF

immediate anticoagulation or venous interruption (ie greenfield filter)

A venous air embolism is a common occurrence during C/S.

What increases this incidence?

Are these common? 

increased incidence with:

steep trendelenburg

exteriorization of the uterus

small ones are very common and usually no big deal

What are the s/sx of a massive air embolism?

What s/sx are seen more commonly with smaller air embolism?

*see table on slide 24 for tx options

massive air embolism - sudden hypoxia, hypotension, cardiac arrest

more commonly - chest pain, decreased O2 saturation, dyspnea, & maybe EKG changes

What is the incidence of an amniotic fluid embolus?

% of maternal deaths?

incidence ~4-5/100,000

accounts for ~12% of maternal deaths

What is the mortality of an amniotic fluid embolus?

2/3 of deaths within first ___ hours.

High incidence of ___ neurologic injury in survivors.

What does NOT correlate with severity?

mortality 25-80%

2/3 of deaths within first 5 hours

High incidence of permanent neurologic injury in survivors

Volume of particulate matter found in lungs does not correlate with severity

What is the pathophys of an amniotic fluid embolus?

What worsens the insult?

possibly arachidonic acid metabolites ie. leukotrienes are responsible for damage?

something in mecomium worsens the insult

How long does the early phase of an amntiotic fluid embolus last? What happens in this time?

Second phase?

early phase - less than 30 minutes duration

intense pulmonary vasospasm with release of vasoactive substances leading to often fatal right heart failure

second phase

left ventricular dysfunction in survivors of the early phase - etiology unclear

almost all develop coagulopathy

An amniotic fluid embolus may be more accurately described as an _________ reaction versus an embolic one.

See slide 28 for tx options

maternal mortality in the US

Overall?

Anesthesia related?

overall = 9.2/100,000

anesthesia related= 1.7/1,000,000

When did the majority of the maternal mortalities occur?

List causes and % of the deaths occurring with GA:(6)

Basically what has been responsible for most anesthesia related maternal deaths?

occurred during C/S

of the deaths occurring with GA:

33% aspiration

22% induction/intubation

22% cardiac arrest

15% inadequate ventilation

5% unknown

3% respiratory faiure

*Airway issues*

*continued attempts at intubation without substantive changes in what you are doing are not likely to be successful, and will make mask ventilation more and more difficult

Need to have more than just a plan A!!!!!

"NEVER surrender ever a marginal airway unless sure can easily get another and have backup" - Ron

see graph on slide 35

What is the preferred technique for dealing with meconium aspiration in the infant?

What determines whether or not you will ET suction the infant after birth?

early pharyngeal suctioning of baby

ie. delivery of the head, suctioning of the hypopharynx, then delivery of the thorax

(OB does this)

if infant is vigorous, no ET suctioning indicated

if not vigorous, tracheal suctioning should be performed

If a previously vigorous infant develops respiratory compromise, tracheal suctioning should be done prior to ____?

Once the ___ is normal, empty stomach with a soft suction catheter.

if a previously vigorous infant develops respiratory compromise, tracheal suctioning should be done prior to PPV.

Once the HR is normal, empty stomach with a soft suction catheter

we keep track of mom

SHE IS PRIORITY