18 “Obstetric Complications in a Resource Limited Setting” Lecture

18
“Obstetric Complications in a Resource Limited Setting”
Lecture
“Obstetric Complications in a Resource Limited Setting”
Speaker
Rachel McLaughlin, MD
Objectives
1) To identify the major causes of maternal and neonatal mortality worldwide
2) To review the treatment of basic obstetrical emergencies
3) To address obstetrical medical and ethical issues specific to a resource
limited setting
Lecture Outline
I.
Causes of Maternal Mortality Worldwide
A. Hemorrhage
B. Infection
C. Eclampsia
D. Unsafe Abortion
E. Obstructed Labor
F. Etc...
II. Statistics, or, Why this lecture is important to you
A. Sub-saharan Africa: 1/16 women die due to obstetrical complication
1. Kenya: 530/100,000 live births
2. Burundi: 970/100,000
3. United States: 24/100,000
B. One quarter of deaths of women between 15-19 attributable to maternity causes
C. MANY OF THESE DEATHS ARE PREVENTABLE
III. Basic Principles of Management
A. Shock
1. Diagnosis
a) Tachycardia (>110)
b) Low BP (<90 systolic)
c) Pallor
d) Clammy skin/diaphoretic
e) Tachypnea
f) Oliguria (<30cc/hr)
2. Management
a) Call for help
b) Monitor vitals
c) Keep warm
d) Side-lying (if unconscious), legs elevated
e) Start 2 large bore IVs
f) Cross match blood if possible
g) Rapid infusion of fluids: 1L in 15 min, then 2L more over the next hour
h) Oxygen by nasal canula or face mask
i) Once patient is stabilized, assess cause of shock and treat
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B. Anemia
1. Causes
a) Blood loss
b) Malnutrition
c) Chronic Disease
d) Malaria
e) Hookworm
2. Classification
a) Mild: Hgb <10
b) Moderate: Hgb <8
c) Severe: Hgb <6
3. Management
a) Transfuse in pregnancy if Hgb <6; goal of 8
b) Oral iron/hematinics x3 months if Hgb <10
c) Encourage hospital delivery
d) If close to delivery or anemia refractory to oral meds, lower threshold for
transfusion
e) Consider treatment for malaria, deworming, etc
IV. Hemorrhage
A. Antepartum Hemorrhage (APH)
1. Placental Abruption: separation of placenta from uterus; painful bleeding/contractions
2. Placenta Previa: placenta implants over cervical os and dilation of cervix causes
painless bleeding
3. Ruptured Uterus: typically occurs in setting of previous scar on uterus or prolonged
pushing in multiparous patient; "loss of station" of fetal head and severe abdominal
pain
4. Other (Vagina, Cervix): cervical CA, infections, etc (typically produce much smaller
amt of bleeding)
B. Management of APH:
1. Stabilize patient
2. Crossmatch blood, start IV and give IV fluids until blood available
3. Assess fetal status: FHT and gestational age
4. Ultrasound if available to assess for previa (do NOT perform vaginal exam unless
previa is ruled out!)
5. Mode of delivery:
a) If fetus alive and severe bleeding, immediate C-section
b) If fetus dead and severe bleeding, immediate C/S (for maternal health)
c) If fetus alive and moderate or decreasing bleeding, can attempt vaginal
delivery (if term and no previa noted) or expectant mgmt with corticosteroids
for fetal lung maturity (if preterm)
d) If fetus dead and moderate or decreasing bleeding, expectant mgmt vs.
induction of labor, or C/S needed if complete previa present
C. Postpartum Hemorrhage
1. Causes:
a) ATONY
b) Cervical/vaginal lacerations
c) Retained placenta
d) Uterine inversion
e) Coagulation defects
2. Management: Call for help
a) Atony
b) Bimanual massage
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“Obstetric Complications in a Resource Limited Setting”
3.
4.
5.
6.
c) Empty bladder w/ foley
d) Pitocin 20u IM or IV
e) Misoprostol (cytotec) 800 mcg PR
f) Ergometrine/Methergine 0.25mg IM if available
g) Foley balloons in lower uterine segment
h) To OR: B Lynch suture, uterine artery ligation, Hysterectomy
Cervical/vaginal lacs
a) Repair in theatre (better visualization)
Retained placenta
a) Pitocin drip in IV can sometimes help spontaneous delivery
b) Manual removal with hand or curette
c) Don't use excessive force on the cord --> uterine inversion
d) Cover with antibiotics
Uterine inversion
a) Administer uterine relaxants (terbutaline, nitrous oxide)
b) Fist method; "last out first in"
c) Pitocin once uterus replaced to help maintain uterine tone/decrease bleeding
d) Watch for patient to have vagal response
Reminder: prevention is the best treatment...all women delivering should receive 1020mg oxytocin IM within 5 minutes of delivering, which reduces risk of PPH by 40%
V. Infection
A. Antepartum:
1. Cystitis/Pyelonephritis
2. Septic Abortion
3. Amnionitis/chorioamnionitis
4. Pneumonia
5. Malaria
6. Typhoid
7. Hepatitis
B. Postpartum/postop:
1. Atelectasis
2. Wound infection/pelvic abscess
3. DVT, thrombophlebitis, septic pelvic thrombophlebitis (SPT)
4. Endometritis
5. Engorgement/mastitis/breast abscess
6. Any of above causes
C. Treatment:
1. Early hospitalization and monitoring --> more likely to develop into septic shock
2. Lower threshold for antibiotics
3. Awareness that infection can cause preterm labor:
evaluate and manage
appropriately!
4. Specifics:
a) Septic Abortion: after stabilization requires D&C
b) Amnionitis: needs delivery regardless of gestational age
c) Wound infection: wound needs opening, washout, and packing/dressing
d) Pelvic abscess: if no improvement after 48-72hrs of IV abx, needs
exploratory surgery, washout, drainage
e) Persistent post-op fevers despite abx with no obvious source: consider SPT
and treat with heparin (x7 days) and abx
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VI. Eclampsia/Pre-Eclampsia
A. Definitions:
1. Pre-eclampsia: Hypertension (BP >140/90) and proteinuria (> 0.3g/24 hours) +/edema occurring in pregnancy >20 weeks gestation.
2. Severe pre-eclampsia: any two of the following:
a) BP >/= 160/110 on at least two occasions,
b) Proteinuria >/= 5g/24 hrs (>/= 3+ on dipstick)...If you cannot do 24 hour
protein measurements, the following is approximate: Dipstick 1+ = 0.3g/24
hr, 2+ = 1g/24 hr and 3+ >/= 3g/24 hr)
c) Symptoms (eg. headache, epigastric pain, visual disturbance, facial edema
3. HELLP Syndrome: Variation of severe pre-eclampsia composed of Haemolysis,
Elevated Liver enzymes, Low Platelets
4. Eclampsia: One or more convulsions occurring in pregnancy after 20 weeks gestation
or within the first week after delivery as a complication of pre-eclampsia
5. Status epilepticus: One continuous unremitting seizure lasting longer than 5-10
minutes, or recurrent seizures without regaining consciousness for greater than 30
minutes.
B. Warning signs/symptoms:
1. Sometimes seizures can occur without warning with only minimally elevated BP
2. Severe headache
3. Visual disturbance/papilledema
4. Epigastric pain/vomiting/RUQ tenderness
5. Edema of face/hands/lower extremities
6. Brisk reflexes/clonus
C. Complications of eclampsia:
1. Maternal death (up to 1/3 of women die if poorly managed)
2. Fetal death (~1/3 of babies die)
3. Placental abruption and massive antepartum and / or postpartum hemorrhage
4. Hypoxic brain injury or CVA
5. Pulmonary edema
6. Hepatic or renal failure
D. Management
1. Outpatient: Patients should only be managed as outpatients for stable chronic HTN
or mild pre-eclampsia in the absence of abnormal labs. If a patient meets criteria for
severe pre-eclampsia, she should be admitted for further observation and/or
treatment.
2. Inpatient: The aim of treatment is to drop BP enough to decrease risk of stroke and
seizure without compromising placental perfusion; target BP should be 140-160/90110.
a) BP should be monitored q 30 min for at least 2 hours—if stable may
decrease to hourly for 4 hours, then 4 hourly.
b) Initial labs: CBC, ALT, Cr, UA
c) Hydralazine 5-10mg IM prn for BP > 160/110
d) Nifedipine 10-30mg PO q6hr...should not be given with MgSO4
e) Labetalol: this is the antihypertensive of choice as it can be given PO or IV,
easily titratable but unfortunately it is rarely available
f) MgSO4: pts meeting criteria for severe pre-eclampsia should be started with
a 4g bolus IV over 20 minutes, then 1g/hr thereafter
g) If patient is <34 wks, give dexamethasone 6mg IM q12hrs x4 doses
h) Consider USN to assess fetal growth and fluid levels
i) FHTs at least 3x/daily, and daily NSTs if available
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“Obstetric Complications in a Resource Limited Setting”
3. Delivery:
a) Only cure for the disease
b) Immediately if any of the following: eclamptic, worsening labs/clinical picture,
after 37 wks gestation, uncontrollable BP
c) Usually safe to induce labor and attempt vaginal delivery with careful
monitoring, even if eclamptic, although if uncontrollable BP or persistent
seizures or failed induction, proceed with C/S
d) Spinal anesthesia usually contraindicated in uncontrolled BP
4. Magnesium: see appendix III
a) Continue 24 hours post-delivery
E. Remember! All seizures in pregnancy are considered eclampsia until proven otherwise!
VII. Abortion
A. Definition: Pregnancy loss < 28 weeks gestation where not all of the products of conception
have been expelled
1. Complete abortion: cervix is closed and all POCs are out of the uterus
2. Incomplete abortion: cervical os is open and some POCs still present in uterus
3. Threatened abortion: cervix is closed and pregnancy viable although bleeding
present
4. Missed abortion: cervix is closed and pregnancy not viable (blighted ovum, no fetal
heart tones) although still present in uterus; bleeding usually minimal
5. Septic abortion: any of above + signs of intrauterine infection
B. Diagnosis
1. Clinically: Amenorrhea, PV bleeding +/- pain, cervix open, products of conception
may be visible upon exam
2. Labs: CBC, GXM 2-4 units, Pregnancy test & ultrasound (if stable)
C. Management
1. Resuscitate per shock protocol (above) if needed
2. If unstable (P > 120, BP <80/50) or bleeding significantly needs urgent D&C
3. If stable may consider misoprostol 400-800mcg PV followed every 4-6 hours by
misoprostol 400 mcg to a maximum of 4 doses. If unsuccessful—needs D&C
4. Give antibiotics at time of D&C: ceftriaxone or cefazolin
5. Give prolonged course of triple antibiotics if evidence of infection (e.g. pyrexia,
offensive vaginal discharge or POC, WBC)
VIII.Obstructed Labor
A. Patient will need a C-section: refer or treat appropriately
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Appendices:
Rapid Initial Assessment
Assess
Danger Signs
Consider
Airway and Breathing
Look for:
cyanosis
respiratory distress
Examine:
skin: pallor
lungs: rales/wheezes
Severe anemia
Heart failure
Pneumonia
Asthma
Circulation (signs of shock)
Examine:
skin: cool and clammy
pulse: fast (>110) and weak
blood pressure: low (<90 systolic)
SHOCK
Vaginal Bleeding
Ask if:
pregnant, length of gestation
recently given birth
placenta delivered
Examine:
vulva: amount of bleeding, placenta
retained, obvious tears
uterus: atony
bladder: full
Abortion
Ectopic Pregnancy
Molar Pregnancy
DO NOT DO VAGINAL EXAM AT THIS
STAGE
Placental Abruption
Ruptured Uterus
Placenta Previa
Atonic uterus
Tears of cervix/vagina
Retained placenta
Inverted uterus
Unconscious or convulsing
Ask if:
pregnant, length of gestation
Examine:
blood pressure: high (diastolic >90)
temperature: 38C or more
Eclampsia
Malaria
Epilepsy
Tetanus
Dangerous fever
Ask if:
lethargic
frequent, painful urination
Examine:
temperature: 38C or more
unconscious
neck: stiffness
lungs: shallow breathing, consolidation
abdomen: severe tenderness
vulva: purulent discharge
breasts: tender
UTI
Malaria
Ask if:
pregnant, length of gestation
Examine:
blood pressure: low (systolic <90)
pulse: fast (>110)
temperature: 38C or more
uterus: state of pregnancy
Ovarian cyst
Appendicitis
Ectopic pregnancy
Abdominal Pain
Endometritis
Pelvic abscessperitonitis
Breast infection
complications of abortion
pneumonia
Possible labor (term or
preterm)
Amnionitis
Placental abruption
Ruptured uterus
Table adapted from Managing Complications in Pregnancy and Childbirth, WHO 2007
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“Obstetric Complications in a Resource Limited Setting”
Diagnosis of Antepartum Hemorrhage
Presenting/Typical Signs and
Signs/Symptoms Sometimes
Symptoms
Present
Probable Diagnosis
Bleeding after 22 wks gestation
Intermittent vs constant abdominal
pain
Shock
Tense/tender uterus
Decreased/absent fetal movement
Fetal distress or absent fetal
heart tones
Placental abruption
Bleeding (intraabdominal and/or
vaginal)
Severe abdominal pain (may
decrease after rupture)
Shock
Abdominal distention/free fluid
Abnormal uterine contour
Tender abdomen
Easily palpable fetal parts
Absent fetal movement and fetal
heart sounds
Rapid maternal pulse
Ruptured uterus
Bleeding after 22 wks gestation
Shock
Placenta previa
Bleeding may be precipitated
by intercourse
Relaxed uterus
Fetus not engaged
Normal fetal condition
Table adapted from Managing Complications in Pregnancy and Childbirth, WHO 2007
Magnesium Use and Guidelines
Administration of Magnesium Sulfate for Severe Pre-Eclampsia and Eclampsia
Loading dose:
i.
Give 4 g of 20% magnesium sulfate solution IV over five minutes.
ii.
Follow promptly with 10 g of 50% magnesium sulfate solution: give 5 g in each buttock as a
deep IM injection with 1 mL of 2% lignocaine in the same syringe.
iii.
Ensure aseptic technique when giving magnesium sulfate deep IM injection. Warn the
woman that a feeling of warmth will be felt when magnesium sulfate is given.
iv.
If convulsions recur after 15 minutes, give 2 g of 50% magnesium sulfate solution IV over
five minutes.
Maintenance dose:
v.
Give 5 g of 50% magnesium sulfate solution with 1 mL of 2% lignocaine in the same syringe
by deep IM injection into alternate buttocks every four hours. Continue treatment for 24 hours
after delivery or the last convulsion, whichever occurs last.
vi.
If 50% solution is not available, give 1 g of 20% magnesium sulfate solution IV every hour by
continuous infusion.
CLOSELY MONITOR THE WOMAN FOR SIGNS OF TOXICITY
Before repeat administration, ensure that:
• Respiratory rate is at least 16 per minute.
• Patellar reflexes are present.
• Urinary output is at least 30 mL per hour over four hours.
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WITHHOLD OR DELAY DRUG IF:
• Respiratory rate falls below 16 per minute.
• Patellar reflexes are absent.
• Urinary output falls below 30 mL per hour over preceding four hours.
Keep antidote ready
• In case of respiratory arrest:
• Assist ventilation (mask and bag, anaesthesia apparatus, intubation).
• Give calcium gluconate 1 g (10 mL of 10% solution) IV slowly until calcium gluconate begins to
antagonize the effects of magnesium sulfate and respiration begins.
Adapted from Managing Complications in Pregnancy and Childbirth, WHO 2007
References:
• Managing Complications in Pregnancy and Childbirth, WHO 2007.
• http://www.who.int/making_pregnancy_safer/documents/9241545879/en/index.html
• Tenwek Hospital: Intern Survival Guide and Maternity Guidelines. Revised from AIC Kiabe
Hospital guidelines, 2011.
• Gabbe: Obstetrics: Normal and Problem Pregnancies, 5th edition. 2007.
• Obstetrics, Gynecology, and Infertility: Handbook for Clinicians, Pocket Edition. Gordon, JD
2007
• Clinical Guidelines for Management and Referral of Common Conditions: Levels IV-VI. Republic
of Kenya Ministry of Medical Services. 2009.
NOTES