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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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Interventional Radiology
Prophylactic
Therapeutic
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Interventional Radiology
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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Interventional Radiology
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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Intraoperative Cell Salvage (IOCS)
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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Intraoperative Cell Salvage (IOCS)
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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Intraoperative Cell Salvage (IOCS)
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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Intraoperative Cell Salvage (IOCS)
Maternal Venous Blood
TissueFactor
FetalCells
AmnioticFluid Proteins
Geoghegan J, BJOG 2009 May;116(6):743-7
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Intraoperative Cell Salvage (IOCS)
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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Intraoperative Cell Salvage (IOCS)
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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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Anesthetic Neurotoxicity
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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Anesthetic Neurotoxicity
No differences in learning disabilities irrespective of
the type of anesthesia for cesarean delivery
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Anesthetic Neurotoxicity
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