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Maternal morbidityDR JAMES ELDRIDGE
QUEEN ALEXANDRA HOSPITAL PORTSMOUTH
Maternal Morbidity One
Maternal Morbidity Two
MBRRACE UPDATE
PRE-ECLAMPSIA
OBESITY
MATERNAL COLLAPSE
CARDIAC DISEASE
Maternal Morbidity One
Maternal Morbidity Two
MBRRACE UPDATE
CARDIAC DISEASE
AMNIOTIC FLUID EMBOLISM
THROMBOPROPHYLAXIS
MATERNAL COLLAPSE
PRE-ECLAMPSIA
ANAESTHESIA
OBESITY
Maternal
Mortality
rates
2015Estimates by WHO,
UNICEF, UNFPA, World
Bank Group and the
United Nations Population
Division
Millennium Development Goal region
MMR
Range of MMR uncertainty(80% UI)
Lower estimate Upper estimate
World 216 207 249
Developed regions 12 11 14
Developing regions 239 229 275
Northern Africa 70 56 92
Sub-Saharan Africa 546 511 652
Eastern Asia 27 23 33
Eastern Asia excluding China 43 24 86
Southern Asia 176 153 216
Southern Asia excluding India 180 147 249
South-eastern Asia 110 95 142
Western Asia 91 73 125
Caucasus and Central Asia 33 27 45
Latin America and the Caribbean 67 64 77
Latin America 60 57 66
Caribbean 175 130 265
Oceania 187 95 381
Millennium Development Goal region
MMR
Range of MMR uncertainty(80% UI)
Lower estimate Upper estimate
World 216 207 249
Developed regions 12 11 14
Developing regions 239 229 275
Northern Africa 70 56 92
Sub-Saharan Africa 546 511 652
Eastern Asia 27 23 33
Eastern Asia excluding China 43 24 86
Southern Asia 176 153 216
Southern Asia excluding India 180 147 249
South-eastern Asia 110 95 142
Western Asia 91 73 125
Caucasus and Central Asia 33 27 45
Latin America and the Caribbean 67 64 77
Latin America 60 57 66
Caribbean 175 130 265
Oceania 187 95 381
Maternity and Child Welfare Annual Report of the Chief Medical Officer 1920
Maternal Mortality 430 /100,000 live births
No Deaths
Puerperal fever 1730
Puerperal albuminuria and convulsions 749
Haemorrhage 521
Puerperal phlegmasia alba dolens, embolism 347
Accidents of pregnancy 329
Puerperal insanity 40
0
100
200
300
400
500
600
700
1850 1900 1950 2000
Mate
rnal M
ort
ali
ty /
100,0
00
bir
ths
Sulphonamides
Penicillin
Ergotamine
Transfusion service
Safe Caesarean Section
Safer induction for PET
The Transformation of Maternal MortalityLoudon
BMJ 1992
Confidential Enquiries in to Maternal Deaths
Trends in Maternal Deaths 1985 - 2014
0
2
4
6
8
10
12
14
16R
ate
s / 1
00
,00
0 m
ate
rnit
ies
Total
Indirect
Direct
Trends in Maternal Mortality
0
2
4
6
8
10
12
14
16
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Rate
per
100,0
00 m
ate
rnitie
s
Mid-year for each three year period
Total deaths
Direct deaths
Indirect deaths
MBRRACE 2018
Direct deaths associated with substandard care
0%
20%
40%
60%
80%
100%
1952-54 2014-16
Improvements to care may have made a difference to outcome
Improvements to care identified but no difference in outcome
Good care
Common◦ Failure of referral
◦ Failure of seniors to attend
◦ Protocols
◦ Communication between specialities
◦ Failure of early identification or severity of disease
CEMD 1955-2018
Thrombosis14%
AFE4%
Haemorrhage8%
Sepsis5%
(Pre)Eclampsia3%
Anaesthesia1%
Other Direct Causes9%
Indirect Causes56%
UK maternal deaths 2014-16
MBRRACE 2018
Thrombosis14%
Haemorrhage8%
(Pre)Eclampsia3%
Indirect Causes56%
UK maternal deaths 2014-16
MBRRACE 2018
Thrombosis14%
AFE4%
Haemorrhage8%
Sepsis5%
Indirect Causes56%
UK maternal deaths 2014-16
MBRRACE 2018
“I can’t breath!”
27 year old fitness instructor
38/40 Primip
Cat 2 CS for failure to progress
BMI 24. Previously fit and well – “spinning” the previous day
Uneventful spinal CS
Syntocinon bolus and syntocinon infusion
Noted SaO2 94% in recovery
Sent back to ward
1 hour later anaesthetist called to review –◦ SaO2 88%
◦ Tachypnoea
◦ Struggling to breath
Direct44%
Indirect56%
UK maternal deaths 2014-16
MBRRACE 2018
MBRRACE 2018
Direct44%
Cardiac24%
Indirect32%
UK maternal deaths 2014-16
Florid pulmonary oedemaRequired rapid intubation and diuretics and inotropesEcho showed mitral valve prolapse and mitral regurgitationTransferred to cardiac surgery centre
Slow recoveryExtubated after 3 days
Mitral valve repair semi-electively 3 weeks laterGood recovery
Lulled by exceptional fitnessConfessed after event that she had felt breathless, but presumed it was normal in pregnancy
Classic timing of presentation – 1-2 hours post delivery.
Year Surveillance data Enquiry Topic Reports Morbidity
Year 32016
2012 -2014
CardiacPreeclampsia & EclampsiaEarly pregnancyCritical Care
Cardiac diseases
Year 42017
2013-2015
AnaesthesiaHaemorrhage, AFE & SepsisEpilepsyRespiratoryStroke, endocrine and other indirect causes
Severe epilepsy
Year 52018
2014-2016
Thrombosis and thromboembolismPsychiatric causesHomicidesMalignancy
Massive obstetric haemorrhage including peripartum hysterectomy
Cardiac disease 09-14SADS/MNH n = 47
(Sudden Arrhythmic Cardiac deaths with morphologically normal heart)
Ischaemic deaths n = 34Atherosclerosis (n = 16)Coronary artery dissection (n = 11)
Myocardial disease / cardiomyopathy n = 27Dilated cardiomyopathy (n = 4)Left ventricular hypertrophy (n = 5)Peripartum cardiomyopathy (n = 9)
Aortic dissection n = 21Valvular heart disease n = 11Essential hypertension n = 6Pulmonary artery hypertension n = 6
Congenital heart disease (included in above) n = 11
MBRRACE 2016
Cardiac disease and pregnancyThink “Is she symptomatic?”
Pre-pregnancy counselling◦ Transition from paediatric to adult care is a recognised risk
HYHA Class Symptoms
I No Symptoms and no limitations in ordinary activity
II Mild symptoms and slight limitations
III Marked limitations even in day to day activity
IV Severe limitations, even at rest – often bed bound.
MBRRACE 2016
Cardiac Disease in Pregnancy
0 20 40 60 80 100
Percentage Mortality
Rheumatic heart disease
VSD
ASD
Tetralogy of Fallot
Eisenmenger's
Pulmonary hypertension
Cardiac disease and pregnancyMDT meeting and senior involvement
Consider need for and method of anticoagulation for antepartum, peripartum and postpartum periods
Consider place of antenatal care and delivery◦ Home / DGH / Tertiary centre / Cardiac theatre
Consider timing of delivery
Consider method of delivery
MBRRACE 2016
Cardiac disease and peripartum careMake sure relevant teams are aware when labour starts
Minimise cardiovascular stress◦ Slow incremental onset epidural analgesia◦ Limited pushing in 2nd stage / assisted vaginal
delivery◦ Rarely indication for CS◦ Be aware of CVS effects of uterotonics◦ Be wary of fluid shifts and changes in CO at delivery
Post partum consider whether level 2/3 care required
Remember advice on contraception
Haemodynamic Effects of Syntocinon
-35
-30
-25
-20
-15
-10
-5
0
5
10
15
0 15 30 45 60 75 90 105 120 135 150 165 180 195 210 225 240 255 270 285 300
Time (s)
Ch
an
ge i
n M
AP
(m
mH
g)
Bolus Mean
Infusion Mean
28 Women
5 iu syntocinon bolus or infusion
BJA 2007
Cardiac disease and pregnancyMDT meeting and senior involvement
Consider need for and method of anticoagulation for antepartum, peripartum and postpartum periods
Consider place of delivery◦ Home / DGH / Tertiary centre / Cardiac theatre
Consider timing of delivery
Consider method of delivery
Consider effects of preload / afterload / contractility
Consider uterotonics
Have a written plan in notes
MBRRACE 2016
MBRRACE Cardiac deaths:Key Points & recommendations
Symptoms such as ↑Resp rate, chest pain, persistent ↑HR and orthopnoeashould be fully investigated. Pulmonary oedema can present as wheeze◦ Aim to make a diagnosis not just exclude a diagnosis
◦ A normal ECG and/or a negative troponin does not exclude acute coronary syndrome
Remember women with prosthetic heart valves are at extremely high risk. Beware absence of valve clicks
Investigate family following SADs/MNH death
MBRRACE 2016
39 year old, BMI 50, Weight 141kgP2 at 38/40. Elective CS
CSE anaesthetic, block a little high – tingly fingers
Uterine incision - difficult delivery
Patient coughs and says “I cant breath”
“I can’t breath!”
Diagnosis?
Hand grip still present
Saturations start to fall
GA induced and intubated
EMD, CPR commenced
Baby delivered
Output re-established with 1mg adrenaline
Echo shows grossly dilated right ventricle
Patient “oozy” – FFP, TXA and cryoprecipitate given
Clotting at zero and 2 hours mildly deranged
Echo at 24 hours normal
Thrombosis14%
AFE4%
Haemorrhage8%
Sepsis5%
(Pre)Eclampsia3%
Anaesthesia1%
Other Direct Causes9%
Indirect Causes56%
UK maternal deaths 2014-16
MBRRACE 2018
AFE4%
UK maternal deaths 2014-16
MBRRACE 2018
Principally diagnosis of exclusion
Rare and potentially catastrophic
Incidence of 1:8000 – 1:30,000
Mechanismmechanical and/or immune mediated
Commonly right heart failure
13-86% mortality
Most (>80%) develop DIC
20-40% neonatal mortality
Amniotic Fluid Embolism
UKOSS Criteria for diagnosis of AFE
Test Possible findings
Non-specific tests
Full blood count Low haemoglobin
Coagulation Low platelets, increased PT and APTT, low fibrinogen
Arterial blood gas Hypoxaemia, raised PaCO2
Chest X-ray Normal, cardiomegaly, pulmonary oedema
ECG Right heart strain, rhythm abnormalities
V/Q scans V/Q mismatch
Echocardiogram Right or left ventricular dysfunction, low ejection fraction
More specific tests (but still not very specific or sensitive) None are established tests
Pulmonary blood sample Presence of squamous cells coated with neutrophils and presence of fetal debris
Sialyl Tn antigen Raised
Zinc coproporphyrin Raised
Serum tryptase levels Normal or raised
Metodiev, BJA Education , August 2018
AFE : Presenting signs & symptomsSymptoms Signs
Dyspnoea Hypotension
Cough Fetal distress
Headache Pulmonary oedema/ARDS
Chest pain Cardiopulmonary arrest
Cyanosis
Coagulopathy
Seizures
Uterine atony
Bronchospasm
Transient hypertension
Metodiev, BJA Education , August 2018
AFE : Differential diagnosisOther embolismn - Thrombotic or air
Anaphylaxis
Eclampsia
Acute myocardial infarction
Septic shock
Anaesthetic complications – high block, local anaesthetic toxicity, aspiration
Cerebrovascular accident
Haemorrhage
Metodiev, BJA Education , August 2018
AFE : TreatmentSupportive• A - early protection of airway
• B – High FiO2, PEEP
• C (& lateral tilt) – Fluid and ionotropes
• Early blood gases and clotting (including fibrinogen)
• Rapid delivery of fetus (expect uterine atony)
• Blood products (early liaison with haematologist)
• CVP / Art line / Urine output
Metodiev, BJA Education , August 2018
AFE : TreatmentGet help!
• Senior obstetrician
• Senior anaesthetist
• Intensivists
• Cardiologists (bedside - echo)
• Haematologists
May require prolonged CPR
UKOSS Amniotic fluid embolism register
http://www.npeu.ox.ac.uk/ukoss.
AFE Key messagesPerimortem caesarean section should be carried out within five minutes of cardiac arrest.
It is prudent to trigger the massive obstetric haemorrhage protocol.
It is important to replace major blood loss with red cells, plasma and platelets as soon as possible to avoid the dilutional effects of volume expanders.
The effectiveness of replacement and supportive therapy should be continuously monitored (including measures of adequate perfusion ie lactate)
MBRRACE 2014
“I can’t breath!”
32 year old midwifery sister
38/40 Primip
Epidural for labour
2nd Top-up
Cardio-Pulmonary Resuscitation (CPR) for “obviously pregnant” mothers
Follow normal BLS
Follow normal ALS
◦ Think of obstetric causes
and get baby off inferior vena cava
Non Pregnant 32 Week Gestation
BJA 1996; 77: 150
Basic Life Support
Can achieve 30% of the normal cardiac output
Think• Rate • Depth• Recoil
Basic Life Support
Can achieve 3% of the normal cardiac output
Displacement of the uterus
Peri-mortem deliveryIf after 4 minutes no return of circulation deliver fetus either vaginally or by perimortem caesarean section
o Improves venous return
o Removes IVC obstruction
o Autologous transfusion with uterine contraction
o Improves chest compliance
o Reduces oxygen demand
o Improves maternal fetal survival (case reports)
o Reported good outcomes for both mother and baby after 30 minutes arrest!
Basic Life Support
I shock150 J -360 J Biphasic
360 J Monophasic
Assess rhythm
CPR for 2 min
Non VF/VT
Assess rhythm
VF/VT
CPR for 2 min
During CPR• Ensure high quality CPR – rate, depth, recoil• Minimise interruptions to CPR• Consider advanced airway and capnography• Continuous chest compresssions once airway in
place• Vascular access• Give adrenaline every 3 mins• Correct reversible causes
Hypoxia Tension puemothoraxHypovolaemia Tamponade (cardiac)Hypo/hyperkalaemia ToxinsHypothermia Thrombosis (coronary or pulmonary)
Reversible causes4 Hs 4 Ts
Specific maternal causes of cardiac arrest - BEAUCHOPS:
Bleeding/DIC
Embolism: coronary, pulmonary,
amniotic fluid embolism
Anaesthetic complications
Uterine atony
Cardiac disease: MI, ischemia, aortic
dissection, cardiomyopathy
Hypertension: preeclampsia/eclampsia
Other: differential diagnosis of
standard ACLS guidelines.
Placenta abruptio or previa
Sepsis
Perimortem Caesarean Delivery
Call the right teams◦ Adult cardiac arrest + Obstetric crisis team + Neonatal crisis team
Remove fetal monitoring if possible
If possible deliver fetus vaginally, if not possible and in hospital perform CD at site of arrest
Performing a PMCD◦ Most senior surgical individual available
◦ Preferably caesarean delivery pack (ED and delivery suite)
◦ Gloves, scalpel, two forceps and packs
◦ Midline or Pfannenstiel incision – depending on surgical experience
◦ ?Uterotonics
◦ Expect bleeding even before ROSC
If ROSC occurs: ◦ think anaesthesia/sedation
◦ Think antibiotic prophylaxis
◦ Think about transfer to an operating theatre for abdominal closure
“I can’t breath!”
After a woman with known substance dependence had surgical management of an ectopic pregnancy …
she presented with shortness of breath and tachycardia.
After a woman with known substance dependence had surgical management of an ectopic pregnancy no risk assessment for VTE was carried out.
When she presented with shortness of breath and tachycardia the focus was on concern about possible withdrawal symptoms though the cause of her symptoms was the pulmonary embolism from which she died.
Thrombosis and Thromboembolism
MBRRACE 2018
Reassessment of VTE risk after miscarriage and ectopic pregnancy … is as important as reassessment … after giving birth.
Antenatal deaths due toThromboembolism 1997-2016
0
5
10
15
20
25
30
35
40
45
50
1st trimester 2nd and 3rd trimesters
Nu
mb
er
of
De
ath
s
CEMD 1997-2014
• Clear pathways for women who need thromboprophylaxis as soon as they become pregnant
• Reassessment of VTE risk after miscarriage and ectopic pregnancy
• Any surgical procedure in pregnancy or puerperium should have 10 days of postnatal thromboprophylaxis.
(RCOG Green-top Guideline 37a 2015)
0
0.5
1
1.5
2
2.5
3
3.5
Rate
per
100,0
00 M
ate
rnit
ies
CEMD 1990-2018
Thrombosis and Thromboembolism
Thrombosis and Thromboembolism
0
0.5
1
1.5
2
2.5
2011 2012 2013 2014 2015
Rate
per
100,0
00 m
ate
rnitie
s
Mid-year for each three year period
Deaths due to thrombosis and thromboembolism
MBRRACE 2018
Lessons -Thrombosis and Thromboembolism:
Women at risk in early pregnancy
Re-assess risk after miscarriage or ectopic pregnancy
Obesity substantial risk. Women with a raised BMI should be given information about symptoms of VTE
Give LMWH asap - at end of surgery after GA or 4 hrs after neuro-axial
Prescriptions for entire postnatal course should be issued in secondary care.
MBRRACE 2015 & 2018
Leading Causes of Maternal Deaths2014-16
0
0.5
1
1.5
2
2.5
3
Card
iac D
isea
se
Th
rom
bo
sis
&T
hro
mb
oe
mb
oli
sm
Oth
er
Ind
irec
t C
au
ses
Neu
rolo
gic
al
Psy
ch
iatr
ic
Sep
sis
Hae
mo
rrh
ag
e
Am
nio
tic F
luid
em
bo
lism
Malig
nan
cie
s
Pre
-ecla
mp
sia
/E
cla
mp
sia
Earl
y P
reg
nan
cy D
ea
ths
An
ae
sth
esia
De
ath
s /
10
0,0
00
ma
tern
itie
s
Direct Indirect
MBRRACE 2018
Admitted in labour with BP 170/90
No Urine analysis
3 hours later she had a neurological event
Given magnesium
She was transferred to theatre for caesarean section under general anaesthesia. No antihypertensives were given prior to intubation nor was fentanyl given until after delivery of the baby.
She did not recover from her general anaesthetic and was found to have had a large intracranial bleed.
MBRRACE 2016
Key Messages for Preeclampsia / eclampsia
Early onset threat to mother and fetus (< 34 weeks)
Aggressive treatment of (systolic) BP◦ BP > 180mmHg medical emergency
◦ Maintain BP < 150 mmHg
◦ Care with intubation and extubation
Care with fluid
Magnesium sulphate is treatment for eclampsia and pre-eclampsia
Preeclampsia
Liver dysfunction
Thrombocytopenia
HELLPHaemolysis
HUS/TTP
Acute Fatty Liver
GT / ITP
Overlapping circles
Renal
Pulmonary
CNS
Treatment of Hypertensive Disease of PregnancyPrimary treatment
◦ Aspirin◦ Calcium supplements◦ LMWH (Meta-analysis Carrier 2014)
Secondary prevention◦ Early detection◦ Prevent progression
Tertiary prevention◦ Treat dangerous symptoms & deliver placenta at appropriate time◦ Trade “risk to mother” vs “fetal development”
◦ < 34/40 Wait if possible; >37/40 deliver; 34-37/40 remains uncertain
Treatment of Hypertensive Disease of Pregnancy
Treat hypertension aiming for BP < 150/100◦ Oral Labetalol
◦ Oral nifedipine
Treat severe hypertension (BP > 160/110 despite above)◦ IV labetalol
◦ Oral nifedipine
◦ IV hydralazine
Fluid restriction◦ 80 ml/hr (or 1ml/kg/hr)
0
2
4
6
8
10
12
14
16
18
20
Intr
acra
nia
lh
aem
orr
hag
e
Ecla
mp
sia
/cere
bra
l o
ed
em
a
Pu
lmo
nary
oed
em
a
He
pa
tic
ru
ptu
re
Hep
ati
cn
ecro
sis
/HE
LL
P
AF
LP
No
. o
f d
eath
s
1997-2002
2003-2008
2009-2014
Mode of Death
Treatment of Hypertensive Disease of PregnancyTreat Hypertension aiming for BP < 150/100
◦ Oral Labetalol
◦ Oral nifedipine
Treat Severe hypertension (BP > 160/110 despite above)◦ IV labetalol
◦ Oral nifedipine
◦ IV hydralazine
Fluid restriction
Reduce risk of fits
Deliver
MagnesiumPET/eclampsia
Arrhythmias
Asthma
Anaesthesia / analgesia
Reduced cerebral palsy
(Reduce response to intubation)
Mechanism of action
vasodilator relieving vasoconstriction.
may protect the blood-brain barrier and limit cerebral oedema formation
NMDA receptor antagonist
may have a central anticonvulsant action
Magnesium
Complications • Reduced muscle strength
• Uterine relaxation
• Hypotension
• Arrhythmias
Treat overdose with iv calcium
Dose • 4g iv Loading dose
• 1g/hr infusion for 24 hours
Anaesthesia and Preeclampsia Care with hypertensive agents
◦ Phenylepdrine / ephedrine
◦ Ergometrine
Care with NSAIDs
Fluid management (including infusions!)
Spinal or Epidural◦ Dependent on platelets and clotting
◦ Reduced incidence of hypotension
GA
Hypotension
Hypo-Perfusion
of Placental Bed
Rapid
Sympathectomy
Intracranial
HaemorrhagePulmonary
Oedema
Hypertension
PET
Aorto-caval
Occlusion
GA
GA and Severe pre-eclampsia
Diastolic > 110 mmHg◦ Arterial line
Obtund intubation response◦ Opiate (alfentanil or remifentanil)
◦ Labetalol / esmolol
◦ Not magnesium or lidocaine
More opiate before extubation
Learning pointsEarly involvement of senior obstetricians and anaesthetists
Communication
Beware epigastric pain◦ HELLP / Intrahepatic bleed / Hepatic rupture
Adequacy of non-invasive BP measurement? ◦ A’line for GAs in severe disease
Sepsis
Maternal sepsis definition WHO 2017
“A life threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or the postpartum period”
Sepsis in pregnancyPregnancy causes modulation of immune system to accept foreign proteins.
Can appear well, despite widespread inflammation.
Usually heart rate, blood pressure, temperature and/or respiratory rate give an indication of early stages of sepsis.
Genital Tract Sepsis:
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Ra
te p
er
10
0,0
00
Ma
tern
itie
s
Deaths from Direct Sepsis 2013-20157 deaths from genital tract sepsis
4 deaths from urinary tract or wound infections
1 death from influenza (H1N1)◦ Decrease probably because of prevalence of less virulent strains
Symptoms of Genital Tract Sepsis
GENERAL
Fever
Sore throat
Influenza-like illness
Diarrhoea
Vomiting
Shortness of breath
Wound infection
SPECIFIC
Premature contractions
Abdominal pain
Sickle cell crisis
Atonic uterus causing PPH
Mastitis
Vaginal discharge – profuse and malodorous
Genital Tract Sepsis:
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Ra
te p
er
10
0,0
00
Ma
tern
itie
sAll causes sepsis
Maternal Mortality Rate due to Sepsis 2009-2015
0
0.2
0.4
0.6
0.8
1
1.2
2009-11 2010-12 2011-13 2012-14 2013-15
Rat
e p
er 1
00
,00
0 m
ater
nit
ies
Direct Sepsis - pregnancy related infections
Indirect Sepsis - Inflenza
Indirect sepsis - pneumonia/others
Organisms
Prevent delays in diagnosis
Pregnant women/recently delivered should be given information about signs and symptoms
Healthcare professionals regular training
MEOWS charts
Sepsis Screening Tools
Signs of SIRS
UK SEPSIS TRUST 2014
ANY TWO of
Confusion / altered mental state
Pyrexia (or hypothermia) >38.3oC or < 36oC
Persistent tachycardia > 100* bpm
Tachypnoea > 20 bpm
WBC > 12 or < 4 x 109/L
Glucose > 7.7mmmol/L
ALSO CONSIDER
↑CRP
Fetal loss
Lactic acidosis
Abdo pain requiring opiate
Organ de-compensation including confusion
*Note the guidelines are not specific for pregnancy and these observations should be interpreted in the context of the normal physiology for the pregnant woman. RCOG guidance suggests using a threshold of 100 beats per minute in pregnancy
Signs of SIRS + organ de-compensation
Systolic BP < 90 mmHg
Heart Rate > 130 bpm
Oxygen Sats < 91%
Resp Rate > 25
AVPU “V”, “P” or “U”
Act immediately if presence of any one of:
Lactate > 4 mmol/l
Creatinine > 175 μmol/l
Platelets < 100 x 109/l
Bilirubin > 34 μmol/l
INR >1.5
Urine Output < 0.5 ml/kg/hr
Treatment of Sepsis: Care Bundles
RESUSCITATION BUNDLE
SEPSIS SIX
Maintain saturation with facial oxygen
Obtain cultures
Give antibiotics
Measure serum lactate
Give intravenous fluid
Commence accurate urine output measurement
FURTHER MANAGEMENT BUNDLE
With hypotension (or ↑ lactate)
◦ Use vasopressors
◦ CVP > 8mmHg
◦ Consider steroids
Consider transfusion if Hb < 7g/dl
Surgical source control
Key Messages: Think sepsis
Timely recognition
Fast administration of antibiotics
Quick involvement of experts andsenior review
◦ Obstetric team
◦ Anaesthetics and critical care
◦ Microbiology
◦ Radiology
◦ Infectious disease physicians
Influenza vaccination
MBRRACE 2014
LessonsImportance of thromboprophylaxis
Importance of recognising PDPH
Communication with GP
Arranging follow-up until resolution
Serious neurological symptoms require urgent referral and/or imaging
If reduced LOC, transfer must be with appropriate medical (anaesthetic) involvement
MBRRACE 2014
Key points5% PDPH are not postural
Incidence of PDPH ◦ >50% after 16/18G Tuohy
◦ 1/3 dural puncture was not recognised
◦ 1.5-11.2% after spinal anaesthesia
Rare but serious complications include cerebral vein thrombosis and intracranial haemorrhage, cranial nerve palsies (VI & VII), seizures
Bed rest may provide temporary relief (DVT prophylaxis)
Simple analgesics should be used
Caffeine may be tried, but treatment limited to 24 hours. Benefit limited to 4 hours. Possible ↑risk of seizures.
No or insufficient evidence for all other treatments apart from blood patch.
This includes: other theophyllines, ACTH and analogues, steroids, triptans, gabapentinoids, DDAVP, methylergonovine, ondansetron, acupuncture, greater occipital nerve block, spenopalatine ganglion block, epidural morpine, epidural crystalloids, dextrans, HES, gelatin, or fibrin glue.
Key pointsBlood patch success rates
◦ Early studies suggested >90%
◦ Recent studies suggest ◦ complete success 30%
◦ Complete or partial success 50-80%
Timing◦ EBP <48 hours has reduced success
Volume – 20ml max
Routine imaging is not required if history and symptoms are typical
Written information should be provided and systemic and “red-flag” symptoms suggesting alternative diagnosis should be excluded
Complications of EBP includes◦ Repeat dural puncture
◦ Back pain -80% at 24 hours. No evidence for chronic backpain
Case reports of:◦ Arachnoiditis (4 cases) – possible associated with
large volumes of blodd – use <20 ml
◦ Isolated reports of spinal-subdural haematomas
◦ Seizures (4 obs cases)
◦ Venous sinus thrombosis (5 cases)
MBRRACE 2018
Anaesthesia1%
UK maternal deaths 2014-16
Lessons for Anaesthesia
◦ Total number of deaths is small.
◦ Focused on prevention and lessons.
Key messages for Anaesthesia 2013-15Ability to palpate a pulse may not indicate adequate cardiac output.
Pulmonary aspiration risk remains prevalent.
CEMD: Cause of Anaesthetic Deaths 1988-2014Failed Airway Management
0
1
2
3
4
5
6
7
8
1988-90 1991-93 1994-96 1997-99 2000-02 2003-05 2006-08 2009-11 2012-14
Nu
mb
er o
f D
eath
s
Deaths not related to airway Deaths associated with failed airway
Key messages for Anaesthesia 2013-15
Ability to palpate a pulse may not indicate adequate cardiac output
Pulmonary aspiration risk remains prevalent.
In cases of MOH, before extubation ensure that patient is warm, adequately resuscitated, bleeding stopped and lactate normalised.
Beware aortocaval compression.
Prophylactic vasopressors should be used for spinal anaesthesia.
Use 7.0mm for intubation and smaller tubes should be immediately available.
Blood transfusion should not be delayed by false reassurance from a single haemoglobin result.*
Obesity39 year old
P2 – two normal deliveries in 2008 and 2011
209kg
Otherwise fit and well!
Quetelet formulaBelgian statistician
Compare populations
1800ish Norwegian fishing village data
Body Mass Index
BMINormal Distribution
Obesity defined as 2 standard deviations from mean
UKOSS Comparison Women
Knight Obstet &Gynecol 2010
BMISkewed “normal” distribution
Obesity defined by WHO
BMIBMI WHO 2000
RGOG and CMACE 2010
NHSIC*
< 18 Underweight Underweight
18-25 Normal Normal
25-30 Overweight Overweight
30-35 ObeseClass 1
Obese Class 1
35-40 ObeseClass 2
ObeseClass 2
>40 ObeseClass 3
Morbidly Obese
>50 Super-Morbidly Obese
Extreme Obesity
*NHS Information Centre
BMISkewed “normal” distribution
Obesity defined by WHO
Limitations ◦ Definitions may need to change for different populations
◦ Lean body mass
◦ Pregnancy etc
EASY
BMI and maternal deaths
0
5
10
15
20
25
30
35
40
45
<20 20-24 25-29 30-34 35-39 >40
Pe
rce
nta
ge o
f W
om
en
BMI
UKOSS study of635 pregnantwomen
Maternal deaths2009-12
Knight Obstet &Gynecol 2010
Over weight and ObeseCMED 2006-08
Risks related to obesity in pregnancyFor the Mother
Spontaneous 1st trimester and recurrent miscarriage
Maternal death or severe morbidity
Cardiac disease
Preeclampsia
Dysfunctional labour
Gestational diabetes
Thromboembolism
Caesarean section
Wound infection post CS
Post partum haemorrhage
Low breastfeeding rates
For the Baby
Still birth
Congenital abnormalities
Prematurity
Shoulder dystocia
CMACE 2006-08
Thyroid Function
Immune system
Cancers
Arthropathies
Increased intraabdominal pressure
Diabetes
Idiopathic Intracranial Hypertension
Fertility
Respiratory disease
and hypoxia and OSA
Cardiovascular disease
Labour, delivery,
analgesia and anaesthesia
Obesity and DeliveryBMI > 35 - Consultant lead unit•NICE Guideline No.55 2007
BMI > 30
Slow labour progression
↑ Difficulty of fetal monitoring
↑Emergency caesarean section ◦ Bonnesen 2013 BMI> 50 doubles EmCS◦ UKOSS 2010 BMI> 50 = 50% CS
↑Difficulty of caesarean section
↑Post partum haemorrhage
Obesity and DeliveryDifficulty in monitoring fetus
Macrosomia – (BMI> 50 - 5 x risk of NICU admission1)
1 Bonnesen 2013
Antenatal discussion, decisions and
planning
Antenatal AssessmentFor whom?
BMI > 40 (?35- ?50)
1. Airway
–Neck circumference
• 35% difficult if NC > 60 cm (23")
–Mallampati
– Tongue size
2. Lumbar spinous processes
3. Obstructive Sleep Apnoea
4. Venous access
Can a GA be performed safely by labour ward anaesthetists?
If No:
• Inform mother, midwives and obstetricians that an urgent Cat 1 in < 30 minutes may not be possible.
• Careful discussion with mother about implications of requiring senior anaesthetic presence.
• Early epidural in labour (? which anaesthetist)
• Must be flagged to anaesthetist on admission in labour
Can a GA be performed safely by labour ward anaesthetists?
If Yes:
• Discuss advantages of early epidural in labour
• Must be flagged to anaesthetist on admission in labour
Planning: EquipmentTheatres
◦ BP cuffs, long epidural / spinal needles
◦ Airway devices
◦ Hover mattresses
◦ Oxford wedge
◦ Foot retainers
◦ Ultrasound
◦ Lateral supports
Labour Analgesia
Labour analgesia and obesityEpidural – early and by senior epiduralist◦ “Get Out of Jail Free”
◦ More difficult◦ ↑failure rate
◦ ↑intravenous cannulation rate
◦ ↑dural puncture rate
◦ Epidural fixation◦ Be aware catheter movement at
skin with movement (upto 4 cm!)
If it fails – resite it!
Epidural Space and BMI
Clinkscales IJOA 2007
Anaesthesia
Regional AnaesthesiaHave a selection of regional block needles
Use usual doses
Expect high blocks (esp. epidurals)
? CSE◦ Technically harder
◦ Higher failure of spinal
◦ Able to rescue poor analgesia, prolonged surgery
General AnaestheticsAntacids in labour
Right anaesthetist and right surgeon(s)
Plan B and C discussed for failed intubation
Positioning
Pre-oxygenation◦ Mask + nasal cannulae
◦ 3L/min pre-induction
◦ 5-15L/min if problem at intubation
General AnaestheticsCalm room
Induction
Drugs dosage:◦ Lean body mass for thiopentone and propofol (induction dose), fentanyl
atracurium and rocuronium.
◦ Adjusted body weight: Sugammadex, alfentanil, neostigmine, antibiotics
ABW = LBM + 40% excess weight.
General AnaestheticsBeware extubation
Beware recovery◦ Night time
◦ General anaesthetic
◦ Busy labour ward
◦ Untrained midwife
◦ Obesity and OSA
HypoventilationPatient was obese.
Prolonged hypoventilation post extubation.
Inadequate monitoring.
Lessons
Recovery must be the same standard as non-obstetric patients including documentation.
Monitoring should include pulseoximetry
Consider capnography
Consider arterial blood gases
MBRRACE 2014
Questions?
