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 2011 Missionary Medicine Seminar 19 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 20 “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 2011 Missionary Medicine Seminar 21 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 22 “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 2011 Missionary Medicine Seminar 23 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 24 “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. 2011 Missionary Medicine Seminar 25 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