Transform Delivery Suite Into ICU for Emergencies


MIAMI BEACH — Treat the labor and delivery suite like an intensive care unit when a maternal intrapartum emergency arises, Dr. Baha Sibai said during a presentation at an ob.gyn. conference sponsored by the University of Miami.

An obstetric emergency response team is vital. This team needs mandatory training in obstetric emergencies, including advanced life support, Dr. Sibai said.

In addition, there should be “fire drills” for common emergencies such as pulmonary edema, abruptio placentae, disseminated intravascular coagulation (DIC), and complications from acute fatty liver of pregnancy.

Increases in maternal age, obesity, nulliparity, and multifetal gestations are spurring a higher incidence of these intrapartum emergencies.

“We are also seeing more women with severe, preexisting conditions, such as cystic fibrosis. I also have two women on dialysis now,” said Dr. Sibai, professor and chairman of obstetrics and gynecology at the University of Cincinnati.

Mandatory policies and procedures for physicians responding to maternal intrapartum emergencies should be required, as they are for nurses, Dr. Sibai said. “Some of you will not like this, but you cannot let every physician do what they want.”

Immediate resuscitation and support of the cardiovascular, respiratory, central nervous, and renal systems are important. Also check and continuously monitor hemostasis, electrolytes, and vital signs, he said.

Act quickly. “You cannot delay things 1 or 2 hours—it may be too late to do anything,” Dr. Sibai said.

Consider crystalloids, colloids, blood and blood products, inotropic agents, and vasopressors for maternal cardiovascular support, Dr. Sibai suggested.

Options for respiratory support include mechanical ventilation, placement of an oro- or nasopharyngeal airway, or administering oxygen by continuous positive airway pressure (CPAP). “A CPAP mask avoids intubation, but if respiratory distress is severe, intubate and ventilate,” he advised.

“You need to know how much oxygen you can deliver by different modalities,” Dr. Sibai said. “If you don't know, ask an anesthesiologist. And remember that none of this matters if you don't have adequate circulation,” Dr. Sibai said.

Some of the more common maternal intrapartum emergencies include the following:

Pulmonary edema. Preeclampsia and eclampsia are the leading causes, but the condition also can be caused by tocolytics, cardiac disease, and infections such as pyelonephritis or varicella pneumonia. Pulmonary edema in preeclampsia is associated with capillary endothelial damage, Dr. Sibai said, which can cause increased permeability, increased interstitial oncotic pressure, and sepsis.

Tocolytics can cause increased capillary wedge pressure, fluid overload, and a need for blood transfusion, Dr. Sibai said, particularly in women with underlying risk factors.

There can also be high output failure caused by multifetal pregnancy, anemia, infection, thyroid disease, or tachycardia.

Treatment of pulmonary edema includes stopping tocolytics, placing the patient in a 45-degree position, giving morphine sulfate 10–15 mg IV, or giving furosemide 20–40 mg IV.

Abruptio placentae. Risk factors for abruptio placentae include preterm premature rupture of the membranes, preeclampsia/hypertension, major abdominal trauma, and substance abuse.

“If the abruptio is occult—you don't see blood—these are the highest risk [cases] for the baby.” By the time you perform a cesarean section, the baby will be dead, Dr. Sibai said.

If a patient presents with abruptio placentae and DIC, give four units of packed red blood cells right away, Dr. Sibai said. “Don't use your brain or think. Just administer, and don't give just one or two units.”

Also give four units of fresh frozen plasma, administer platelets if levels are below 40,000, and monitor coagulation studies. Maintain renal perfusion and deliver the baby.

Disseminated intravascular coagulation. There are three types of disseminated intravascular coagulation. DIC of consumption is very easy to correct, Dr. Sibai said. Once you remove the placenta, the patient will be back to normal within 24 hours. DIC as the result of production (for example, from a fatty liver) can be very difficult and take a week or more to correct. Dilutional DIC occurs when a patient is losing coagulation factor through blood loss while an anesthesiologist is giving fluid. “This is when you have to start calling for fresh frozen plasma,” Dr. Sibai said.

Other treatment options include packed red blood cells, platelets, cryoprecipitate, and recombinant factor VII. “You need these things handy, along with people who know how to use them,” Dr. Sibai said. “A lot of anesthesiologists are familiar with these things, so make use of them.”

Acute fatty liver of pregnancy. “Women with fatty liver are among the sickest women you will see,” Dr. Sibai said, and a differential diagnosis from HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome is important because of overlapping symptoms and laboratory findings.

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