1. Anaesthetic management of obstetric emergencies
Dr M Booyens
Mb,chb (ufs), da (sa)
Medical officer – anaesthesia – RMS Hospital

3. Content Umbilical cord prolapse Antepartum Hemorrhage (APH)
Postpartum Hemorrhage (PPH)
Hypertensive disorders
HELLP syndrome
Amniotic fluid embolism
Anaesthesia for obstetric patients
Maternal resuscitation

6. Indications for emergency cesarian section
True emergency vs urgent surgery
Emergency (threat to mother, baby or both):
Massive bleeding
Umbilical cord prolapse
Fetal distress
Close communication with obstetricians
Choice of anaesthetic technique
Maternal safety
Technical issues
Personal experience

7. Signs of fetal distress
Non-reassuring heart rate pattern
Late decelerations
Loss of variability
Depth of decelerations and rate recovery
Fetal Bradycardia (<80beats/min)
Fetal scalp pH<7,2
IUGR
Meconium stained amniotic fluid

8. Umbilical cord prolapse
Cord is present in front of the presenting fetal part (cord presentation)
Leads to cord compression and fetal asphyxia
Risk factors
Excessive cord length
Malpresentations
Low birth weight
Grand parity (>5)
Multiple pregnancies
AROM

9. Management Immediate steep Trendelenburg position
Pt can be placed in a knee position – not ideal for anaesthesia
Manual elevation of presenting part by assistant
Fetus is elevated to relieve pressure on the cord
Palpate cord for pulsation to evaluate effectiveness
Patient is prepared for a general anaesthetic
If the fetus is not viable – vaginal delivery

11. Antepartum Hemorrhage
Most common obstetric emergency
High morbidity to mother and baby if not managed correctly
Uterus receives 12% cardiac output
Should be no delay in managing APH
May be concealed
Fetus at greater risk due to maternal haemorrhage
Main problems
Hypovolaemia
Aneamia

12. Causes Abruptio Placentae Placentae previa Uterine rupture
Bleeding associated with pain
May be concealed retroplacental
Small concealed bleeds may be treated conservatively, but monitored closely
Placentae previa
Painless bleeding
Different degrees
Uterine rupture
Fetal distress
Very painful
Loss of contractions / uterine tone

14. Postpartum Hemorrhage
Defined: Blood loss >500ml post delivery
4 T’s
Trauma: Vaginal tract laceration
Tumor: Retained products/placenta
Tone: Uterine Atony or Inversion
Thrombin: Clotting abnormalities

16. Management of Haemorrhage
Have a protocol set-up prior
Call for help
Give supplemental oxygen via facemask
If airway reflexes are lost or LOC = intubate
Remember your pelvic tilt – aortocaval compression
Two 14 G peripheral lines and blood for cross matching
Fluid resuscitation with crystalloids and colloids
Don’t fall behind
Consider vasopressors if haemodynamically unstable
Start appropriate monitoring of mother and fetus
Keep the patient informed – if awake

17. Cont… Treat the cause – surgery General anaesthesia
Blood transfusion as per situation
Rule of thumb: aim for an Hb of 7
Individualize
Try and wait until bleeding is controlled
Hospital protocol for massive transfusion: 1:1:1 vs 3:1:1
Consider auto transfusion devices
Correct coagulopathies with FFP, cryo and Plt
Keep your patient warm!
Continuous communication with obstetrician
Early communication with ICU

18. Uterotonic drugs Oxytocin Ergometrine Synthetic
Causes uterine contraction and peripheral vasodilation
Mild antidiuretic effect
Can be given IM or IV
Rule of 3’s: 3U, every 3 min, times 3
Infusion: 30U in 1L R/L – titrate to effect an BP
Ergometrine
Ergot alkaloid derivative
Nausea and vomiting common side effect
Potent vasoconstriction – CI in hypertensive pt’s
0,5mg IM or 0,125mg IV (slowly)

19. cont Carboprost (Prostaglandin F2a) Misoprostol
Effective uterine contractions
Also causes nausea, vomiting and diarrhoea
May produce bronchospasm
0,25mg intramyometrial or IM every 15 min
Max dose of 2mg
Misoprostol
Very similar effect as carboprost
Less potent bronchospasm
Can be given sublingual or PR

20. Surgical interventions
Rubbing of the uterus
Bimanual compression of uterus
Balloon cath of uterus (temporary)
B-Lynch suture
Ligation of uterine arteries
Ligation of internal iliac arteries
Hysterectomy
Reserved as last line

24. Amniotic fluid embolism
Incidence: 1:20000 deliveries
Effects due to anaphalctic reaction to fetal tissue
86% mortality rate
50% in the first hour
Amniotic fluid can enter through any break in the uteroplacental membrane
Fetal debris, prostaglandins and leukotrienes are involved

25. Risk factors Age>25 Multiparous women Obstructed labour
Multiple pregnancy
Abruptio placentae
Uterine rupture
Placenta praevia

26. Symptoms
Sudden onset of tachypnoea, cyanosis, shock and generalized bleeding.
Three major pathophysiological manifestations
Acute pulmonary embolism
DIC
Uterine atony
Pulmonary oedema and right heart failure within the first 30min
Often a diagnosis of exclusion, but should not be last on the differential

27. Management Mainly supportive ABC’s
Deliver the fetus as soon as possible
Mechanical positive pressure ventilation
Inotropic support
Invasive monitoring
Coagulation monitoring and management
Uterotonic drugs
ICU admission

28. Hypertensive disorders
Pregnancy induced Hypertension
Chronic Hypertension
Preeclampsia
SBP>140mmHg or DBP>90mmHg after 20weeks gestation with proteinuria (>300mg/d) that resolves within 48h after delivery
Superimposed preeclampsia
Eclampsia
Seizures
HELLP syndrome

29. Pathophysiology Vascular dysfunction of placenta
Leads to abnormal prostaglandin metabolism
Elevated TXA2 and decrease in Prostacyclin
TXA2 potent vasoconstrictor and promotor of plt aggregation
Decrease production of nitric oxide and increase endothelin-1
Severe pre-eclampsia:
BP>160/110
Proteinurea>5g/day
Increased creatinine
IUGR
Pulmonary oedema
CNS manifestations

31. Complications Neurological Hepatic Renal Pulmonary Cardiovascular
Headache
Impaired function
Visual disturbances
Elevated enzymes
Hyperexcitability
Hematoma
Seizures
Rupture
Intracranial haemorrhage
Renal
Cerebral oedema
Proteinuria
Pulmonary
Sodium retention
Upper airway oedema
Decreased GFR
Pulmonary oedema
Failure
Cardiovascular
Heamatological
Decreased intravascular volume
Coagulopathy
Increased SVR
Thrombocytopenia
Hypertension
Plt dysfunction
Heart failure
Microangiopathic hemolysis

32. Management Bed rest Sedation Antihypertensives MgSO4 Delivery!!!!
B-blokkers: Labetalol 5-10mg IV every 10min
Hydralazine 5mg Iv (max of 20mg)
Ca-channel blokkers: Nifedipine 10mg oral
MgSO4
Delivery!!!!

34. Anaesthesia Mild preeclampsia only requires caution and vigilance
Normal anaesthetic practices
Severe disease
Hypertension controlled and hypovolaemia should be corrected prior to surgery
Epidural is the golden standard – requires skill
Plt count> 70 for regional techniques
Invasive monitoring
Hypotension should be treated with small doses of vasopressors
Goal directed fluid therapy
Nitrocine, labetalol or MgSO4 can be used to treat hypertension
Magnesium potentiates muscle relaxants
Calcium gluconate antidote

35. Eclampsia ABC’s Left lateral position – bag mask ventilation
Obtain IV access
Control seizures with 4g Magnesium IV over 5-10min
Magnesium 1g/hr
Monitor levels
Delivery with GA as soon as possible
Consult ICU for post-op

36. HELLP syndrome Evidence of haemolysis Elevated liver enzymes
Falling Hb without bleeding
Haemoglobinuria
Elevated bilirubin
Elevated LDH
Fragmentation on smear
Elevated liver enzymes
AST, ALT, GGT, ALP
RUQ pain
Falling or low plt count
<100

37. Suggested technique for GA
Supine position with wedge under right hip and ramped
Preoxygenate with 100% oxygen for 3-5min
Patient is cleaned and draped
RSI
Cricoid pressure
Propofol 2mg/kg or Ketamine 1-2mg/kg iv
SUX 1,5mg/kg
Surgery is started once ETT is secured
Avoid hyperventilation (keep ETCO2>25)
Volatile agents: MAC 0,8 – avoid atomy
Consider TIVA in cases were pt is at risk of atony
Once neonate is born: give bolus of 3U oxytocin IV
Opioids may no be given
Consider post-op Abd wall blocks
Patient is extubated fully awake and reversed in the head-up position

38. Maternal resuscitation – Key points
After 20w gestation: wedge under right hip to minimize aortocaval compression
Chest compressions done over sternum
Fetus should be delivered as soon as possible
Front room c/s
Decreases aortocaval compression
Improves survival of mom and baby
Aspiration risk: intubate as soon as possible
Consider obstetric causes of arrest with H’s and T’s
Normal dosages of drugs should be used
Adrenaline

39. Toxins (anaphylaxis/anaesthetic) Tension pneumothorax Thrombi
H’s
T’s
Toxins (anaphylaxis/anaesthetic)
Tension pneumothorax
Thrombi
Cardiac
Pulmonary
Bone cement
Air
Tamponade
Trauma
qT prolongation
pulmonary hyperTension
Hypoxia
Hypovolaemia
Hyper/HypoKalemia
Hydrogen ion (acidosis)
Hypothermia
Hypoglycaemia
malignant Hyperthermia
Hypervagal

41. Questions?