1. Obstetric Emergencies Postpartum Hemorrhage and Hypertension Annelee Boyle, MD, FACOG Assistant Professor Department of Obstetrics and Gynecology Division of Maternal-Fetal Medicine University of Virginia School of Medicine

4. Disclosures

5. Pregnancy-related mortality in the United States: 1987-2010 Source: CDC Pregnancy Mortality Surveillance System

6. Obstetrics and Gynecology, May 2014

7. Causes of pregnancy-related death in the United States: 2006 -2010 Source: CDC Pregnancy Mortality Surveillance System

8. Maternal mortality is only the tip of the iceberg

9. Obstetrics and Gynecology, February 2012

10. 93% of deaths preventable! – Berg et al. Preventability of pregnancy related deaths: results of a statewide review. Obstet Gynecol 2005; 106:1228-34. Common mistakes: – Under-recognition of blood loss – Under-recognition of hypovolemia – Failure to act decisively – Failure to restore blood volume Postpartum Hemorrhage

11. Recognize the extent of blood loss Dildy et al, Estimating Blood Loss: Can Teaching Significantly Improve Visual Estimation? Obstetrics & Gynecology. 104(3):601-606, September 2004.

12. Recognize the extent of hypovolemia Class 1Class 2Class 3Class 4 EBL in ml< 750ml750-1500ml1500- 2000ml >2000ml EBL in % Vol.<15%15-30%30-40%>40% Pulse<100>100>120>140 BPNormal or ↑↓↓↓ RR14-2020-3030-40>35 UOP>30ml/h20-30ml/h5-15ml/hnegligible Mental State Slightly anxious Mildly anxious Anxious, confused Confused, lethargic

13. Obstetrics and Gynecology, May 2014

14. Systolic BP 160 Diastolic BP >100 Heart Rate 120 Resp Rate 30 Oxygen Sat <95% on room air Urine output <35ml/hr for 2 hours Agitation, confusion, or unresponsiveness Shortness of breath or a non-remitting headache in a patient with pre-eclampsia – Mhyre et al. The maternal early warning criteria: a proposal from the national partnership for maternal safety. Obstet Gynecol 2014;124:782-6. Early warning signs

15. Act decisively/Restore blood volume

16. Rule number one: Postpartum Hemorrhage is a definition, not a diagnosis! Post-Partum Hemorrhage

17. Actively manage the third stage of labor Pearls for Atony

18. Consider additional utero-tonics for those at highest risk of PPH Pearls for Atony

19. Have a low threshold for going to the OR for repair. Pearls for Lacerations

21. Source: California Maternal Quality Care Collaborative

22. 60% of deaths are preventable! – Berg et al. Preventability of pregnancy related deaths: results of a statewide review. Obstet Gynecol 2005; 106:1228-34. Common mistakes: – Failure to adequately control blood pressure – Failure to recognize HELLP syndrome – Failure to diagnose and treat pulmonary edema Preelcampsia

23. Systolic BP 160 Diastolic BP >100 Heart Rate 120 Resp Rate 30 Oxygen Sat <95% on room air Urine output <35ml/hr for 2 hours Agitation, confusion, or unresponsiveness Shortness of breath or a non-remitting headache in a patient with pre-eclampsia – Mhyre et al. The maternal early warning criteria: a proposal from the national partnership for maternal safety. Obstet Gynecol 2014;124:782-6. Early warning signs

24. Control Blood Pressure

26. Hi Annelee. Hope you’re doing well and liking your new job. It’s 10:30 pm here and for me, that’s the middle of the night so rather than be friendly and “chat”, I’m going to get straight to the point – it’s business… So our hospital protocol essentially regurgitates ACOG, but it doesn’t specify that it is for use only with preeclamptic/eclampic patients. Would you use it for someone with chronic HTN also, barring known renal disease or other cause of the HTN? Thanks! Love, Aunt Crunchy

27. Recognize HELLP Syndrome

28. The most important paper on HTN in pregnancy in the last year

29. SBP >160 DBP >110 Platelets < 100,000) LFTs >2x normal Creatinine > 1.1 Pulmonary edema New-onset cerebral or visual disturbances Right upper quadrant pain American College of Obstetricians and Gynecologists. Hypertension in pregnancy: executive summary. Obstet Gynecol 2013;122:1122–31. Severe Features of Preeclampsia

30. Recognize and treat pulmonary edema

32. “If you’re going down take everybody else with you.” – Susan Modesitt, Gyn Oncologist The UVA way (or maybe it was UNC)

33. David Barker 1938-2013

34. The Barker Hypothesis The Thrifty Phenotype Fetal Origins Hypothesis

35. Intrauterine Growth Restriction

36. 30 years from now

37. Thank you!!!