Sorry, so I made a shorter, high-yield version of this talk, so we can go pretty quickly through some of this. Some of the physiologic changes associated with pregnancy, so remember increase in blood volume, increase in cardiac output, a decrease in our blood pressure, and then as we said before, a decrease in our systemic vascular resistance and unchanged filling pressures. All right, some of the other changes, respiratory, so again, an increase in our minute ventilation, a decrease in our chest wall compliance, again, because of that gravid uterus, increase in airway mucosal edema and a bleeding tendency, and then a compensated respiratory alkalosis. Patients are at higher risk for hypoxia, right? They have a decrease in their FRC, also an increase in oxygen delivery and consumption because of the fetus. We'll start going through some of the hypertensive disorders, so severe preeclampsia. Well, I guess here are the definitions, so pregnancy-induced hypertension, so we can see that we call this also gestational hypertension. Some of our women do have, some of our patients do have essential hypertension, more of a chronic disorder. Preeclampsia, so this is what we think of more as the placental dysfunction related to some of these pro-inflammatory angiogenic factors, and they get a decrease in their VEGF and placental growth factor, and they also get a decrease in their nitric oxide. Think of it as a generalized vasospastic disease with endothelial dysfunction and a predilection for involving the renal and cerebral vasculature. Eclampsia, this is where we say severe preeclampsia with seizures. So preeclampsia, we think of as occurring after 20 weeks gestation. Blood pressure here is above 140 over 90, but we don't have that evidence of significant end-organ dysfunction. Severe preeclampsia is when our blood pressure is now bordering on over 160 over 110, and we do have evidence of end-organ dysfunction. And then eclampsia, again, is that severe preeclampsia with seizures. One thing to be cognizant of is that it can occur up to one to two weeks after delivery, so our patients still need to be monitored after they deliver. So some of those end-organ features that we talk about, so again, the blood pressure over 160 over 110, we'll start seeing proteinuria, we'll start seeing oliguria, and potentially some renal failure, right, hyperuricemia. Other things that they can get, pulmonary edema, cerebral or visual disturbances, thrombocytopenia, hepatic dysfunction, and they can start getting some cardiac insufficiency. So here, this is where we want to start talking about delivering the fetus, and I think we talked about that in that question earlier, is that we start considering delivery if they're over 34 weeks. We'll start with maternal and fetal monitoring, and you also want to prescribe to your guidelines about blood pressure control, so decrease by 25%, but you don't want to necessarily overdo it. And then the big thing is going to be the IV magnesium. This is both for seizure prophylaxis and seizure treatment, okay, if they progress into full-on eclampsia. Fluids, you always want to be a little bit cautious with our pregnant women because of that increase in capillary permeability, they're at much higher risk for pulmonary edema. Blood pressure control, so we want to get the diastolic to below that 90 to 100 goal. Medications that we're going to use here, labetalol is always going to be your first line. Hydralazine can be used, nifedipine, we can do nicardipine, but you want to avoid ACE inhibitors, ARVs, nitroproside, or diuretics. In terms of the seizure prophylaxis and treatment, magnesium, it's magnesium over and over and over again. You want pretty high levels of magnesium, right, so you're targeting that 4.8 to 8.4 meg level for a patient, and then you continue that after they deliver. HELP syndrome, so this is another big one, so hemolysis, right, elevated liver enzymes and a low platelet count. There can be variants on this, you don't need necessarily all parts of the HELP just to meet their criteria, but we do see this intrapartum and, you know, postpartum as well. Again, typically occurring in the kind of third trimester of pregnancy, but can occur up to about a week out in up to 30% of patients. And the other big thing is that it can occur with or without hypertension, right, so about 20% of patients don't have that typical high blood pressure that we're looking for, that 160 over 110, so it's something that especially the follow-up providers need to be kind of cognizant of. Big things here, so for HELP, especially if you've already delivered the baby and, you know, the mom is still suffering, plasmapheresis is an option, right, especially if you have any evidence of TTP and you're at the, you know, this is still kind of occurring up to 72 hours postpartum if you still have some of those lab abnormalities. Dexamethasone can be considered. We haven't seen benefit in clinical trials, but it is an option. And then part of this is also thinking about some of those complications, so you can get capsular and subcapsular hematomas, hepatic rupture, and renal failures associated with HELP. And that's a picture of a liver hematoma there. TTP versus HELP, so hypertension is not typical for TTP. They're not necessarily always going to have the LFT abnormalities, certainly not as high as they can get with HELP. LDH is higher, right, because they're lysing a lot more. Intestinal status changes, and we don't typically get DIC with TTP. Management here, steroids, and then you would go forward with the plasmapheresis. Hemorrhage, so this is the most common cause of maternal death worldwide. Things that we think about here, placenta previa, placental abruption, ectopic and abdominal pregnancies, or trauma. Other causes, so after delivery, uterine atony, retained placenta, uterine inversion, and then rarely we can get uterine rupture as well. So in terms of managing that hemorrhage, resuscitation is the big key here, right? And we'll always start with our massive transfusion protocol. I think this varies hospital to hospital, but for us, we get six units of blood, six units of FFP, and pulled platelets, six units of pulled platelets. And then you would also consider TXA infusion to really try and stop that bleeding. Other things, placental removal, manual compression of the uterus. You can use oxytocin, prostaglandin, for uterine contractions. And then other things, so if the mom goes into DIC, you want to think about trying to reverse that coagulopathy that she has. You may also be involving, if you can't manage this with manual compression, you might be thinking about a balloon tamponade, an embolization, and sometimes, in some cases, we need to move forward with hysterectomy. Peripartum cardiomyopathy, so this typically occurs in the last month of pregnancy. Again, this can occur postpartum as well, up to five months. The mom will show signs of congestive heart failure. Things that we do here, so salt and water restriction, diuretics, vasodilators, inotropes if they need them, and then because they're at increased risk of systemic and pulmonary thrombosis, you might want to consider anticoagulation. And I'm going to move ahead because this was a slightly longer talk than I was anticipating. So in terms of trauma, big thing is you really want to get the mom into the left lateral decubitus position if possible. You want to offload the IVC as much as possible. Remember that gravid uterus is going to be pressing down, compressing the IVC, so try and get her into the left lateral decubitus. And then even for minor trauma, you do want to be assessing fetal cardiac activity. And in terms of mechanical ventilation, you want to be using potentially a smaller ET tube, especially because the mom sometimes has a lot of edema, right? Expect higher airway pressures because of that restrictive chest wall and also an increase in her abdominal pressure. And be careful with non-invasive ventilation. Do we use it? Definitely, but just be aware that she's at increased risk of aspiration and you might be moving toward more of an emergent airway than you expected. Tocolytic-associated pulmonary edema, so we most often see this when a mom goes into premature labor and she gets a tocolytic like terbutaline, ritidrine, albuterol even. And the treatment here is to discontinue the tocolytics. We usually will also use some diuretics, but really you want to get the terbutaline off. Asthma, so I see this a lot in clinic. This is probably the most or this is the most common respiratory disorder in pregnancy. What I'll tell the moms is they kind of fall into this one of three groups. A third improve, a third worsen, and a third will have the same kind of asthma symptoms that they had before. Inhaled agents that we prefer are bronchodilators and steroids. Very often we'll be using drugs like Simbacort or Budesonide formaterol to kind of manage their symptoms. Chronic steroids are safe if the mom needs them to control asthma, asthma symptoms. Other drugs, have I used a llama? Certainly have. Singular, also okay to use. The guidelines suggest that you don't start singular if you can avoid it, but if the mom is already on it, this is something that you can continue. Pregnancy, moms may get more severe disease. It's possible. I think we've all seen probably a spectrum of pregnant women coming in with COVID-19 from fairly mild to very, very severe. So when it gets to some of our advanced life support, so again, you want to, as much as possible, you want to try and get the mom into the left lateral decubitus, elevate the right hip. Sometimes you can't do that though, right? We know that chest compressions are not as effective if the patient's not, you know, in the supine position. So you can try and push the uterus over, right, to administer more effective compressions and also to offload that IVC. There are no changes in the standard compression rate, ACLS dosing, so medication dosing or defibrillation. And one concept is perimortem cesarean delivery, especially if the fetus is above 24 weeks, again, that's going to immediately reduce some of the oxygen demand on the mom and restore some of the blood volume, circulating blood volume. The kind of rule of thumb here is to do this within five minutes. So compressions for about four minutes, and then the fetus should be delivered by the fifth minute. Obviously, this is very scary, so it's not something that's routinely done if it can be avoided, but that's kind of the idea there. All right. And then finally with some, I think this is the end, getting to the end. So some of these emboli that we encounter, so amniotic fluid embolism, so they'll get cardiovascular collapse. They might get DIC, hemorrhage, respiratory failure, so they'll go into ARDS. And then this is kind of the person that you want to be calling an ECMO team or transferring to an ECMO center as soon as you suspect one. This AR embolism, it has that typical precordial millwheel murmur. Again, here, move the mom into the left lateral decubitus, but the treatment here is hyperbaric oxygen, or starting with 100% oxygen, but moving into hyperbaric therapy if she's not getting better. Thrombobolic disease, so pregnant women are very, very high risk for VTE, right? And so if you suspect a patient is coming to you with symptoms consistent with a PE, you know, and you should move forward with CTA testing. Don't delay, especially if there's any concern that there's, you know, any kind of hemodynamic instability or she's going to decompensate, get a CT. You can use an abdominal shield if needed, right, to protect the fetus, but you don't want to delay testing or get incorrect testing or inadequate testing if she's pregnant. In terms of DVT, remember, well, so pelvic, iliofemoral, popliteal clots, all possible. In the left leg, right, you just get a Doppler, and then in terms of treatment, you can start with heparin, and then very often we'll just move forward with low molecular weight heparin. Warfarin is contraindicated. We don't necessarily consider all those DOACs that we use for other patients, really. They just go home with some low molecular weight heparin. If she's unstable, you might consider thrombolytics. You might also be considering perimortem C-section. If she arrests, or you might be thinking about potentially calling an ECMO center if this is an unstable patient. But if these are not options and you're really considering a thrombolytic, you would give the same dose that you give to another patient. And then she needs to be treated for six weeks postpartum for at least three months total. Sepsis. So we associate it with poor outcomes, and very often it's polymicrobial bugs. And then common organisms, we think about E. coli, group A and B strep. We do see like endometriitis, chorioamnionitis. And so they can get the vaginal flora can be the cause of the sepsis here. Once again, imaging, CT. If you need a CT, get a CT and use dose reduction methods as able, and you can use abdominal shielding when you need to. And, all right, that was a very fast overview of obstetric emergencies.

obstetric emergencies

hypertensive disorders

hemorrhage management

respiratory conditions

sepsis treatment