Intraoperative Hemodynamic Emergencies In obstetrics
Omar Mohammad Zafer;
Abstract
SUMMARY
O
bstetric patients are a particularly unique cohort for the anesthesiologist. These patients are young and otherwise healthy; the management is challenged by their concerns for fetal viability, altered maternal physiology, and diseases specific to pregnancy. Major adaptations in maternal anatomy, physiology, and metabolism are required for a successful pregnancy.
Soon after conception, the maternal cardiovascular system undergoes major adaptations that progress throughout gestation. In conjunction with the increased circulatory burden of pregnancy, these changes may unmask previously unrecognized heart disease and result in significant morbidity and mortality. Most of these changes are almost fully reversed in the weeks and months after delivery. The physiological hemodynamical changes include hematological changes, cardiac output changes, heart rate changes, arterial blood pressure changes, changes in blood flow of different organs and functional and anatomic cardiac changes.
Hypertension is the most common medical disorder of pregnancy and is reported to complicate up to 1 in 10 gestations and affects an estimated 240, 000 women in the United States every year Although physicians for millennia have recognized Pre-eclampsia, relatively little is known about its pathogenesis and prevention. The primary concern about elevated blood pressure relates to the potential harmful effects on both mother and fetus. These potential adverse effects range in severity from trivial to life threatening.Hypertensive disorders include chronic hypertension, gestational hypertension and pre-eclampsia and Eclampsia.
Maternal deaths from Pre-eclampsia and eclampsia are on the rise. Cerebral haemorrhage remains the commonest cause of death in this group and hence rapid and effective treatment of hypertension to prevent haemorrhagic stroke is highlighted. As aetiology is largely unknown, preventative measures and screening tools are lacking and management is directed at the control of clinical manifestations. Delivery remains the only definitive treatment.
An obstetric hemorrhage may occur before or after delivery, but more than 80% of cases occur postpartum. Worldwide, a massive obstetric hemorrhage, resulting from the failure of normal obstetrical, surgical and/or systemic hemostasis, is responsible for 25% of the estimated maternal deaths each year. Most women will not have identifiable risk factors. Nonetheless, primary prevention of a postpartum hemorrhage (PPH) begins with an assessment of identifiable risk factors. Women identified as being at high risk of a PPH should be delivered in a center with access to adequately trained staff and an onsite blood bank. A critical feature of a massive hemorrhage in obstetrics is the development of disseminated intravascular coagulation (DIC), which, in contrast to DIC that develops with hemorrhage from surgery or trauma, is frequently an early feature.Main causes of obstetric hemorrhage are uterine atony, genitourinary tract laceration, retained products of conception, invasive placentation, uterine rupture and uterine inversion.
Amniotic fluid embolism (AFE) is an unforeseeable, life-threatening complication of childbirth. Despite an incidence rate that ranges from only 2 to 8 per 100 000 births in different countries, AFE is one of the leading causes of death resulting directly from childbirth, accounting for 5% to 15% of cases worldwide. According to statistics, it is the most common cause of maternal death in Australia and the second-most common in the USA and the U.K. These are underestimates of the rate of nonfatal and fatal AFE, due to heterogeneous diagnostic criteria and the unreliability of physicians’ death certificates.Rapid diagnosis and immediate obstetric and intensive care play a decisive role in maternal prognosis and survival.
Arrhythmias in pregnancy are common and may cause concern for the wellbeing of both the mother and the fetus. For some mothers the arrhythmias may be a recurrence of a previously diagnosed arrhythmia or the first presentation in a woman with known structural heart disease. In most cases, however, there is no previous history of heart disease, and the new occurrence of a cardiac problem can generate considerable anxiety. The majority of arrhythmias that occur during pregnancy are benign, and simply troublesome; hence, advice about appropriate actions during symptomatic episodes, together with reassurance, is usually all that is required. In the remaining minority of cases, judicious use of antiarrhythmic drugs will lead to a safe and successful outcome for both mother and baby. While there were no documented maternal deaths from primary arrhythmias in the last UK confidential enquiry into maternal mortality, 9% of cardiac deaths were defined as sudden adult death syndrome, which raises the possibility of death from a primary arrhythmia. In women with known structural heart disease, however, arrhythmia is one of the five independent predictors of having a cardiac event during the pregnancy and should therefore be treated seriously.
The scenario of cardiac arrest is a feared one in the labor and delivery suite; yet, the incidence is 1 in 30, 000 pregnancies. Parturients tend to be young, healthy patients without previous hospitalizations or medical problems. Unlike the operating suite, the labor and delivery ward is often crowded with family members, walking parturients and families welcoming the arrival of their newest relatives. Not only is cardiac arrest a feared entity in this population, it is often unexpected. For these reasons, it is necessary that the obstetric anesthesiologist be knowledgeable about the risk factors for cardiac arrest, the physical changes in the parturient and the management of cardiopulmonary resuscitation during pregnancy.
O
bstetric patients are a particularly unique cohort for the anesthesiologist. These patients are young and otherwise healthy; the management is challenged by their concerns for fetal viability, altered maternal physiology, and diseases specific to pregnancy. Major adaptations in maternal anatomy, physiology, and metabolism are required for a successful pregnancy.
Soon after conception, the maternal cardiovascular system undergoes major adaptations that progress throughout gestation. In conjunction with the increased circulatory burden of pregnancy, these changes may unmask previously unrecognized heart disease and result in significant morbidity and mortality. Most of these changes are almost fully reversed in the weeks and months after delivery. The physiological hemodynamical changes include hematological changes, cardiac output changes, heart rate changes, arterial blood pressure changes, changes in blood flow of different organs and functional and anatomic cardiac changes.
Hypertension is the most common medical disorder of pregnancy and is reported to complicate up to 1 in 10 gestations and affects an estimated 240, 000 women in the United States every year Although physicians for millennia have recognized Pre-eclampsia, relatively little is known about its pathogenesis and prevention. The primary concern about elevated blood pressure relates to the potential harmful effects on both mother and fetus. These potential adverse effects range in severity from trivial to life threatening.Hypertensive disorders include chronic hypertension, gestational hypertension and pre-eclampsia and Eclampsia.
Maternal deaths from Pre-eclampsia and eclampsia are on the rise. Cerebral haemorrhage remains the commonest cause of death in this group and hence rapid and effective treatment of hypertension to prevent haemorrhagic stroke is highlighted. As aetiology is largely unknown, preventative measures and screening tools are lacking and management is directed at the control of clinical manifestations. Delivery remains the only definitive treatment.
An obstetric hemorrhage may occur before or after delivery, but more than 80% of cases occur postpartum. Worldwide, a massive obstetric hemorrhage, resulting from the failure of normal obstetrical, surgical and/or systemic hemostasis, is responsible for 25% of the estimated maternal deaths each year. Most women will not have identifiable risk factors. Nonetheless, primary prevention of a postpartum hemorrhage (PPH) begins with an assessment of identifiable risk factors. Women identified as being at high risk of a PPH should be delivered in a center with access to adequately trained staff and an onsite blood bank. A critical feature of a massive hemorrhage in obstetrics is the development of disseminated intravascular coagulation (DIC), which, in contrast to DIC that develops with hemorrhage from surgery or trauma, is frequently an early feature.Main causes of obstetric hemorrhage are uterine atony, genitourinary tract laceration, retained products of conception, invasive placentation, uterine rupture and uterine inversion.
Amniotic fluid embolism (AFE) is an unforeseeable, life-threatening complication of childbirth. Despite an incidence rate that ranges from only 2 to 8 per 100 000 births in different countries, AFE is one of the leading causes of death resulting directly from childbirth, accounting for 5% to 15% of cases worldwide. According to statistics, it is the most common cause of maternal death in Australia and the second-most common in the USA and the U.K. These are underestimates of the rate of nonfatal and fatal AFE, due to heterogeneous diagnostic criteria and the unreliability of physicians’ death certificates.Rapid diagnosis and immediate obstetric and intensive care play a decisive role in maternal prognosis and survival.
Arrhythmias in pregnancy are common and may cause concern for the wellbeing of both the mother and the fetus. For some mothers the arrhythmias may be a recurrence of a previously diagnosed arrhythmia or the first presentation in a woman with known structural heart disease. In most cases, however, there is no previous history of heart disease, and the new occurrence of a cardiac problem can generate considerable anxiety. The majority of arrhythmias that occur during pregnancy are benign, and simply troublesome; hence, advice about appropriate actions during symptomatic episodes, together with reassurance, is usually all that is required. In the remaining minority of cases, judicious use of antiarrhythmic drugs will lead to a safe and successful outcome for both mother and baby. While there were no documented maternal deaths from primary arrhythmias in the last UK confidential enquiry into maternal mortality, 9% of cardiac deaths were defined as sudden adult death syndrome, which raises the possibility of death from a primary arrhythmia. In women with known structural heart disease, however, arrhythmia is one of the five independent predictors of having a cardiac event during the pregnancy and should therefore be treated seriously.
The scenario of cardiac arrest is a feared one in the labor and delivery suite; yet, the incidence is 1 in 30, 000 pregnancies. Parturients tend to be young, healthy patients without previous hospitalizations or medical problems. Unlike the operating suite, the labor and delivery ward is often crowded with family members, walking parturients and families welcoming the arrival of their newest relatives. Not only is cardiac arrest a feared entity in this population, it is often unexpected. For these reasons, it is necessary that the obstetric anesthesiologist be knowledgeable about the risk factors for cardiac arrest, the physical changes in the parturient and the management of cardiopulmonary resuscitation during pregnancy.
Other data
| Title | Intraoperative Hemodynamic Emergencies In obstetrics | Other Titles | الحالات الطارئة للدورة الدموية اثناء عملية التوليد | Authors | Omar Mohammad Zafer | Issue Date | 2015 |
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