Obstetric and Gynecologic Emergencies, An Issue of Obstetrics and Gynecology Clinics (The Clinics: Internal Medicine)

266 Pages·2007·3.54 MB·English

by  Henry Galan MD

ObstetGynecolClinNAm
34(2007)xvii–xviii
Foreword
WilliamF.Rayburn,MD
ConsultingEditor
This issue of the Obstetrics and Gynecology Clinics of North America,
guest edited by Henry Galan, MD, pertains to emergencies that can occur
in obstetrics and gynecology. An obstetrician-gynecologist may be con-
fronted with a sudden emergency at any time, either at the hospital or in
the outpatient setting. Prompt corrective action is necessary, whether it is
severe postpartum hemorrhage, acute chest or abdominal pain, or an ana-
phylactic reaction to an injection in the office. Preparing for an emergency
requiresplanning,provisionofresources,awareness ofearly warningsigns,
and specialized trainees who are aware of what to do in an emergency.
Certainemergencies,suchasamassivepulmonaryembolusoracomplete
abruptio placentae, can be sudden and potentially catastrophic. Standard-
ized responses will increase the efficiency and quality of care. A protocol
should provide a full evaluation of the problem and clearly communicate
the patient care issue. Periodic drills may lead to a more standard response
with a favorable outcome.
Planning for potential emergency events such as anaphylactic shock or
cardiopulmonary resuscitation can be complex. At a minimum, it should
involveanassessmentofsuspectedrisksrelatedtotheunderlyingcondition.
Allphysiciansshouldbefamiliarwiththe‘‘crashcart.’’Byplacingnecessary
items in one place, time is not lost in gathering supplies. A small kit can be
createdforhandlingallergicreactions.Aswithacrashcart,thiskitmustbe
maintained regularly to ensure that supplies are current.
Itbecomesclearwithanyemergencywhentocallforhelp.Activationof
a response team before a full arrest may lead to improved survival and less
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xviii FOREWORD
need for an intensive care admission. Rapid correction of problems is
bettermetwithasmallemergencyteamwhosememberstalkwitheachother
andshare information.Althoughaleadermustcoordinatetheresponse,all
membersoftheteamshouldbeempoweredtopracticetogether.Bypracticing
together,barriershinderingcommunicationandteamworkcanbeovercome.
Adultlearningtheory,asdescribedinthisissuebyitsdistinguishedpanel
of contributors, supports the value of experiential learning. Training can
entail a sophisticated simulated environment or a customary work space
withamockevent.Emergencydrillsallowphysiciansandotherstopractice
principlesofeffectivecommunicationinacrisis.Ourdesireisthatthisissue
will attract the attention of providers caring for those women at risk for
emergencies. Practical information provided herein will hopefully aid in
the development and implementation of more-specific and individualized
treatment plans.
William F. Rayburn, MD
Department of Obstetrics and Gynecology
University of New Mexico School of Medicine
MSC10 5580
1 University of New Mexico
Albuquerque, NM 87131-0001, USA
E-mail address: [email protected]
ObstetGynecolClinNAm
34(2007)xix–xxi
Preface
HenryL.Galan,MD
GuestEditor
Every medical or surgical specialty has emergencies that are somewhat
specific to that specialty. This is also true in obstetrics and gynecology.
However, several characteristics set the specialty of Ob/Gyn apart from
allothers.Notonlycannearlyalloftheemergenciesseeninotherspecialties
beseeninthefieldofOb/Gyn,butpregnancyalsobringsanewandunique
dimension to emergency situations in our specialty. Three primary charac-
teristics of Ob/Gyn set it apart from other fields of medicine when it comes
to emergencies: (1) it is the only specialty committed completely to women;
(2) it is the only specialty in which a single emergent event can threaten the
livesoftwoindividuals,themotherandherfetus;and(3)anotherwisecom-
pletely healthy patient may succumb purely to a pregnancy-related compli-
cation. It is these three general themes that drive the topics in this issue of
the Obstetrics & Gynecology Clinics of North America.
Theauthorscontributingtothisissuewereinvitedtocovertopicsthatare
ofparticularinteresttothemandinwhichtheyareconsideredleaders.They
haveutilizedthebestavailableevidenceandtheirownexperiencetoprovide
thereaderwithknowledgeofandguidancethroughtheseemergencycondi-
tions. Considerable focus is given to the physiological changes in pregnan-
cies that impact emergency conditions.
Several of the articles in this issue are related to hemorrhage, which, be-
causeof the600cc/minuterineblood flowatterm, can bemassive. Gyamfi
and Berkowitz launch this issue by guiding us through the challenges of
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doi:10.1016/j.ogc.2007.08.004 obgyn.theclinics.com
xx PREFACE
caringfortheJehovah’sWitnesspatientwhorefusesthemedicallyindicated
blood transfusion. Fuller and Bucklin provide the basics of blood product
transfusionanditsapplicationtothehemorrhagingpatient.TealandMukul
review first-trimester bleeding, which itself can be massive and without the
benefitofhaving reached thefullmaternalexpansion ofbloodvolume seen
later in pregnancy. Monga and Kilpatrick address the physiologic and
physicalchangesoftheabdomenandcontentswithinrelatedtopregnancy,
which are dramatic and impact the differential diagnosis, diagnostic proce-
dures, and thresholds for surgical exploration. Oyelese, Scorza, Mastrolia,
and Smulian provide guidelines for the management of postpartum hemor-
rhage,includingthenewerB-LynchandBakriballoonprocedures,followed
by theexpert descriptions by Banovac,Lin,Shah,White, Pelage, and Spies
of interventional radiologic approaches to hemorrhage.
Of all the obstetric-related emergencies, few match the profound mater-
nal cardiovascular collapse and disseminated intravascular coagulation of
amntioticfluidembolism,whichisdiscussedindepthbySheffield andStaf-
ford.GottliebandIreviewriskfactorsandmanagementofshoulderdysto-
cia, which most often rears itself in without warning and carries risk for
long-term fetal sequelae and medical-legal action. Muench and Canterino
thoroughly review catastrophic and noncatastrophic trauma in pregnancy
with emphasis on evaluation of the trauma patient and how physiologic
changesimpacttheevaluation.GardnerandAttaconcludetheemergencies
articles with a review of cardiopulmonary resuscitation with a focus on the
effect of physiologic changes in pregnancy and which may be an end result
of any of the above-mentioned emergencies.
While not always presenting as acutely or urgently as some of the afore-
mentionedemergencies,severalmedicalconditionsandsocialcircumstances
predispose pregnant patients to serious and life-threatening events. Guinn,
Abel, and Tomlinson provide information on sepsis, the leading cause of
deathinthecriticallyillpatient.ConwayandParkerreviewthemostserious
conditioninthediabeticpatient,diabeticketoacidosis.Pregnancyisaknown
thrombogenic state with great potential for adverse events; Lockwood and
Rosenbergguidethereaderthroughthromboembolicdisease.Gunterdraws
our attention sharply to the prevalence, dangers, and the need for height-
enedawarenessofdomesticpartnerviolenceandprovidesuseverydaytools
with which to address this problem in our office practice. This issue con-
cludeswithan article byShwayderreviewingthemedical-legal implications
of obstetric emergencies and strategies for prevention of legal action in the
setting of an adverse event.
I would like to add a personal note of gratitude to all the gifted individ-
uals contributing to this issue of the Obstetrics & Gynecology Clinics of
NorthAmericaandtoCarlaHollowayofElsevierforherpatienceandpro-
fessionalism. Most of all, on behalf of my fellow authors, I would like to
thank our patients, students, nurses, and house staff, from whom we learn
so much about our beautiful specialty. This gift allows us to push the
PREFACE xxi
frontiers ofknowledge andprovidethe best carepossible forthenext mom
and unborn baby that we encounter.
Henry L. Galan, MD
Department of Obstetrics and Gynecology
University of Colorado at Denver Health Sciences Center
Academic Office 1, 12631 East 17th Avenue, Rm 4001
Aurora, CO 80045, USA
E-mail address: [email protected]
ObstetGynecolClinNAm
34(2007)357–365
Management of Pregnancy
in a Jehovah’s Witness
Cynthia Gyamfi, MD*, Richard L. Berkowitz, MD
DivisionofMaternal-FetalMedicine,DepartmentofObstetricsandGynecology,
ColumbiaUniversityMedicalCenter,622West168thStreet,
PH-16,NewYork,NY10032,USA
The refusal of blood products by Jehovah’s Witnesses makes this group
auniqueobstetricpopulationwiththepotentialfordisastrousperinatalout-
comessecondarytohemorrhage.Obstetrichemorrhageisthesecondleading
causeofmaternalmortalityintheUnitedStatesafterpulmonaryembolism
[1].Singlaandcolleagues[2]reportedonmaternalmortalityamongstJeho-
vah’sWitnesseswhorefuseallbloodproducts.Whenthisgroupdevelopsan
obstetric hemorrhage, they have a 44-fold increased risk of death.
The care of these patients must be meticulously coordinated to achieve
good pregnancy outcomes. This involves coordination of care with the
patient’sprimarycareprovider,maternal–fetalmedicinespecialist,anesthe-
siologist,andpossiblyothersubspecialiststoreduceperinatalmorbidityand
mortality.
ToprovidecomprehensivecaretopatientswhoareJehovah’sWitnesses,
the care provider should understand the background of their belief system.
CharlesRussellfoundedthegroupin1872inPennsylvania[3].Manyofthe
followers’beliefsarebasedonliteraltranslationsoftheBible.Genesis9and
Leviticus 17 state that one cannot eat the blood of life; these passages are
interpretedtoincludetheexchangeofbloodproducts[4].FortheJehovah’s
Witness,receivingbloodproductsmayleadtoexcommunicationandeternal
damnation[3],andanindividualwhoofferstotransfusebloodisconsidered
bymanymembersofthesecttobeactingthroughthedevil’sinfluence.Un-
derstandingthesefactsiscrucialwhencaringforpatientswhoareJehovah’s
Witnesses.
* Correspondingauthor.
E-mailaddress:[email protected](C.Gyamfi).
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doi:10.1016/j.ogc.2007.06.005 obgyn.theclinics.com
358 GYAMFI&BERKOWITZ
Addressing the risk of hemorrhage
As the editors of Williams Obstetrics have reemphasized over many edi-
tions, ‘‘Obstetrics is ‘bloody business’!’’ [5]. The incidence of postpartum
hemorrhageisdifficulttoquantifybecauseofvaryingdefinitions.However,
ithasbeenestimatedtooccurin4%ofvaginaldeliveriesand6%to8%of
cesarean deliveries [5]. The need for blood transfusion is fairly common.
Klapholz [6] reported a 2% transfusion rate for women who delivered at
Beth Israel Hospital in 1986. Rouse and colleagues [7] reviewed over
23,000 primary cesarean deliveries and found that the rate of transfusion
in that population was 3.2%. Among patients with a previous cesarean
delivery, Landon and colleagues [8] found that transfusion was more likely
withatrialoflaborthanwithanelectiverepeatcesarean,1.7%versus1.0%,
respectively (odds ratio: 1.71; 95% CI, 1.41–2.08, P!.001).
Because the risk of requiring blood transfusion is not negligible, the po-
tential for transfusion should be discussed with all obstetrical patients dur-
ingtheirprenatalcare.ThepolicyatColumbiaUniversityMedicalCenteris
to ask all new obstetrical patients whether they will accept a blood transfu-
sion in an emergency situation. Without specifically asking about religion,
this serves to open the dialog about transfusion and can identify patients
who hold fast to the beliefs of the Jehovah’s Witnesses.
The authorshavepreviouslyshown that there are varying degrees ofad-
herencetothedoctrineofbloodrefusalamongstJehovah’sWitnesses[9].In
astudy ofpregnantJehovah’sWitnesses,almost 50%indicated,when are-
view of health care proxies was undertaken, that they would accept some
formofbloodorbloodproducts[9].Thismeansthat,ratherthanassuming
that a Jehovah’s Witness will not accept any blood products, the clinician
mustinquireastothespecificbeliefsoftheindividualpatient.Strongfamil-
ialandchurchpressurescaninfluenceapatient’sdecisioninthepresenceof
others. This is why it is important for the clinician to be alone with the pa-
tient when discussing her wishes. At the very minimum, the patient should
beaskedaboutwhethershewillbewillingtoacceptanyorallofthefollow-
ing: whole blood, fresh frozen plasma, cryoprecipitate, albumin, isolated
factor preparations, nonblood plasma expanders, hemodilution, and cell-
saver. At the authors’ institution, this inquiry is presented in the form of
achecklist,whichisthensignedbythepatientandincludedinthepatient’s
chart. Additionally, a statewide health care proxy is signed.
Prenatal care
For a variety of reasons, identification of a patient who will not accept
blood,andthediscussion aboutwhichproducts,ifany,sheiswilling toac-
cept, should be undertaken at the first prenatal visit. First, most obstetric
patients are young and healthy and may not consider themselves to be at
risk to hemorrhage. It is important to explain to the patient what puts her
MANAGEMENTOFPREGNANCYINAJEHOVAH’SWITNESS 359
in this category. A discussion of the health care proxy and blood product
checklist requires extensive education because the average person is not
familiar with the terms ‘‘nonblood plasma expanders’’ or ‘‘cell-saver.’’ In
most cases the patient will want to discuss this with her family and/or
churchleaders,sotherewillbeadelayinsigningthechecklist.Anearlydis-
cussion allows the patient a chance to make an informed decision. Second,
identificationandtreatmentofanexistinganemiaareveryimportantinthe
care of these patients. Because the treatment of anemia is a slow process,
aggressive early management may obviate the need for transfusion later.
Finally, a physician has to be both willing and able to allow a properly ed-
ucated patient to die once she has indicated that she prefers death over
transfusion. It is always difficult for a physician, who has been trained to
savelives,toacceptapatient’sdecisionthatcanleadtoherdeath.Ifaphy-
sician does not want to participate in the care of such a patient, she should
be transferred to the practice of a physician associated with a tertiary care
center,andconsultationshouldbeobtainedwithamaternal–fetalmedicine
specialist. The transferring physician is obligated to ensure that another
physician has agreed to accept the patient. This may be difficult to arrange
inanemergencysituation,soearlytransferofthepatient’scareisextremely
prudent.
Evaluation and treatment of anemia
WhenaJehovah’sWitnesspresentsforherfirstprenatalvisit,acomplete
blood count with platelets should be included in the routine prenatal labo-
ratorytests,andthepatientshouldbestartedonironandfolicacidsupple-
mentation. The goal should be to maintain her hematocrit above 40% [10].
Once that level has been achieved, a patient can sustain a 2-L peripartum
blood loss, and is unlikely to require transfusion. If the initial hematocrit
is below this level, a workup for potential causes of anemia should be initi-
ated.Ifirondeficiencyisdocumented,thedoseofironsupplementationcan
be adjusted accordingly, and a stool softener should be prescribed. Iron is
best absorbed through the gastrointestinal tract in an acidic medium, so
vitaminC,orsimplyorangejuice,shouldbetakenalongwiththeironpills.
Foods high in heme content, such as meat, poultry, and fish, should
be encouraged [4]. Vegetarian diets are low in heme, and tannins found
in tea and phylates in bran can decrease the absorption of iron [11]; so it
is important to supplement this subgroup.
Many patients complain of constipation while taking iron supplementa-
tion. This can lead to noncompliance. An easy way to assess whether a pa-
tientistakingherironsupplementsistoaskheraboutthecolorofherstool,
whichshouldbemarkedlydarkerifironisbeingconsumed.Onestrategyto
encouragecomplianceistoprescribeastoolsoftenerinadditiontoiron.In
womenwhocannotorwillnottakeoraliron,parenteralironisareasonable
alternative. Intravenous iron has traditionally been discouraged because
360 GYAMFI&BERKOWITZ
iron dextran can lead to anaphylactoid reactions. Iron sucrose, however, is
considered a safer alternative, with hypersentivity reactions estimated at
0.005% compared with 0.2% to 3% for iron dextran [12]. A test dose is
notrequiredbeforeadministrationofironsucrose,butitshouldnotbecon-
sidered the first-line agent for treatment of anemia because adverse drug
events other than hypersensitivity are common [12].
Erythropoietin may also be administered to an obstetrical patient with
ahematocritoflessthan40%whohasnotrespondedtoironsupplementa-
tion[10].Erythropoietinstimulatesthebonemarrowtomaximizeredblood
cell production. Recombinant erythropoietin is available either in the form
of epoetin alfa or darbepoetin alfa. Both of these drugs are erythropoesis-
stimulating agents (ESAs) that increase hemoglobin in a similar fashion.
Darbepoetin ismore expensive,butcan bedosedless frequentlythanepoe-
tin alfa [13]. ESAs should be stopped once the hemoglobin is greater than
12 g/dL because adverse cardiovascular events can occur above that level
[14]. Not all Jehovah’s Witnesses accept these medications because each is
packaged with 2.5 mL of albumin per dose. To help the patient make
an informed decision, a discussion should ensue about how the medication
works and how it is constituted.
Review blood products and their alternatives
Another key element in the initial prenatal visit is a comprehensive dis-
cussion about what blood products the patient may be willing to accept
and the available alternatives. As mentioned earlier, this conversation
shouldoccurintheabsenceofoutsideinfluencesthatmayalterthewoman’s
responses. This is the appropriate time to review the checklist of blood and
bloodproducts,describedearlier,toseewhichofthese,ifany,isacceptable.
Next,adiscussionofautologousblooddonationshouldensue[4].Autol-
ogousblooddonationinvolvesoptimizingthepatient’shematocritwithoral
iron supplementation (or erythropoietin, if this is acceptable) [4] and then
havingherdonateherownbloodatleast72hours(butideally,2weeks)be-
fore elective cesarean delivery or the estimated date of confinement. After
appropriate testing, the blood is stored and held for the patient. It will be
discarded if not used at the time of delivery [15]. This process is somewhat
tedious,butifthepatientiswillingtoacceptherownblood,itcouldbelife-
saving [15].
In addition to allogenic blood or blood products, other options should
also be discussed with the patient. Cell salvage systems can be employed
asaformofintraoperativeautologousblooddonation[4,16].Cell-saversys-
temsallow forfree bloodintheabdomentobeaspirated,filtered,andthen
reinfused into the patient perioperatively [16]. Such systems use centrifugal
cell separators that segregate the red cells from the plasma, wash the red
cells with normal saline, and prepare them for reinfusion. Clotting is pre-
vented by using a double-lumen tube with one lumen providing suction