Month: March 2019

Postpartum Emergencies

Chris Ebright Back to the Basics 0 Comment

Ah, childbirth—the miracle of life. Some EMS professionals may make several calls in which they place “storks” on their preverbal career belts, while others will never get the chance. In actuality, most emergencies and maternal deaths occur after childbirth, during the postpartum period, according to the World Health Organization.   Rapid change is present within the first six to twelve hours after birth, and thus, creates a potential for an immediate crisis—postpartum hemorrhage, embolism, and pre-eclampsia being the most common emergencies. However, major changes in hemodynamics and metabolism can take place up to six weeks after birth.1

In this article, we’re going to look at our three most likely crises in different scenarios and discuss what a prepared EMS team can do.

Case 1: Postpartum Bleeding

A 32-year-old female has been home for four days after delivering an 8lb., 10 oz. baby. She has been active at home and noticed some vaginal bleeding after the first day home. The bleeding has persistently worsened the past three days. When she got up in the middle of the night to tend to the baby, her husband heard a crash, found she had fainted and called 911. She presents with pale, cool, clammy skin, BP: 86/50, Pulse: 130, RR: 24, Pulse Ox: 99% room air, and mentating normally.

Postpartum hemorrhage is the leading cause of maternal death, and accountable for 25% of all annual deaths, globally.2 It is defined as blood loss greater than 500 milliliters following a normal vaginal delivery, or greater than one liter following a cesarean section within 24 hours of birth. A useful mnemonic to help remember the major causes of postpartum hemorrhage is “Four T’s”:  Tone, Trauma, Tissue, and Thrombin (coagulopathy).

Tone refers to uterine tone, and in this instance, lack thereof. It’s the most common cause of postpartum hemorrhage, occurring once in every twenty deliveries. Causes include prolonged labor, grand multiparity, a newborn weight greater than 8.5 pounds, a maternal age greater than 35, maternal oxytocin or magnesium administration, and multiple gestations.3 Hemorrhage from trauma typically is induced by uterine, cervical, perineal or vaginal lacerations. Less likely causes include uterine inversion and uterine rupture. An invasive placenta can lead to retained tissue. Not only will this increase the likelihood of postpartum hemorrhage, but also the development of endometritis. An invasive placenta occurs once in every 533 pregnancies and has the potential for blood loss that exceeds three liters.4,5,6 Albeit rare, coagulation disorders, whether from an inherited form of hemophilia, or an acute case of sepsis leading to disseminated intravascular coagulation, increases the potential for massive blood loss.

Keep in mind, at full term, a pregnant female’s plasma volume increases close to 50% of her average non-pregnant volume. This equates to about 1250 milliliters that she can lose, in addition to another 1500 milliliters, before showing any visible signs of shock. Have a high index of suspicion for massive blood loss and treat aggressively before signs appear with a postpartum female. Prehospital management centers around controlling bleeding externally by placing pads over, not within, the vaginal opening; fundal massage, as needed; IV fluid replacement titrated to a sufficient mean arterial pressure, and oxygen administration.

Case 2:  Embolism

You are called to a home of a 30-year-old female with chest pain. She delivered a healthy baby one week ago, now complaining of chest pain with deep inspiration, dyspnea, and painful left leg swelling. Her lung sounds are clear, skin is pale, warm, dry; BP: 106/82; Pulse:130; RR: 28 Pulse Ox: 83% room air.

Pulmonary embolism is the second most common cause of pregnant female death in the U.S. and is fifteen times more likely to develop during the postpartum period.7 When a female is pregnant, her body naturally increases the production of products responsible for making a blood clot, while at the same time, decreasing the production of anticoagulants. The reversal of this process may take days to weeks, leaving a new mother susceptible to pulmonary vessel blockage. Another source for a maternal pulmonary embolism is from amniotic fluid. It’s a rarer condition but carries a much higher mortality, usually occurring within 48 hours after birth. Risk factors include a history of placenta previa or abruption, pre-eclampsia, recent cesarean section, and multiparity.

One prevalent theory is that the amniotic fluid enters the mother’s bloodstream via a breach in the placenta, resulting in a bubble that eventually lodges within the pulmonary trunk or the branches of the left and right pulmonary arteries. Another theory surmises that the entry of amniotic fluid into the mother’s bloodstream activates her inherent immune response, producing what appears to be an acute anaphylactic reaction. In either case, the clinical presentation is similar. The patient will have signs/symptoms of acute respiratory failure, cardiogenic shock, and disseminated intravascular coagulation.8

An amniotic fluid embolism is unpredictable, unpreventable, and has no specific management.  EMS professionals will be charged with the task of managing the presenting respiratory and cardiovascular compromise. Standard supportive BLS and ALS measures as well as oxygen administration by the most effective means, IV fluids and/or vasopressors to attain a mean arterial pressure above 60 mmHg, and intravenous or intramuscular epinephrine, if required.  Even with aggressive and proper management, these postpartum patients may not respond positively. Be prepared for cardiac arrest at all times.

Case 3:  Pre-Eclampsia

Your patient is a 38-year-old female complaining of a bad headache, blurred vision and that her stomach hurts—pointing to the upper right abdomen. She also tells you that she had her first child a week ago. Her pregnancy was normal and she has never had any medical problems. Vital signs are BP: 186/112, Pulse: 98, RR: 14, Pulse ox: 100% room air.

Pre-eclampsia is a pregnancy-related illness on a spectrum which includes eclampsia and HELLP syndrome. It typically occurs after twenty weeks’ gestation, but can also occur as late as six weeks postpartum. Pre-eclampsia is twice as prevalent with first-time mothers and occurs in 4% of all U.S. pregnancies.9 Risk factors include: first-time pregnancy, twins, advanced maternal age, gestational diabetes, a history of hypertension, and obesity.

It occurs secondary to an arterial malformation within the placenta. These arteries are supposed to dilate during placental development but never do. As a result, placental tissue becomes ischemic, releasing vasoconstrictive and inflammatory products into the mothers’ bloodstream.  These products cause characteristic hypertension, peripheral edema, and end-organ damage (most notably to the kidneys and liver). Liver damage manifests as HELLP syndrome, which stands for Hemolysis, Elevated Liver enzymes, and Low Platelet count. HELLP can appear anytime between 48 hours to seven days postpartum and can cause the liver to rupture, as well as increase the amount of peripheral edema, bleeding, and pain.10

Postpartum pre-eclampsia is defined by a systolic blood pressure greater or equal to 140 mmHg or diastolic blood pressure greater or equal to 90 mmHg. There are many additional criteria included to make this diagnosis, but in the prehospital setting look for the following: severe right upper abdominal quadrant or epigastric pain, bleeding, nausea/vomiting/indigestion with pain after eating, pulmonary edema, blurred vision, peripheral edema, and/or a severe, persistent headache.

The definitive treatment for women with HELLP syndrome and pre-eclampsia is the delivery of the baby. Obviously, during the postpartum period, other management strategies need to be made by EMS professionals. Unmanaged, pre-eclampsia will develop into the convulsive state known as eclampsia. Measures must be taken to prevent this, as the likelihood of maternal death increases significantly. Along with standard BLS and ALS interventions, position the patient to prevent any possible aspiration, should a seizure occur.  When an IV is established, the primary medication is magnesium sulfate. Administer a loading dose between four and six grams over fifteen minutes, per local protocol, and follow with a continuous infusion of one to two grams per hour. This is for seizure resolution/prevention as well as blood pressure reduction. Target numbers for blood pressure, generally, are less than 150 mmHg systolic and less than 100 mmHg diastolic. Additionally, various beta-blocking agents, such as labetalol, may be administered to assist in lowering blood pressure.

References
  1. Brown JS, Posner SF, Stewart AL. J Am Geriatr Soc. 1999 Aug; 47(8):980-8.
  2. Ngwenya S. Postpartum hemorrhage: incidence, risk factors, and outcomes in a low-resource setting. Int J Womens Health. 2016 Nov 2;8:647-650.
  3. Retrieved from: https://www.healthline.com/health/pregnancy/complications-delivery-uterine-atony#causes-and-risk-factors.
  4. Bowman ZS, Eller AG, Bardsley TR, et al. Risk factors for placenta accreta: a large prospective cohort. Am J Perinatol. 2014;31:799-804.
  5. Sadashivaiah J, Wilson R, Thein A, et al. Role of prophylactic uterine artery balloon catheters in the management of women with suspected placenta accreta. Int J Obstet Anesth. 2011:20:282-287.
  6. Committee on Obstetric Practice. Committee opinion no. 529: placenta accreta. Obstet Gynecol. 2012;120:207-211
  7. Retrieved from: https://www.cdc.gov/ncbddd/dvt/data.html.
  8. Benson MD. A hypothesis regarding complement activation and amniotic fluid embolism. Med Hypotheses. 2007;68:1019–25
  9. Ananth CV, Keyes KM, Wapner RJ. Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis. BMJ. 2013;347:f6564.
  10. Retrieved from: http://americanpregnancy.org/pregnancy complications/hellp-syndrome/