Kenichi Ta naka, MD, MSC

• Associate Professor
• Anesthesiology
• Emory University School of Medicine
• Atlanta, Georgia

Ordinary physical activity results in mild symptoms Marked limitations on physical activity blood pressure medication and juice purchase benicar now. Less than ordinary physical activity results in symptoms Unable to carry out any physical activity without discomfort prehypertension kidney disease order benicar 20 mg amex. Discomfort increases with any physical activity a Symptoms include fatigue arteria renalis quality 40mg benicar, palpitations hypertension heart disease buy generic benicar 20mg online, dyspnea blood pressure record purchase benicar paypal, or anginal pain blood pressure medication how it works order generic benicar pills. When patients present with severe symptomatic disease early in preg nancy, termination of pregnancy should be offered. Counseling for these women may include a discussion of alternative means of family formation, including surrogacy and adoption. Basic diagnostic testing includes a 12lead electrocardiogram, tran sthoracic echocardiogram, and/or exercise testing. An echocardiogram helps determine the type and severity of valvular lesions, concomitant ventricular dysfunction, and the presence of pulmonary hypertension or other associated cardiac defects. Any factors that may potentially increase cardiac work, such as anxiety, anemia, infection, arrhythmia, or nonphysiological edema, should be identified and eliminated or minimized. Any diminution in cardiac function or worsening of maternal functional class should prompt further evaluation and consideration for hospitalization. Oxygen, diuretics, and inotropes such as digitalis can be used as necessary to optimize cardiac function. Women with cardiac disease should consult with their cardiologist before attempting strenuous activity during pregnancy. Depending on the maternal functional class and fetal status, weekly or biweekly evaluation of fetal wellbeing should be considered beginning in the third trimester. Anticoagulation Pregnancy is a hypercoagulable state, and pregnant women with mechani cal heart valves or cardiac failure are at especially high risk of thrombo embolism. However, anticoagulation management is challenging as no therapy is devoid of maternal and fetal risk, therefore an individualized treatment plan should be formulated with the patient using a joint deci sionmaking model. If used in the first trimester, it increases the risk of early pregnancy loss or may result in warfarin embryopathy, which includes abnormal cartilage formation and a hypoplastic midface. If used in the second or third trimesters, warfarin increases the risk of pregnancy loss, growth restriction, and abnormalities caused by vascular disruption like cerebral bleeding or limb reduction defects. The various forms of heparin do not cross the placenta and are therefore safe for the fetus, but are not completely effective in preventing thrombosis. The effect of vitamin K persists and can make antico agulation after delivery more of a challenge. Heart rate, stroke volume, cardiac out put, and mean arterial pressure all increase during labor and in the imme diate postpartum period. Lateral positioning and adequate pain control can reduce maternal tachycardia and increase cardiac output. In patients without cardiac disease, scheduling induction of labor at this time reduces the risk of emergency cesarean deliv ery by 12% and the risk of stillbirth by 50%. However, planned delivery prior to 39 weeks of gestation must weigh poten tial maternal benefit with the increased risk of fetal lung immaturity. Medications on L&D Providers need to be aware that many cardiac medications have obstetric implications (Table 17. In addition, lactation should be considered to optimize medications for breastfeeding as inappropriate advice can lead patients to unnecessarily discontinue breastfeeding. Delivery and the immediate postpartum period Vaginal delivery with anesthesia and limited Valsalva. Operative assistance with forceps or vacuum with the second stage of labor may decrease maternal cardiac work. Cesarean delivery results in increased blood loss (on average twice that associated with vaginal delivery), greater hemodynamic fluctuations, as well as increased risks of infection, throm boembolism, and postoperative complications. Generally, elective cesarean delivery confers no maternal benefit and results in earlier delivery and lower birthweight. However, women with certain severe cardiac condi tions may benefit from elective cesarean delivery. These include women with severe congestive heart failure or recent myocardial infarction, severe aortic stenosis, dilated aortic root (>4 cm), pulmonary hypertension, warfarin use within two weeks of delivery (due to risk of fetal intracranial hemor rhage during delivery), and those who require valve replacement immedi ately after delivery. Blood loss must be minimized and blood pressure maintained, on one hand, and attention must be paid to avoid congestive failure from fluid overload, on the other. Postpartum, highrisk patients may require further monitoring in the cardiac intensive care unit. The American College of Cardiology and the American Heart Association Task Force on Practice Guidelines have stated that, in general, intrapartum antibiotics are not necessary for women undergoing vaginal or cesarean delivery unless bacteremia is suspected or there is an active infection. This is because most cases of endocarditis are attributed to random bacteremia from routine daily activities rather than invasive procedures, so prophylactic antibiotics would prevent only a small subset of endocarditis cases. Therefore, the risk of antibioticassociated adverse events outweighs the potential benefit. However, prophylactic anti biotics should be considered at the time of membrane rupture or prior to delivery for certain highrisk patients. However, it is important to avoid hypotension when establishing regional anesthesia. Careful administration of intravenous crystalloid before placement of the catheter, close monitoring of fluid status, and slow administration of the anesthetic agent help to prevent this com plication. Ephedrine is generally the agent of choice for the treatment of hypotension associated with regional anesthesia because it does not con Table 17. Do not use cephalosporins in patients with a history of immediatetype hypersensitivity reactions to penicillins. However, as ephedrine increases the maternal heart rate, phenylephrine may be more appropriate for patients in whom tachycardia and increased myocardial work must be avoided. A singledose spinal technique is relatively contraindicated in patients with significant cardiac disease because hypo tension frequently occurs during establishment of the spinal block. A nar cotic epidural is an excellent alternative method and may be particularly effective for patients in whom systemic hypotension must be avoided. Regional anesthesia should only be administered during labor after clotting studies return to normal to avoid spinal or epidural hematomas. Therefore, it may be reasonable to continue aspirin therapy, but the choice of anesthesia should be decided in conjunction with an anesthesiologist. However, the hemodynamic changes of pregnancy may not fully resolve for six months. Based on the outcome of the pregnancy and the results of the cardiac reevaluation, the patient should be counseled regarding the risks for subse quent pregnancy and provided with appropriate contraception if desired. Management of pregnancy in patients with complex congenital heart disease: a scientific statement for healthcare profession als from the American Heart Association. Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels, 9th edn. Echocardiographic evaluation of hemodynamic changes in leftsided heart valves in pregnant women with valvular heart disease. This seemingly simple definition is challenged by the complexities of caring for patients in the third trimester of pregnancy and postpartum. Despite these challenges, the increasing contribution of both cardiovascular disease and cardiomyopathy to maternal mortality highlights the importance of a framework for diagnosis and management of the disease. First, the provider must entertain this condition in the patient with the appropriate clinical presentation and pursue appropriate workup to establish the diagnosis. The provider is then challenged to stabilize the patient while awaiting the input of consulting colleagues with expertise in the management. Finally, the obstetric care provider must be familiar enough with the short and longterm management to provide input about treatment options while balancing the goals of care for the patient and her fetus or neonate. The obvious overlap between symptoms of this lifethreatening condition and a normal Protocols for High-Risk Pregnancies: An Evidence-Based Approach, Seventh Edition. Reassuringly, physical exam can help distinguish normal pregnancy physiology from pathological conditions warranting further investigation. Patients with cardiomyopathy typically demonstrate vital sign abnormalities including hypoxia, tachypnea, hypo or hypertension, and tachycardia. Echocardiography is essential for the diagnosis and can be helpful to narrow the differential diagnosis for other disease states such as preeclampsia or noncardiogenic pulmonary edema. Echocardiography can demonstrate the presence of known or newly diagnosed medical comorbidities exacerbated by pregnancy such as congenital heart disease or valvular heart disease. The echocardiographic features in cases with reduced ejection fraction can further narrow the differential. Cardiomyopathy is classically subdivided into dilated, restrictive, and hypertrophic types. Patient demographics and clinical presentation can suggest clues to the underlying diagnosis, but echocardiographic features are central to diagnostic criteria (Table 18. Etiopathogenesis of peripartum and other cardiomyopathies Dilated cardiomyopathy Dilated cardiomyopathy, of which peripartum cardiomyopathy is a subtype, is the most frequently encountered type of cardiomyopathy. The echocardiographic features include dilation of the left ventricle with reduced systolic function most commonly expressed as reduced ejection fraction. The contemporary understanding coupled with the timing of presentation seems to refute this notion. More rare but notable risk factors include longterm tocolytic therapy with betaadrenergic agonists such as terbutaline, maternal cocaine abuse, and nutritional deficiencies (such as selenium). The presence of a genetic predisposition is suggested by both pedigrees and the wide variation in incidence globally, ranging from a reported 1 in 100 patients in Zaria, Nigeria, to 1 in 20 000 live births in Japan. An underlying genetic predisposition may explain part of the pathology but additional mediators of endothelial damage and oxidative stress leading to damage of cardiac myocytes play an important role in the pathogenesis of the disease. Basic science studies have revealed a role for both prolactin and the placenta in the mechanism of the disease. In times of increased oxidative stress, the enzyme cathepsin D cleaves prolactin released from the anterior pituitary to a 16 kDa fragment that causes endothelial apoptosis. The expression of soluble fmslike tyrosine kinase receptor 1 (sFlt1) is an antiangiogenic protein that sequesters circulating vascular endothelial growth factor leading to endothelial dysfunction in a similar manner to preeclampsia. Apoptosis of myocytes leads to additional stress and release of cathepsin D, providing a positive feedback loop for cardiac damage. For example, hypertrophic cardiomyopathy is characterized by a hypertrophied left ventricle without dilation. Although chronic diseases like hypertension or valvular heart disease in the setting of aortic stenosis can lead to hypertrophy of the left ventricle, hypertrophic cardiomyopathy classically refers to asymmetrical septal hypertrophy due to mutations in the genes encoding the sarcomere proteins in the contractile apparatus. The thickened hypertrophied ventricle can also predispose the patient to ischemia, ventricular arrhythmias, and cardiac death. Understanding this hallmark physiology helps anticipate the adaptation to pregnancy and inform the treatment needs for pregnant women with this comorbidity. The clinical presentation often includes pulmonary congestion manifest as pulmonary edema as well as systemic congestion with associated hepatosplenomegaly and ascites. Atrial arrhythmias can be common due to the increased burden of work with atrial contraction to force blood into a stiff and noncompliant ventricle. Echocardiographic features include a nondilated ventricle with normal wall thickness with impaired relaxation and diastolic filling from stiff noncompliant ventricles. Biatrial enlargement is often seen and excluding evidence of constructive pericarditis is essential. Restrictive cardiomyopathies are rare and can be caused by familial syndromes, infiltrative disorders (amyloidosis, sarcoidosis), glycogen storage diseases, or endomyocardial fibrosis. As with the other cardiomyopathies, an understanding of the echocardiographic features and pathophysiology is of critical importance, both to guide acute treatment and provide anticipatory guidance about prognosis and recurrence risk. Frequent hemodynamic monitoring including cardiac 174 Protocol 18 telemetry, continuous fetal monitoring, and close urine output monitoring with the placement of a urethral catheter are warranted. In addition to assessment of heart rate, blood pressure, and respiratory status, other components of the clinical exam should be considered, including evidence of tissue hypoperfusion such as oliguria, cold skin either centrally or peripherally, an elevated lactate, or a depressed mixed or central venous oxygen saturation for those rare patients in whom invasive hemodynamic monitoring is warranted. The obstetric care provider should understand and explain maternalfetal physiology to the multidisciplinary team, and counsel the patient and her family about goals of care. Stabilization of acute heart failure Supplemental oxygen may be necessary with a target of an SpO2 >95% for pregnant patients and SpO2 >90% for postpartum patients. Supplemental oxygen in the absence of hypoxemia is not warranted and may reduce cardiac output via vasoconstriction. Optimization of preload is an essential stabilizing measure for patients presenting with heart failure. For patients presenting with evidence of volume overload, the use of furosemide or other loop diuretics should be initiated at a low dose and quickly escalated until a clinical response is achieved. Infusion of vasodilators may not be immediately attainable on the labor and delivery unit, so hydralazine is a reasonable alternative to achieve this goal. While betablockers are contraindicated in acute decompensated heart Peripartum Cardiomyopathy 175 failure, their use may be more appropriate adding rate control during the stabilized compensated phase of heart failure management. Oral antihypertensives are avoided due to their longer halflife and challenges with titration compared to intravenous medications. Vasopressors often used first line for undifferentiated or cardiogenic shock, such as norepinephrine and epinephrine, are often avoided in favor of inotropic agents such as milrinone due to the catecholaminergic effects of the betaagonists.

Lower concentrations (<10%) are used for peripheral hydrations blood pressure goals jnc 8 purchase benicar 10 mg free shipping, providing calories pulse pressure 43 order benicar with mastercard, and assessing kidney function (if patients do not need electrolyte replacement) pulmonary hypertension 60 mmhg benicar 20 mg without a prescription. In higher concentrations blood pressure chart female discount 40mg benicar overnight delivery, dextrose is used for reversing hypoglycemia arteria mesenterica inferior order benicar 10mg with mastercard, providing calories when less fluid is indicated hypertension jnc 8 classification order cheap benicar on line, and with amino acids for total parenteral nutrition. This fluid is used for temporary treatment of circulatory insufficiency and shock caused by hypovolemia (low circulating blood volume), in the absence of a plasma extender, and for early treatment with plasma for loss of fluid caused by burns. They provide a source of water, electrolytes, and carbohydrates to cover hydration, insensible water loss, and urinary excretion. It should not be used in patients with the inability to metabolize lactate (found in the solution). Patients at high risk are those with liver disease, Addison disease (see Insight 8. Plasma-Lyte and Isolyte E are electrolyte-balanced solutions compatible with the pH of blood. They are used to treat the massive loss of water and electrolytes seen in uncontrolled vomiting or diarrhea. It does not disturb normal electrolyte relationships and may be used as an adjunct to increase circulatory volume in patients with moderate blood loss. Normosol-R does not cause hemolysis of blood, so it can be used as a priming solution for the blood infusion set. The needle is removed, leaving the catheter in the vein where it is taped securely in place. Physiologically hypotonic = the dextrose is quickly metabolized and only water remains, making it a hypotonic fluid. Blood Replacement Physiology Review Blood is a fluid connective tissue that performs several critical functions in maintaining homeostasis. It is used to transport oxygen, nutrients, wastes, hormones, and enzymes throughout the body. Blood is so crucial to maintaining life processes that it has a self-protection mechanism- clotting-to prevent harmful loss. In an average adult, though, the circulating blood volume is approximately 70 mL/kg of body mass. For the body to be kept functioning normally, this blood volume should be maintained. Some surgical patients are at high risk for substantial blood loss during surgery; these include patients needing cardiac and peripheral vascular procedures or those with trauma. The goal of blood replacement in scheduled surgical procedures is to maintain the circulating volume of blood, as well as its oxygen-carrying capacity. Blood consists of two main components: formed elements (approximately 45%) and fluid called plasma (approximately 55%). Leukocytes provide protection against foreign microbes by phagocytosis and antibody production. Most surgical patients undergo laboratory tests to determine the amount of Hgb present in their blood. A normal Hgb level is 12 to 16 g/100 mL of blood in adult females and 14 to 18 g/100 mL in adult males. Because oxygen levels must be optimum during administration of general anesthesia, elective surgery may be canceled if the Hgb dips below normal levels. Another important measure of the oxygencarrying capacity of the blood is hematocrit. Hematocrit is the volume of erythrocytes in a given volume of blood and is expressed as a percentage. Normal hematocrit levels range from 35% to 52%, varying by age and gender (Table 11. Blood is also designated as Rh positive (Rh antigen present) or Rh negative (no Rh antigen present). A blood cross-match is performed to determine compatibility between the donor and the recipient. This can result from incompatible blood types or Rh factors and must be treated immediately. If any suspicious reactions occur during blood transfusion, the following steps should be taken: 1. Begin appropriate medication therapy, which usually includes steroids and prophylactic measures to reduce risk of kidney failure, as soon as possible. In some cases, the patient may have to undergo renal dialysis to rid the system of mismatched blood. It is an injectable blood product manufactured from human plasma that contains anti-D to suppress the immune response of an Rh-negative mother to an Rhpositive fetus. This Rh disease could result in miscarriage in subsequent pregnancies if not treated. Rho(D) immune globulin is for intramuscular injection only and is routinely given to Rh-negative mothers who deliver Rh-positive babies. Amazingly, the boy did not die, perhaps because of the small amount of blood he received. This method was popular for a time until transfusion reactions were recognized and reported. James Blundell performed many transfusions in the early nineteenth century (approximately half were successful), developed instruments for the process, and published his results. Since the discovery that all human blood is not alike in 1901 by Karl Landsteiner, many advances have been made in blood transfusion therapy. Currently, blood transfusions are implemented with the knowledge that blood must be compatible in type and Rh factor. The most common indication for blood replacement in surgery is hypovolemia (low circulating blood volume), seen most frequently in trauma and vascular procedures. When patients lose a certain amount of blood, they experience this syndrome, which is also called hemorrhagic or circulatory shock. The result is decreased oxygen supplied to vital organs, increased heart rate, and decreased cardiac output. This can be further complicated by the anesthetic, which may enhance the effects of hemorrhage. Other indications for blood replacement include restoration of the oxygen-carrying capacity, as seen in anemic patients or those with blood diseases, and to maintain clotting properties, as needed in patients with hemophilia. In either case, the surgeon must document the need for blood release without compatibility testing. Some of these options may not be feasible in certain cases, depending on the situation. A blood bank is responsible for collecting, processing, and releasing donor blood for use. All blood donors go through careful screening of their medical history, and those who are at risk of transmitting an infectious disease are not allowed to donate. However, it is still possible for donor blood to present some risk for transmission of bloodborne pathogens. Blood is separated during processing into components and then administered to treat specific needs. Component replacement therapy is an effective and efficient use of limited resources because a unit of donor whole blood separated into components can be used to treat several patients. Whole Blood the term whole blood indicates the blood composition has not been broken down or altered. Note In some situations involving massive trauma and severe blood loss, the replacement of blood and fluids may be as a "1:1:1 ratio. Packed cells are obtained by removing approximately 200 mL of plasma and most of the platelets from 1 unit (500 mL) of whole blood. Plasma Plasma may be administered when clotting factors are needed in addition to circulating volume. This need is frequently seen when several units of blood have been replaced because the clotting factors have been removed from donor blood. Plasma is not used for volume expansion alone because albumin and synthetic expanders are as effective and eliminate the risk of transmission of bloodborne diseases. Plasma is stored as fresh-frozen plasma to preserve clotting factors and thawed in a water bath before use. Platelets are infused to restore a more normal clotting process and to help to repair damaged blood vessels. They may also be administered prophylactically in patients who have low platelet counts, such as those receiving chemotherapy or radiation therapy or with leukemia. At room temperature, platelets must be continually gently agitated to prevent clumping. A unit of platelets is defined as the amount separated from a unit of whole blood. They do not have a blood type, so can be received from any qualified donor (or donors). Platelet-rich plasma, growth factors obtained from platelet concentrate, can be obtained from blood plasma for wound healing (Insight 11. Cryoprecipitate may be administered in surgery when massive amounts of blood have been replaced, severely impacting the normal coagulation process. It is usually given in 4 to 6 unit pools at a time rather than a single unit, and blood typing is not required. When this platelet concentrate is reintroduced into the wound, it releases growth factors that recruit and increase the reparative cells. It is used for wound healing in surgery, treatment of tendonitis, cartilage repair, cardiac care, spinal disc regeneration, and dental care. Autologous Donation Patients scheduled for elective surgical procedures in which blood loss is anticipated, such as a total hip replacement, may be allowed to donate their own blood. This can be done up to 4 days before surgery, although a much longer period of time, such as 1 month, is preferred. This process is called autologous transfusion and usually involves two units of blood. Most patients can safely donate two units of whole blood over a period of weeks just before their scheduled procedure, possibly eliminating the need for donor blood. Patients often choose this option, if available, to protect themselves from potential bloodborne disease transmission. However, some medical conditions may make autologous donation unsafe, so not all patients are eligible. Autotransfusion Another form of autologous donation used intraoperatively and postoperatively is called autotransfusion. Some are designed specifically for emergency procedures when rapid infusion is required. Blood can be collected in a suctiontype device or via bloody sponges drained into a sterile basin of saline, then aspirated into the machine. However, blood that has been exposed to collagen hemostatic agents and some medications (such as certain antibiotics) cannot be used because clotting in the machine may occur. When the canister is filled, the blood is washed in a red cell washer (usually found in the blood bank) and reinfused. In this method, the blood is sent out of the surgical department to be washed, and so there is time lost before reinfusion. Autotransfusion is performed during open heart surgery, vascular procedures, major orthopedic procedures, and some trauma procedures, such as splenectomy. Autotransfusion has several advantages over the use of donor blood, including immediate replacement of blood loss without the potential for transfusion reaction or delay for blood typing and cross-matching and no risk of transmission of bloodborne pathogens. In addition, patients with religious objections to donated blood often do not object to autotransfusion. Autotransfusion is not suitable for all patients because some trauma patients may have lost so much blood already that there is little volume left to salvage. A disadvantage of autotransfusion is that it cannot be used in the presence of cancer cells, infection, or gross contamination. Autotransfusion is generally contraindicated during cesarean section because of the presence of amniotic fluid. Autotransfusion is commonplace in most operating rooms currently, and is an effective option for replacement of blood lost during certain surgical procedures. Volume Expanders Volume expanders are used to increase the total volume of body fluid when hypovolemia occurs. One category is crystalloids, solutions that contain salts (electrolytes) and/or sugars. Another category of volume expanders is colloids, solutions that contain proteins or other substances with large molecules that increase osmolarity and do not dissolve in solution. Volume expanders can be used when donated blood or autotransfusion is not immediately available for emergency procedures. Albumin is available in concentrations of 5%, which is equal to plasma, or as a concentrated 25% in sodium chloride solution. Dextran expands plasma volume by drawing fluid from the interstitial space to the intravascular fluid space. It is formed by the action of a bacterium and has osmotic properties but not oxygencarrying capacity. It improves microcirculation independent of basic volume expansion and minimizes the changes that occur in blood viscosity that accompany shock. Dextran 70 or 75 is used to expand plasma volume in impending hypovolemic shock, as caused by hemorrhage, burns, or trauma. Hetastarch Hetastarch (Hespan) is also a synthetic used for its osmotic properties. It contains electrolytes (sodium, calcium potassium, and magnesium) and acts as albumin in the management of shock.

Similarly hypertension blurred vision generic 10mg benicar with visa, a suspicion of a ruptured vasa previa after viability should lead to immediate cesarean delivery hypertension causes order benicar 20 mg amex. When a patient presents with active bleeding arrhythmia flashcards discount benicar 20 mg, intravenous access with widebore (16 or 18 gauge) catheters should be established prehypertension blood pressure treatment purchase benicar no prescription. Maternal blood should be assessed expeditiously for complete blood count wide pulse pressure icd 9 buy benicar with amex, type and screen arrhythmia yahoo purchase benicar 10 mg free shipping, and coagulation factors if there is suspicion of placental abruption, coexisting hypertensive disorder of pregnancy or fetal demise. If laboratory services are limited, maternal blood may be collected in a tube without anticoagulant (plain red top tube) and inverted every few minutes. Failure of maternal blood to spontaneously clot within 10 minutes suggests coagulopathy. In cases of placenta previa, suspected placenta accreta, when there is coagulopathy, or when estimated blood loss is in excess of 500 mL, blood should be crossmatched. Restoration of intravascular volume with crystalloid should be performed promptly, with appropriate blood product replacement as required for significant blood loss or coagulopathy. Coagulopathy is typically corrected using fresh frozen plasma, although cryoprecipitate may be used (Table 48. RhD immunoglobulin given as an intramuscular dose of 300 g will cover 30 mL of fetal whole blood or 15 mL of fetal red cells. The fetus should be monitored continuously until it is clear that the fetal status is both stable and reassuring. If the fetus is stable and the gestational age is less than 33+6/7 weeks, antenatal corticosteroids should be considered to promote fetal lung maturation. In cases of placenta previa where the placental edge covers or lies within 1 cm of the internal os, delivery should be by cesarean. When the placental edge is more than 2 cm from the internal os, vaginal birth is considered safe as long as there are no other contraindications. The unifying principle in the management of patients with various etiologies of thirdtrimester bleeding is to optimize the delivery circumstances from both the maternal and fetal standpoint. These principles are applied to generate the recommended times of admission, steroid administration, and delivery (Table 48. Potential complications Perhaps the most important complication of thirdtrimester bleeding is hypovolemic shock, which may have acute onset and be severe and lifethreatening. Disseminated intravascular coagulation may occur in abruption or fetal demise, and sometimes with placenta previa when there has been massive blood loss with volume replacement deficient in coagulation factors. However, the majority of these complications are preventable by accurate prenatal diagnosis and prompt appropriate management. Conclusion Bleeding in the third trimester is often a serious complication of pregnancy that can confer a significant risk of perinatal death and severe maternal morbidity. Vaginal bleeding should always be treated seriously and with a high index of suspicion for lifethreatening conditions. Careful evaluation should begin with transvaginal ultrasonography and clinical history taking to assist in the diagnosis. Accurate diagnosis and appropriate treatment will optimize outcomes for mother and fetus in most cases. Vaginal delivery in women with a lowlying placenta: a systematic review and metaanalysis. Lower uterine segment thickness to prevent uterine rupture and adverse perinatal outcomes: a multicenter prospective study. Fetal imaging: Executive summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop. Since then, over 1000 case reports and series have been published and there are ongoing attempts to elucidate the etiology, risk factors, and pathogenesis of this mysterious obstetric complication. This rate of allergy is essentially double the rate found in the general obstetrical population at our institution over the same time period, at 34%. Early studies describe the histological presence of amniotic fluid components, such as fetal squamous cells, mucin and components of meconium, in maternal lung tissue during postmortem Amniotic Fluid Embolism 509 examination in obstetric patients who had unexplained death. Similar inconclusive results were found when analyzing the current international registry, although only a few families requested autopsy, and in most cases there was no coroner report. Another significant limitation is that the definitions of methods used for labor induction. In the contemporary registry, 100% of women had profound respiratory symptoms at onset. The interval between the onset of symptoms and collapse reportedly varies between almost nil to over four hours. Other signs and symptoms include nausea, vomiting, fever, chills, headache, and even a sense of impending doom. There have also been reports of isolated right ventricular dysfunction with high rightsided pressures and tricuspid regurgitation. Progression to cardiac arrest can occur quickly, with pulseless electrical activity, ventricular tachycardia, ventricular fibrillation, and asystole all being reported. If the event occurs before delivery, electronic fetal monitoring may demonstrate decelerations and/or profound bradycardia, as oxygenated blood is shunted away from the uterus. In the contemporary registry there was significantly less morbidity and this may be attributed, at least in part, to the current hospitalwide hemorrhage and massive transfusion protocols which have led to improved escalation and response times, as well as more balanced transfusion strategies, than were used in the 1980s and 1990s. Cardiac enzymes may be elevated and arterial blood gas levels will demonstrate hypoxemia. The primary management goals include rapid maternal cardiopulmonary stabilization with prevention/treatment of hypoxia along with maintenance of vascular perfusion. Immediate noti cation to neonatology, maternalfetal medicine and/or obstetric care provider, anesthesiology, intensive care Consider immediate delivery in viable pregnancies either by operative vaginal delivery or emergent cesarean section. May con rm with bedside transthoracic echocardiography Avoid excessive uid resuscitation. Right ventricular faliure addressed with inotropes, such as dobutamine or milrinone. Decrease pulmonary afterload with inhaled nitric oxider or inhaled/intravenous prostacyclin if indicated. Second phase characterized by left ventricular failure and cardiogenic pulmonary edema. Maintain hemodynamics with use of norepinephrine and inotropes, such as dobutamine or milrinone. Coagulopathy may have immediate or delayed onset following cardiovascular collapse. Left heart failure is treated by optimizing cardiac preload, vasopressors to maintain coronary perfusion pressure if hypotensive, and inotropes. In cases of refractory hypotension, vasopressors such as norepinephrine and dopamine may be necessary, with norepinephrine recommended as first line. In terms of dysrhythmia, the most common pattern found Amniotic Fluid Embolism 513 was electromechanical dissociation. Dosages of vasopressors, antiarrhythmic medications, and defibrillation joules should not be altered for the pregnant patient. In cases in which asystole or malignant arrhythmia is present for greater than four minutes, perimortem cesarean delivery should be considered if the fetus is >23 weeks. If possible, operative vaginal delivery by forceps or vacuum assist should be considered, otherwise an emergency cesarean is indicated. In the most current international registry, 80% of patients underwent cesarean delivery, of which the majority were urgent. Intact fetal survival has been shown to be highest when delivery is accomplished within five minutes of Table 49. Uterine atony should be managed with standard medications, tamponade devices, and surgical procedures as appropriate for such refractory cases. In over 60% of patients across all registries, cesarean hysterectomy was performed for atony and related hemorrhage. This is especially critical if there is evidence of uterine atony, hemorrhage, coagulopathy, and/or significant maternal cardiopulmonary compromise. Ideal management is also unclear, but involves prompt evaluation and intervention for each of the pathological features found in this complex obstetric condition. This starts with effective cardiopulmonary resuscitation with or without evacuation of the uterus, especially in cases where there is cardiac arrest. Incidence and risk factors of amniotic fluid embolisms: a population based study on 3 million births in the United States. Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Proposed diagnostic criteria for the case definition of amniotic fluid embolism in research studies. Cardiac arrest in pregnancy: a scientific statement from the American Heart Association. In this early stage, rule out underlying renal disease, molar pregnancy, and other medical disorders. Pathophysiology Preeclampsia is a disorder of unknown etiology that is peculiar to human pregnancy. The pathophysiological abnormalities in preeclampsia include inadequate maternal vascular response to placentation, endothelial dysfunction, abnormal angiogenesis, and exaggerated inflammatory response with Protocols for High-Risk Pregnancies: An Evidence-Based Approach, Seventh Edition. These abnormalities result in pathophysiological vascular lesions in peripheral vessels and uteroplacental vascular beds, as well as in various organ systems, such as the kidneys, liver, lungs, and brain. Consequently, these pregnancies, particularly those with preeclampsia and severe features, are associated with increased maternal and perinatal mortality and morbidity due to reduced uteroplacental blood flow, placental abruption, and preterm delivery. The concentration of urinary protein is influenced by contamination with vaginal secretions, blood, bacteria, or amniotic fluid. The ultimate goals of any management plan must be the safety of the mother first and then delivery of a live mature newborn that will not require intensive and prolonged neonatal care. The decision between immediate delivery and expectant management will depend on one or more of the following: maternal and fetal conditions at the time of evaluation, fetal gestational age, presence of labor or rupture of membranes, severity of the disease process, and maternal desire. There was no difference in the rate of cesarean sections or neonatal outcomes between the groups. The patient should also have no subjective symptoms, and should be compliant and reliable. Whether the patient is in the hospital or being managed at home, the following should be observed. Patient should be instructed about daily kick counts and labor signs or vaginal bleeding. There is no need for assessment of fetal lung maturity and delivery should not be delayed for administration of steroids for fetal lung maturity. Expectant management is intended to provide neonatal benefit but is associated with increased maternal risks. If patient does not elect to terminate, manage expectantly but counsel about maternal risks and poor perinatal outcome. Others will have vague abdominal pain, flank or shoulder pain, jaundice, hematuria, gastrointestinal bleeding, or gum bleeding. If hypertension persists, antihypertensive medications are prescribed for one week, after which the patient is reevaluated. In addition, all patients should be given written instructions about signs and symptoms to report as well as a phone number to call in case of development of new symptoms or severe hypertension. Neurologiclike eclampsia, hypertensive encephalopathy, ischemia, infarcts, edema, and hemorrhage can also occur, as can cardiorespiratory arrest. With severe disease in the second trimester, the risk of recurrent preeclampsia is 50%. This is especially true in patients with two episodes of preeclampsia in the second trimester. Diagnosis, controversies, and management of the syndrome of hemolysis, elevated liver enzymes, and low platelet count. Expectant management of severe preeclampsia remote from term: patient selection, treatment, and delivery indications.

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