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High Risk OB Case

Studies
Patricia M. Witcher, RNC-OB, MSN
Northside Hospital
Labor and Delivery, High Risk Obstetrics
Atlanta, Georgia
Maternal Mortality Rates in the
U.S. 1979 to 2005
16

Maternal Deaths per 100,000 Live Births


12.8

9.6

6.4

1979 3.2
1981
1983
1965
1987
1989
1991
1993
1995 0
1997
1999
2001
2003
2005

Source: http://www.census.gov/compendia/statab/2010/tables/10s0112.pdf. Last accessed 6/7/11


Top Reasons for Hospitalization
During Pregnancy
• Preterm labor
• Hypertensive disease
• Anemia / hemorrhage
• Infection-related
• Anesthesia-related complications
• Diabetes
• Embolism-related
Cause-Specific Pregnancy-Related
Mortality in the U.S., 1987 - 2005

1987-1990 1991-1997 1998-2005


30

25

20
Mortality %

15

10

0 Hemorrhage Thrombotic PE AFE Infection Hypertension Cardiomyopathy Anesthesia CVA CV Conditions Non CV Medical

Berg CJ, Callaghan WM, Syverson C, Henderson Z. Pregnancy-related mortality


in the United States, 1998 to 2005. Obstet Gynecol, 2010; 116(6): 1302-9.
Case Studies

• Case studies are not provided in handout


material in order to protect the
confidentiality of the patients and
institutions from which they are derived.
Pregnancy Adaptations that
Necessitate Consideration
During Assessment and
Interventions
General Considerations
• Pregnancy does not change the overall
therapeutic goal
– Restoring oxygenation is aggressive
– Interventions directed at restoring
hemodynamic instability are not withheld
out of concern for fetal effects
• Some clinical practices may require adaptation
General Considerations
• Hemodynamic and laboratory interpretation requires
adaptation based upon normal values in pregnancy
– i.e. Septic shock criteria typically requires adaptation
– i.e. Renal insufficiency despite normal nonpregnant values
• Anticipate increased potential for anesthesia-related
adverse events
– Difficult or failed airway
– Aspiration
• Pregnant women may deteriorate more rapidly due to
changes in pulmonary volumes and mechanics
• Higher risk for complications (i.e. DKA)
• Increased risk for UTI and pyelonephritis
Decreased Maternal Cardiac Output:
Impact Upon Uteroplacental Perfusion

!CO

Placental
vasoconstriction
! uteroplacental !PaO2
perfusion "PaCO2

FHR abnormality
Hemodynamic
Stabilization
• Assess according to normal hemodynamic values for
pregnancy
• Ensure adequate circulating blood volume whenever
possible to maintain uteroplacental perfusion
– Lateral positioning
– Judicious afterload reduction
– “Gental” diuresis in the setting of fluid overload
Determinant of Fetal Oxygenation

• Uteroplacental perfusion
• Greatly determined by maternal cardiac
output and circulating blood volume

• Maternal oxygenation status