Maternal Outcomes Making a Difference

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Maternal Outcomes Making a Difference

• MANA Spring Meeting 2009
• Karen Crawforth, CRNA, Ph.D

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Goals

• Identify substandard maternal care.
• Make recommendations regarding clinical
  practices.
• Suggest the direction of research and audit.
• Ultimately improve the care that pregnant and
  recently delivered women receive.

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Maternal Mortality

• Recent reports from CDC ? rates in the last 2
  decades.
• Obesity (MDD).
• Increased c-section rate.
• Advanced maternal age.
• Race.

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Causes of Maternal Death

• 50 of maternal deaths are deemed preventable!

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Confidential Enquiries in Maternal Deaths

• Began in England and Wales 50 years ago.
• The philosophy regarding each death
• Goes beyond denoting women as statistics
• Views each as a young woman who died before her
  time.
• As a loss of a mother, a member of a family, and
  of a community.
• Tells a story with the ultimate goal of improving
  the standard of maternal health.

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Stories of Maternal Deaths in the Literature

• Charles Dickens
• Oliver Twist
• Ernest Hemingway
• A Farewell to Arms
• J. K. Rowling
• Harry Potter

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The Story

• Second grade teacher.
• Active member and volunteer at her Church.
• Wife married to her husband for 10 years.
• Mother of 2 daughters aged 6 and 8.
• Patient she was pregnant with her third child.

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Demographics

• 38 year old AA female.
• 54, 286 lbs, BMI 49.
• NKDA (fish), meds PNV.
• No significant medical hx.
• Cholecystectomy 2000 w/o problem.
• G3 P2
• Two previous NSVDs without complication.

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Developed a Severe Headache at Work

• Seen in obstetricians office and found
• 3 Protein
• BP 180/99
• Generalized edema
• Complaint of black spots in vision
• Fetal Status
• 37 weeks with reassuring FHTs

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Obstetrical Plan

• Admit the patient to L D.
• Dx preeclampsia.
• Treat hypertension (Labetolol).
• Start Magnesium Sulfate.
• Induce Labor.
• Monitor maternal and fetal status
• Proceed to surgical delivery if necessary.

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Labs Etc..

• Admission at 1600
• Hbg 11.4, HCT 33.6, platelets 225,000
• Lungs clear to auscultation.
• Room air 02 saturation - 99.
• BP 198/102, HR 76, Respiration 24, Temp 37
• BUN 8, Creat. 0.7, ALT 19, AST 24, and LDH 127.

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Anesthesia

• 0300 - Labor epidural (11 hours after admission).
  
• Patient has been on bed rest and NPO.
• BP 170-190/80-100.
• Magnesium and Oxytocin infusions.
• IV 75 ml/hr.
• FHTs reassuring (130-150).
• Dilated to 3cm, -2 station.

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Course of Labor

• 0600 - Pt dilated to 5 cm.
• 1300 - 7 cm
• 1500 - despite a good contraction pattern no
  further dilation.
• 1600 - continued hypertension and variable
  decelerations decision is made to proceed with a
  c-section and tubal ligation. (24 hours after
  admission).
• Arrest of Labor, Severe Preeclampsia, NRFHTs

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C-Section Tubal Ligation

• Epidural dosed with 20 cc of 3 Chlorprocaine
• T- 4 level attained.
• 1718 Incision.
• 1730 - Male infant delivered.
• Apgars 7 and 9.
• Antibiotic given at cord clamp.
• 1915 - Surgery completed (1 hr 57 min).
• EBL 800 ml, 1800 ml of crystalloid, 200 ml urine.
• VS stable.
• No thromboembolism prophylaxis.

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Parturients at Risk

• Pregnancy is associated with a 5-10 fold ? in the
  risk of VTE.
• Occurs with a frequency of .5 2 per thousand
  pregnancies.
• When untreated 24 of pregnant women with DVT
  will develop a PE with a subsequent mortality of
  15.

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Virchows Triad

• Venous stasis (aortocaval compression)
• Hypercoagulability (? levels of factors II, VII,
  VIII and X)
• Damage to the vessel wall during vaginal and
  operative delivery,(varicose veins).

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Evidence Based Risk Factors Specific to this
Patient

• 35 years of age
• Obesity
• Prolonged immobilization
• Surgical delivery (time factor
• Risk of a PE is 7 times greater with a cesarean
  delivery compared to a vaginal delivery
• Preeclampsia
• Dehydration

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Recovery

• Admitted to maternal intensive care unit.
• Magnesium restarted.
• BP 160/98, HR 82, R 22 temp 37.1, Sa02 98.
• Pain controlled with epidural.
• No headache.

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Following day progress note

• Incision clean
• Pain Controlled
• Positive flatus
• Discontinue magnesium
• Transfer to postpartum unit
• DC Epidural
• Use Labetolol for BP control
• No calf pain with dorsiflexion.

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Evidence for Calf Pain

• Homans sign positive when there is resistance
  to passive dorsiflexion of ankle. (not the
  elicitation of calf pain)
• Poor Negative Predictive Value
• Poor Positive Predictive value
• Confused with pain from strains, contusions, etc.

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24 hours post operatively

• Patient up to rest room has complaint of
  shortness of breath and pain in her chest with
  exertion.
• Resident called
• Chest x-ray and an EKG
• Auscultates lungs ? CTA bilateral no wheezing
• Impression most likely related to body habitus.

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Patient with Continued Complaint

• Patient is adamant about shortness of breath.
• She is restless and agitated.
• HR 128, BP 166/98, RR 32, T 37.2
• Husband speaks to resident and expresses concern.
• Resident informs patient CXR and EKG are normal.
• Conclusion likely related to pain and obesity.

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Presumptive Diagnosis based on Evidence

• PE causes death in 100,000 patients each year
  in the U.S.
• PE the most common medical cause of maternal
  death associated with live births.
• Many cases of PE and DVT are subclinical and
  never diagnosed
• PE may be the most common preventable hospital
  event.

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Presentation Associated with PE

• Symptoms are absent in 70 of patients with a
  well documented PE.
• The CXR and EKG may be normal
• Tachycardia and tachypnea without pyrexia in a
  recently delivered woman strongly suggest
  thromboembolism

• Chest Pain (70)
• Tachypnea (70)
• Cough (40)
• SOB (25)
• S S of DVT (10)
• Syncope (5)

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Orders for Dyspnea

• 2200 Oxygen per nasal cannula oxygen sat 92.
• If continues will order a spiral CT scan or
  possibly an ECHO in a.m.
• Has nurse administer pain medication.
• 0500 patient calls nurse with complaint of SOB at
  rest oxygen sat with cannula is 86
• 0700 sent for CT scan

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Evidence when Suspicious Clinical Findings for PE

• Start anticoagulation treatment while awaiting
  the results.
• Supportive measures to ? and preserve oxygenation
  and circulation.
• If hypoxemia is refractory to oxygen
  supplementation by face mask intubation and
  mechanical ventilation may be necessary.
• Resuscitation takes priority over any diagnostic
  or other therapeutic measure.

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Specific Measures

• Limit the damage.
• Prevent expansion or further embolization of
  other thrombi
• Anticoagulation with un-fractionated heparin (UH)
  remains the therapy of choice.
• IV bolus of 7,500 to 10,000 IU followed by an
  infusion of 1200 to 1300.
• APTT of 1.5 to 2.0 x the upper level of
  laboratory control values for 10-14 days.

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Spiral CT Scan

• 0820 patient returns from CT, results read as
  inconclusive for PE
• Respirations labored
• Ashen color
• Oxygen saturation 46
• HR 124
• Put a ventimask on patient and give 40 lasix and
  transfer back to ICU.

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Spiral CT Scans

• Recent meta-analyses that evaluated spiral CT
  scans in the dx of PE suggest
• Insufficient evidence to rely on a negative
  spiral CT scan to justify with holding
  anticoagulation.
• Mullins MD, et al. Arch Inter Med 2000,
  160293-298.
• Rathbun SW, Ann Intern Med, 2000, 132227-232.

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Clinical Technical Limitations to Spiral CT
Scans

• Requires pt cooperation
• Pts must hold their breath 10-30 seconds.
• In patients unable to cooperate with breath
  holding.
• Breathing artifacts can change the orientation
  and the diameter of the vessles.
• A normal spiral CT does not r/o a PE.

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Transfer to Maternal ICU

• Sa02 ? to 82.
• 0900 Arrived non-responsive and severe labored
  breathing and an Sa02 of 56.
• Anesthesia called to intubate.
• Intubated
• Saturation ? to 92-94
• Pink frothy sputum
• 0930 Sa02 ? to 46-50

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ICU Managment

• 1020 patient in PEA
• ACLS protocol initiated
• 1100 despite exhaustive resuscitation efforts
  the patient failed to respond and was pronounced
  dead.
• An autopsy revealed a pulmonary embolus most
  likely originated from a DVT in the left
  popliteal vein.

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Prevention

• Pharmacologic
• Targets hypercoagulability
• Warfarin, heparin and low molecular weight
  heparins are the mainstay.
• Mechanical
• Combat the venous stasis portion of the Virchows
  triad
• No increased risk of postoperative bleeding

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Prevention What is the Evidence?

• Graduated compression stockings
• A Cochrane review of randomized controlled trials
  reported a 50 ? in DVT formation with GCS.
• Low cost and simple.
• Fit is essential, improper fit may act as a
  tourniquet at the knee or mid-thigh causing an ?
  in venous stasis.
• Knee length thigh in effectiveness and should
  be preferentially used.

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Pneumatic Compression Devices

• Intermittent pneumatic compression devices reduce
  stasis by compressing the calf with an inflatable
  pneumatic sleeve.
• The leggings are repeatedly inflated and then
  deflated with the goal of ? venous return.
• Action mimics the natural calf muscle
  contraction.

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Pneumatic Compression Devices

• When used these devices are as effective as low
  dose heparin low molecular weight heparin in ?
  DVT incidence.
• Most studies are underpowered to demonstrate
  efficacy in preventing PE
• May also have the benefit of causing an increase
  in fibrinolysis.

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Evidence

• RCT to study the effectiveness of calf
  compression in reducing the incidence of DVT.
• 141 patients undergoing coronary bypass grafting.
  
• Randomized to ICD or nothing.
• No other preventative measures.
• 7th post op day all were evaluated.
• DVTs found in 3.4 of patients with ICDs vs.
  30.1 in control group.
• Pogson Missouri Medicine, March 1985, vol 82. No.
  3, pp 133-136

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Evidence

• Meta-analysis regarding the effectiveness of
  pneumatic compression devices
• Used all original articles from 1966 to 1996 that
  fit the inclusion criteria.
• Found IPC was more effective than placebo,
  graduated compression stockings or mini dose
  heparin in preventing DVE.
• Did not seem to be protective against PE because
  the incidence is low.
• Vanek, et al The America Surgeon November 1998
  64(11)

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More Evidence

• In an analysis that combined results from 19
  trials involving 2255 patients
• ICDs reduced the incidence of DVT by 66
• No significant difference in efficacy from single
  chamber as opposed to sequential compression
  devices.
• Towards evidence based guidelines for the
  prevention of venous thromboembolism systematic
  reviews of mechanical methods, oral
  anticoagulation, dextran and regional anesthesia
  as thromboprophylaxis. Health Technol Assess,
  2005 9(49) III-IV, IX-X, 1-78

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Not all Pneumatic Compression Devices are Created
Equal

• Circumferential vs. posterior only
• Single Bladder vs. multiple
• Thigh high vs. knee high
• Sequential /Graduated compression vs.
  intermittent constant pressure
• Venous foot pumps imitate the physiologic
  pumping action of weight bearing on the venous
  plexus of the sole of the foot.

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Pneumatic Compression Devices
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Following the Directions Matters

• Because venous thromboembolism begins in the
  perioperative period
• Both graduated and compression stockings and
  pneumatic compression devices should be placed
  before the initiation of surgery and continued
  until the patient is fully ambulatory.
• Correct fit and placement are important may
  consider bariatric sized cuffs for obese patients
• ACOG Practice Bulletin Number 84, August 2007

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SCIP Guidelines

• SCIP-VTE-1  Surgery patients with recommended
  venous thromboembolism prophylaxis ordered.
• SCIP-VTE-2  Surgery patients who received
  appropriate venous thromboembolism prophylaxis
  (VTE) within 24 hours prior to surgery to 24
  hours after surgery.

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What could have been done differently?

• Quote from the mother of an 18 month old died
  when caregivers failed to correctly communicate
  and listen to the mother when she voiced
  concerns
• Josies death was not the fault of one doctor, or
  one nurse, or one misplaced decimal point. It was
  the result of a total breakdown in the system.
  It was the result of doctors and nurses not
  listening, it was the result of a combination of
  errors all of which were avoidable

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Questions

• Prolonged labors 2-3 day inductions should they
  have compression stockings on?
• Should we be identifying patients at risk and
  encouraging VTE prophylaxis?
• Ensure that the devices are placed and turned on.
  (Proper size and placement)
• If we can ? the number of existing children and
  newborn babies that lose their mother by just one
  wont it be worth it?

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CRNAs Advance Patient Safety

• Somebody has to do something, and its just
  incredibly pathetic that it has to be us.
• Jerry Garcia (of the Grateful Dead)