EMS Protocol of the Week: Obstetric Emergencies!

Hi all, 

This week we will be focusing on Obstetric Emergencies!

The prehospital approach exists as a progression of care based on the provider’s level of training. CFRs start with ABCS and monitoring vital signs for shock. They will check for crowning and if present prepare for imminent delivery. If delivery has not begun, they will place the patient in a left lateral recumbent position. 

BLS crews can address vaginal bleeding in pregnancy by placing dressing over the vagina to help estimate quantity of blood loss. If immediately postpartum, they can massage the mother’s abdomen over the uterus. 

If the on-scene team is ALS-trained, they can obtain IV access for patients with severe pre-eclampsia, eclampsia or postpartum hemorrhage. For patients with eclampsia, they can administer Magnesium Sulfate 4 g IV over 10 minutes. 

From an OLMC standpoint, providers can authorize 2g Magnesium Sulfate over 10 minutes for patients with concern for pre-eclampsia. 

KEY POINTS: 

• Consider supine hypotension syndrome as a cause of shock 

• Severe pre-eclampsia is when pregnant patients have BOTH of the following conditions: 

  • Systolic blood pressure ≥ 160 mm Hg OR a diastolic blood pressure ≥ 110 mm Hg 

  • Symptoms of a headache, visual disturbances, pulmonary edema or lower extremity edema 
    

• Eclampsia and pre-eclampsia do not occur prior to 20 weeks of gestation 

• Eclampsia and pre-eclampsia may occur up to one (1) month post-partum 

More words to read at www.nycremsco.org

Case of eclampsia in your resus bay

Diagnosis:

• new-onset tonic-clonic, focal, or multifocal seizures in the absence of other causative conditions (eg, epilepsy, cerebral arterial ischemia and infarction, intracranial hemorrhage, drug use), 

• typically but does not have to be present in the presence of preexisting hypertensive disorder of pregnancy (preeclampsia, gestational hypertension, HELLP syndrome)

Presentation:

• Hypertension 

• Headache (persistent frontal or occipital headaches or thunderclap headaches)

• Visual disturbances (scotomata, loss of vision [cortical blindness], blurred vision, diplopia, visual field defects [eg, homonymous hemianopsia], photophobia)

• Right upper quadrant or epigastric pain 

• Asymptomatic 

Management:

• Start with ABCs

• Consider alternative causes of seizures based on additional information other than eclampsia: hyponatremia, ICH, hypoglycemia, etc.

• Usually eclamptic seizures subside on its own

• If pt is seizing => administer Mg Loading dose 4-6 g IV over 15 to 20 minutes. An alternative dose/route is magnesium sulfate 5 g intramuscularly into each buttock for a total of 10 g

• Followed by Maintenance dose – magnesium sulfate 2 g/hour as a continuous IV infusion to women with good renal function.

• If pt is in status => in cases refractory to magnesium sulfate (patient is still seizing at 20 minutes after the bolus or more than two recurrences), administer sodium amobarbital (250 mg IV over three minutes), thiopental, or phenytoin (1250 mg IV at a rate of 50 mg/minute). In this case pt will need to be intubated.

If need to consider intubation:

• Medications:

  • Induction - consider propofol (category B)

    • You want to avoid: Etomidate - lowers seizure threshold and Ketamine - worsens HTN

• Paralytics - rocuronium or succinylcholine, yet both of the medications are category C so use minimal dose to reach the desired effect, avoid additional doses

Next consider hypertensive control if BP diastolic pressures greater than 105 to 110 mmHg or systolic blood pressures ≥160 mmHg:

• Labetalol - 20 mg IV gradually over 2 minutes.

• Hydralazine - 5 mg IV gradually over 1 to 2 minutes.

• Nifedipine immediate release - 10 mg orally.

• Nicardipine (parenteral) - The initial dose is 5 mg/hour intravenously by infusion pump and can be increased to a maximum of 15 mg/hour.

Proceed with labs, consider HELLP syndrome labs, type and screen, fluids. 

Call OB/GYN early

The definitive treatment for eclampsia is prompt delivery.