180 Review Articles Medical Education

Emergencies in J. Wallenborn1 · I. Kühnert2 · D. O. Chebac1 · H. Stepan3 obstetric anaesthesia

 Citation: Wallenborn J, Kühnert I, Chebac DO, Stepan H: Emergencies in obstetric anaesthesia. Anästh Intensivmed 2017;58:180-193. DOI: 10.19224/ai2017.180

Summary The main causes of maternal and neo­‑ 1 Klinik für Anästhesie und Intensivmedizin, natal morbidity and mortality are HELIOS Klinikum Aue The main factors of maternal and 2 Klinik und Poliklinik für Anästhesiologie peripartum haemorrhage, hypertensive neonatal morbidity and mortality are und Intensivmedizin, Universitätsklinikum pregnancy diseases and sepsis [1,2], in Leipzig peripartum haemorrhage, hypertensive addition, critical situations during deli- 3 Abteilung für Geburtsmedizin, Universitäts­ pregnancy diseases and maternal sepsis very and endocrinological emergencies klinikum Leipzig as well as critical situations under during pregnancy. labour and endocrine emergencies. Peripartum haemorrhage is the main reason of pregnancy-induced mortality; Peripartum haemorrhage early detection of the life-threatening situation and interdisciplinary coopera­ Epidemiology and general aspects t­ion are imperative. During hypertensive pregnancy diseases, prolongation of Peripartum haemorrhage (PPH) is the pregnancy and prevention of maternal most frequent cause of pregnancy- complications have priority; the anaes- related mortalities [1,2,3]. thetist is mainly challenged during delivery. Risk factors for maternal sepsis In Western Europe, seven women per are divided in obstetrical and patient- 100,000 live births die of PPH, in Central related reasons; therapy is conducted Africa their number amounts to 1,570 in accordance with general guidelines. [4]. In Germany, the incidence rate of Stalled labour and umbilical cord pro- PPH has increased to approx. One out lapse are common indications for caesa- of 250 deliveries, to which the increas­ rean delivery. Amniotic fluid embolism ing rate of caesarean deliveries (>30%) is treated symptomatically. Endocrine with consecutively increasing placenta emergencies like hyperthyroid and dia- implantation disorders and an increased betic disorders are of rare occurrence. risk of uterus rupture during subsequent pregnancies have made a contribution. Introduction In the Netherlands, 0.7% of all home births had to be admitted to hospital because of PPH [5]. In emergency situations in obstetric Keywords anaesthesia, the anaesthetist and The blood loss during a delivery pro- Obstetric Emergencies – obstetrician must focus their atten­­- ceeding without complications amounts Peripartum Haemorrhage – tion­ on the welfare of both the mother to up to 500 ml; bleeding is terminated Hypertensive Pregnancy and the unborn child, whereby the and/or compensated for by the con- Diseases – Maternal Sepsis – well-being of the child requires that traction of the uterus and physiological Stalled Labour – Umbilical the vital functions of the mother are hypervolemia. A blood loss of >500 ml Cord Prolapse – Amniotic Fluid consistently stable. within a period of 24 hours is referred Embolism to as primary postpartum haemorrhage; Medical Education Review Articles 181

frequent causes are uterine atony and Tab. 2 shows the potential causes, Injuries of the genital tract placental retention. Every larger bleed­ their frequencies and the risk of PPH ing after 24 hours and up to 12 weeks occurrences. In addition, PPH might Injuries of the genital tract might be postpartum is considered as secondary develop as a consequence of dissemi- either unintentional (laceration of postpartum haemorrhage [6,7]. In ad­ nated intravascular coagulation (DIC) the perineum, cervical rupture) or dition, the following definitions apply due to amniotic fluid embolism, septic iatrogenic (episiotomy). [6,7]: abortion, intrauterine infection, eclamp- • In German-speaking countries PPH sia and HELLP syndrome (haemolysis, • The best prophylaxis of PPH consists exists if the loss of blood after either elevated liver enzymes, low platelet in rapid surgical treatment of the vaginal or caesarean delivery amounts count). injury, whereby a high vaginal tear is to >500 ml and >1,000 ml, respec- tively. A serious case of PPH exists if Tab. 1 the acute blood loss exceeds 1,500 Risk factors for peripartum haemorrhage (PPH) [1,7]. HELLP syndrome = haemolysis, elevated liver – 2,000 ml. enzymes, low platelet count. • The WHO (World Health Organi­ zation) considers every blood loss Factor Prepartum Intrapartum /Postpartum greater than 500 ml as PPH irrespec- Placenta Placental abruption Placental retention tive of the birth modality. Placenta praevia Placenta accreta, percreta, increta Most young and healthy mothers are Uterus Precedent uterine atony Uterine atony initially able to compensate for a greater Precedent uterine surgery Uterine rupture blood loss for quite some time, before a Uterus myomatosus Inversion of the uterus haemorrhagic shock with agitation or Distension of the uterus (multiparity, clouding of consciousness, cold sweat, polyhydramnios, transverse foetal position) paleness, tachycardia, hypotension and Coagulation Congenital or acquired haemostasis Consumptive coagulopathy due to hyperventilation sets in. The amount of disorder pre-eclampsia /HELLP syndrome blood captured in towels, compresses Placental abruption and sponges etc. is often underestimated, Amnion infection syndrome, sepsis Amniotic fluid embolism for which reason the use of calibrated blood collection bags or surgical drapes Other Haemorrhages prior to delivery Protracted delivery Multipara with blood collection pouches is recom- Induction of labour and prolonged Nicotine abuse administration of oxytocin mended [7,8]. Advanced age Macrosomia (>4,500 g) Non-Caucasian ethnicity • From a blood loss of approx. 1,000 Surgical vaginal delivery PPH in the medical case history ml onward, the basic actions pre- Injury of the genital tract sented in more detail below must be Section, emergency section immediately taken, e.g. retention of warmth, application of large-lumen indwelling venous cannulas, basic Tab. 2 laboratory analyses, cross-matching Potential causes and their frequencies as well as the odds ratio (OR) with 95% confidence interval of erythrocyte concentrates (EC) etc. (CI) for the occurrence of peripartum haemorrhage (PPH) [6,7,8,9,10]. • From a blood loss of about 1,500 ml and more, regular antifibrinolysis Cause Frequency OR for PPH (95% CI) and, if indicated, a transfusion of Injury of the genital tract 1:8 1.4-4.7 (1.04-8.4) EC and coagulation factors will be Uterine atony 1:20 No data available necessary [3,7,8,9]. Pre-eclampsia 1:20 5 (3.0-8.5) Multiparity 1:85 5 (3.0-6.6) Next to recognising the life-threaten­ ing situation in time, interdiscipli­ Emergency section 1:150 4 (3.28-3.95) nary cooperation will be essential. Premature detachment of the placenta 1:80 - 1:150 13 (7.61-12.9) Placental retention 1:100 - 1:500 5 (3.36-7.87) Risk factors and potential causes Placenta praevia 1:200 12 (7.17-23.0) A summary of the risk factors for PPH Placenta accreta 1:2,000 - 1:2,500 3.3 (1.7-6.4) are shown Tab. 1. The medical case Uterine rupture 1:1,250 - 1:3,000 history, physical examination and sono- Inversion of the uterus 1:6,400 graphy contribute to the diagnosis. 182 Review Articles Medical Education

surgically very demanding and likely Fig. 1 to be accompanied by great blood losses not to be underestimated. Placental retention Normal placenta with Placenta increta intact decidua basalis In case of a placental retention with­ out haemorrhage one can wait at maximum for 30 minutes for the placenta to detach spontaneously – however, it is a corroborated fact Placenta accreta Placenta percreta that the incidence rate of PPH can be reduced by about 60 percent through an active initiation of the placental stage of labour [11].

• Active procedures are – apart from Placental implantation disorders. a controlled traction on the umbi­ lical cord (CCT) – the administration of uterotonic drugs, clamping and residues can be loosened by means We distinguish: cutting of the umbilical cord and of a curettage, whereas hysterectomy • Low-lying placenta – one part of massage of the uterus. Recent studies will have to be carried out in case of the placenta lies in the lower uterine indicated that only the administration placenta increta or placenta percreta. segment; vaginal delivery is possible. of uterotonic drugs reduces the inci- • Placenta praevia marginalis – the Placental malposition dence rate of PPH [12]. placental tissue reaches the internal • The expelled placenta must always cervical os; in most cases vaginal A placenta praevia develops in be examined for completeness. Pos­‑ delivery will still be possible. 0.5% of all pregnancies – the pla- sible placental residues can be iden- centa is either situated near the • Placenta praevia partialis – the pla­‑ tified by ultrasound. Then, a manual uterine cervix or obstructs the birth cental tissue overlies the cervical or instrumental palpation done in canal (Fig. 2). os to some extent; vaginal delivery proper time will prevent the develop- should be avoided. ment of a larger PPH.

Placental implantation disorders Fig. 2

A placental retention might conceal a placental implantation disorder (Fig. 1).

If the placenta lacks the basal decidua, in part or fully, trophoblasts and thus placental villi may grow all the way into the uterine musculature (placenta accreta, 78%), (placenta increta, 17%), or even cross it into neighbouring organs (placenta percreta, 5%). The Classifi cation: - classic - Typ I - Typ II - Typ III - Typ IV reason for this is cicatricial alterations of - modern - low lying - marginal - partial - total the uterus – e.g. after caesarean section, - ultrasound - minor - minor - major - major curettage and myoma removal surgery. • The myometrium is injured when Classification of placenta praevia (placenta is represented in red) [13]. the placenta detaches and severe Top row: Vertical section through the uterus showing various types of placental insertion. haemorrhages occasionally occur. Bottom row: Cross-section at the level of the internal cervix. • In case of minor implantation dis- Below the classifications. Instead of placenta praevia partialis/ totalis the terms placenta praevia incompleta / completa are not seldom used, respectively. orders the firmly adhering placental Medical Education Review Articles 183

• Placenta praevia totalis – the pla­ signs of shock with disordered hae- Epidural analgesia to mitigate the centa lies over the cervical os, vaginal mostasis will become noticeable. pain of labour might not fully conceal delivery is impossible. Smaller placental detachments also the pain of an impending uterine The cardinal symptom of placenta rapidly give rise to a DIC syndrome. • Ultrasound will confirm the clinical rupture [17] – sustained labour pain praevia is an announcing vaginal under correctly applied epidural haemorrhage; it is painless, fresh and diagnosis and reveal the dimensions of the hematoma. Cardiotocography analgesia is therefore to be taken light-red in colour and occurs mostly as an indication of an impending in the middle of pregnancy. The high (CTG) is applied to identify a condi- tion of foetal bradycardia or already rupture of the uterus. degree of vascularisation of the placenta absent cardiac sounds. and its malposition in a less contractile • If vital signs of the foetus are detected area explain the persistent bleeding; Uterine atony an emergency section will be done in addition, a placenta accreta often under general anaesthesia (if indi­ Basics exists concomitantly [14]. The therapy cated, accompanied by an adequate depends on the type of the placenta transfusion and haemostasis therapy). Uterine atony is a condition of praevia, the week of gestation, the In the event of a lifeless foetus a vagi- ute­rine contraction weakness, from intensity of bleeding and the condition nal delivery can be initiated provided which a severe to life-threating hae­ of mother and child. that the mother’s vital functions are morrhage might result. The incidence stable. has increased due to the growing An emergency delivery under general number of caesarean sections in re- anaesthesia is carried out in case of Uterine rupture cent years [9]. an already pronounced bleeding in A rupture of the uterus – incomplete order to develop the infant rapidly with an intact peritoneum, or com- Uterine atony internationally is the and achieve definitive surgical re­ plete comprising the peritoneum – most common cause of PPH, whereby mediation. mostly occurs while delivery is in maternal mortality in developed coun- process. tries with established atony prophylaxis Placental abruption is 200 times lower than in African In most cases it will be a rupture of a countries [4]. A primary uterine inertia, Placental abruption (abruptio placen­ scar we are dealing with in this case, a too high concentration of volatile tae) is a prepartum emergency situa­ due to a preceding section or any other anaesthetics – a MAC value (minimum tion. As a result of the premature surgical operation previously carried alveolar concentration) above 0.8 – 0.9 detachment of the placenta, the per- out on the uterus [1,10,16], whereby reduces the action of oxytocin on the fusion of the foetus will be disturbed an overstimulation of the uterus with uterus – and other factors come into or cease and the hematoma between uterotonic drugs might promote the question as causes for uterine atony (cf. placenta and uterus will rapidly pro- occurrence of a uterine scar rupture. A Tab. 1 and Tab. 2). Uterine atony occurs duce a consumptive coagulopathy. rupture due to distension of tissues is more often in cases of multigravidity, possible in cases of protracted delivery, polyhydramnios, multipara, prolonged the child’s presentation making delivery labour or chorionamnionitis. Risk factors are trauma, hypertensive impossible, or macrosomia. The high diseases, premature rupture of the section rate is of significance as a cause The cause of an atonic uterine amnion, repeated pregnancies, smoking for the increasing incidence of uterine haemorrhage must be established and uterine anomalies [15]. The hema- ruptures. and treated specifically, otherwise toma might spread undiscovered in • Cardinal symptoms of an impending the PPH will not stop even after a retroplacental direction or, as a marginal rupture are highly severe abdominal massive transfusion. placental hematoma, be accompanied pain (uterine tetany) associated with by – now visible – dark-red vaginal foetal bradycardia as well as mater- smear bleeding. Maternal mortality is nal anxiety and unrest. The pain sud- Prevention of PPH due to uterine atony nearly 1%, foetal mortality 20-60%. denly subsides after both rupture and • The cardinal symptom is a persistent labour contractions stop; a condition The decisive prophylactic interven-­­ abdominal pain in the mother, asso- of foetal hypoxia ensues. Symptoms t­ion is a slow IV administration or ciated with hardening of the uterus; of shock develop rapidly. short infusion of 3 - 5 I. U. (interna- further unspecific symptoms are un- • An emergency section under general tional units) oxytocin (Syntocinon®) rest, weakness, anxiety and nausea. anaesthesia with adequate transfu- after delivery of the front shoulder In the event of a greater maternal sion and haemostasis therapy has to or delivery of the child [7]. blood loss (up to 3 litres intrauterine) proceed without delay. 184 Review Articles Medical Education

• A prophylactic administration of cardiac arrhythmias, flushes, headache Tab. 3 oxytocin decreases the risk of PPH and chest pain, nausea, vomiting, but Prophylactic and therapeutic measures in by 50 percent and reduces the ne- also coronary spasms and myocardial cases of peripartum haemorrhage [7,22]. cessity of a therapeutic application of infarction. Oxytocin should therefore Prophylaxis uterotonic drugs by about 50 percent be administered in doses as low as as well [7,18]. possible and IV application should be • Slow administration IV or short infusion of 3-5 I. U. oxytocin • The synthetic oxytocin analogue carried out slowly [8,19,20,21]. Methyl­ ® carbetocin (Pabal ) acts longer than ergometrine is contraindicated in cases Drug therapy – escalating, parallel to oxytocin and is currently approved of high blood pressure, pre-eclampsia/ surgical therapy exclusively for a single application eclampsia, ischemic vascular diseases, • Slow administration IV or short infusion (100 µg slow IV.), in cases of caesa­‑ severe disorders of liver and kidney of 3-5 I. U. oxytocin (if not already done) rean delivery carried out in spinal or • Infusion von 10-40 I. U. oxytocin (in function and sepsis. 500-1.000 ml balanced electrolyte epidural anaesthesia after develop­ solution) ment of the child [7]. Carbetocin An oxytocin-resistant haemorrhage • Consider administration of 0.1 mg should not be concomitantly ad- methylergometrine IV should be treated without much ministered with oxytocin, nor in • Infusion of sulprostone (500 µg in delay with prostaglandin derivatives, 500 ml solution), initial dose 100 ml/h cases of migraine, bronchial asthma, whereby oxytocin and prostaglan- (up to 500 ml/h) cardiovascular disease (including pre- dins should not be administered • 1-2 g and/or 15-30 mg/kg b.w. eclampsia and eclampsia) or epilepsy. tranexamic acid simultaneously [7]. • Prophylactic techniques to therapy • 20-30 ml/kg b.w. frozen plasma; alternative or in addition to 30-60 mg/ an atony-dependent PHH without kg b.w. fibrinogen • Sulprostone (Nalador®; 500 µg in 500 drugs includes uterus massage (with • Consider PPSB (initial dose 25 I. U./kg endogenous prostaglandin release) ml solution) is applied by an infusion b.w. IV.) and factor XIII (15-20 I. U./kg and bimanual uterus compression pump. The initial dose amounts to b.w. IV.) 100 ml/h (if necessary: 500 ml/h at • Heparin or antithrombin only after (Hamilton’s manoeuvre). cessation of bleeding maximum), the maintenance dose is Therapy of PPH due to uterine atony • In substantiated individual cases 100 ml/h, the maximum dose 1,000 administration of desmopressin and µg in 10 hours, the daily maximum recombinant factor VIIa If prophylactic measures fail, the dose 1,500 µg. Side effects – e.g. epi­‑ therapeutic measures mentioned Surgical therapy – escalating, parallel to gastric and mesogastric spasms, bron­‑ drug therapy below should be applied immediately choconstriction, myocardial ischemia (Tab. 3) They are described in the • Identification of the cause of bleeding and blood circulation reactions all according to the 4 T‘s pertinent Guideline of the German the way to pulmonary oedemas – • First uterine tamponade Society of Gynaecology and Obstet- must be relativised in a life-threaten­ • Surgical or radiological-interventional rics (DGGG) which refers to further haemostasis ing situation. An injection into the guidelines with haemostaseological • If necessary, hysterectomy myometrium is contraindicated. options [7]. • When initially administered, miso­ Accompanying measures – parallel and prostol is not more effective than early on • If not done prophylactically, 3-5 I. oxytocin and was taken from the • Emptying the bladder U. oxytocin are injected slowly IV market in Germany; prostaglandin • Application of efficient venous accesses (maximum IV bolus dose 6 I. U.); • Blood sampling for cross-matching and F2α (e.g. Dinoprost®) is no longer followed by an infusion dosed ac­ emergency laboratory, information of approved in Germany for the treat- blood bank /depository cording to action consisting of 10-40 ment of uterine atony or PPH. • Volume therapy, vasoactive substances I. U. oxytocin dissolved in 500 ml • (Invasive) monitoring of blood circulation balanced electrolyte solution (cau- Measures in case of sustained bleeding • Sequential laboratory analyses tion: side effects). (differential blood-cell count, Parallel to these drug-related measures, coagulation, blood gas analysis) • In addition, a slow IV administration it is the responsibility of the obstetrician • Seeking of the best-possible personal of up to 0.1 mg methylergometrine to exclude the typical causes of sustained expertise ® (Methergin ) might be taken into bleeding such as placental residues • In case of regional anaesthesia or status consideration; however, the sub- post vaginal delivery, if indicated, (ultrasound) and injuries due to delivery endotracheal intubation to secure stance is only officially approved (by speculum adjustment); in addition, airways and oxygenation for cases of very severe postpartum the bladder should be emptied. The • Generous indication for a central haemorrhages. identification of the cause of bleeding venous catheter Typical side effects of oxytocin and (cf. Tab. 2) shall proceed in conformity I. U. = International units; methylergometrine are blood pressure with the DGGG guideline and the b.w. = body weight. rises/drops, tachycardia and further “PPH Consensus Group (Germany- Medical Education Review Articles 185

Austria-Switzerland)” according to the information of the blood bank and cross- mor­rhage in case of a caesarean section) four T-s [7,22]: matching of erythrocyte concentrates and a septic uterus. An emergency • Tonus and/or uterine atony – uterine and perhaps the provision of fresh hysterectomy must proceed in case of distension (multiparity, hydramnios, frozen plasma (FFP) must proceed now. an uncontrollable PPH. After surgery, foetal macrosomia), tocolytic agents, As is the case in every serious bleeding, the patient must be monitored at an in- rapid or delayed delivery, (long) oxy- the anaesthetist must also in case of a tensive care medical ward, for example, tocin replacement, chorioamnionitis, PPH undertake all efforts to maintain because of a relatively high relaparo- uterine myomas. and/or restore the following common tomy rate. • Tissue and or placenta – placental target values [7,8,22]: The escalating indicated surgical mea­ retention, placental implantation dis­ • body core temperature >34 °C sures must be flanked by a simultaneous order, placental residues. (normo­ thermia,­ if possible), and weighed-escalating therapy of the • Trauma – vulvovaginal injury, cer­ • pH value >7.2, haemostasis disorder either now prevail­ vical rupture, episiotomy/laceration • ionised calcium (Ca++) concentration ing or yet to develop. In this context, of the perineum, uterine rupture, >0.9 mmol/l (normocalcaemia, if tranexamic acid and fibrinogen have an uterine inversion. necessary). important part to play in cases of PPH, • Thrombin and/or coagulopathy – In case of a therapy-refractory bleeding, for which reason both substances should pregnancy-induced (thrombocyto­ the obstetrician will now insert an be applied at an early stage [6,7,8,22]: penia in case of HELLP syndrome, initial tamponade into the cavity of the • Tranexamic acid: As a hyperfibrino­ DIC in case of pre-eclampsia, intra­ uterus in order to enable a permanent lysis regularly exists in cases of PPH uterine foetal death, placental ab­ or temporary (“bridging”) haemostasis due to the massive release of plas­ ruption, or amniotic fluid embolism) with hemodynamic stabilisation and minogen activators from the uterus, or other disorder of haemostasis. initiate further surgical and interven­ an IV administration of 1-2 g or The guideline recommends consulting tional-radiological measures [7,22]. Tam­‑ 15-30 mg tranexamic acid /kg body ® an anaesthetist in case of a PPH at an ponade strips or balloon systems are weight (b.w.) (Cyklokapron ) is in­ early stage [7]. An initial notification used to achieve this end; in addition, dicated and may also be repeated by the obstetrician should proceed at also local haemostatic agents such as [7]. Alternatively, a short infusion of maximum 30 minutes after PPH has chitosan. Now, at the latest, the best- 1 g tranexamic acid is recommended been diagnosed, after a maximum of possible personal expertise must be after blood losses of approx. 1,000 further 30 minutes and sustained bleed­ acquired. Actual surgical haemostasis ml [8,22]. Tranexamic acid reduces ing an anaesthetist should be consulted comprises laparotomy with eventeration the postpartum blood loss (when for further therapy and the surgical team of the uterus, traction in cranial direction administered in addition to uterotonic alarmed [22]. and compression, in addition, clamping drugs) and prevents PPH as well as of the uterine arteries and applying com- blood transfusions, both in cases The anaesthetist faces a professional pression sutures (e.g. B-Lynch sutures) of vaginal delivery and caesarean challenge already at this stage and is with tamponade. Uterine compression section [23]. The data currently responsible especially for establish­ sutures can be applied quickly and available do not suffice to draw exact conclusions on the side-effect ing efficient venous accesses, (inva- with a positive success rate (>90%) risk concerning thromboembolic in­‑ sive) monitoring of blood circulation, [7]. If the infrastructure is available an cidents. volume therapy, sequential labora­ interventional-radiological embolisation • Only after this is it recommendable tory analyses (differential blood cell of the uterine arteries may proceed. to substitute coagulation factors counts, coagulation, blood-gas ana- in case of a persistently prevailing lysis) as well as the provision and, if Uterus-retaining measures are only severe bleeding tendency [7]. To indicated, transfusion of blood com- reasonable as long as the patient this end, the administration of fresh ponents and coagulation factors remains hemodynamically stable and frozen plasma (FFP) at a dose of [7,22]. does not have a life-threating hae­ 20-30 ml/kg b.w. is recommended, morrhage – a perhaps necessary either alternatively or in addition, the hysterectomy should not be indi­ Particularly in case of an unexpected administration of fibrinogen (Hae­ cated too late [6,7]. occurrence of an emergency situation mocomplettan®) at a dose of 30-60 during a hitherto “uncomplicated” mg/kg b.w. IV (2-4-8 g) [7]. delivery the anaesthetist will have to Relative contraindications for uterus- • Fibrinogen: In cases of PPH, the convince himself of an existing blood maintaining measures are placental fibrinogen concentration in plasma group determination, otherwise an disorders (placenta increta, placenta will correlate best with the overall immediate blood sampling for cross- percreta), an irreparable uterine injury quantity of lost blood [24]. That a matching and emergency laboratory, (uterine rupture, intraabdominal hae­ fibrinogen concentration of <200 186 Review Articles Medical Education

mg/dl (<2 g/l) at the end of preg­‑ The following applies to therapy with Hypertensive pregnancy diseases nancy is correlated with the occur- blood components in cases of massive rence of PPH has a likelihood of bleeding [7]: Incidence and definitions almost 100%. The determination of • Erythrocyte concentrates with a target Data pertaining to the incidence of fibrinogen might therefore help to value of Hb 7-9 g/dl (4.3-5.6 mmol/l) pre-eclampsia vary between 3% and identify patients who are at risk of are transfused in order to substitute 10%; pregnancy-induced hypertension contracting PPH [7]. The target value for oxygen carriers. In case of a mas­‑ and pre-eclampsia are believed to be for substitution is a concentration sive transfusion, it is recommeded responsible for approx. 25% of peri­‑ of ≥200 mg/dl [7]. 3 g fibrinogen to warm up the erythrocyte concen­- natal morbidity and perinatal mortality elevate the plasma concentration by trates (using either a heating ap­ [25, 26]. In combination with a peri­ approx. 100 mg/dl. pliance or inline heating). partum lung oedema, the lethality of • Furthermore, PPSB might be given • Patients who require massive trans- pre-eclampsia ranges at about 5% [27]. intravenously in an initial dose of fusions (if predictable) or who are Risk actors are high age, adiposity, 1,000 – 2,500 I. U. (25 I.U./kg b.w.); suffering from a life-threatening shock diabetes mellitus, pre-existing hyperten- under certain circumstances also might benefit from a high FFP: EC ® sion, pre-eclampsia in the medical case factor XIII (Fibrogammin P) at a dose ratio (≥ 1:2) and from the combined history of the patient and her family as of 1,250 I. U. (15-20 I.U./kg b.w.), administration of FFP and factor well as kidney diseases and the existence whereby factor XIII is intended to concentrates. of an antiphospholipid syndrome [28]. stabilise soluble fibrin monomers. • Platelet concentrates (PC) with a pla­te­‑ In addition, the following aspects must let count target value of ≥ 100,000/ The following definitions apply accord­ be observed [7]: µl are transfused in order to com- ing to the guideline of the DGGG [29]: • In order to avoid an enhancement pensate for losses incurred during • Gestational hypertension exists of bleeding, heparin should not be primary haemostasis. whenever blood-pressure values of administered when the haemorrhage • In cases of emergency erythrocyte ≥140/90 mmHg without proteinuria is active. con­centrates derived from a 0 rhe­sus- appear in previously normotensive • Neither should antithrombin (AT) be negative blood groups must be ap­‑ pregnant women after completion given in the course of active bleed­ plied without cross-matching as well of the 20th week of gestation. ing. After the bleeding has been as FFP derived from the blood group • In cases of pre-eclampsia (or EPH stopped – especially after the admin­ AB and/or coagulation factors, with­ gestosis) proteinuria ≥300 mg/24 h istration of single factors or complex out waiting for the laboratory values. appears; often resulting in foetal drugs (PPSB)-the activity of AT may Holding a contingency depot in growth retardation. be determined at the ICU and a reserve is obligatory in obstetrics. • A severe pre-eclampsia exists when­ target value of ≥ 80% is aspired. • In addition, an active heat supply as ever at least one of the following • In case of patients under medication well as the application of a cell cen- criteria are fulfilled in addition: blood with platelet aggregation inhibitors, trifuge (Cell-Saver) and rapid-trans- pressure ≥ 160/110 mmHg, impaired or patients with suspected thrombo- fusion systems are recommended kidney function (creatinine ≥79.6 cytopathy, it may be endeavoured [ 6,7,8,9 ] . µmoles/l or 0.9 mg/dl, or oliguria to improve platelet function by an <500 ml/24 h), liver involvement enhanced release of factor VIII and (elevation of transaminase activities, Actions must be taken rapidly, with von-Willebrand factor. Desmopres- persisting epigastric pain), pulmo- determination and interdisciplinary sin (Minirin®) is applied IV to this nary oedema, hematologic disor­‑ consensus. Monitoring of the patient end, at a dose of 0.3 µg/kg b.w. over ders (thrombocytopenia <100,000/µl, should be extended at an early stage a period of 30 minutes. hae­molysis), neurological symptoms by arterial pressure measurement • In the individual case and if all other (strong headaches, visual disorders), and a central venous catheter (CVC) therapy options and optimisation of foetal growth restriction (estimated and the ICU should be notified common factors fail (sufficient plasma foetal weight <5th percentile and/or coagulation potential, sufficient pla- about the patient’s transfer. pathological Doppler of the umbili- telet counts and haemoglobin (Hb) cal artery). concentration, lacking acidosis, nor- After PPH diagnosis, an adjusted monitor­ • Tonic-clonic seizures that appear in mothermia and normocalcaemia), it ing for 24 hours and an interdisciplinary the context of a pre-eclampsia not may be endeavoured to stop a diffuse discussion of the case should take place. attributable to any other cause are bleeding with an administration of A pharmacological thrombosis prophy- referred to as eclampsia. Eclampsia recombinant factor VIIa (Novo­ laxis will be obligatory, at the latest, 24 is not always associated with severe Seven®) at an initial dose of 90 µg/ hours after the haemorrhage. A sufficient hypertension and might also manifest kg b.w. iron substitution is recommended [7]. itself as late as postpartum. Medical Education Review Articles 187

• A HELLP syndrome exists in case severity, dynamics and short-term prog­­ stolic pressure of 80-100 mmHg are of the following triad: haemolysis, nosis of the disease [32]. considered to be recommendable elevated liver enzymes and low pla- target values [29,33]. ® telet counts <100.000/µl. In 5-20% The primary objective of therapy • α-methyldopa (Dopegyt ) is the of HELLP syndrome cases there is between the 24th and 34th week of drug of first choice for long-term neither proteinuria nor hypertension gestation consists in the prolonga­­- oral therapy. Suitable to a limited [30]. t­ion of pregnancy in order to extent are nifedipine retard as well prevent premature delivery and to as selective β1-receptor blockers (pre- Pathophysiology induce foetal pulmonary maturity. ferentially metoprolol). Not appro- All other measures focus on the pre- priate because of their pronounced The aetiology of hypertensive pre­g­ vention of maternal complications. foetal side effects are diuretics, an- nancy diseases is not fully known. giotensin-converting-enzyme (ACE) As for pre-eclampsia, a disordered inhibitors, angiotensin-II-receptor- The only causal therapy is delivery [29]: trophoblast invasion with conse­ subtype-1 (AT1)-antagonists and all cutive placental insufficiency and • In cases of pre-eclampsia delivery other antihypertensive agents [29]. generalised endothelial dysfunction is regularly indicated after the 37th • Recommended for acute therapy in are discussed as pathogenic events. week of gestation. case of an hypertensive emergency • In cases of severe eclampsia the are nifedipine (e.g. Adalat®), urapidil patient should soon deliver starting (e.g. Ebrantil®) and dihydralazine Furthermore, an imbalance of angio- with the completed 34th week of (Nepresol®). Furosemide (e.g. Lasix®) genic factors (PIGF = placental growth gestation, the same applies in case of is injected in case of a pulmonary factor) and antiangiogenic factors (sFlt- a severe foetal growth restriction. oedema [29]. 1-Protein; soluble fms-like tyrosineki- • A primarily conservative procedure nase-1) has been shown [30]. is to be recommended if pre- Anticonvulsive therapy proceeds with magnesium sulphate. Consequences of generalised vasocon- eclampsia either starts in the com- • Initially, 4 g (up to 6 g) magnesium striction and endothelial dysfunction pleted 24th to 34th week of gestation sulphate are administered as a short are: or appears in connection with the infusion over 15 minutes, followed • Chronic placental insufficiency and HELLP syndrome. Maternal indica­ by a maintenance infusion of 1 g/h foetal growth retardation, increased t­ions to terminate pregnancy in this to 48 hours postpartum [28,29,30]. risk of a premature detachment of interval are therapy-refractory severe The targeted level is 2-4 mmol/l; in the placenta; hypertension, therapy-refractory kid­‑ addition, respiration rate (respiratory • Damage of the renal glomeruli asso- ney insufficiency, cardiac decom- depression at 5 mmol/l), patellar ten- ciated with proteinuria and oedema pensation, acute pulmonary oedema, don reflex (disappears at 4 mmol/l) tendency; DIC, persistent epigastric pain, new and diuresis (at least 100 ml/4 h) • Cerebral oedemas and intracranial occurrence of serious central ner- should be monitored. Calcium glu- microhaemorrhages associated with vous symptoms and eclampsia. conate is available as an antidote. an increased risk of disordered vi­‑ The following recommendations apply • A cerebral convulsive seizure must sion, nausea, vomiting, headaches to drug therapy: be broken with diazepam (10-20 mg and generalised tonic-clonic seizures; • Antihypertensive drug therapy (Tab. IV, if indicated, repeatedly) or mida­ • Periportal haemorrhagic necrosis and 4) should be initiated at the latest if zolam (5-10 mg IV, if indicated, capsule swelling of the liver with blood pressure values are at ≥160/ repeatedly). Thiopental or phenytoin epigastric pain and elevation of trans­ 110 mmHg. It should proceed in the are second-choice drugs. aminase activity; hospital setting under close blood- • Thrombocytopenia and anaemia due pressure monitoring of the mother Glucocorticoids are increasingly ap- to platelet activation and aggregation and – if the infant is able to survive – plied in order to prolong pregnancy in and microangiopathic haemolysis. under CTG monitoring. It serves the case of a HELLP syndrome (e.g. daily purpose of preventing cerebrovascu- 2-3x 10 mg dexamethasone IV). Apart Diagnosis and therapy lar and cardiovascular complications from an induction of foetal pulmonary The diagnosis already ensues from the (especially cerebral haemorrhages), maturity, positive maternal effects have stated definitions; in addition, a blood whereas an additional administration also been demonstrated (increase in test which determines the quotient of of magnesium IV is required to estab­‑ platelet counts), so that ultimately up sFlt-1/PIGF is capable of distinguishing lish an effective eclampsia prophy- to 50 percent of the mothers could healthy pregnant women from those laxis. As a too strong blood-pres­ receive regional anaesthesia for delivery having pre-eclampsia [31]. In patients sure decrease increases the rate of [34]. However, a decline of maternal with manifest pre-eclampsia, the test growth-retarded newborns, a systolic and foetal morbidity and mortality has permits drawing conclusions on the pressure of <150 mmHg and a dia- not been demonstrated, wherefore this 188 Review Articles Medical Education

Tab. 4 Vasopressor agents must be carefully Antihypertensive drugs in cases of pre-eclampsia [29]. titrated as overshooting reactions are often induced. Active substance / product Dosage Comment • Pregnant women with pre-eclampsia Long-term oral therapy have a high risk of contracting a α-Methyldopa / e.g. Dopegyt® 4x500 mg/d First-choice therapy peripartum lung oedema [40]. Main reasons are the disease-related high Nifedipine retarded / generics 2-6x 10 mg/d, max. 120 mg/d No teratogenic effects determined hydrostatic and low colloid-osmotic Metoprolol / generics 2x 25-100 mg/d Elevated risk of foetal pressure (COP), in addition to the growth restriction often applied tocolysis and a perhaps Acute therapy iatrogenic volume loading. Cerebral convulsive seizure and pulmonary Nifedipine / e.g. Adalat® Initial oral dose of 5 mg (if required, Off-label-use repeatedly); syringe pump (5 mg/50 ml) oedema can manifest themselves after effect, at maximum 15-30 mg/24 h even hours or days after delivery, for Urapidil / e.g. Ebrantil® Initial 6.25 mg IV (if required, Off-label-use which reason patients with eclampsia repeatedly); syringe pump 3-24 mg/h and HELLP syndrome should be first Dihydralazine / Nepresol® Initially 5mg IV; syringe pump 2-20 mg/h Multiple side effects, monitored in the ICU and subse- second-choice therapy quently closely monitored on peri- Furosemide / e.g. Lasix® 10-20 mg IV In case of pulmonary pheral ward level. oedema Sepsis during pregnancy and lactation option is discussed controversially [29, • In female patients with HELLP 35]. Therapy of thrombocytopenia and syndrome, spinal or epidural anaes- Incidence thesia have been carried out after coagulopathy follows the principles Infections appearing during pregnancy the administration of glucocorticoids described for PPH. might result in premature delivery, pre­‑ [34] – however, in cases of HELLP mature rupture of membranes, prema- Anaesthesiological treatment syndrome it must be considered that ture uterine contractions and in breast- the platelets are not only reduced in feeding difficulties. According to cohort Spinal or epidural anaesthesia is the number, they are also functionally studies conducted in the United States, method of choice in case of a caesa- impaired, for which reason general the incidence rate of sepsis is at 3-10: anaesthesia is preferred in the hospi- rean delivery and patients with pre- 10,000 births [41,42]; the incidence rate tals of the authors. eclampsia, because there is a risk of a sepsis-dependent case of death at • In cases of eclampsia and after initial of cerebral oedemas, intracranial 1:100.000 births [2,42]. On an interna- haemorrhages, acute left-heart in- therapy, an emergency caesarean section under general anaesthesia tional scale, sepsis is responsible for 15 sufficiency and pulmonary oedema percent of all maternal deaths. due to blood-pressure rises during will mostly be inevitable. In order to laryngoscopy as well as intubation prevent blood-pressure peaks caused Risk factors by intubation an opioid is applied in and extubation whenever general The risk factors for developing maternal anaesthesia is applied [36,37]. this case before administration of the hypnotic agent and before severing sepsis can be divided to obstetric-related the umbilical cord of the foetus. and patient-related factors: • In case of vaginal delivery, epidural When applying remifentanil (1 µg/kg • Obstetric-related factors are cer- analgesia applied in proper time con- b.w. IV) as described in the literature clage, caesarean section, premature tributes to a moderate blood-pressure [38, 39], respiratory depression and rupture of the membranes, placental decrease and an improvement of chest rigidity in both mother and retention after delivery or abortion, uteroplacental perfusion (decrease child must be taken into account – vaginal trauma, wound infection and of pain-dependent maternal cate- such procedure must therefore be amniocentesis. cholamine levels, increase of the communicated to the neonatologist. • Patient-related factors are high age, intervillous blood flow and decrease • A pre-existing vasoconstriction with group B streptococcal infection in of peripheral vascular resistance). relative hypovolemia affecting the the medical case history, group A • The low dose of acetylsalicylic acid patients makes anaesthesia more streptococcal infection in the family, (ASA; 100 mg/d) often applied to difficult, wherefore the indication for perturbed vaginal flora, immuno- patients with pre-eclampsia is not a invasive arterial pressure measure- suppressive medication, cardiac in­‑ contraindication for an intervention ment and CVC should be generous sufficiency, chronic hypertension, near the spinal cord. in cases of severe pre-eclampsia. chronic liver and kidney disease, Medical Education Review Articles 189

infection with human immunodefi­ riaceae and anaerobic bacteria often stabilisation as apply to other pa­ ciency virus (HIV), malaria, sickle- prevail. E. coli is dominant in cases of tients (mean arterial pressure ≥65 cell anaemia, systemic lupus erythe- pyelonephritis, whereas in case of pneu- mmHg), whereby the risk of a peri- matosus as well as Afro-American or monias pneumococci, Haemophilus partum pulmonary oedema must be Asian ethnicity and low social status spp., staphylococci, chlamydia, myco- observed. [41,42]. plasmas and varicella must be taken into • Microbiological diagnostics requires account [42,48,49]. Pregnant women • In case of PPH, the odds ratio (OR) a blood culture, urinalysis and a for the development of sepsis is at 4.2, are considered to represent a risk popu- vaginal swab [50]. with a 95% CI of 2.5-7.1; whereas in lation during outbreaks of influenza-A • As only scarce data are available on case of pre-eclampsia, the OR is at virus H1N1, whereas HIV is the main the side effects of an antibiotic the- 3.7, with a 95% CI of 2.5-4.4 [41]. factor for sepsis-dependent maternal mortality in developing countries [47]. rapy on mother and child, absolute The most common causes of sepsis during contraindications in cases of severe pregnancy and lactation are infections Therapy maternal sepsis after childbirth do of the genital tract (chorioamnionitis, not exist. The immediately necessary, endometritis, septic abortion), pneumo- Maternal sepsis is categorically treat­ initially still calculated antibiotic nia, pyelonephritis, peritonitis, mastitis ed according to the applicable Guide­ therapy starts with broad-spectrum and wound infections. An antibiotic line on the Prevention, Diagnosis, prophylaxis is therefore recommended antibiotics IV [47,49,52]. As the Therapy and Aftercare of Sepsis [52]. in cases of caesarean delivery, prema- penicillins and cephalosporins re­ ture rupture of membranes and amniotic commended for common bacterial fluid containing meconium [43,44,45]. • Consequently, the same target values infections during pregnancy and In case of caesarean delivery, antibiotic are applicable to initial hemodynamic lactation (Tab. 5) [53] – and/or ma- prophylaxis significantly reduces the rate of wound infections, endometritis and Tab. 5 serious maternal infections, irrespective Common antibiotic therapy during pregnancy and lactation; contraindications and limitations must of the type of section (elective, non- be overruled in case of sepsis [53,54] elective) and administration before or after clamping the umbilical cord [43,46]. Antibiotic Comment Recommended Spectrum of pathogens Penicillins, amoxicillin Ampicillin/sulbactam is safe Numerous pathogens are potential Cephalosporins Ceftriaxone assumes bactericidal concentrations in the amniotic fluid; candidates for casing sepsis [47,48]. In antibiotic of choice during lactation Great Britain, β-haemolysing strepto- Macrolides in case of penicillin hypersensitivity and infection with Chlamydia cocci belonging to Lancefield group A Contraindicated were responsible for almost one-half of all sepsis-related maternal deaths in the Tetracyclines 14th week of gestation until 7th year of life years from 2006 to 2008 [49]. Next to Quinolones Cartilage damage staphylococci they are the major cause of Rifampicin Bleeding tendency in the newborn due to vitamin K antagonism, but puerperal sepsis (“childbed fever”) and drug of choice in cases of tuberculosis applicable during pregnancy and lactation mostly transmitted by droplet infection by asymptomatic carriers (children) or Allowed with restrictions persons with acute upper respiratory Aminoglycosides 30% cross the placental barrier, ototoxicity and nephrotoxicity; tract infections [50]. β-haemolysing applicable during lactation streptococci belonging to Lancefield Metronidazole Experimentally cancerogenous and mutagenic; applicable in cases of infection with anaerobic bacteria during pregnancy and lactation group B are representatives of the vaginal flora and can cause neonatal Clindamycin Diarrhoeas in neonates , more effective than penicillin against group A streptococci infections and sepsis by means of “ver- tical” transmission. Prophylaxis with Cotrimoxazole Neural tube defect possible, passes into breast milk only to a limited extent antibiotics fails to reduce the incidence Piperacillin/tazobactam No data available, applicable in cases of sepsis of puerperal sepsis in cases of colo- nisation with group B streptococci; Carbapenemes Crosses the placental barrier and passes into breast milk, applicable in cases of sepsis the evidence regarding a reduction of neonatal infections is unclear [51]. In Linezolid Reproduction toxicity possible, applicable in cases of MRSA sepsis case of wound infections, peritonitis Vancomycin Second choice during pregnancy and lactation and endometritis, mixed infections with MRSA = methicillin-resistant Staphylococcus aureus. Staphylococcus aureus, Enterobacte- 190 Review Articles Medical Education

crolides in case of an allergy against Obstructed labour cies. The most relevant predisposing β-lactam antibiotics or infection Reasons for obstructed labour might alte­rat­ions [56] during pregnancy are with chlamydia – have a too narrow be uterine inertia, positions obstructing haematocrit decline, enhanced cardiac action spectrum in cases of maternal delivery (transverse position, oblique output and a COP decrease. A COP of sepsis, piperacillin-tazobactam and position, mentoposterior face position), 13-16 mmHg [57] is considered to be carbapenems are recommended [47, presentation abnormalities (high foetal the threshold limit value for the develop- 49], or an initial triple combination station, occiput posterior presentation), ment of a pulmonary oedema; the most of β-lactam, aminoglycoside and or a shoulder dystocia. critical decrease in COP [58,59] occurs metronidazole is used because of • Obstructed labour occurring in the up to 48 hours postpartum (from 22 to the mixed infection often prevailing dilation stage is usually terminated 15 mmHg) and in pre-eclampsia patients [48]. Antibiosis should be tested on by caesarean section. (from 18 to 14 mmHg). Other risk factors a daily basis and continued for the • In the expulsion stage vaginal deli- are the application of tocolytic drugs, duration of at least 7 to 10 days [47, very is attempted by applying specific the existence of maternal infections, pre- 49]. measures. In case of bradytocia, this eclampsia or a HELLP syndrome as well • As is the case in every sepsis, the might consist in an administration of as an excessive volume supply under rapid detection and, if indicated, oxytocin or vaginal-surgical delivery; tocolysis, and cases including general surgical elimination of the focus of in case of abnormal presentations, or regional anaesthesia for caesarean infection is decisive. This might span episiotomy and special manoeuvres delivery [56]. from the curettage of a residual pla- are carried out by the obstetrician. • Therapy will depend on the respec- centa over exploratory laparotomy to • Shoulder dystocia occurs in about tive causes and will be flanked by hysterectomy. A septic uterus must 0.5 percent of all births and merges liquid balancing, forced diuresis and, be extirpated, otherwise it is likely rapidly into state of infantile hypoxia. if indicated, ICU circulation therapy to trigger an uncontrollable PPH. Risk factors are foetal macrosomia, and (non)invasive ventilation. Hysterectomy in an instable patient diabetes mellitus and maternal adi­ is fraught with risk, however, it might posity. In cases of suspected macro- Paracolpium tear, paracolpium also be the only chance for maternal somia (estimated weight >4,500 g) hematoma survival [49]. and preceding shoulder dystocia the A tear of the paracolpium or a hematoma indication for primary section should In addition, it should be mentioned after spontaneous or vaginal-surgical de­‑ be generous. In case of a manifest that for the macrolides and β-lactams, livery is of rare occurrence. The cause is shoulder dystocia the obstetrician will a venous, externally invisible haemor- which are generally regarded as safe, make an attempt to solve the critical an increased neonatal mortality (relative rhage from the paracolpial plexus with situation by episiotomy, McRoberts blood flowing into the parametrium. The risk 1.5; 95%-CI 1.05-2.15) has been manoeuvre, acute tocolysis and discussed when applied in cases of patients are distinguished postpartum other specific manoeuvres (e.g. after by a uterine fundus persisting over the impending premature delivery without Woods). breaking of waters and without signs of umbilicus and lacking recovery. The maternal inflammation, despite a signifi- Umbilical cord prolapse cardinal symptoms are pain, urinary retention and a pressure sensation on cantly reduced maternal infection rate; An umbilical cord prolapse occurs in the colon. The diagnosis proceeds by whereas there had been an increased approx. 0.3 percent of all births. After means of a vaginal examination in which risk for infantile cerebral paresis (relative rupture of the amnion the umbilical cord the hematoma is palpated as a bulging risk 2.8; 95%-CI 1.02-7.9) in cases of falls in front of the presenting part of simultaneous applications [55]. the foetus, the foetus becoming hypoxic tumour. After reaching a certain size, or due to an ensuing compression of the if diagnosed at a later event, a haemor- umbilical cord. rhagic shock with cloudy consciousness Other emergency situations • Initial actions taken are elevation or mental agitation, pale skin, cold sweat of the mother’s pelvis and pushing as well as hypotension and tachycardia General considerations foetus and umbilical cord back into is likely to develop. In some obstetric emergencies the anaes- the uterine cavity – afterwards an • Therapy consists in the surgical treat­ thetist can only contribute to solving the emergency section must be per­‑ ment by a vaginal approach for mak­ problem by means of adequate epidural formed. ing an incision into the hematoma, analgesia (subsequent injections always suturing and, if indicated, drainage. only upon request and/or after conferring Peripartum pulmonary oedema Spreading of the hematoma in cra- with the midwife or obstetrician) or by The peripartum pulmonary oedema (PPE) nial direction into the retroperitoneal immediate realisation of an emergency has an incidence rate of 0.05-0.2% and space with the necessity of laparo- or urgent section. belongs to the rare obstetric emergen­‑ tomy is feared. Medical Education Review Articles 191

Ogilvie’s syndrome and colon • Amniotic fluid embolism is a diagnosis of cardiac insufficiency, with diure­tics perforation by exclusion with the symptom triad [65], if indicated, with plasmapheresis of hypoxia, hypotension and DIG; or with resection of the organ as the In case of an Ogilvie’s syndrome – an early symptoms are unrest, confusion ultimate rationale. acute pseudo-obstruction of the colon – and dyspnoea. The course is mostly • After delivery, the metabolic situation there is a massive dilation of the colon biphasic; after a period of 30 minutes of hyperthyroidism frequently reap- without any mechanical obstruction; to 9 hours, the initial cardiorespira- pears; carbimazole and thiamazole the incidence rate amounts to 1:1,500 tory insufficiency is followed by a are drugs considered to be safe dur­ births. coagulation disorder [7,62]. ing lactation [66]. • Therapy is primarily conservative • Therapy is symptomatic, cardiopul- (neo­stigmine, erythromycin, endo- monary resuscitation is often initially Pregnant women with type 1 diabetes scopic suction); only one-fourth of required. With regard to anaphylaxis, mellitus should be attended at a specia- the patients require laparoscopic an early high-dosed application of lised obstetric centre. Maternal insulin intervention [60]. glucocorticoids is recommended next sensitivity declines in the second and A perforation of the colon after caesa- to an initial catecholamine and vo­ third trimester of pregnancy, so that rean section has been described to occur lume therapy [62]. Therapy of the the insulin dose has to be increased in in individual cases [61]; causes were coagulation disorder and (multiple) most cases. About 2-3% of the affected paralytic ileus or an Ogilvie’s syndrome organ failure follow the general crite- women develop diabetic ketoacidosis, with ischemia after section. As the ria of intensive medical care. which may also appear at the end of mortality rate amounts to 30-50%, this pregnancy despite nearly normogly­ serious complication must be borne in Endocrinological emergencies caemic values prevailing [65]. mind early on after an “obstetric routine during pregnancy • The therapy of diabetic ketoacidosis intervention”. Indications are increasing is the same as in non-pregnant women abdominal pain (despite analgesia), Endocrinological emergencies dur­ and consists of an adequate liquid, defensive tension and lacking peristalsis ing pregnancy are seldom. They are electrolyte and insulin substitution. and/or discharge of gas. A perforation mostly imbalances of hyperthyroid As ketones are capable of crossing of the colon might rapidly result in a or diabetic metabolism [65]. the placental barrier the foetus might peritonitis and sepsis; most frequently develop an acidosis which will dis- appear once the maternal hypergly­ the caecum will be affected. A state of hyperthyroidism appears in caemia is being treated. • Therapy consists in laparotomy with approx. 1:500 pregnancies [66]. The oversewing or caecostomy all the growth of the foetus, associated with an way to hemicolectomy. increased requirement of thyroid gland References Amniotic fluid embolism hormone, is physiologically accounted for by a slight hypertrophy of the ma- 1. Waterstone M, Bewley S, Wolfe C: Incidence and predictors of severe ternal thyroid gland. Hypothyroidism A case of amniotic fluid embolism – obstetric morbidity: Case-control study. might result in premature birth, growth or anaphylactic pregnancy syndrome BMJ 2001;322:1089-1093 retardation, low foetal weights, or still- – occurs in about 1:50,000 births 2. McClure J, Cooper G; Centre for Maternal births, whereas hyperthyroidism leads to and Child Enquiries (CMACE): Saving [56,62,63]. Maternal mortality ranges uncontrollable vomiting of pregnancy, Mothers’ Lives: Reviewing maternal at 10-40% [63]. deaths to make motherhood safer: hypertension, cardiac insufficiency or 2006-08. The eighth report on confi- thyrotoxic crisis. dential enquiries into maternal deaths Amniotic fluid embolism (AFE) appears • Propylthiouracil is the thyreostatic in the United Kingdom. Chapter 8: particularly during caesarean delivery, agent of choice in the first trimester, Anaesthesia. BJOG 2011;118: Suppl.1, in case of a high cervical tear, placenta as carbimazole and thiamazole are 102-108 praevia, or placental abruption. Risk teratogenic [66]; from the second 3. Cooper GM, McClure JH: Anaesthesia chapter from Saving mothers’ lives; factors include high age and initiation trimester onward, thiamazole is pre- reviewing maternal deaths to make of pregnancy with drugs. An obstruc- ferred due to the risk of potential liver pregnancy safer. Br J Anaesth 2008;100: tion of pulmonary vessels by cellular damage. The lowest-possible dose is 17-22 and humoral foetal factors with abrupt aspired because thyreostatic drugs 4. Hogan MC, Foreman KJ, Naghavi M, pulmonary hypertension and pulmonary are known to cross the placental Ahn SY, Wang M, Makela SM, et al: heart are discussed to be involved in barrier and thus might induce foetal Maternal mortality for 181 countries, 1980-2008: A systematic analysis of pro- hypothyroidism. the pathogenesis of the disease [64], gress towards Millennium Development but increasingly also an anaphylactoid • A thyrotoxic crisis is treated with glu- Goal 5. Lancet 2010;375:1609-1623 reaction in the sense of an anaphylactic cocorticoids (dexamethasone, hydro­‑ 5. Smit M, Dijkman A, Rijnders M, pregnancy syndrome. cortisone), propranolol and, in case Bustraan J, van Dillen J, Middeldorp J, 192 Review Articles Medical Education

et al: Haemorrhage after home birth: 17. Deutsche Gesellschaft für Gynäkologie Schwanger­schaftserkrankungen. http:// Audit of decision making and referral. und Geburtshilfe 2007: Schwangeren­ www.awmf.org/leitlinien/detail/ll/015- Pract Midwife 2013;16:12-15 betreuung und Geburtsleitung 018.html 6. Mavrides E, Allard S, Chandraharan E, bei Zustand nach Kaiserschnitt. (am 27.12.2016) Collins P, Green L, Hunt BJ et al; on be- http://www.awmf.org/leitlinien/detail/ 30. Tallarek AC, Stepan H: Präeklampsie half of the Royal College of Obstetricians II/015-021.html (Stand August 2010) und HELLP-Syndrom als geburtshilfliche and Gynaecologists: Prevention and 18. Westhoff G, Cotter AM, Tolosa JE: Notfälle. Med Klin Intensivmed Notfmed management of postpartum haemorrhage. Prophylactic oxytocin for the third 2012; 107: 96-100 BJOG 2016; DOI: .10.1111/1471- stage of labour to prevent postpartum 31. Verlohren S, Galindo A, Schlembach D, 0528.14178. https://www.rcog.org.uk/ haemorrhage. Cochrane Database Syst Zeisler H, Herraiz I, Moertl MG, et al: en/guidelines-research-services/ Rev 2013; CD001808 An automated method for the deter- guidelines/gtg52/ (am 16.01.2017) 19. Butwick AJ, Coleman L, Cohen SE, mination of the sFlt-1/PIGF ratio in the 7. Deutsche Gesellschaft für Gynäkologie Riley ET, Carvalho B: Minimum effective assessment of preeclampsia. Am J Obstet und Geburtshilfe 2016: Peripartale bolus dose of oxytocin during elective Gynecol 2010;202:161.e1-161.e11 Blutungen, Diagnostik und Therapie. Caesarean delivery. Br J Anaesth 2010; 32. Stepan H, Schaarschmidt W: Bluttest auf (S2k-Leitlinie, AWMF Nr. 015-063, 104:338-343 Präeklampsie – reif für den klinischen Stand 01.04.2016). http://www.awmf.org/ 20. Carvalho JCA, Balki M, Kingdom J, Einsatz? Geburtshilfe Frauenheilkd 2010; leitlinien/detail/ll/015-063.html Windrim R: Oxytocin requirements at 70:6-9 (am 27.12.2016) elective caesarean delivery: A dose-­ 33. Abalos E, Duley L, Steyn DW, 8. Knapp J, Hofer S, Lier H: Anästhesio­ finding study. Obstet Gynecol 2004; Henderson-Smart DJ: Antihypertensive logisches Vorgehen bei peripartaler 104:1005-1010 drug therapy for mild to moderate hyper- Blutung. Anaesthesist 2016;65:225-240 21. Thomas JS, Koh SH, Cooper GM: tension during pregnancy. Cochrane 9. Durchführung von Analgesie- und Haemodynamic effects of oxytocin Database Syst Rev 2007; CD002252 Anästhesieverfahren in der Geburtshilfe. given as i.v. bolus or infusion on women 34. O’Brien JM, Shumate SA, Satchwell SL, 2. überarbeitete Empfehlungen der undergoing Caesarean section. Milligan DA, Barton JR: Maternal benefit Deutschen Gesellschaft für Anästhe­ Br J Anaesth 2007;98:116-119 of corticosteroid therapy in patients siologie und Intensivmedizin und des 22. Postpartale Blutung. Handlungsalgo­ with HELLP (hemolysis, elevated liver Berufsverbandes Deutscher Anästhe- rithmus nach vaginaler Geburt oder enzymes, and low platelet count) sisten in Zusammenarbeit mit der in der postoperativen Überwachungs- syndrome: Impact on the rate of regional Deutschen Gesellschaft für Gynäkologie phase nach Sectio caesarea 2012: anesthesia. Am J Obstet Gynecol 2002; und Geburtshilfe. Anästh Intensivmed PPH-Konsensus-Gruppe (D-A-Ch) 186:475-479 2009;50:S490-S495 http://www.postpartum-hemorrhage. 35. Woudstra DM, Chandra S, Hofmeyr GJ, 10. Crochetière C: Obstetric emergencies. com/downloads/algorithmus_ Dowswell T: Corticosteroids for HELLP Anesthesiology Clin N Am 2003;21: a6-20120521.pdf (am 27.12.2016) syndrome in pregnancy. Cochrane 111-125 23. Novikova N, Hofmeyr GJ, Cluver C: Database Syst Rev 2010; CD 008148 11. Begley CM, Gyte GM, Devane D, Tranexamic acid for preventing postpar- 36. Gremm B, Sohn C: Spezifische geburts-­ McGuire W, Weeks A: Active versus tum haemorrhage. Cochrane Data-base hilfliche Risiken. In: Osswald PM, expectant management for women in the Syst Rev 2015: CD007872 Hartung HJ, Wulf H, Neises M (Hrsg): third stage of labour. Cochrane Database 24. de Lloyd L, Bovington R, Kaye A, Geburtshilfliche Anästhesie und Syst Rev 2011; CD007412 Collis RE, Rayment R, Sanders J, et al: Analgesie. Stuttgart: Wissenschaftliche 12. Rath W: Aktive Leitung der Nachgeburts­ Standard haemostatic tests following Verlagsgesellschaft; 2003:120-130 periode – Das Ende eines 50-jährigen major obstetric haemorrhage. Int J Obstet 37. Stamer UM, Stuber F: Spinal- oder Dogmas? Z Geburtshilfe Neonatol Anesth 2011;20:135-141 Epiduralanästhesie zur Sectio caesarea 2013;217:173-176 25. Steinhard J, Klockenbusch W: Schwanger­ bei Präeklampsie. Anasthesiol Intensiv­ 13. Chamberlain G, Steer P: ABC of labour schaftsinduzierte Hypertonie und Prä-­ med Notfallmed Schmerzther 2007; care: obstetric emergencies. BMJ 1999; eklampsie: Risikofaktoren und Vorher­ 42:200-207 318:1342-1345 sagemöglichkeiten. Gynäkologe 1999; 38. Girard T, Brugger S, Hössli I: Neues 14. Palacios-Jaraquemada JM: Caesarean 32:753-760 aus der geburtshilflichen Anästhesie. section in cases of placenta praevia 26. Walker JJ: Severe pre-eclampsia and Anaesthesist 2013;62:963-972 and accreta. Best Pract Res Clin Obstet eclampsia. Baillieres Best Pract Res Clin 39. Ngan Kee WD, Khaw KS, Ma KC, Gynaecol 2013;27:221-232 Obstet Gynaecol 2000;14:57-71 Wong AS, Lee BB, Ng FF: Maternal and 15. Gleeson C, Scrutton M: Obstetric 27. Huang WC, Chen CP: Pulmonary edema neonatal effects of remifentanil at emergencies. Anaesth Intensive Care in pregnancy. Int J Gynecol Obstet 2002; induction of general anesthesia for Med 2008;9:115-121 78:241-243 cesarean delivery: A randomized, 16. Torbé A, Mikołajek-Bedner W, Kałużyński W, 28. Arulkumaran N, Lightstone L: Severe double-blind, controlled trial. Gutowska-Czajka D, Kwiatkowski S, pre-eclampsia and hypertensive crises. Anesthesiology 2006;104:14-20 Błogowski W, et al: Uterine rupture in Best Pract Res Clin Obstet Gyn 2013; 40. Wallenborn J, Rohrbach A, Stepan H, the second trimester of pregnancy as an 27:877-884 Kühnert I, Olthoff D: Das peripartale iatrogenic complication of laparoscopic 29. Deutsche Gesellschaft für Gynäkologie Lungenödem – Anästhesiologische myomectomy. Medicina (Kaunas) und Geburtshilfe 2014: Diagnostik Aspekte eines geburtshilflichen Notfalls. 2012;48:182-185 und Therapie hypertensiver Anästh Intensivmed 2004;45:341-350 Medical Education Review Articles 193

41. Acosta CD, Knight M, Lee HC, Lives: Reviewing maternal deaths to pseudo-obstruction in pregnancy. ANZ J Kurinczuk JJ, Gould JB, Lyndon A: The make motherhood safer: 2006-08. The Surg 2015;85:728-733 continuum of maternal sepsis severity: eighth report on confidential enquiries 61. Shakir AJ, Sajid MS, Kianifard B, Baig MK: Incidence and riskfactors in a population- into maternal deaths in the United Ogilvie‘s syndrome-related right colon based cohort study. PLoS One 2013; Kingdom. Chapter 7: Sepsis. BJOG 2011; perforation after cesarean section: A case 8(7):e67175 118: Suppl.1, 85-101 series. Kaohsiung J Med Sci 2011;27: 42. Bauer ME, Bateman BT, Bauer ST, 50. Arulkumaran N, Singer M: Puerpal sepsis. 234-238 Shanks AM, Mhyre JM: Maternal Best Pract Res Clin Obstet Gynecol 62. Clark SL, Hankins GD, Dudley DA, sepsis mortality and morbidity during 2013;27:893-902 Dildy GA, Porter TF: Amniotic fluid hospitalization for delivery: Temporal 51. Ohlsson A, Shah VS: Intrapartum embolism: Analysis of the national trends and independent associations antibiotics for known maternal group B registry. Am J Obstet Gynecol 1995;172: for severe sepsis. Anesth Analg 2013; streptococcal colonization. Cochrane 1158-1169 117:944-950 Database Syst Rev 2013; CD007467 63. Knight M, Berg C, Brocklehurst P, 43. Smaill FM, Gyte GM: Antibiotic 52. Deutsche Sepsis-Gesellschaft und Kramer M, Lewis G, Oats J, et al: prophylaxis versus no prophylaxis for Deutsche Vereinigung für Intensiv- und Amniotic fluid embolism incidence, preventing infection after cesarean sec- Notfallmedizin 2010: S2k-Leitlinie risk factors and outcomes: A review tion. Cochrane Database Syst Rev 2010; Sepsis – Prävention, Diagnose, Therapie and recommendations. BMC Pregnancy CD007482 und Nachsorge. http://www.awmf.org/ Childbirth 2012;12:7 44. Kenyon S, Boulvain M, Neilson JP: leitlinien/detail/ll/079-001.html. In 64. Locksmith GJ: Amniotic fluid embolism. Antibiotics for preterm rupture of Überarbeitung (am 15.01.2017) Obstetrics and Gynecology Clinics of membranes. Cochrane Database Syst 53. Gabler-Sandberg E: Schwangerschaft North America 1999;26:435-444 Rev 2013; CD001058 und Stillzeit – Antibiotikawahl bei 65. Khoo CM, Lee KO: Endocrine emer­- 45. Siriwachirachai T, Sangkomkamhang US, Infektionen. Deutsches Ärzteblatt 2000; gencies in pregnancy. Best Pract Res Clin Lumbiganon P, Laopaiboon M: 97:A-1158-1159 Obstet Gynaecol 2013;27:885-891 Antibiotics for meconium-stained 54. http://www.embryotox.de/einfuehrung. 66. Franklin JA, Boelaert K: Thyrotoxicosis. amniotic fluid in labour for preventing html (am 15.01.2017) Lancet 2012;379:1155-1166. maternal and neonatal infections. 55. Flenady V, Hawley G, Stock OM, Cochrane Database Syst Rev 2010; Kenyon S, Badawi N: Prophylactic anti- CD007772 biotics for inhibiting preterm labour with 46. Heesen M, Klöhr S, Rossaint R, intact membranes. Cochrane Database Allegeaert K, Deprest J, Van de Velde M, Syst Rev 2013; CD000246 Correspondence et al: Concerning the timing of antibiotic 56. Wallenborn J, Kühnert I: Das peripartale address administration in women undergoing Lungenödem: Anästhesiologische caesarean section: A systematic review Aspekte. In: Eckart J, Jaeger K, Möllhoff T Priv.-Doz. (Hrsg): Anästhesiologie – Kompendium and meta-analysis. BMJ Open 2013; Dr. med. habil. pii:e002028. doi: 10.1136/bmjopen- und Repetitorium zur Weiter- und Jan Wallenborn 2012-002028 Fortbildung. Landsberg/Lech: ecomed 47. Lucas DN, Robinson PN, Nel MR: Sepsis Medizin 2007 Klinik für Anästhesiologie in obstetrics and the role of the anaes- 57. Davison JM: Edema in pregnancy. und Intensivmedizin thetist. Int J Obstet Anesth 2012;21:56-67 Kidney International 1997;51:90-96 HELIOS Klinikum Aue 48. Timezguid N, Das V, Hamdi A, Ciroldi M, 58. Stewart LS: Pulmonary edema during Gartenstr. 6 pregnancy. NAACOGS Clin Issu Perinat Sfoggia-Besserat D, Chelha R, et al: 08280 Aue, Germany Maternal sepsis during pregnancy or the Womens Health Nurs 1992;3:454-460 postpartum period requiring intensive 59. Phelan JP: Pulmonary edema in Phone: 0049 3771 58-1398 care admission. Int J Obstet Anesth obstetrics. Obstet Gynecol Clin North Fax: 0049 3771 58-1638 2012;21:51-55 Am 1991;18:319-331 Mail: 49. Harper A; Centre for Maternal and Child 60. Reeves M, Frizelle F, Wakeman C, [email protected] Enquiries (CMACE): Saving Mothers’ Parker C: Acute colonic