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La valutazione anestesiologica

Congresso Regionale A.O.G.O.I. - A.G.I.T.E. - F.N.C.O. Regione Emilia Romagna

Corso di analgesia perimidollare in travaglio di partoRimini 23 marzo 2011

Dr. Enzo Valtancoli

SERVIZIO SANITARIO REGIONALE

EMILIA — ROMAGNA

Azienda Unità Sanitaria Locale di Forlì

Stabilimento Ospedaliero “G.B. Morgagni — L. Pieranto ni

Reviewing maternal deaths to make pregnancy safer

Every day around 1600 women and over 5000 newborn babies die due to complications of pregnancy.Eighty per cent of these deaths are largely preventable or treatable at little or no extra cost,even in resource-poor setting.Consequently more than six milion newborns and 600.000 women die needlessly each year and another 20 milion women developed long-term complications.

The reality is that the vast majority of the women in the world die because they do not receive the healthcare that they need.Only 53% of women in developing countries receive assistance from a skilled attendant at birth.

World Health Organization (WHO) “ making pregnancy sa fer”

Gwyneth Lewis – Best Practice & Research Clinical Ob stetrics and GynaecologyVol. 22,No.3,pp.447-463.2008

Aim: to save mothers’ lives

1. Better management of complications– By individual professionals– By systems– By systems

2. Prevention of complications– Identify early warning signs– Identify risk factors

Maternal near miss-towards a standard tool for monitoring quality of maternal health care

For deaths occurring in health facilities,it is crucial to understand the processes of obstetric care in order to address any identified

weakness or failure within the system and take corr ective action.

Studying cases of women who nearly died but survived a complication during pregnancy,childbirth or postpartum (maternal near miss or severe acute maternal morbidity) are increasingly recognized as useful means to examine quality of obstetric care .

Lale Say,Joao Paulo Souza,Robert C.Pattinson –Best Practice & Research Clinical Obstetrics and Gy naecology 23 (2009) 287-296

La Qualità in Anestesia Ostetrica

è la risultante di un insieme di elementi scientifici procedurali tecnologici

organizzativi relazionali di comunicazionein cui un ruolo determinante è svolto dalle variabili umane : professionista sanitario e paziente che interagiscono fortemente nei

processi produttivi

Postpartum care: we can and should do better

• In the immediate postpartum period,careful attention must be paid to the mother’s hemodynamic status,vaginal bleeding and pain control.

• Additional risks include late post-partum hemorrhage,infection and venous thromboembolism.

• Standardized protocols have been developed and implemented in some institutions to reduce the overall risk of pregnancy – related complications, to promote early to reduce the overall risk of pregnancy – related complications, to promote early identification and to initiate effective therapy in a timely fashion.

Despite these advances many postpartum complication s remain underdiagnosed and suboptimally treated

EDITORIAL - Stephen F. Thung- Errol R.Norwitz American Journal of Obstetric & Gynecology – january 2010

The “top ten” key reccommendations

Confidential Enquiry into Maternal and Child Health 2003-2005

1-Pre-conception care

2-Access to care

3-Pregnant women who are already 12 or more weekspregnant should be seen within two weeks of the referral

4-Migrant women

5-Systolic hypertension requires treatment


6-Caesarean section (mothers must be advised that CS is not a risk-free procedure and can cause problems in current and future pregnancies)

7-Clinical skills


8-All clinical staff must undertake regular, written, documented and audited training (there is also a need for staff to recognise their limitations and to know when, how and whom to call for assistance)

9-Early warning scoring system (chart similar to those in use in other areas of clinical practice)

10-Guidelines are urgently required for management of: the obese pregnant woman, sepsis in pregnancy, pain and bleeding in early pregnancy

The maternal mortality rate for2006–08 was 11.39 per 100 000

maternitiescompared with the 13.95 per

100 000 maternities reported for the previous triennium, 2003–05 .

The maternal mortality rate for mothers who died from medical conditions that could only be the conditions that could only be the

result of pregnancy, such as obstetric haemorrhage or eclampsia,and which are

internationally classified as Direct deaths significantly decreased to4.67 this triennium compared with

the rate of 6.24 per 100 000 maternities for 2003–05.

Cause of death 2000–02 2003–05 2006–08

Direct deaths

Sepsis 13 18 26

Pre-eclampsia and eclampsia 14 18 19

Thrombosis and thromboembolism 30 41 18

Amniotic fluid embolism 5 17 13

Spontaneous miscarriage 1 1 5

In 2006–08 n. maternities was 2 .291.493 and the maternal mortality rate was 11.39 per 100 000 maternities

Spontaneous miscarriage 1 1 5

Haemorrhage 17 14 9

Anaesthesia 6 6 7

All Direct 106 132 107

Indirect deaths

Cardiac disease 44 48 53

Indirect neurological conditions 40 37 36

Psychiatric causes 16 18 13

All Indirect 155 163 154



Recommendation 1 Pre-pregnancy CounsellingForty-one women who died from direct or indirect causes had no antenatal care.

Recommendation 2 Professional interpretation services

Recommendation 3 Communications and referrals

Recommendation 4 Women with potentially serious medical conditions require immediate and appropriate multidisciplinary specialist care

Recommendation 5 Clinical skills and training



Recommendation 6 Specialist clinical care: identifying and managing very sick women

Recommendation 7 Systolic hypertension requires treatmentRecommendation 7 Systolic hypertension requires treatment

Recommendation 8 Pathology

Recommendation 9 Serious Incident Reporting and Maternal Deaths

Recommendation 10 Genital tract infection/sepsis

Signs and symptoms of sepsis

• Pyrexia is common, but a normal temperature does not exclude sepsis. Paracetamol and other analgesics may mask pyrexia, and this should be taken into account when assessing women who are unwell.

• Hypothermia is a significant finding that may indicate severe infection and should not be ignored.

• Swinging pyrexia and failure to respond to broad-spectrum intravenous antibiotics is suggestive of a persistent focus of infection or abscess.

• Persistent tachycardia >100 b.p.m. is an important sign which may indicate serious underlying disease and should be fully investigated.

• Tachypnoea is sepsis until proved otherwise—persistently increased respiratory rate >20 breaths/minute is a significant clinical finding that can also indicate other serious pathology, such as pulmonary oedema, pneumonia, significant clinical finding that can also indicate other serious pathology, such as pulmonary oedema, pneumonia, thromboembolism or amniotic fluid embolism, and impending cardiac arrest.

• Leucopenia <4 · 109 white blood cells/l is a significant finding that may indicate severe infection.

• Diarrhoea is a common and important symptom of pelvic sepsis. Diarrhoea and/or vomiting in a woman with any evidence of sepsis is a very serious sign and an indication for commencing immediate broad-spectrum intravenous antibiotic therapy.

• Severe lower abdominal pain and severe ‘after-pains’ that require frequent analgesia or do not respond to the usual analgesia are also common important symptoms of pelvic sepsis. In some cases, very severe lower abdominal pain may be the result of the action of bacterial toxins on the bowel wall.

• An abnormal or absent fetal heart beat with or without placental abruption may be the result of sepsis.

Perianesthetic Evaluation

• Conduct a focused history and physical examination before providing anesthesia care

• Maternal health and anesthetic history• Relevant obstetric history• Back examination when neuraxial anesthesia is planned or placed • Airway and lung examination • Airway and lung examination • Heart examination and baseline blood pressure measurement

A communication system should be in place to encourage early and ongoing contact between obstetric providers, anesthesiologists and others members of the multidisciplinary team

Practice guidelines for obstetric anesthesia: an Up dated Report by the American Society of Anesthesiol ogists Task Force on Obstetric Anesthesia ANESTHESIOLOGY; Volume 10 6(4) april 2007 pp 843-863

Should routine pre-operative testing be abandoned ?More preoperative assessment by physicians

and less by laboratory tests

In january 2010 the Association of Anaesthetists of Great Britain and Ireland published its safety guideline Pre-operative Assessment and Patient Preparation –

The Role of the Anaesthetist.

“ Routine pre-operative investigations are expensive ,labour intensive and questionable value,expecially as they may contribut e to morbidity or cause

EDITORIAL - Anaesthesia ,2010,65 pages 971-979

questionable value,expecially as they may contribut e to morbidity or cause additional delays due to spurious results”.

The more tests that are performed,the more likely it is that an abnormal result will be detected,even in healthy individuals.The important question is the significance of the

abnormal result in an asyntomatic patient and how this will alter his or her management.

Should routine pre-operative testing be abandoned ?More preoperative assessment by physicians

and less by laboratory tests

Regardless of whether a preoperative test was indicated or not the finding of an abnormal result carries with it the obligation to determine its clinical relevance and

decide if further investigation is required.

The positive predictive value of individual tests,when used to screen for disease,is low.

EDITORIAL - Anaesthesia ,2010,65 pages 971-979

The superiority of history and examination over routine pre-operative testing was demonstrated in a prospective study of 17638 day-case surgical patients.

Clinical risk factors such as hypertension,obesity,smoking,asthma and gastro-oesophageal reflux were much better predictors of peri-operative

adverse events than abnormal pre-operative test results.

WHO-World Health OrganizationClassification of Body Mass Index

Classification BMI (KG/M2) Risk of co-borbilities kg. Ib

normal 18.5-24.9 average 11.5 -16 25-35

overweight 25-29.9 increase 7-11.5 15-25

The 2009 Institute of Medicine recommendations for total weight gain ranges for pregnant women

Recommended total gestationalweight gain

overweight 25-29.9 increase 7-11.5 15-25

Obese class 1 30-34.9 moderate 5 -9 11-20

Obese class 2 35-39.9 severe / /

Obese class 3 > 40 very severe / /

Teachable moment: weight control and obesity prevent ion –American Journal of Obstetric& Gynecology – february 2010

Pregnant women with a booking BMI> 40 should have an antenatal consultation with an obstetric anaesthetist,so that potential difficulties with venous access, regional or general anaesthesia can be identified.Epidural re-site rates have been reported to increase with increasing BMI and the initial failure rate of epidural cannulation in parturients with morbid obesity has been reported to be as 42% in one hospital.For these reasons an early epidural may be advisable

Risk related to obesity in pregnancy (CEMACH 2003- 2005)

For the mather• Maternal death or/and severe morbidity• Cardiac disease• Spontaneus first trimester and recurrent miscarrage• Pre-eclampsia• Gestational diabetes• Thromboembolism• Post caesarean wound infection• Infection from others causes• Post partum haemorrhage• Low breast feeding rates

For the baby• Stillbirth and neonatal death• Congenital abnormalities• Prematurity

Prepregnancy overweight and obesity is associated with adverse pregnancy outcome in glucose-tolerant women.adverse pregnancy outcome in glucose-tolerant women.

Dorte M. Jensen (American J Obstet Gynecol 2003;volume189,Issue 1,pages 239-244.)

BMI (kg/m 2)

No. Affected

% affected

OR vs baseline* 95% CI

Preeclampsia and PIH‡

18.5-24.9*25-29.9

>30

403778

3.75.112.5

1.01.43.8

—0.9-2.22.5-5.6

Shoulder dystocia 18.5-24.9* 15 1.6 1.0 —

The impact of overweight and obesity on maternal outcomes in 2459 women with normal glucose tolerance

Shoulder dystocia 18.5-24.9*25-29.9

30

15117

1.61.81.4

1.01.10.9

—0.5-2.50.4-2.2

Preterm delivery 18.5-24.9*25-29.9

30

271822

3.03.04.8

1.01.01.6

—0.6-1.90.9-2.9

Cesarean section 18.5-24.9*25-29.9

30

161125140

14.717.222.0

1.01.21.6

—0.9-1.61.3-2.1

Induction of labor 18.5-24.9*25-29.9

30

12896

141

12.414.123.4

1.01.22.2

—0.9-1.5

1.7-2.81

Recurrent preeclampsiaThe effect of Weight Change Between Pregnancies

From 1989 through 2005 in the Missouri maternally linked birth registry,19.044 women had preeclampsia diagnosed during their first pregnancy .Of these information required

to calculate the prepregnancy BMI was present for both first and second pregnancies in 17.913 women .

The women were placed into three groups:The women were placed into three groups:

• those who decreased their BMI• those who maintained their BMI • those who increased their BMI between their first two pregnancies.

The prymary outcome was recurrent preeclampsia in t he second pregnancy

D.Mostello,J.J.Chang,J.Allen – OBSTETRIC&GYNECOLOGY – vol.116,NO.3,september 2010

Recurrent preeclampsiaThe effect of Weight Change Between Pregnancies

The overall rate of recurrent preeclampsia in women between pregnancies was:

• 12.8% BMI decreased• 14.8% BMI was maintained• 18.5% BMI increased

• For women who face the prospect of recurrent preeclampsia with its attendant risks of maternal and perinatal morbidity,mortality and indicated preterm delivery,few options exist that may ameliorate their risk:

• control of underlyng medical illnesses• low-dose aspirin therapy• prudent weight gain during pregnancy

Interpregnancy weight loss,however,is the most reas onable measure to meaningfullylower the risk of preeclampsia recurrence .

D.Mostello,J.J.Chang,J.Allen – OBSTETRIC&GYNECOLOGY – vol.116,NO.3,september 2010

Practice guidelines for obstetric anesthesia: An U pdateReport by the

American Society of Anesthesiologists Task Force on Obstetric Anesthesia

Early insertion of a Spinal or Epidural Catheter for Complicated Parturients: recommendations

Early insertion of a spinal or epidural catheter for ostetric (twin gestation or preeclampsia) or anesthetic indications (anticipated difficult airway or obesity) preeclampsia) or anesthetic indications (anticipated difficult airway or obesity) should be considered to reduce the need for GA if an emergent procedure becomes necessary.

…Consultants and ASA members agree that early insertion of a spinal or epidural catheter for complicated parturients reduces maternal complications.

Submitted for publication october 31, 2006. Anesthesiology : volume 106 (4) aprile 2007 pp 843-863

Back examination when


Back examination when neuraxial anesthesia is planned

or placed

Terms and Incidence of Unsatisfactory Epidural Bloc k

Term Incidence Author Year

Initial failure rate 4.2%Dill-Russel P. 2001

Catheter failure rate 13.1% Eappen S. 1998

Failure to produce anesthesia 4.1% Tanaka K 1993

Failed or inadequate block 0.9 to 13.1% Douglas J 2000

Failure to produce a block 1.2% Norris MC 1998

Inadequate pain relief 0.9% to 24% Agaram 2009

Failure in obstetric neuraxial analgesia 2004Pan12%

Inadequate pain relief 0.9% to 24% Agaram 2009

Inadequate anesthesia 18% Carp H. 1990

Inadequate block up to 25% Morgan BM 1983

Need for IV supplementation 38% Riley E. 1995

Intraoperative discomfort/ pain Segal 1997

up to 50% Beck 1992

Intraoperative supplementation 42% Davies S. 1997

“Some discomfort” 33% Keohane M 1996

Visceral pain 56.5% Alahuhta S. 1990

Unsatisfactory block 1.5% to 21% Narang V. 1988

Epidural replacement rate

14.3

Some of the difficulties can be circumvented by using ultrasound to identify the epidural space and calculate its depth.Ultrasound studies have found the skin epidural distance

to be greater in pregnancy.

The majority of studies report that only a few have an epidural space deeper than 8 cm. hence it seem appropiate to use a standard needle to identify the epidural space

on the first attempt.

Every studies found that cardiac output decreased more in the lateral decubitus position with maximal

Obesity and obstetric anaeshesiaRegional anaesthesia

Every studies found that cardiac output decreased more in the lateral decubitus position with maximal lumbar flexion compared with the sitting position. Another studies found the depth of the space from the

skin to be greater in patients where the epidural was inserted in the lateral decubitus position.

Overall the sitting position is preferable

Obesity and obstetric anaesthesia.Anaesthesia 2006,61:36-48

Rapid sequence spinal anaesthesia for category – 1 urgency caesarean section: a case series

Components of the rapid sequence spinal

Deploy other staff for intravenous cannulation and monitoring

Pre-oxygenate during attempt

No touch’ technique – gloves only with glove packet as sterile surface for equipment.Skin prepared withsingle wipe of 0.5% chlorhexidine solution

If no opioid – consider increased dose hyperbaric bupivacaine 0.5% (up to 3 ml.); add fentanyl 25y ifprocuring it does not produce unacceptable delay

S.M.Kinsella,K.Girgirah and M.J.Scrutton – Bristol H. Anaesthesia,2010,65,pages 664-669

procuring it does not produce unacceptable delay

Local infiltration not mandatory

One attempt at spinal unless obvious correction allows a second

If necessary start surgery when block > T10 and ascending.Be prepared to convert to general anaesthesia –keep mother informed

Il T.per preparare ed eseguire la spinale era di 2 min.Il T.per avere (sviluppare) un blocco soddisfacente era di 4 min.Il T.totale per indurre una anestesia spinale era di 6-8 min .


Lung examination

Airway examination

MODIFICAZIONE RESPIRATORIE

parametri gravidanza obesità gravidanza + obesità

Volume corrente ↑ ↓ ↑

Frequenza respiratoria ↑ ↔ o ↑ ↑

Volume minuto ↑ ↓ o ↔ ↑

Capacità inspiratoria ↑ ↓ ↑

Volume di riserva inspiratoria ↑ ↓ ↑

Volume di riserva espiratoria ↓ ↓ ↓

Volume residuo ↓ ↓ o ↔ ↑

Modificazioni nel sistema respiratorio

Capacità funzionale residua ↓↓ ↓ ↓ ↓ ↓ ↓

FEV1 ↔ ↓o ↔ ↔

FEV1/CV ↔ ↔ ↔

Capacità polmonare totale ↓↓ ↓ ↓ ↓

Compliance ↔ ↓↓ ↓

Lavoro respiratorio ↑ ↑↑ ↑

Resistenze vie aeree ↓ ↑ ↓

PaO2 ↓ ↓ ↓ ↓

PaCO2 ↓ ↑ ↑

AIRWAY

The incidence of failed tracheal intubation is approximately 1 in 280 in the obstetric population compared to 1 in 2230 in the general surgical population.

This contrast with an incidence of difficult intubation in an obese population as high as 15.5%. Dewan reports the incidence as high as 33% in morbidity obese parturients.

In addition pregnancy induced hypertension, upper respiratory tract infection, stridor and In addition pregnancy induced hypertension, upper respiratory tract infection, stridor and voice changes may suggest the presence of airway oedema.

Obesity and obstetric anaesthesia.Anaesthesia 2006,61:36-48

Weight gain in excess of 15 kg .during pregnancy has been shown to be associated with an increase in suboptimal laryngoscopic views

Airway Changes during labor and delivery

Study 1. The first study used the conventional Samsoon modification of the Mallampati airway class.The airway was photographed at the onset and the end of labor.Women with class 4 Mallampati airways were excluded from initial participation.

Bhavani-Shankar Kodali,M.D. Sobhana Chandrasekhar,M.D.Anesthesiology 2008,108:357 -62

Results. In study 1 (n.61), there was a significant increase in airway class from prelabor to postlabor.The airway increased one grade higher in 20 (33%) and two

grades highter in 3 (5%) after labor. At the end of labor there were 8 parturients with airway class 4 and 30 parturients with airway class 3 or class 4 (50%)..


Study 2. In the second study, upper airway volumes were measured using acoustic reflectometry at the onset and the conclusion of labor.Acoustic reflectometry software computed the values for the components of upper airway,oral volume,and pharyngeal volume.


Results. In study 2 (n.21), there were significant decreases in oral volume and pharyngeal area and volume after labor and delivery. There is a positive relation between the duration of stage 2 of labor ,which is associated with maximum pushing and straining ,with decreases in pharyngeal volume.


Conclusion

Mallampati classification is not static , but can change over hours with processess such as labor.


hours with processess such as labor.

Therefore a careful airway evaluation is essential just before administering anesthesia during labor rather than obtaining this information from prelabor data.

Mallampati class changes during pregnancy,labour and after delivery:can these be predicted?

No study has reported the evolution of the Mallampati class in the same population of obstetric patients during pregnancy, labour and after delivery.

• Inclusion criteria were age ≥ 18 yr,monofetal pregnancy at ≥37 weeks gestation and epidural analgesia for childbirth

• Exclusion criteria were non French speaking women,the absence of consent ,multiple

M.Boutonnet,V.Faitot,A.Katz,L.Salomon and H.Keita – Service d’Anesthesie and Departement de Santè Publique,Assistance Publique Hopitaux de Paris,Hopital Louis Mourier,France – British Journal of Anesthesia 104 (1):67-70 (2010 )

• Exclusion criteria were non French speaking women,the absence of consent ,multiple pregnancy and anaesthesia consultation in which Mllampati class was not recorded.

The goal of this study was to evaluate upper airway changes at each time point and to identify any predictive factors

Mallampati class changes during pregnancy,labour an d after delivery:can these be predicted?

The class Mallampati was evaluated at four time poi nts:

• (T1) during consultation for anaesthesia during 8° month of pregnancy• (T2) placement of epidural catheter• (T3) 20 min after delivery• (T4) 48 h after delivery

The variables evaluated as potential predictive factors of Mallampati class evolution were:


The variables evaluated as potential predictive factors of Mallampati class evolution were:

• between T1 and T2: gain in body weight

• between T2 and T3: duration of first and second stages of labour, volume of fluids administered during labour

• between T1 and T4: duration of second stage of labour and volume of i.v.fluids administered during labour


87 pregnant women were included in the study

The mean age of the patients was 31.2 (5,2) yr and the mean BMI before pregnancy was 23.9 (4,7) kgm2.Eight women (9.2%) were diagnosed with obesity before pregnancy and 21 (24.1%) were overweight.

The Mallampati class did not change for 32 women (36 .8%)

• nine Mallampati 1 patients (34.6%)• twenty Mallampati 2 patients (38.5%)• three Mallampati 3 patients (33.3%)


For the remaining parturients (55), Mallampati class increased betweenT1-T2 and T2-T3 and decreased between T3 and T4 .

Pat

ient

s (%

)


Pat

ient

s (%

)

The Mallampati classes at different time points.T1 8months of pregnancy – T2 during labour – T3 20 min.after delivery – T4 48 h. after delivery


This study has demonstrated an increase in the incidence of Mallampati classes 3 and 4 from the 8° month of pregnancy to the beginning of labour and during labour.

These changes were not fully reversed up to 48 h after delivery

Airway oedema can be augmented by fluid overload and prolonged Valsalva efforts , as described in previous case reports, were hypothesized that the volume of i.v.fluids administered and durations

of first and second stages of labour might be potential factors.However none of these potential factors was predictive of Mallampati class changes in these study.

These changes may potentially occur in every pregnant woman sinceno predictive factor could be identified

These findings suggest that it is imperative for an aesthetist to re-evaluate the airway just before anaesthetic management in obstet ric patients and

up to 48 h after delivery.

M.Boutonnet,V.Faitot,A.Katz,L.Salomon and H.Keita – Service d’Anesthesie and Departement de Santè Publique,Assistance Publique Hopitaux de Paris,Hopital Louis Mourier,France – British Journal of Anesthesia 104 (1):67-70 (2010)

PERIANESTHETIC EVALUATION

BLOOD CONSTITUENTS

What is hemostasis?

Although there are many ways to define hemostasis,one clinical definition would be control of bleeding without the occurrence of pathologic thrombotic

events (when balance among procoagulant,anticoagulant,fibrinolytic and antifibrinolytic activities is achieved)

The most important initial factors for haemostasis at delivery are uterine muscle contractionsand constriction of the spiral arteries that interrupt blood flow.

Obstetric and postpartum hemorrhage

At the end of pregnancy uterine blood flow is approximately 800 to 1000 ml/min and after delivery of the placenta,

the uterus must rapidly establish hemostasis.

This process occurs via uterine involution,vasoconstriction and localized thrombosis. and localized thrombosis.

Jerrold H.Levy,Richard P.Dutton,J.Claude Hemphill – Anesthesia&Analgesia vol.110.No.2 february 2010

Given the increasing rate of cesarean delivery (approximately 30%of deliveries in the United States and the epidemic of maternal obesity ,

postpartum hemorrhage will continue to dominate maternal morbidity and mortality in the foreseeable future

Triennium Placentalabruption

Placentapraevia

Postpartumhaemorrhage

Total

1985–87 4 0 6 10

1985–87 6 5 11 22

1991–93 3 4 8 15

Direct deaths by type of obstetric haemorrhage and mortality rate per 100 000 maternities; UK: 198 5–2008

1994–96 4 3 5 12

1997–99 3 3 1 7

2000–02 3 4 10 17

2003–05 2 3 9 14

2006–08 2 2 5 9

In the UK, major obstetric haemorrhage was uterine atony, the incidence of peripartum hysterectomy to control haemorrhage to be 40.6 per 100 000 maternities. Fewer than 1% of the women who had a hysterectomy died.

OBSTETRIC HAEMORRHAGE: SPECIFIC RECOMMENDATIONS

•all staff require regular training on identification and management of maternal collapse, including the identification of hidden bleeding and the management of haemorrhage….

• guidelines for the management of women who refuse blood products must be made available to and discussed with all maternity staff as part of their routine training

Direct deaths by type of obstetric haemorrhage and mortality rate per 100.000 maternities; U.K. 2006-2 008

• when severe haemorrhage occurs it is good practice to call straight away for the aid of colleagues with greater gynaecological surgical experience

• the management of women with placenta percreta requires careful multidisciplinary planningin the antenatal period and the involvement of a consultant-led multidisciplinary team at delivery

• women delivered by caesarean section should have regular observations of pulse and blood pressure for the first 24 hours after delivery recorded on a modified early obstetric warning score (meows) chart. abnormal scores on meows should be investigated and acted upon immediately.

Numbers of deaths attributed to pulmonary embolism and rates per 100 000 maternities by age; UK: 1985– 2008.

Under 25 years

25–29 years

30–34 years

35–39 years

40 years and over

Total

1985–90 3 19 12 13 7 54

1997–99 5 6 11 8 1 31

2000–02 3 8 7 6 1 25

2003–05 9 8 10 5 1 33

2006–08 3 5 4 4 0 16

The fall in deaths from pulmonary embolism, from 33 to 16, was mainly theresult of a reduction in antenatal deaths and deaths following vaginal delivery. Deaths after caesarean section also fell slightly.

THROMBOSIS AND THROMBOEMBOLISMSPECIFIC RECOMMENDATIONS

• Obesity remains the most important risk factor for thromboembolism.

• Public information and education messages are necessary so that women a riskof problems in pregnancy because of their weight , family history or past history can

The Confidential Enquire into Maternal Deaths in th e United Kingdom (2006-2008)

of problems in pregnancy because of their weight , family history or past history can seek advice before pregnancy

• Health professionals must be aware that women are at risk of thromboembolismfrom the very beginning of pregnancy

• Vulnerable women, such as those with mental illness or learning disability , may not be able to follow advice or selfadminister injections, and so require particular care.


HEART EXAMINATION

parametri Gravidanza obesità Gravidanza+obesità

Frequenza cardiaca. ↑ ↑↑ ↑↑

Gittata sistolica ↑↑ ↑ ↑

Portata cardiaca. ↑↑ ↑ ↑↑↑

Indice cardiaco ↑ o ↔ ↑↑ ↔ o ↓

ematocrito ↓ ↓ ↑ ↓

Volume ematico ↑↑ ↑ ↑

Resistenze vascolari sistemiche ↓ ↓ ↑ ↔ o ↓

Pressione arteriosa media ↑ ↑↑ ↑↑

Apparato cardiovascolare

Pressione arteriosa media ↑ ↑↑ ↑↑

Ipotensione supina presente presente ↑↑

Morfologia ventricolare sinistra ipertrofia ipertrofia Ipertrofia e dilatazione

Attività simpatico ↑ ↑ ↑↑↑

Funzione sistolica ↔ ↔ o ↓ ↔ o ↓

Funzione diastolica. ↔ ↓ ↓

Pressione venosa centrale ↔ ↑ ↑↑

Pressione capillare polmonare ↔ ↑↑ ↑↑

Ipertensione polmonare assente può essere presente può essere presente

preeclampsia ↔ non applicabile ↑↑

Aims of obstetric critical care management

The supine hypotension syndrome is an important consideration after 24 weeks.

The most significant cardiovascular challenge occur s at birth. Up to 500 ml. of blood is autotransfused back into the circulation following relief of aortocaval compression by the fetoplacental unit and contraction of the uterus and CO may increase by up to 80% of preterm fetoplacental unit and contraction of the uterus and CO may increase by up to 80% of preterm baseline.

Laura Claire Price,Andrew Slack,Catherine Nelson-Piercy –Best Practice&Research Obstetrics and Gynaecology – vol.22,No.5,pp 775-779,2008

These fluid shifts are especially challenging in pa rturients with cardiac disease,who should be monitored for 72 h post partum.

PATOLOGIACARDIACA

BASALE

Limitata riservafunzionale

Mancatoadattamento

Sovraccarico

SCOMPENSO

Type and cause of death 2000–02 2003–05 2006–08

Acquired

Aortic dissection 7 9 7

Myocardial infarction 8 12 6

Ischaemic heart disease 0 4 5

Sudden adult/arrhythmic death syndrome (SADS) 4 3 10

Peripartum cardiomyopathy 4 0 9

Causes of maternal death from cardiac disease; UK: 2000–2008

Peripartum cardiomyopathy 4 0 9

Other cardiomyopathy 4 1 4

Mitral stenosis or valve disease 3 3 0

Infective endocarditis 1 2 2

Congenital

Pulmonary hypertension 4 3 2

Congenital heart disease 2 3 1

Total 44 48 53

Danni da fumo, Ipercolesterolemia, obesità,anamnesi familiare positiva, ipertensione,diabete

Eziopatogenesi :• Alterazioni qualitativa del sangue• Compromissione circolo coronarico• Discrepanza tra letto coronarico e massa miocardica

Alterazioni bioumorali:• VES aumentata

Cardiopatie ischemiche

• VES aumentata• Leucocitosi neutrofila• Iperglicemia• Aumento enzimi nel siero (Got-Ldh-Cpk)

Prova da sforzo per valutare la riserva coronarica

Anestesia :

Ossigenazione-Evitare tachicardia-Evitare squilibri pressori

Peripartum Cardiomyopathy

For a definitive diagnosis of peripartum cardiomyopathy four criteria must be present and they include:

.

• the development of congestive heart failure in the past month of pregnancy or within 5 months after delivery

• the absence of preexisting cardiac dysfunction

• the absence of a determinable cause of cardiomyopathy

• documented left ventricular systolic dysfunction such as depressed ejection fraction

E.V.Kuklina and W.M.Callaghan- VPG – Obstetric and Gynecology - vol.115,NO.1. JANUARY 2010

Sudden adult/arrhythmic death syndrome (SADS)

Ten women died of SADS during this triennium compared with three in the last Report.

Six of them were obese , with booking BMI ranging from 30 to 45.

The case definition for SADS is a sudden unexpected cardiac death (presumed fatal arrhythmia ) where all other causes of sudden collapse are excluded, including a drug screen for stimulant drugs such as cocaine.

The women who died of sudden unexpected cardiac death who were not hypertensive during pregnancy (or who were well treated) and did not have one of the ‘explained’ cardiac pathologies. It includes those who were obese and those with otherwise unexplained left ventricular hypertrophy.

It is established that obesity and cardiac hypertrophy are associated in the absence of concurrent hypertension, and that obesity and cardiac hypertrophy are both r isk factors for

arrhythmia and sudden cardiac death .

Cardiac disease: specific recommendations

• Pregnant immigrant women require a complete medical examination,including cardiovascular examination…

Causes of maternal death from cardiac disease UK 20 03-2005

• Maternity health care professionals must remember the possibility of rheumatic heart diseasein immigrant women …

• Women at higher risk of developing cardiac disease in pregnancy: the obese ,those who smokeor who have existing hypertension and/or diabetes ,a family history of heart disease and those over the age of 35 ,should be appropriately counselled of these risk pre-conception…


Baseline blood pressure measuremetBaseline blood pressure measuremet

Reducing the risk of hypertensive disorders in preg nancy

Advise women at high risk of pre-eclampsia to take 75 mg.of aspirin daily from 12 weeks untill the birth of the baby.Women at high risk are those with of the following:

• hypertensive disease during a previous pregnancy• chronic kidney disease• autoimmune disease such as systemic lupus erythematosis or antiphospholipid syndrome• type 1 or type 2 diabetes• chronic hypertension

Discontinuation of antihypertensive drug use during the first trimester of pregnancy and the risk of preeclampsia and eclampsia among women with chronic hypertension

This study was conducted within the Quebec Pregnancy Registry that contain information on all pregnancies occurred in Quebec between Jan.1,1997 – Dec. 31,2003.

To be elegible for this study women had to be:• Between 15-45 years old on the IDG (the first day of gestation,defined as the first day of

the last menstrual period)• Covered by the drug plain for at least 12 months before the IDG and during the

pregnancy• On an antihypertensive drug on the IDG• On an antihypertensive drug on the IDG• Have had a delivery

Hamid Reza Nakhai-Pour,Evelyne Rey,Anick Berard American Journal of Obstetrics & Gynecology – August 2009

Covariates

• Maternal sociodemographic characteristic• Antihypertensive drug use in the year before and during the pregnancy• Maternal chronic conditions in the 2 years before: cardiovascular diseases,

diabetes mellitus,chronic renal diseases,dyslipidemia

Antihypertensive discontinuation at the beginning of a pregnancy was defined as using the drugs for less than 80% of the duration of the first trimester ( 0-14 completed weeks of gestation)

ANTIHYPERTENSIVE DRUGS USED DURING PREGNANCY

ANTIHYPERTENSIVE CLASSES 1 DG,n(%) 1 °trimester(0-14wk),n%

2° trimester(15-26wk),n(%)

Selective B-blockers (atenololo-metopralolo-acebutolo…)

46 (18.70%) 34 (13.82%) 2 (1.56%)

Nonselettive B-blockers (labetalolo-propranololo…)

34 (13.82%) 31 (12.6°%) 1 (0.78%)

Calcium channel blockers 33 (13.41%) 27 (10.98%) 2 (1.56%)

ACE inhibitors 28 (11.38)% 18 (7.32%) 0

Thiazide diuretics 19 (7.72%) 18 (7.32%) 2 (1.56%)Thiazide diuretics 19 (7.72%) 18 (7.32%) 2 (1.56%)

Potassium-sparing diuretics 24 (9.76%) 22 (8.94%) 1 (0.78%)

Central antihypertensive 16 (6.50%) 14 (5.69%) 5 (3.91%)

Angiotensin II inhibitors 12 (4.88%) 8 (3.25%) 0

Alpha- and B-blockers 4 (1.63%) 4 (1.63%) 0

Vasodilatator 1 (0.41%) 1 (0.41%) 0

>1 class 29 (11.79%) 69 (28.05%) 115 (89.90)

Hamid Reza Nakhai-Pour,Evelyne Rey,Anick Berard American Journal of Obstetrics & Gynecology – August 2009

The risk of PE/E associated with the discontinuatio n of antihypertensivesduring the first trimester of pregnancy

• Of 686 women with a diagnosis of chronic hypertension before pregnancy, 246 (35.9%) were receiving their antihypertensive medication during the first trimeste pregnancy and 440 (64.1%) were not treated after the beginning of pregnancy.

• Of 246 women who are receiving antihhypertensive medication on the IDG,108 (43.9%) continued to receive antihypertensives during the first trimester,138 (56.1%) discontinued their medication (<80% of the first trimester)

Hamid Reza Nakhai-Pour,Evelyne Rey,Anick BerardAmerican Journal of Obstetrics & Gynecology – August 2009

Antihypertensive drug discontinuation OR (95% CL) Crude Adjusted

0.69 (0.33-1.45) 0.66 (0.27-1.56)

There were 31 cases of PE/E.

Of 31 cases, 17 women continued to use antihypertensive medication during the first trimester. Of the17 women who continued to use their medicationonly 7 women continued their medication use during

the second trimester of pregnancy and the remainder discontinued their medication during the second trimester.

Maternal risk factors for hypertensive disorders in pregnancy: a multivariate approach

The study aimed to develop prediction algorithms for hypertensive disorders in womenattending for their routine first hospital visit in pregnancy.In this visit which is held at11-13 weeks of gestation ,all women have an ultrasound scan to confirm gestational age.

Women were asked to complete a questionnaire on maternal age,racial origin,cigarettesmoking during pregnancy,method of conception,medical history,medication,parity,previous pregnancy with PE and family history of PE.The maternal weight and height were measured (BMI)

Between March 2006 and November 2007 there were 8366 cases, 165 (2.0%) that developedBetween March 2006 and November 2007 there were 8366 cases, 165 (2.0%) that developedPE including 37 that required delivery before 34 weeks ( early-PE ) and 128 with late-PE , 140 GH and 8061 (96.4%) cases that were unaffected by PE or GH.

LCY Poon,NA Kametas,T Chelemen,A Leal – King’s College Hospital,London,UK –Journal of Human Hypertension - advance online publication 11 June 2009;doi:10.1038/jhh . 2009.45

Risk factors

• age of 40 years or older,• nulliparity,• BMI• family history• history of PE• preexisting vascular disease

Maternal variables

Unaffected(n=8061)

Early PE(n=37)

Late PE(n=128)

GH(n=140)

Maternal age (>32) 32.3 (28.1-35.8) 31.6 (25.4-36.3) 32.3 (27.3-36.8) 33.0 (28.8-35.7)

BMI (>24) 24.4 (22.1-27.5) 27.7 (23.2-32.0) 27.4 (23.8-32.0) 26.5 (23.9-31.0)

Racial origin

White,n% 5666 (70.3) 14 (37.8) 56 (43.8) 104 (74.3)


Black,n% 1581 (19.6) 18 (48.6) 52 (40.6) 28 (20.0)

parity

Nulliparous,n% 2554 (31.7) 12 (32.4) 54 (42.2) 54 (38.6)

Parous-no previous PE,n%

4074 (50.5) 8 (21.3) 30 (23.4) 38 (27.1)

Parous-previous PE,n%

200 (2.5) 8 (21.4) 20 (15.2) 13 (9.3)

LCY Poon,NA Kametas,T Chelemen,A Leal – King’s College Hospital,London,UK –Journal of Human Hypertension advance online publication 11 June 2009;doi:10.1038/jhh.2009.45

Maternal variables

Unaffected(n=8061)

Early PE(n=37)

Late PE(n=128)

GH(n=140)

Family history of PE

Mother,n% 308 (3.8) 3 (8.1) 15 (11.7) 15 (10.7)

Sister,n% 155 (1.9) 3 (8.1) 1(0.8) 2 (1.4)

Conception

Spontaneus,n% 7706 (95.6) 32 (86.5) 121 (94.5) 131 (93.6)


Ovulation induction,n%

235 (2.9) 4 (10.8) 5 (3.9) 4 (2.9)

In vitro fertilisation,n%

120 (1.5) 1 (2.7) 2 (1.6) 5 (3.6)

Medical history

none.,n% 7881 (97.8) 31 (83.8) 121 (94.5) 138 (98.6)

Chronic hypertension,n%

59 (0.7) 5 (13.9) 4 (3.1) 0

Diabetes mellitus,n%

64 (0.8) 0 2 (1.6) 2 (1.5)

LCY Poon,NA Kametas,T Chelemen,A Leal – King’s College Hospital,London,UK –Journal of Human Hypertension advance online publication 11 June 2009;doi:10.1038/jhh.2009.45

La gravidanza è un viaggio lungo e speciale per la donna. E’ un viaggio che

Generazioni di donne hanno fatto la stessa

Concludendo:

E’ un viaggio che comporta un cambiamento fisico,psicologico e sociale.

strada,ma ogni viaggio è unico…

…dipende da Noi far si che questo viaggio avvenga in sicurezza…..

Fare l'esame cuore pure, con dissezione completa delle arterie coronarie, il peso esatto del cuore, misurazione degli spessori ventricolo e attenta valutazione delle valvole.

• Mettere in relazione questi dati con il peso corporeo della donna e indice di massa corporea (BMI).• Evitare istologia su una fetta standard medio orizzontale di muscolo cardiaco, ad esaminare la ventricoli destro e sinistro.• Osservare l'istopatologia polmonare di indizi (ad esempio polmonare ipertensione).• Conservare un campione di sangue in caso di cocaina e di altre farmaco stimolante l'analisi è necessario.• Considerare la consultazione di un patologo cardiaco per guadagnare consulenza e supporto per la diagnosi.per la diagnosi.• Se la diagnosi sarà SADS, assicurarsi che tutte Altre diagnosi ragionevole cardiaco, così come la gravidanza diagnosi correlate (come il liquido amniotico embolia), sono esclusi.

• Se SADS o una cardiomiopatia standard sembra essere la diagnosi, conservano un campione di milza congelato per eventuale successiva valutazione genetica; il medico legale non si aspettare che le indagini tale risorsa, ma la NHS cliniche cardiache genetiche.

Sudden adulti / morte aritmicasindrome

Dieci donne sono morte di SADS durante questo triennio rispetto con tre negli ultimi report. Questa è maggiore che in qualsiasi precedente relazione. Sei di loro erano obesi, con prenotazioneBMI da 30 a 45.Il Network UK patologia cardiaca sta incoraggiando gli esami più piena autopsia (e informativa per una banca dati centrale) e fornisce un elenco completo delle possibili diagnosi per auto improvvisa-Patologica di morti cardiache

morte cardiaca che è non-ischemica (ateromi) e non-valvolare (con l'eccezione di degenerazione della valvola mitrale mucoide) in nesso di causalità. La classificazione è suddivisa in quelli in cui viene spiegata valvola mitrale mucoide) in nesso di causalità. La classificazione è suddivisa in quelli in cui viene spiegata la morte lordi ed istologici criteri e quelli in cui resta inspiegabile alla nostra stato attuale delle conoscenze. miocardite,ipertrofia ventricolare sinistra e fibrosi, e ipertesi malattie del cuore sono ', ha spiegato'; inspiegata morte cardiaca in epilessia, abuso di alcool, l'obesità e il diabete sono 'inspiegabili'.Sotto l'etichetta SADS venire quei casi inspiegabili con un cuore morfologicamente normali di un esame lordo e istologia. Una parte può essere dimostrata con elettrografiche esame di parenti (e talvolta delladonna prima della morte) di avere un difetto di conduzione, un channelopathy, ad esempio La sindrome del QT lungo. In questo triennio, non decessi sono stati attribuiti a una aritmia specifico, ma che probabilmente riflette la valutazione imperfetta degli stessi

La gestione efficace della fallita intubazione tracheale è una competenza di base anestetico che dovrebbe essere provato e valutatoregolarmente.• Il riconoscimento e la gestione di grave, malattia acuta in una donna incinta, richiede il lavoro di gruppo multidisciplinare.multidisciplinare.Un anestesista e / o specialista di terapia intensiva, devono essere coinvolti in anticipo.• Ostetricia e ginecologia di servizi, in particolare quelli senza unità sul posto di terapia intensiva, deve avere un locale definitolinee guida per ottenere un accesso rapido alle, e l'aiuto, specialisti di terapia intensiva.

Box 1.6. Risks related to obesity in pregnancy14For the mother increased risks include:

• spontaneous first trimester and recurrent miscarriage• maternal death or severe morbidity• cardiac disease• pre-eclampsia• dysfunctional labour• gestational diabetes• thromboembolism• higher chance of needing a caesarean section• post-caesarean wound infection• post-caesarean wound infection• postpartum haemorrhage• low breastfeeding rates.

For the baby increased risks include:• stillbirth and neonatal death• congenital abnormalities• prematurity.References for these are available in the CMACEreport14 and the last Report of this Enquiry for 2003–05

Thromboembolism and thromboembolism: specific recom mendation

• Obesity remains the most important risk factor for thromboembolism. New guidance on the management of women with obesity in pregnancy has been published by Centre for Maternal and Child Enquries (CMACE)

• Risk assessment in early pregnancy continues to be a key factor in reducing mortality. Obese women with a body mass index (BMI) of 35 or more are unsuitable for midwife-only care, and should be seen in pregnancy by a consultantobstetrician.

• Women are at risk of thromboembolism from the very beginning of pregnancy until the end of • Women are at risk of thromboembolism from the very beginning of pregnancy until the end of the puerperium, and all health professionals must be aware of this. Early pregnancy units and gynaecology wards must carry out risk assessment appropriate for pregnant women.

• Vulnerable women, such as those with mental illness or learning disability, may not be able to follow advice or selfadminister injections, and so require particular care.

• Chest symptoms appearing for the first time in pregnancy or the puerperium in at-risk women need careful assessment, and there should be a low threshold for investigation.

In the triennium 2006–2008, 261 women in the UK died directly or indirectly related to pregnancy. The overall maternalmortality rate was 11.39 per 100,000 maternities. Direct deaths decreased from 6.24 per 100,000 maternities in 2003–2005to 4.67 per 100,000 maternities in 2006–2008 (p = 0.02). This decline is predominantly due to the reduction in deaths fromthromboembolism and, to a lesser extent, haemorrhage. For the first time there has been a reduction in the inequalitiesgap, with a significant decrease in maternal mortality rates among those living in the most deprived areas and those in thelowest socio-economic group. Despite a decline in the overall UK maternal mortality rate, there has been an increase indeaths related to genital tract sepsis, particularly from community acquired Group A streptococcal disease. The mortalitydisease. The mortalityrate related to sepsis increased from 0.85 deaths per 100,000 maternities in 2003–2005 to 1.13 deaths in 2006–2008, andsepsis is now the most common cause of Direct maternal death. Cardiac disease is the most common cause of Indirectdeath; the Indirect maternal mortality rate has not changed significantly since 2003–2005. This Confidential Enquiry identifiedsubstandard care in 70% of Direct deaths and 55% of Indirect deaths. Many of the identified avoidable factors remainthe same as those identified in previous Enquiries.

Recommendations for improving care have been developed and arehighlighted in this report. Implementing the Top ten recommendations should be prioritised in order to ensure the overallUK maternal mortality rate continues to decline.Our aim is to improve the health of mothers, babies and children by carrying out confidential enquires and relatedwork on a nationwide basis and by widely disseminating our findings and recommendations.Please cite this work as: Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: reviewing maternaldeaths to make motherhood safer: 2006–08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the UnitedKingdom. BJOG 2011;118(Suppl. 1):1–203.This work was undertaken by the Centre for Maternal and Child Enquries (CMACE). The work was funded by theNational Patient Safety Agency, the Scottish Programme for Clinical Effectiveness in Reproductive Health, by the Departmentof Health, Social Services and Public Safety of Northern Ireland and the States of Jersey and Guernsey, and Isle ofofMan. The views expressed in this publication are those of the Enquiry and not necessarily those of its funding bodies.Ireland joined the Enquiry in January 2009, at the commencement of the 2009–11 triennium, and its contribution will beincluded in the Saving Mothers’ Lives report for that triennium. The Irish office is located at the National Perinatal EpidemiologyCentre, Cork University Maternity Hospital, Cork.All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means,without the prior written permission of CMACE, or in the case of reprographic reproduction, in accordance with the termsof licences issued by the Copyright Licensing Agency in the UK (www.cla.co.uk). Enquiries concerning reproduction outsidethe terms stated here should be sent to CMACE at the address printed on this page.

Making duplicate copies of this Report for legitimate clinical or other noncommercial purposes with the UK NHS is permittedprovided the CMACE is identified as the originator of the information. Making alterations to any of the information containedwithin, or using the information in any other work or publication without prior permission, will be a direct breach ofcopyright and may result in civil action.The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement,that such names are exempt from the relevant laws and regulation and therefore free for general use.use.Product liability: CMACE can give no guarantee for information about drug dosage and application thereof contained in thisguideline. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature

Maternal deaths** Deaths of women while pregnant or within 42 days of the end of the pregnancy* from any cause relatedto or aggravated by the pregnancy or its management, but not from accidental or incidental causes.

Direct** Deaths resulting from obstetric complications of the pregnant state (pregnancy, labour and puerperium),from interventions, omissions, incorrect treatment or from a chain of events resulting from any of theabove.

Indirect** Deaths resulting from previous existing disease, or disease that developed during pregnancy and whichwas not the result of direct obstetric causes, but which was aggravated by the physiological effects of

Definitions of maternal deaths

was not the result of direct obstetric causes, but which was aggravated by the physiological effects ofpregnancy.

Late*** Deaths occurring between 42 days and 1 year after abortion, miscarriage or delivery that are the result ofDirect or Indirect maternal causes.Coincidental (Fortuitous)**** Deaths from unrelated causes which happen to occur in pregnancy or the puerperium.

Identifying very sick women

In many cases in this Report, the early warning signs andsymptoms of impending severe maternal illness or collapsewent unrecognised. The early detection of severe illness inmothers remains a challenge to all involved in their care.The relative rarity of such events combined with the normalchanges in physiology associated with pregnancy andchanges in physiology associated with pregnancy andchildbirth compounds the problem. Modified early warningscoring systems have been successfully introduced intoother areas of clinical practice, and the last Report gave anexample of a Modified Early Obstetric Warning System(MEOWS) chart. This is available on the CMACE websiteat www.cmace.org.uk. Their introduction for all pregnantor postpartum women who become unwell and requirefurther treatment, including following obstetric interventionsand gynaecological surgery, is one of the ‘Top ten’recommendations of this Report.

S Donati, S Senatore, A Ronconi, the Regional maternal mortality working group†

Article first published online: 10 MAR 2011DOI: 10.1111/j.1471-0528.2011.02916.x© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOGIssue BJOG: An International Journal of Obstetrics & Gyna ecologyEarly View (Articles online in advance of print)Additional Information(Show All)How to CiteAuthor InformationPublication HistoryHow to CiteDonati, S., Senatore, S., Ronconi, A. and the Regional maternal mortality working group , Maternal mortality in Italy: a record-linkage study. BJOG: An International Journal of Obstetrics & Gynaecology, no. doi: 10.1111/j.1471-0528.2011.02916.xAuthor InformationNational Centre for Epidemiology, Surveillance, and Health Promotion, Istituto Superiore di Sanità-Italian National Institute of Health, Rome, Italy*Correspondence: Dr S Donati, National Centre for Epidemiology, Surveillance, and Health Promotion, Istituto Superiore di Sanità-Italian National Institute of Health, via Giano della Bella 34, 00161 Rome, Italy. Email [email protected]† V Basevi, V Casotto, A Cernigliaro, G Dardanoni, M De Nisi, D Di Lallo, V Dubini, C Lupi, L Mondo, S Piffer, R Pizzuti, A Polo, R Rusciani, M † V Basevi, V Casotto, A Cernigliaro, G Dardanoni, M De Nisi, D Di Lallo, V Dubini, C Lupi, L Mondo, S Piffer, R Pizzuti, A Polo, R Rusciani, M Santoro, M Saporito, D Spettoli, E Verdini.Publication HistoryArticle first published online: 10 MAR 2011 Accepted 7 January 2011. Published Online 10 March 2011.SEARCHSearch Scope Search String Advanced >Saved Searches >SEARCH BY CITATIONVolume: Issue: Page: ARTICLE TOOLSGet PDF (231K)Save to My ProfileE-mail Link to this ArticleExport Citation for this ArticleGet Citation AlertsRequest PermissionsShare|

Cause di Substandard care

•Mancanza di adeguata comunicazione tra i professionisti

• Incapacità di apprezzare la gravità del problema

•Diagnosi non corretta•Diagnosi non corretta

•Trattamento non corretto o sub-ottimale

•Terapia intensiva non disponibile

•Mancanza di protocolli

Clear liquidsThe consultant and ASA members both agree that oral intake of clear liquids durig labour improves maternal confort and satisfaction

Recomendations

The oral intake of modest amounts of clear liquids may be allowed for uncomplicated laboring patients. The uncomplicated patient undergoing elective caesarean delivery laboring patients. The uncomplicated patient undergoing elective caesarean delivery may have modest amounts of clear liquids up to 2h before induction of anesthesia .

However patients with additional risk factors for aspiration ( morbid obesity, diabetes,difficult airway ) or patients at increase risk for operative delivery (non reassuring fetal heart rate pattern) may have further restrinctions of oral intake determined on a case by case basis.

Practice guidelines for obstetric anesthesia:an Upd ated Report by the American Society of Anesthesiolo gists Task Force on Obstetric Anesthesia-ANESTHESIOLOGY; Volume 106(4) april 2007 pp 843-863

Solids

The consultant and ASA members strongly agree that patients undergoing either elective cesarean delivery should undergo a fasting period of 6-8h depending on the type of food ingested.

Recommendations

Solid foods should be avoided in laboring patients.

Practice guidelines for obstetric anesthesia:an Upd ated Report by the American Society of Anesthesiolo gists Task Force on Obstetric Anesthesia-ANESTHESIOLOGY; Volume 106(4) april 2007 pp 843-863

PERIANESTHETIC EVALUATIONPERIANESTHETIC EVALUATION

FUNCTIONS OF THE KIDNEYFUNCTIONS OF THE KIDNEY

Renal physiology

• The increase in glomerular filtration may be overwelm the ability of the renal tubules to reabsorb leading to glucose and protein losses in the urine

• Tubular absorption of sodium,chlorine and water is increased

• In practice the plasma concentrations of electrolytes,glucose and urea fall if more water than sodium is retained

• Mild glycosuria (1-10mg/day) and/or proteinuria (to 300 mg/day) can occur in normal pregnancy

Physiological changes associated with pregnancy - Issue 9 (1998) article 2Christopher F.Ciliberto-Gertie F.Marx - Department of anesthesiology-New York-USA

1°trimestre 36 ° settimana

azotemia 26 mg/dl 20 mg/dl

uricemia 2,2-7,5 mg/dl 3,2-3,5 mg/dl

Indici di funzione renale in gravidanza

creatininemia 0,5-0,8 mg/dl 0,3-0,6mg/dl

cl.creatinina 100-180 ml/min 150-200 ml/min

Prot. 24 ore <150 mg/24 ore <300 mg/24 ore

PH 7,35-7,45 7,40-7,45

WHO-World Health Organization

Classification of Body Mass Index

. In England, females in the reproductive age group (16-44 years), have shown a dramatic increase in BMI. The percentage of women with BMI above 30 increased from 12% in 1993 to 18.3% in 2002.

Obesity is major healt problem in the United States.Obesity is major healt problem in the United States.National data indicate that 65.1% of Americans are considered overweight or obese.

The prevalence of obesity has increased > 50% over the past 2 decades and even more alarming is that the percentage of morbidity obese women

has doubled in the last decade.

Teachable moment: weight control and obesity prevent ion –American Journal of Obstetric& Gynecology – february 2010

PERIANESTHETIC EVALUATION

GASTROINTESTINAL SYSTEM

M.Berger,E.Valtancoli,G.Gambale – G.B.Hospital,Forlì,Italy – Anaesthesia and Intensive Care 2010;38:212

The differing approach of professionals

Pregnancy is not a disease but a physiological process.Anaesthetist are medically qualified being trained to treat the sick.Midwives specialise in normality.

There is a difference in approach

• Anaesthetist have to accept there is a different mind set required when a doctor is dealing with women who are not ill compared to those who are sick. dealing with women who are not ill compared to those who are sick.

• The anaesthetist often considers that the women cease to be”clients” and become”patients” when they are under the care of a doctor.

• Anaesthetists,like other doctors,have to meet people”where they are at” which is the moment of interaction and are obliged to respond appropriately.

The pregnant and the parturient – Wendy E.Scott Best Practice& Research Clinical Anaesthesiology – vol.20,No 4,pp 565-576,2006

Maternal critical care: what’s in a name?

…although there are useful data from 50 years of maternal mortality reports resulting in recommendations that have improved maternity care,

data are also needed on sick mothers who do not die.

A clear definition of high dependency care,accurate data collection and national guidance are needed.national guidance are needed.

There is no accurate information on the need forobstetric high dependency care

Editorial – International Journal of Obstetric Anesthesia (2010) 19,353-355

INDAGINE ECOCARDIOGRAFICA

Alterazioni del VS (geometria concentrica)in 1/3 delle pazienti

fattore di rischio o di complicanze

Novelli GP Novelli GP ValensiseValensise H H etet Al . Al . LeftLeft venticularventicular concentricconcentric geometrygeometry asas a a riskrisk factorfactor in in gestationalgestational hypertensionhypertensionHypertensionHypertension 2003; 41: 4692003; 41: 469--7575

fattore di rischio o di complicanze materne o fetali

Raccomandazioni del Ministero della Salute (Governo clinico Aprile 2007)

Fattori di rischio tromboembolico in gravidanza - in corso di parto e in puerperio

Età > 35 anni

Immobilità ( > 4 giorni di allettamento)

BMI > 30 kg / m2

Parto operativo ( applicazione di ventosa o forcipe )

Pre-eclampsia

Parità > 4

Interventi chirurgici in gravidanza e puerperio ( es. legatura tube postpartum )Interventi chirurgici in gravidanza e puerperio ( es. legatura tube postpartum )

Pregressa tromboembolia

Trombofilia congenita ( deficit AT3,proteina C, proteina S,fattore V Leiden )

Trombofilia acquisita ( anticorpi anticardiolipina, anticoagulante lupico )

Eccessiva perdita ematica

Paraplegia

Anemia falciforme

Processi infiammatori e infettivi ( es.infezioni urinarie )

Disidratazione

Modificato da RCOG 2004

INQUADRAMENTO DEL RISCHIO TROMBOTICO IN CORSO DI PAR TO CESAREO

Rischio basso

Cesareo elettivo

Gravidanza non complicata

Assenza di fattori di rischio specifico

Rischio moderato

Età > 35 anni

Obesità ( BMI > 30)


Obesità ( BMI > 30)

Parità ≥ 4

Grosse vene varicose

Infezioni in atto

Pre-eclampsia

Immobilità > 4 giorni precedente l’intervento

Malattie importanti in corso ( cardiopatie,pneumopatie,neoplasie, malattie infiammatoria intestinale,sindrome nefrosica )

Cesareo in urgenza in corso di travaglio


INQUADRAMENTO DEL RISCHIO TROMBOTICO IN CORSO DI PAR TO CESAREO

Rischio alto

Donna con tre o più fattori di rischio moderato tra quelli elencati precedentemente

Chirurgia pelvica o addominale maggiore ( es.cesareo demolitore )


Chirurgia pelvica o addominale maggiore ( es.cesareo demolitore )

Donna con storia personale o familiare di TVP, embolia polmonare o trombofilie

Paralisi arti inferiori

Sindrome antifosfolipidi ( anticorpi cardiolopinici o anticoagulante lupico)


NICE Guideline

Hypertension in pregnancy: the management of hypertensive disorders

during pregnancyduring pregnancy

Draft for consultation

September 2009

Degree of hypertension

Mild hypertension(<149/99 mmhg.)

Moderate hypertension(150/100 to 159/109 mmhg)

Severe hypertension(160/110 mmhg.)

Admit to hospital no no yes

Treat no

Yes-with oral labetalol to keep:•Diastolic blood pressure less than 100 mmhg but more than 80 mmhg.•Systolic blood pressure less than 150 mmhg.

Yes-with oral labetalo l to keep: •Diastolic blood pressure less than 100 mmhg but more than 80 mmhg•Systolic blood pressre less than 150 mmhg

Measure blood pressure

Yes routinely not more than once a week

Yes at least week Yes at least four timesa day

Management of women with gestational hypertension - NICE

pressure once a week a day

Test for proteinuria

Yes at each visit using automated dipsticks

Yes at each visit using automated dipsticks

Yes daily using automated dipsticks

Blood tests

No

(none in addition to those for routine antenatal care

Yes•Test urea electrolytes and request a full blood count,platelets,serum creatinine,transaminases,bilirubin•Do not carry out further blood test if no proteinuria at subsequent visits

Yes•Test at presentation : full blood count,platelets,serum creatinine, transaminases,bilirubin•Monitor weekly :full blood count,platelets,serum creatinine,transaminases,bilirubin

Management of women with pre-eclampsia - NICE

Degree of hypertension

Mild hypertension(<149/99 mmhg.)

Moderate hypertension(150/100 to 159/109 mmhg)

Severe hypertension(160/110 mmhg.)

Admit to hospital yes yes yes

Treat

No

(none in addition to routine antenatal care)

Yes-with oral labetalol to keep:•Diastolic blood pressure less than 100 mmhg but more than 80 mmhg.•Systolic blood pressre less than 150 mmhg.

Yes-with oral labetalol to keep: •Diastolic blood pressure less than 100 mmhg but more than 80 mmhg•Systolic blood pressre less than 150 mmhg

Measure blood pressure

Yes at least four times a day

Yes at least four times a day

Yes more frequently thansix hourly ,depending on

clinical circumstancesclinical circumstances

Test for proteinuria Do not repeat quantification of proteinuria

Do not repeat quantification of proteinuria

Do not repeat quantification of proteinuria

Blood tests

yes

Monitor using the following test twice a week: full blood count,platelets,Serum creatinine,transaminases,bilirubin

Yes

Monitor using the following test three times a week:

full blood count,platelets,Serum creatinine,transaminases,bilirubin

Yes

Monitor using the following tests every other day :

full blood count,platelets,serum creatinine,transaminases,bilirubin

Predictive value of diagnostic

The purpose of the tests in the context of presurgical evaluation is to reduce the risks associated with anesthesia and surgery and the postoperative complications through preventive care or modifications of surgical technique and /or anesthesiologica.

In the preoperative evaluation can be seen using two alternatives:

• The risk-benefit balance that indicates the point up which you can take risks to patient depending on the benefitdepending on the benefit

• The cost-benefit ratio that indicates the point up to which it is worthwhile to spend energy economic to achieve benefit of the patient

The term common to both alternatives is always a be nefit.This is the fundamental point, the goal is to work for health.

Practice guidelines for obstetric anesthesia: an Up dated Report by the American Society of Anesthesiol ogists Task Force on Obstetric Anesthesia ANESTHESIOLOGY; Volume 10 6(4) april 2007 pp 843-863

Haemostatic changes in normal pregnancy

All blood coagulation factors except XI and XIII increase .The plasma fibrinogen concentration increases from non-pregnant levels of 2.5 – 4 g/l to 6 g/l in

late pregnancy and labour.

Most blood coagulation inhibitors are unchanged .Antithrombin and protein C levels are normal during pregnancy.However the plasma concentration of free protein S decreases and may contribute to the

hypercoagulable state.hypercoagulable state.

Plasma fibrinolytic activity is reduced during pregnancy and labour and returns to normal within 1h after placental delivery.

The platelet count decreases by an average of 10% during the third trimester as a result of haemodilution or accelerated destruction leading to younger and larger platelets.

The most important initial factors for haemostasis at delivery are uterine muscle contractions andconstriction of the spiral arteries that interrupt blood flow.

Thrombocytopenia in the parturient – P.C.A.Kam-S.A.Thompson and A.C.S.LiewAnaesthesia 59; 2004. 255-264

Numbers and percentage of Direct and Indirect deaths assessed as having substandard care by cause of death; United Kingdom 2003-2005

Cause of death Major Minor Major and minor Total cases P ercentage

DIRECT

THROMBOEMBOLISM 19 4 23 41 56

PULMONARY EMBOLISM 18 4 22 33 67

CEREBRAL THROMBOSIS

1 0 1 8 13

PREECLAMPSIA/ECLAMPSIA

9 4 13 18 72

HAEMORRHAGE 10 0 10 17 59

AMNIOTIC FLUID EMBOLISM

6 1 7 17 41

EARLY PREGNANCY 10 1 11 14 79

SEPSIS 12 2 14 18 78

ANAESTHETIC 6 0 6 6 100

ALL DIRECT 6 0 6 11 55

INDIRECT

CARDIAC 15 7 22 48 46

OTHER INDIRECT 25 5 30 86 35

PSYCHIATRIC 3 5 8 19 42

CANCER 2 3 5 10 50

ALL INDIRECT 45 20 65 163 40

GOOD PRACTICE

A guide for departments of anaesthesia,critical car e and pain management

Third edition 2006

AUDIT : SETTING, MONITORING AND REVIEWING STANDARDS

• maintain a folder of information and evidence drawn from your medical practice

• reflect regularly on your standards of medical practice in accordance with GMC guidance on licensing and revalidation

• take part in regular and systematic audit

• take part in systems of quality assurance and quality improvement

• respond constructively to the outcome of audit,appraisals and performance reviews,undertaking further training where necessary

• help to resolve uncertainties about the effects of treatment

• contribute to confidential enquiries and adverse event recognition and reporting,to help reduce risk to patients

• report suspected adverse drug reactions in accordance with the relevant reporting scheme

Obstetric and postpartum hemorrhage

Factors associated with postpartum hemorrhage are multiple

and include:

• abnormal labor patterns

Coagulopathy and transfusion rates range from 1% to 25% for first cesarean deliveries and up to 15% to 67% for patients who

have had multiple operative deliveries.

• abnormal labor patterns• large or multiple fetuses• preeclampsia• lacerations• multiple gestation• history of antepartum or intrapartum hemorrhage• placental disorders such as placenta previa or placenta accreta

Jerrold H.Levy,Richard P.Dutton,J.Claude Hemphill – Anesthesia&Analgesia vol.110.No.2 february 2010

Cardiac output and fluid replacement in a Jehovah’s Witnesswith severe postpartum hemorrhage

• a 24 year old (163 cm.51 kg) primiparous Jehovah’s Witness with a baseline hemoglobin of 16.3 g/dl,had a term vaginal delivery accompanied by an estimated blood loss of 1450 ml.

• ongoing bleeding required vaginal packing and surgery 10 h.postpartum

• a FloTrac/Vigileo was placed in the radial artery to assess cardiac index (CL) and stroke volume variation (SVV)

• on post-operative day the patient had a HB of 3.0 g/dl was tachypneic (22-24 breaths/min) and was given oxygen by facial Venturi mask.The oxygen delivery (DO2) was calculated as 360 ml/min. A slight respiratory alkalosis (PH 7.49,pCO2 34 mmhg) with hyperthermia (39°) and transient episodes of hy potension (BP 70/40 mmhg) were present and treated with fluids as indicated by CL and SVV

• the patient’s electrocardiogram indicated tachycardia and S-T segment depression in the anterior and lateral leads• the patient’s electrocardiogram indicated tachycardia and S-T segment depression in the anterior and lateral leads

• slight increases in serum lactate levels and Ttroponin increase were recorded

• creatinine,transaminases,serum lactate and urea were sampled daily and remained within normal limits

on POD 5 she was discharged from ICU (HB 4.5 g/dl) with a DO2 of 700 ml/min and was discharged on POD 14 with a HB of 6.8 g/dl .Throught the patient’s ICU stay,her CL and SVV were maintained

without the use of vasoactive drugs and she maintained normal cognitive function

E.Piraccini,R.M.Corso,V.Agnoletti,M.Terzitta,E.Valtancoli,G.Gambale – Department of Anesthesia and Intensive Care.- ForlìInternational Journal of Obstetric Anesthesia – p.462-463 - vol.19 Issue:4,october 2010

• The maternal mortality rate, calculated from all maternal mortality Directly or Indirectly due to pregnancy identified by this Enquiry, for 2006–08 was 11.39 per 100 000 maternities compared with the 13.95 per 100 000 maternities reported for the previous triennium, 2003–05

• The maternal mortality rate for mothers who died from medical conditions that could only be the result of pregnancy, such as obstetric haemorrhage or eclampsia,and which are internationally classified as Direct deaths significantly decreased to 4.67 this triennium compared with the rate of 6.24 per 100 000 maternities for 2003–05.

The women who died 2006–2008

• The main reason for the decline in deaths from Direct causes is a significant reduction in deaths from thromboembolism and, to a lesser extent, from other Direct conditions such as haemorrhage . The prevention and management of these two life-threatening conditions has been subject to national clinical guidelines and standards, arising in part from previous recommendations in earlier Reports of this Enquiry.

• The case fatality rate from ectopic pregnancy has almost halved from an estimated 31.2 per 100 000 estimated ectopic pregnancies for 2003–05 to 16.9 for this triennium .

Maternal deaths identified through death certificat e data alone and mortality rates per 100000 maternities; UK: 198 5–2008

Triennium n rate 95%CL n.maternities

1985–87 174 7.67 6.61–8.90 2 268 766

1988–90 171 7.24 6.24–8.42 2 360 309

1991–93 150 6.48 5.52–7.60 2 315 204

1994–96 158 7.19 6.15–8.40 2 197 640

1997–99 128 6.03 5.07–7.17 2 123 614

2000–02 136 6.81 5.76–8.05 1 997 472

2003–05 149 7.05 6.00–8.27 2 114 004

2006–08 155 6.76 5.78–7.92 2 291 493

Pulmonary embolism cerebral vein thrombosis thrombosis and thromboembolism

n rate 95 per Cent cl n rate 95 per Cent cl n rate 95 per Cent cl

1985-87 30 1.32 0.83 1.89 2 0.09 0.02 0.32 32 1.41 1.00 1.99

1988-90 24 1.02 0.68 1.51 9 0.38 0.20 0.72 33 1.40 1.00 1.96

Direct deaths from thrombosis and thromboembolism a nd rates per 100.000 maternities;UK 1985-2005

1991-93 30 1.30 0.91 1.85 5 0.22 0.09 0.51 35 1.51 1.09 2.10

1994-96 46 2.09 1.57 2.79 2 0.09 0.02 0.33 48 2.18 1.65 2.90

1997-99 31 1.46 1.03 2.07 4 0.19 0.07 0.48 35 1.65 1.19 2.29

2000-02 25 1.25 0.85 1.85 5 0.25 0.11 0.59 30 1.50 1.05 2.14

2003-05 33 1.56 1.11 2.19 8 0.38 0.19 0.75 41 1.94 1.43 2.63

Cause of haemorr hage

Placental abruption

Placenta previa

Post partum haemorrhage

total Genital tract

trauma

overall total

number number number rate 95 per 100 cl number number rate

1985-87 4 0 6 10 0.44 0.24 0.81 6 16 0.71

1988-90 6 5 11 22 0.93 0.62 1.41 3 25 1.06

Direct deaths by type of obstetric haemorrhage and mortality rate per 100.000 maternities UK 1985-2005

1991-93 3 4 8 15 0.65 0.39 1.07 4 19 0.82

1994-96 4 3 5 12 0.55 0.31 0.95 5 17 0.77

1997-99 3 3 1 7 0.33 0.16 0.68 2 9 0.42

2000-02 3 4 10 17 0.85 0.53 1.36 1 18 0.90

2003-05 2 3 9 14 0.66 0.39 1.11 3 17 0.80

Group A b-haemolytic streptococcus(Streptococcus py ogenes): learning points

The number of maternal deaths from Group A b-haemolytic streptococcus (Streptococcus pyogenes) infectionhas been increasing over the past 10 years.Group A streptococcus is typically community basedand 5–30% of the population are asymptomatic carrierson skin or in throat.1 It is easily spread by person-topersoncontact or by droplet spread from a person withinfection.

Streptococcal sore throat is one of the most common bacterial infections of childhood, and Streptococcal sore throat is one of the most common bacterial infections of childhood, and all of the mothers who died from Group A streptococcal sepsis either worked with, or had, young children. Several mothersor family members had a history of recent sore throat or respiratory infection.

Contamination of the perineum is more likely when a woman or her family or close contacts have a sorethroat or upper respiratory infection as the organism may be transferred from the throat or nose via herhands to her perineum. Antenatal education should raise awareness of this and the importance of good personal hygiene and washing hands before and after using the lavatory or changing sanitary towels.

Sepsis following pregnancy loss: learning points

All units should have an effective and robust system in place to ensure that peri-abortion antibiotic prophylaxis (metronidazole 1 g rectally at the time of abortion plus,commencing on the day of abortion, either doxycycline 100 mg orally twice daily for 7 days or azithromycin 1 g orally) is offered routinely in accordance with RCOGguidelines.6

Infection must be suspected and actively ruled out when women who have had a recent termination of pregnancy or spontaneous miscarriage have pyrexia, persistentbleeding or abdominal pain, especially if the pain is constant and severe.

Vaginal swabs, ultrasound scan to exclude retained products of conception and diagnosticevacuation of uterus (evacuation of retained products of conception) should be considered if there is still doubt; haemoglobin, white cell count, C-reactive protein, and blood cultures if pyrexia >38C are minimum investigations; and high-dose broad-spectrum intravenousantibiotics should be commenced immediately, without waiting for microbiology results.

Sepsis prophylaxis: learning points

All units should have an effective and robust system in place to ensure that peri-abortion antibiotic prophylaxis (metronidazole 1 g rectally at the time of abortion plus,commencing on the day of abortion, either doxycycline100 mg orally twice daily for 7 days or azithromycin 1 g orally) is offered routinely in accordance with RCOGguidelines.6

Routine antenatal antibiotic prophylaxis with erythromycin (250 mg orally 6-hourly) for 10 days is recommended in women who have PPROM before 37 weeks of gestation.3

For prelabour rupture of the membranes at term (i.e.after 37 weeks of gestation), if there is evidence of infection,a full course of broad-spectrum intravenous antibioticsevidence of infection,a full course of broad-spectrum intravenous antibioticsshould be prescribed.9

Women having a caesarean section should be offered prophylactic antibiotics, such as a single parenteral dose of first-generation cephalosporin or ampicillin, toreduce the risk of postoperative infections (such as endometritis and urinary tract and wound infections),which occurs in about 8% of women who have had a caesarean section.10

Broad-spectrum antibiotics are recommended following obstetric anal sphincter repair (third-and fourth-degree tears) to reduce the incidence of postoperative infections and wound dehiscence.11

Functional changes

Renal blood flow increases by 35-60% increasing the functional capacity of the kidneys.The glomerular filtration rate (GFR) increases by 40-50% by the end of the first trimester,peaking at 180 ml/min.It is then maintained at this level until 36 weeks of gestation.This reduces serum urea and creatinine compared with non-pregnant levels,as the GFR rises without a similar increase in production.This is important when interpreting the results of renal profiles in pregnancy.

Timed urinary collections are also affected by alterations in GFR causing an increase in urinary protein excretion up to 0.26g/24 h and creatinine clearance up 25% at 4 weeks and 45% at 9 weeks of gestation.Loss of glucose through the kidneys is normal in pregnancy due to increased GFR and reduced distal tubular re-absorption;therefore screening for gestational diabetes using urinalysis alone is unreliable.

Physiological changes of pregnancy and monitoring – A.Carlin-Z.Alfirec –Best Practice &Research Clinical Obstetrics and Gynaecology – vol.22,n 5,pp801-823,2008

1°trimestre 36 ° settimana

azotemia 26 mg/dl 20 mg/dl

uricemia 2,2-7,5 mg/dl 3,2-3,5 mg/dl

Indici di funzione renale in gravidanza

creatininemia 0,5-0,8 mg/dl 0,3-0,6mg/dl

cl.creatinina 100-180 ml/min 150-200 ml/min

Prot. 24 ore <150 mg/24 ore <300 mg/24 ore

PH 7,35-7,45 7,40-7,45

Functional changes

In pregnancy resistance to the pressor effects of angiotensin II develops along with a rise in all components of the renin-angiotensin system.This result in a large increase in extracellular water volume (by 4-7L) and retention of sodium andwater which acts to maintain normal blood pressure.This water retention causes a decrease in plasma sodium from 140 to 136 mmol/L and plasma osmolality from 290 to 280 mosmol/kg.

A final and important point is that a pregnant woman’s physiology does not recognize the renal system as a priority; therefore when subjected to certain haemodynamic challenges such as massive haemorrhage,renal blood supply is preferentially reduced.This results in poor perfusion,a reduction in urine output and an inherent risk of acute tubular necrosis.

Physiological changes of pregnancy and monitoring – A.Carlin-Z.Alfirec –Best Practice &Research Clinical Obstetrics and Gynaecology – vol.22,n 5,pp801-823,2008

Indirect maternal deaths from congenital and acquir ed cardiac disease and rates per 100.000 maternities

Triennium Congenital Acquired Acquired Total Rate 95 per cent Cent cl

ISCHAEMIC OTHER

N(%) N(%) N(%) N(%)

1985-1987 10 (43) 9 (39) 4 (17) 23 (100) 1.01 0.68 1.52

1988-1990 9 (50) 5 (28) 4 ( 22) 18 (100) 0.76 0.48 1.21

1991-1993 9 (24) 8 (22) 20 (54) 37 (100) 1.60 1.16 2.20

1994-1996 10 (26) 6 (15) 23 (59) 39 (100) 1.77 1.30 2.43

1997-1999 10 (29) 5 (14) 20 (57) 35 (100) 1.65 1.19 2.29

2000-2002 9 (20) 8 (18) 27 (61) 44 (100) 2.20 1.64 2.96

2003-2005 4 (8) 16 (33) 28 (58) 48 (100) 2.27 1.67 2.96

During the past two decades,anesthesiologists,have focused on improving their management of difficulty airway-failed intubation,gaining expertise with the laryngeal mask and other airway devices.

In cases of hemorrhage with hemodynamic instability or prolapse of the umbilical cord ,general anesthesia may be the most appropiate choice for cesarean delivery.

They reported that 93% of mothers received a regional anesthetic with a 3% failure rate and rare maternal morbidity.

General anesthesia was more likely to be used for cases when the decision -to-incision interval was

Anesthesia-related Maternal Mortality in the United States:1979-2002

General anesthesia was more likely to be used for cases when the decision -to-incision interval was less than 15 minutes or when ASA status was 4 or higher ,that is,the most emergent cases and sickest patients.

Anesthesia – related Maternal Mortality in the United States : 1979 – 2002J.L.Hawkins – J.Chang – S.K.Palmer Vol.117,NO 1, january 2011 – Obstetric & Gynecology

That general anesthesia should not be avoided when necessarybecause the mortality rate is extremely low,only 6. 5 per million general anesthetics .

Year of death General anesthetic Regional anesthetic Rate ratios

1979-1984 20.0 8.6 2.3 (95% CL 1.9-2.9)

Case Fatality Rates and Rate Ration of Anesthesia- Related Deaths during Cesarean Deliveryby Type of Anesthesia in the United States,1979-200 2

Deaths per milion general or regional anesthetics


1985-1990 32.3 1.9 16.7 (95% CL12.9-21.8)

1991-1996 16.8 2.5 6.7 ( 95% CL 3.0-14.9)

1997-2002 6.5 3.8 1.7 (95% CL 0.6-4.6)


Anesthetic –related maternal mortality decreased nearly 60% when data from 1979-1990 were comparated with data 1991-2002.


There is new reports of increasing complications du ring regional anesthesia.

They reported that 93% of mothers received a regional anesthetic with a 3% failure rate and rare maternal morbidity.

In some cases there were undetected intrathecal catheters and providers were not always prepared to treat these emergencies.

The Doctors Insurance Company reported on 22 anesthesia malpractice closed claims filed after maternal cardiac arrests on labor and delivery wards between 1998 and 2006:

• thirteen cases were respiratory arrest after epidurals or spinals• eight followed labor epidural placement with unintentional subarachnoid block • five occurred during spinal anesthetics for cesarean delivery.


None of the operating room cases had “ audible alarms “on the monitors at the time of arrest making delay in response like ly.

Congresso Regionale A.O.G.O.I. - A.G.I.T.E. - F.N.C.O ... - A… · La valutazione anestesiologica...

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Transcript of Congresso Regionale A.O.G.O.I. - A.G.I.T.E. - F.N.C.O ... - A… · La valutazione anestesiologica...