Episode 54 — Term Pregnancy Part 1 With Jacqueline Galvan
Highlights
- Fetal Heart Tone Tracings
Summary:
The fetal heart tone tracings are categorized into one, two or three. One category is the best most reassuring we'll talk about some characteristics in a minute. Category three meaning that the baby is not doing well probably moving towards an operative delivery of some sort either vaginal or C section and certainly that involves anesthetic management. Things that can reasonably be done by anesthesiologist help administer oxygen, help the mom reposition to a left urine displacement position, treat blood pressure, give fluids, give tocolytics.
Transcript:
Speaker 1
So the fetal heart tone tracings are categorized into one, two or three. So one category one is the best most reassuring we'll talk about some characteristics in a minute. Category three meaning that the baby is not doing well probably moving towards an operative delivery of some sort either vaginal or C section and certainly that involves anesthetic management. Things that can reasonably be done by anesthesiologist help administer oxygen, help the mom reposition to a left urine displacement position, treat blood pressure, give fluids, give tocolytics. These are things we can reasonably do during those situations. And then unfortunately category two is that black box or gray area of 80 percent of the tracings where they're not that great but it's not that bad and so we're going to talk about what can anesthesiologist do to interact with those kind of in the middle of the row tracings to prevent maternal harm or fetal harm. That sounds great. Great. So I think just to get some to cover the, as you mentioned, high yield basics, right? Fetal heart rates should be between 110 and 160 ideally when the babies, when adults get stressed or sympathetic tone takes over when babies get stressed their parasympathetic tone takes over so they manifest that as a fetal bradicardia. A baby should have good (Time 0:04:58)
- What's Normal Tracing?
Summary:
The fetal heart tone tracings in relation to maternal contractions. Means the heart rate goes up and down especially with fetal movement. When there's a late deceleration, mean the fetal heart tone decreases after the unit contraction. That's generally a bad sign and is a sign of uro placental insufficiency. And then there's variable decelerations meaning that the heart rate of the fetus doesn't necessarily correlate with the contractions or umbilical horror compression.
Transcript:
Speaker 1
variability. Meaning the heart rate goes up and down especially with fetal movement. And then of course there is the fetal heart tone tracings in relation to maternal contractions. So very quickly, I mean they're reasonably testable questions is that a early deceleration, so when the fetal heart rate dips down at the same time the contraction comes up, that's a normal pattern and that means a sign of intact fetal and neurologic activity. When there's a late deceleration, mean the fetal heart tone decreases after the unit contraction. That's generally a bad sign and is a sign of uro placental insufficiency. And then there's variable decelerations meaning that the heart rate of the fetus doesn't necessarily correlate with the contractions and then classically associated with umbilical horror compression. Yeah. And you know, Jackie, one way that I was taught that I always like to remember that is that it's the same order as the baby comes out. So the first thing to come out is the head. Yeah. That's the early, early decelerations are from head compression. And then the next thing to come out in theory is the cord. And so cord compression is the variable because that's between early and late. And then the late decelerations, the last thing to come out is the placenta. And so placental insufficiency for late decelerations. And so that just always helped me kind of remember which is which. Great. (Time 0:06:19)
- Preterm Labor - What's the Delivery Plan?
Summary:
Anesthesiologist: I think we need to be aware of what's the delivery plan, if any. Are they going to stay 24 hours for steroids or are they going to be meant to the floor and possibly deliver? An obstetrician may elect to do a classical urine incision, ending up and down on the uterus. That can confer things like more bleeding for the mom,. Sometimes it also has a to do with the fetal position as well.
Transcript:
Speaker 1
I think beyond the scope of our talk today, risk factors we should look at in intrauterine infection or urine distention such as multiple infants. But again, I kind of want to talk about or discuss things that an anesthesiologist, what do we, what do we need to know? So for example, if we have a preterm delivery, again, I think we need to be aware of what's the delivery plan, if any. Are they going to stay 24 hours for steroids or are they going to be meant to the floor and possibly deliver? I think we need to know the position of the fetus. So if the fetus is anything other than vertex, that means if the preterm labor went into full minute labor, we're going to the OR. If it's a head down baby, well, then it's not sort of as we have a little bit of time to make a plan. Again, these really early deliveries, 24 or 25 weeks, the obstetrician may elect to do a classical urine incision, ending up and down on the uterus, and that can confer things like more bleeding for the mom, which we obviously need to interact with. And why would they opt for that incision, Jackie, over a traditional incision? That's a great question. So the loader-utiren segment is not fully developed at that particular area, which is at that time of gestation, the 24 or 25, that periviable period. So making an incision on that is less favorable than making an incision on the top of the uterus. Sometimes it also has a to do with the fetal position as well. Okay. And then the other thing was you mentioned, you know, do we want to know if they're going to stay for (Time 0:12:38)
- Preeclampsia
Summary:
Morphine is a gold standard of post-operative care for c-section, I would still administer it. hypertensative disorders are still an important cause of maternal death. You don't need protonuria anymore to diagnose preeclampsia.
Transcript:
Speaker 1
I guess you should be aware that that's out there in the literature. But because morphine is a gold standard of post-operative care for c-section, I would still administer it. But it's an interesting tidbit. Okay. Good to know. So maybe we should let's move on and talk about, you know, what I think are some of the more common issues that we see with term or near-term pregnancy. So preeclampsia and a clampsia comes up all the time. And how do you think about those? Sure. So I think, and these are really dense topics. So I just want to hit the highlights. One that hypertensative disorders are still an important cause of maternal death. So it's an important thing to interact with. Pre-clampsia, right, is nuanced at hypertension after 20 weeks of gestation, before 20 weeks, that's probably chronic hypertension. And certainly, gestational hypertension is in the latter terms of pregnancy 35, 37 weeks without evidence of end organ damage. Interesting thing about preeclampsia or new developments is that you don't need protonuria anymore to diagnose preeclampsia. So that is important important to recognize in its diagnosis. As you mentioned, it doesn't actually encompass a ton of pregnancy. (Time 0:30:30)
- Is There a Diagnosis of Gestational Hypertension?
Summary:
If a woman develops hypertension after 20 weeks, is there no longer a diagnosis of gestational hypertension? It's automatically preeclampsia. Dispatational hypertension in its uncomplicated form doesn't really manifest until the 35, 37 weeks away later. But we no longer need definitively to have the protonuria to make the diagnosis. And that is a very complicated immunologic and vascular process.
Transcript:
Speaker 1
hypertension, diabetes, and multiparity are important risk factors that again are always on exams. And that is a very complicated immunologic and vascular process. So Jacqueline, let me ask you, interesting, if a woman develops hypertension after 20 weeks, is there no longer a diagnosis of gestational hypertension? It's automatically preeclampsia, or how do you differentiate between gestational hypertension and preeclampsia? Sure. Dispatational hypertension in its uncomplicated form doesn't really manifest until the 35, 37 weeks away later. So there's a new onset hypertension that meets their blood pressure criteria, so like 140 over 90 or 160 over 110 for a severe range than that. And they have the other factors they might have domicylipinia or renal dysfunction or pulmonary edema, signs of help. Then that patient is probably preeclamtic. Okay. But if it's just just hypertension with nothing else, then we don't call it preeclampsia. Yes, that's correct. Okay. But we no longer need definitively to have the protonuria to make the diagnosis. Yes. It's still a characteristic of preeclampsia, but you don't need it to diagnose preeclampsia anymore. Okay. Great. So what's the, I can think about the overview of a pathophysiology of preeclampsia? (Time 0:32:00)
- Hypoxia and Preeclampsia
Summary:
The thought is that when there's a dysfunction in this formation of these cells that help develop spiral arteries, that that results in hypoxia of the placenta. There's vascular remodeling, that's abnormal, and endothelial dysfunction. And systemically, this manifests not only at the fetal placenta unit as utopacenta insufficiency, but then unfortunately, things like preeclampsia and these hypertensive issues and organ damage associated with that.
Transcript:
Speaker 1
So the thought is that when there's a dysfunction in this formation of these cells that help develop spiral arteries, that that results in hypoxia of the placenta. And this hypoxia can contribute to inflammatory responses that are misaligned with the placenta perfusion. There's vascular remodeling, that's abnormal, and endothelial dysfunction. And systemically, this manifests not only at the fetal placenta unit as utopacenta insufficiency, but then unfortunately, things like preeclampsia and these hypertensive issues and organ damage associated with that. Now, so yeah, the way, you know, I've thought about it, and I guess this is a very simplistic way, but is that essentially if the placenta isn't getting sufficient normal blood flow, it basically says, I need to make the mother's blood pressure go up to give me more blood. That's one theory. And again, this topic is very complex, but there's also a thought that the mother has dysfunctional endothelial and that contributes to why the placenta is developed abnormally as well. So it's kind of like chicken or the egg is the placenta dysfunction, cause maternal dysfunction, or the maternal endothelial dysfunction cause placenta dysfunction. So it's probably a complex interplay between the two. Absolutely. And I'm sure we could do an entire podcast just on pre- You can do (Time 0:33:54)
- What Is Health Syndrome?
Summary:
Airway, pulmonary edema is important. I ask my residents to off-cultate the lungs,. look at the oxygen saturation, you know, make sure that that's not deteriorating. The acronym for health syndrome is hemalysis, elevated liver enzymes, and low platelets. And so a patient has elevated pressures, and this spectrum of dysfunction in after 20 weeks, then they definitely have preeclampsia with severe features.
Transcript:
Speaker 1
later on, especially blood pressure control. Right. All right. So, what are some things we see in women who are preeclamptic? How does it manifest? Great. So things we see, so I think of it as a top down assessment, so we look at the top, the head. So what does their airway look like? And especially if it looks bad right away at the ego through 12 hours of labor, magnesium, and betosian, this and that, it's not going to get any better. So airway, pulmonary edema is important. So I ask my residents to off-cultate the lungs, look at the oxygen saturation, you know, make sure that that's not deteriorating. From a part of that, there's standpoint, you know, see, hyper tension, your SVR goes up, there could be some effects on the heart, which I'll touch based on in a few minutes, in the human cell logic category, darmosidopenia, and DIC are important things to evaluate for, of course, health, which we'll touch based on in one second again, in the renal category, protonaryon, oliguria, again, are still important manifestations, and then at the fetus level, decrease or compromise utopecentro blood flow. Okay. And so now you mentioned kind of more, in some ways, I guess more extreme manifestation of this, or maybe it's a different pathophysiology, but what is health syndrome? Sure. Health is, so the acronym is hemalysis, elevated liver enzymes, and low platelets. So it is a, so a patient has elevated pressures, and this spectrum of dysfunction in after 20 weeks, then they definitely have preeclampsia with severe features. (Time 0:36:45)
- Platelet Levels in Pregnant Patients
Summary:
If you can catch it early enough, usually we should make sure that we establish some sort of existing uraxial. If we think that the platelets are deteriorating or the hemoglobin is going down, we should look at things like type-inschleting blood and like FFP and cryo and platelets. And then how about help? What are we going to do for patients with help? Sure.
Transcript:
Speaker 1
control. Okay. And then how about help? What are we going to do for patients with help? Sure. So if we can, luckily, help is very rare and help rarely gets to the degree where we can't offer any sort of labor anesthetic, which is more of a role in these patients. So if you can catch it early enough where the platelets haven't deteriorated to like, you know, 2000, usually we should make sure that we establish some sort of existing uraxial. If we think that the platelets are deteriorating or the hemoglobin is going down, we should look at things like type-inschleting blood and like FFP and cryo and platelets, how transduce if that were to arise. Now, you know, we often, when we talk about platelet levels in pregnant patients, I think a lot of our obstetric and the seizure providers will say it's not an absolute level. It's the trend. And so would you, let's say someone has help and at the moment, their platelets are 100, but they have help. And so you, you know, are worried they're not going to be 100 for long. Where do you, will you put an epidural in them or not? Yes, definitely. The platelets are 100 and they're not spontaneously oozing every mucus membrane, then absolutely. (Time 0:40:05)
- Is Fluid Restriction a Good Option?
Summary:
Pre-clametric heart disease may share a spectrum of disease with peripartum cardiomyopathy. The recommended methodologies to go with fluid restriction unless there's something else going on. And then as we discussed, I would advocate for epidural in these patients just because they avoidance of airway and avoidance of hypertension on induction during a general anesthetic is very advantageous.
Transcript:
Speaker 1
pre-clametric heart disease may share a spectrum of disease with peripartum cardiomyopathy. So these are these point of care tests might be useful. Just moving on, fluid management, again, usually the recommended methodologies to go with fluid restriction unless there's something else going on. And then as we discussed, I would advocate for epidural in these patients just because they avoidance of airway and avoidance of hypertension on induction during a general anesthetic is very advantageous. All right. And why is it that we want to fluid restrict them? Well, you want to get into fancy things like this glyco-kalix, of the endothelium. But basically, they have decreased un-cretic pressure in leaky blood vessels. So they're more likely to have the things like pulmonary dema, just peripheral edema, generally speaking. So they accept it standard right now is to keep them on a just fluid, like a cavial or I mean, keep being open. Sorry. (Time 0:42:53)
- Fetal Acid Base Status
Summary:
Anesthesiologist: One of the first things we learn when residency is that you tilt them up 15 degrees. And actually that's surprisingly new evidence is coming out that that's not actually as effective as we think. Two MRI study that also looked at IVC volume found that a 15 degrees of tilt IVC volume didn't change at all. You need almost 30 degrees to even get some increase in IVC volume, which can be difficult with obese patients.
Transcript:
Speaker 1
you know, well ingrained concept in anesthesiologist. And so the thought is that about for 20 weeks, the gravin uterus pressures on the IVC, so the fear, fear of vena cava, your preload decreases, cardiac output decreases, and you get a hypotensive response and the mom has some manifestations like dizziness, nausea, vomiting, there's even case reports of cardiovascular collapse. So it's an important thing to remember. And so what do we do about that? And so again, one of the first things we learn when residency is that you tilt them up 15 degrees. And actually that's surprisingly new evidence is coming out that that's not actually as effective as we think. Sorry, go ahead. No, no, I'm just curious to hear that. Yeah. Great. So as recent as this year, anesthesiology article was published that looked at the fetal acid base status in moms that were either tilted 15 degrees or not during elective sections. And part of their methodology was that they did a full dose spinal, leg to C section. Everyone got a life hitter ringers coload and they did a phenylaphone infusion to maintain maternal blood partner. And what they found that whether the moms were 15 degrees tilted or not didn't make a difference at all in terms of how the baby came out and meaning their fetal acid base status. So didn't affect the fetal percental unit at that micro level. Secondly, two MRI study that also looked at IVC volume found that a 15 degrees of tilt IVC volume didn't change at all. And you need almost 30 degrees to even get some increase in IVC volume, which you can imagine is sometimes not clinically feasible to tilt someone, especially our obese patients 30 degrees. (Time 0:46:49)
- Can She Give Birth Vaginally?
Summary:
Tolac is trial of labor after C section and v-back is vaginal birth after C section. If she's had a low transverse or a fanden seal which is that classic like bikini cut incision well then she probably can badge of delivery after C section or she can tolac and the risk of rupture is actually only 1% so it's actually fairly low. So I think things that we can do to interact with this is again like a timely epidural.
Transcript:
Speaker 1
mean? Great so the so before I get into this quick topic the two acronyms so tolac is trial of labor after C section and v-back is vaginal birth after C section. So tolac means someone is trying to have a vaginal delivery after C section and v-back means someone has successfully completed that so they had a C section then had a vaginal delivery successfully. Okay. And so those are getting two-part acronyms that need to be put out there before we discuss this topic. So I think one of the part things you need to know is what is the previous uterine scar and then again this is a characteristic I expect my residents or my fellow to know. So if as we discussed earlier in the pre-term labor section if it wasn't up and down or classical urine incision and this lady comes in the tree either she's laboring I know she's going right to the OR that lady is not going to labor after a classical C section and that's again a well accepted standard. If she's had a low transverse or a fanden seal which is that classic like bikini cut incision well then she probably can badge of delivery after C section or she can tolac and the risk of rupture is actually only 1% so it's actually fairly low. So I think things that we can do to interact with this is again like a timely (Time 0:55:09)
- Do You Need an Epidural?
Summary:
If the feet of heart tones are not doing well then that's a good time to discuss labor and enthusiasm. An important thing to know is that no matter what if you have a regular low dose or sorry low density local anesthetic regimen for your labor epidurals that will not mask signs of urine rupture which is the most catastrophic outcome of these type of deliveries.
Transcript:
Speaker 1
know. So if as we discussed earlier in the pre-term labor section if it wasn't up and down or classical urine incision and this lady comes in the tree either she's laboring I know she's going right to the OR that lady is not going to labor after a classical C section and that's again a well accepted standard. If she's had a low transverse or a fanden seal which is that classic like bikini cut incision well then she probably can badge of delivery after C section or she can tolac and the risk of rupture is actually only 1% so it's actually fairly low. So I think things that we can do to interact with this is again like a timely epidural. Do you need an epidural when they walk in the door they have no pain certainly not but once they're a reasonable, once either mom wants one or they're a reasonable course in their labor and certainly if the feet of heart tones are not doing well then that's a good time to discuss labor and enthusiasm. Sorry. No that sounds good. An important thing to know is that no matter what if you have a regular low dose or sorry low density local anesthetic regimen for your labor epidurals that will not mask signs of urine rupture which is the most catastrophic outcome of these type of (Time 0:55:50)