Managing Respiratory Distress in Pregnancy in the Emergency Department

Podcast Transcript

Raed Dweik, MD: Hello and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, chief of the Integrated Hospital Care Institute at Cleveland Clinic. This podcast series of short, digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease in the areas of lung health, critical illness, sleep, infectious disease, and related disciplines. We will share with you information that will help you take better care of your patients. I hope you enjoy today's episode.

Dan Culver, DO: Welcome to another episode of Respiratory Exchange. Thank you for joining us. My name is Dan Culver. I'm the chair of pulmonary medicine at Cleveland Clinic. I have with me today as a special guest, Dr. Marina Freiberg.

Marina Freiberg, MD: Hi.

Dan Culver, DO: One of our critical care and ER faculty here at Cleveland Clinic. Welcome, Marina.

 Marina Freiberg, MD: Thank you so much for having me.

Dan Culver, DO: The topic today is something that I think scares us all, which is critically ill pregnant patients, and especially when they come in, in emergency or undifferentiated situations. Many things go through our minds right after the adrenaline surge. And so Dr. Freiberg is going to help us talk a little bit about her approach to those patients today.

 Marina Freiberg, MD: I really like that you brought up the psychological factor in all of this, because that's something that I try to address in this talk. I think there is a certain amount of trepidation that we as non-obstetric providers end up having in the approach to the pregnant patient.

Even though I think clinically we know exactly what to do there's a, what I call a “Russian doll” effect of taking care of a patient inside of a patient that just gets inside our heads. And since knowledge is power, I think getting that knowledge is really helpful.

Dan Culver, DO: So just taking a deep breath, remembering first principles and going through things in an algorithmic fashion is probably a big key.

[00:01:56]

Marina Freiberg, MD: It is. And actually, when I do this talk with a PowerPoint, I have an Elmo holding “A is for Airway” in that slide. And it really is sticking to those resuscitative principles that we know so well and then making small modifications based on what we understand of obstetric physiology.

Dan Culver, DO: So maybe we could just start off at the beginning with the patient coming in, and I think many of us work in settings where there's undifferentiated patients coming in, typically in emergency department settings, but this can happen in other places.

So, when you think about symptoms of normal pregnancy and then symptoms, that really should truly worry you as a provider. What are the red flags? What are the warning signs that really make you say, here's a problem, I've got to deal with this in a pretty urgent way?

Marina Freiberg, MD: I think there's two major vital sign abnormalities that I want to point out to people in the pregnant patient.

So, hypertension, I think, is a problem that affects a great majority of our population, and we have a tendency as emergency physicians and critical care providers to kind of ignore that [hypertension] there, unless it is causing other symptoms.

But in pregnant patients, that can be an early sign of one of the pre-eclampsia/ eclampsia disorders. And so, anything over 140 over 90 in a pregnant patient is considered abnormal. And it may or may not be preeclampsia, but it should set off some red flags.

The other thing that I like to talk to people about is pregnant patients at baseline are going to have higher respiratory rates to maintain the kind of gradient that they need, but they also have very, very poor respiratory reserves. So, if you're seeing someone who's particularly tachypneic, that's another red flag that you should pay attention to.

Dan Culver, DO: So high blood pressure and tachypnea,

Marina Freiberg, MD: Big bads

Dan Culver, DO: ...are the ones that really get you going?

Marina Freiberg, MD: They do.

Dan Culver, DO: Okay. Maybe we can talk about a couple of particular issues. You mentioned eclampsia already, preeclampsia and eclampsia syndrome, and of course you must deal with that quite often without obstetric backup; sometimes it can be quite severe. So, what are your reflexes? Who needs to be around the table? How do you get a team together for that and what are the things that are the first thoughts that go through your head when you're managing those patients?

[00:04:15]

Marina Freiberg, MD: I think the big distinction we're going to have to make is whether we're dealing with a preeclampsia person or an eclampsia person.

And one of the things that I found interesting in obstetric literature over the last couple of years is that people don't progress nicely through preeclampsia to severe preeclampsia states as well as we thought. And so, you can have somebody who has mild symptoms that progresses to eclampsia. We have to take anything in that spectrum fairly seriously.

I think if you have somebody who is pre-eclamptic, what you need to worry about is supporting the organs that have been affected, getting them to an obstetric specialist center so they can be cared for, and then having OB really do what they do best. We're stabilizers; they are obstetric doctors.

I think in contrast, if we're dealing with somebody who is eclamptic and is actively seizing, that's much more of an emergency than I would say a preeclampsia or even a preeclampsia with severe features is.

And so, you're going to need somebody to potentially manage the airway. You're going to need somebody who's going to be there to watch the hemodynamics of the patient, and if you have the resources for it, it would be really great to get fetal monitoring on board there.

If obstetrics is around anywhere in the hospital, please, please, utilize them. They're, again, we're really good stabilizers, but this is what they do every day. So do not be afraid to call on your colleagues.

Dan Culver, DO: So, phone a friend.

Marina Freiberg, MD: Phone a friend all the time.

Dan Culver, DO: Okay, that's the message for today, perhaps. So, you mentioned a little bit about issues with eclampsia, severe eclampsia, seizing patient and airway stabilization.

And I suppose that's a good segue to talk about the airway issues that are a little bit unique to patients with pregnancy, especially third trimester patients. So, I think both in terms of ventilatory respiratory physiology and in terms of airway anatomy and how you manage the airway physically, what are the main considerations you think that people should know about?

[00:06:20]

Marina Freiberg, MD: I like to scare people a little bit when I give this talk. So, a failed airway attempt is eight times more likely in your pregnant patients than your non-pregnant patients. And that's terrifying because these are oftentimes very young, otherwise healthy patients, and the mortality and morbidity risk is pretty significant.

Dan Culver, DO: And that's with DL or with some other kind of direct laryngoscopy or any kind of modality?

Marina Freiberg, MD: All modalities, unfortunately. And I think again that's just a part of it. It is just the psychological hurdle of overcoming the fact that you're dealing with a young, incredibly ill patient. And the other part is just not anticipating some of the complications that can happen.

So, you mentioned what are some of the anatomical things that we need to worry about? So, I think the most obvious thing about a pregnant patient is that they're pregnant, right? Fair enough. They have a gravity uterus and that gravity uterus, when you lay them supine, if you're doing a supine intubation attempt, is going to result in some, some pretty significant preload reduction, and so you'll be dealing with hypotension for a lot of that.

It also increases the intra-abdominal pressure, and so you have a greater gradient between the abdomen and the thorax. It severely increases your aspiration risk, and I think that's something that people go in unprepared for is how likely it is that you may have an aspiration episode.

And that's actually compounded by the fact that progesterone is a very potent, smooth muscle dilator. So, the gastroesophageal junction is more dilated in pregnant patients, and you really have the perfect recipe for an aspiration episode in those patients.

Dan Culver, DO: So, you really want an experienced operator if you have to get in an airway into a patient.

[00:08:04]

Marina Freiberg, MD: Absolutely. I think that, you know, we are a place that trains a lot of people, I did my training here, so I think it is very tempting to allow somebody who is less experienced to attempt something. But there is so much to be learned and gained from watching an experienced person intubate somebody that is high risk both anatomically and physiologically. And I don't want to discount how important it is to get that observational experience until you yourself are practicing independently.

Dan Culver, DO: So, as an experienced operator and an expert in this space now, I have to ask you if experience doesn’t account for anything else. I have to ask you, what are your tips and tricks for intubation and, you know, especially thinking about aspiration prevention, do you have any kind of positional tips, any kind of equipment, any other sorts of things you do to help make sure you're successful with that and that you don't get an aspiration event?

Marina Freiberg, MD: I think that's a really good question, and I have to preface my answer with everything that we do to modify our intubation techniques, it's going to come with a risk in and of itself. So, you have to make sure that you are comfortable with taking those risks and managing the end points of those risks before you make the decision to alter.

So, I personally like to intubate my pregnant patients completely upright. I'm using video laryngoscopy that decreases the amount of pressure that the uterus is putting on the lungs. So, it gives you a little bit more residual capacity. And I think, personally, not speaking literature-wise, it mitigates a little bit of that hypotension that you see with the aortic caval compression.

Dan Culver, DO: Can I just clarify that? You're saying in any trimester, you intubate them upright or just third trimester?

Marina Freiberg, MD: Typically, my third. Yeah. I think most of the physiologic and anatomic differences that we see are most pronounced in the third trimester. So, if you've got a pregnant person who is early second trimester, you can probably just manage them as you would anyone else.

[00:10:04]

Dan Culver, DO: Great. So upright. Any other tricks, cricoid pressure or any other thing to reduce aspiration risk?

Marina Freiberg, MD: No. So Cricoid pressure, I don't think, has been proven to work in any population. So, if you can avoid using positive pressure ventilation, know at that point that you may be under-ventilating.

So, avoid bagging. Use high flow nasal cannula if you can. That'll decrease the chance that you're going to introduce air into the esophagus of the stomach and increase your aspiration risk. Just going back to intubating upright in general, I think this is something that a lot of people may or may not be comfortable with and the pregnant crashing patient is not the first person you intubate upright ever.

The other thing that I want to point out with the upright intubations is airways of pregnant people are very friable and so you can have a lot of mucosal bleeding should there be any trauma. And so, you can see where video laryngoscopy with a hyper angulated blade, which you would need if you're doing an upright intubation may very quickly become obsolete. If you're having a lot of bleeding in the airway, that would obstruct your camera. So again, there's a risk to everything that we're doing with these patients.

Dan Culver, DO: So again, your first pass is your best pass.

Marina Freiberg, MD: Your first pass is your very, very best chance.

Dan Culver, DO: Okay, that's interesting and I think that it points out that really being planful when you approach the patients and knowing how you want to respond to a situation like that before you get into it is pretty important.

Marina Freiberg, MD: I ask my fellows and residents who will listen to me, although not many of them will, to make an airway algorithm for themselves when they're approaching critically ill patients in general. I think if you know your own personal algorithm, it takes a lot of that mental load off of being in an extremely critical situation, which is what we do every day.

[00:12:00]

Dan Culver, DO: So, these are high impact, low frequency situations.

Marina Freiberg, MD: They are.

Dan Culver, DO: One of the things that sometimes is used to help mitigate those and really to make sure that you get the best outcomes is simulation training.

Marina Freiberg, MD: Yes.

Dan Culver, DO: Has that been something that's caught on in terms of either airway management or even just management of obstetric emergencies in general? Is there a robust simulation practice?

Marina Freiberg, MD: So actually, yes. So, I did my simulation fellowship here as well. One of the projects that I did was airway management in the pregnant patient. So, we do that simulation with the emergency medicine residents, who are probably going to be the most front-facing to that patient population.

But then another one of our doctors, Lauren Moore, has a simulation curriculum in low incidence, high impact. Or high impact, low incident occurrences that look at obstetric emergencies. She did that in residency and then developed it more through her curriculum. That information is out there, and simulation is truly an invaluable resource that we have here at Cleveland Clinic.

Dan Culver, DO: Is that something that's caught on nationally? Are most institutions offering that sort of training for their staff or their trainees?

Marina Freiberg, MD: I think so. I think, again, I'm a little bit biased because I've done so much of my training here, but we have a great sim center and there's been a ton of literature about the efficacy of simulation in these low occurrence emergencies and the data is so supportive of simulation that I think it's hard to argue against it.

Dan Culver, DO: Yeah. I think that as we get less procedurally oriented, in some ways simulation will be more and more important. And, of course, the low incidence ones, you just have to do it. There's no other way around it.

Marina Freiberg, MD: Absolutely. And there are a lot of clinical situations that we may not get to approach on the regular. That's the whole, you know, low occurrence thing. And getting to approach those situations in a safe space where you can make mistakes without patient harm, where you can ask questions is so vital to education.

[00:14:08]

Dan Culver, DO: Maybe I can follow up on that a little bit. You made me think about mistakes and everybody gets nervous about taking care of two lives instead of one.

Marina Freiberg, MD: Absolutely.

Dan Culver, DO: And as you mentioned, young patients, people who might be the same age as many of us or certainly younger and who have much of their life ahead of them, and so everybody gets quite anxious in that situation and it makes me wonder about the medical-legal environment around treating these patients and whether there are any special concerns around medical-legal issues. And how has that changed over the last several years? Anything going on differently there in terms of the environment?

Marina Freiberg, MD: I don't know that the environment in and of itself has changed, although I am far from being an expert on the topic. But we know that obstetric care and these obstetric resuscitations are fraught with medical-legal implications because you're going to be dealing with a young patient, you're going to be dealing with two young patients, and a lot of the morbidity and mortality is so significant both in economic and social cost.

These are just fodder honestly for plaintiff's lawyers. So, I don't think approaching these with medical-legal ramifications in mind is the best thing to do, although you would be remiss in forgetting that that is a very real part of our practice in today's medical-legal landscape.

I think it comes back down to the same kind of stuff that makes you safe in any medical-legal situation, so appropriate and timely documentation. And then if you're discharging these patients from your practice, from your ED, whatever, making sure that anything that you have not ruled out that was on your differential is included in the return precautions so that patients feel welcome and safe coming back should their situation change.

[00:16:07]

Dan Culver, DO: That makes sense. So basically, again, blocking and tackling, doing the basics really well.

Marina Freiberg, MD: Correct.

Dan Culver, DO: Is the key to this.

Marina Freiberg, MD: Yeah, and I think when we're approaching these situations that are very adrenaline inducing, sometimes we forget those very, very basic things. I do find it comforting that you can just kind of fall back on your very basic resuscitative, your very basic patient care bedside manner to care for these patients.

Dan Culver, DO: Yeah, I'm sure everybody wants the same thing at the end of the day.

Marina Freiberg, MD: Correct. Healthy mom, healthy baby.

Dan Culver, DO: So we talked about third trimester and some of the big things that can come up and the really critically ill person who needs an airway, but there's a lot of other obstetric emergencies in the ER, aren't there?

Marina Freiberg, MD: Yes. So, we don't see as many here at Main, but certainly at Hillcrest, and at Fairview where we have these obstetric programs, there is an immense amount of obstetrics that comes through the ED and then the ICU.

Dan Culver, DO: So, I was thinking about things like vaginal bleeding in the first trimester and things like precipitous delivery. Those are probably two of the ones that cause a lot of consternation to docs. What do you suggest people who are in the emergency department who are thinking from a critical care perspective, especially managing those two things?

[00:17:29]

Marina Freiberg, MD: I think we have to approach the first trimester with a little bit of trepidation because you don't necessarily have a viable fetus at that point, and so there may or may not be something that you can actually do to save the fetus there.

One of the things that I ask people to be careful with is doing their vaginal examinations in the first and second trimester if you don't have an ultrasound showing where the placenta is. Because if you have the placenta covering the [cervical] OS and you poke something in there you can actually cause some pretty significant bleeding and do a lot of damage. So that's one of those things that I always tell people is if you have an ultrasound where you can confirm placental location, great.

The other thing that we have to be aware of is how significant vaginal bleeding can be hemodynamically. The placenta is an extremely vascular structure right by design, and so you can get pretty significant bleeding from the placenta, from the cervix. And it's the same approach as you would with any sort of rapidly bleeding patient, right? Your one-to-one-to-one resuscitated approach with blood products and making sure that any coagulopathies are addressed.

Dan Culver, DO: So, you take this as more of a typical massive bleeding patient deal if that's the situation and deal with it like that?

Marina Freiberg, MD: Correct. Just kind of keep in the back of your mind that if there's not already significant bleeding, you should not be the one causing significant bleeding by poking at a placenta.

Dan Culver, DO: Okay, thank you.

Marina Freiberg, MD: And then you mentioned the precipitous delivery. We don't do these very often in the emergency department, and they're terrifying when they do happen because they are so rare. And one of the things that I again encourage you to do is get obstetrics there as fast as you can. If you can get your hands on Pitocin to run for mom, there is such benefit in actively managing that fourth stage of labor in terms of preventing maternal hemorrhage.

And then, last but not least, I think we get caught in these situations and forget that this is an important part of that person's life. And so, what we think is appropriate resuscitative technique may not necessarily be in line with how the patient imagined their birth. And so, talking to the patient as much as you can in an emergent situation and seeing if there are things that you can do to mitigate the trauma of that precipitous delivery.

Dan Culver, DO: Yeah. Tell me more about that. What does that look like in the real-world situation?

[00:20:02]

Marina Freiberg, MD: I think one of my colleagues had a situation where he delivered a baby, like in a car and he clamped the cord, cut the cord, got the baby out, etc. and that mom had imagined a delayed cord clamping and had imagined the baby being delivered immediately onto her chest, which is common, right? People spend a lot of time with these birth plans.

And I think the idea there is that it was just a very small lapse in communication that, you know, had effects. Baby did great, mom did great from a medical standpoint, A+ resuscitation, but that mom didn't get the delivery she had imagined and that's difficult.

Dan Culver, DO: Yeah. You spend a long time planning for those and imagining it and dreaming about it. And I suppose as the provider or the doctor, you're just happy that you remembered how to turn the baby's shoulders.

Marina Freiberg, MD: Yeah.

Dan Culver, DO: And you've got a nap.

Marina Freiberg, MD: You're just like, there's an alive baby and an alive mom at the end of this. This is a great day. But I think that's part of the burden of being the first responders to these situations. We're dealing with real human beings in very, very important events in people's lives that have implications for them outside of what we do in medicine.

Dan Culver, DO: It is all about perspective, isn't it?

Marina Freiberg, MD: It really is. And it's hard.

Dan Culver, DO: You know, I want to circle back to something that you mentioned a little bit about the placental position, and that's the use of ultrasound.

Marina Freiberg, MD: Yeah.

Dan Culver, DO: And you know, of course, that can be used for a variety of things. And I wonder how that's changing with the rapid uptake of point of care ultrasound across many areas of critical care and emergency medicine. How does that come into play in these particular patients?

[00:21:55]

Marina Freiberg, MD: I do a lot of point of care ultrasound teaching, and so this is something that I'm very passionate about and I take kind of the opposite position of a lot of people. Point of care ultrasound is amazing in the right hands, for the right patient, done for the right indication.

So, if you are someone who is not routinely scanning obstetric patients, I don't think that you should necessarily be making determinations on placental position and that kind of thing. It's important to understand your own limitations. One of the great things about point of care ultrasound is when we have precipitous deliveries or somebody coming in in labor is you can confirm head position fairly easily because you know, it's a big reflective...

Dan Culver, DO: You're saying that even I could tell the head position.

Marina Freiberg, MD: I bet you could.

Dan Culver, DO: That's a low bar.

Marina Freiberg, MD: It is what it is. But I think knowing where that bar is for you and knowing what you do and don't know that using point of care ultrasound is so critical as this becomes something that is becoming so much more prominent in our clinical care.

Dan Culver, DO: So, for people who are experienced using it, are there some particular areas where you think it's either got utility now or where you see some future applications of it?

Marina Freiberg, MD: We don't do a ton of that education in the emergency medicine curriculum, and I know the same is true for critical care. We don't spend a lot of time on obstetric ultrasonography. And so, I think that practice is currently limited. Again, confirming head position and looking for the placenta, seeing if it's anterior or posterior is fairly easy if you know what you're doing with an ultrasound or over the cervical OS.

So those are things that you could do, but I don't know that we are necessarily training our trainees. That way now, it is just not a part of the point of care ultrasound curriculums that we're doing.

[00:23:50] Dan Culver, DO: Presumably, they're also using it as part of somebody who's hypotensive, who's pregnant, right?

Marina Freiberg, MD: Yes.

Dan Culver, DO: Looking at the IVC and looking about whether or not there's compression and things like that.

[00:24:02]

Marina Freiberg, MD: Yes, my poor, poor daughter, I have a 1-year-old, did a lot of ultrasound teaching, and so when I was pregnant with her, I had all the residents scan me to look at differentiating things like the amniotic fluid from abdominal peritoneal fluid that could indicate bleeding, or looking at the IVC. Again, realizing that these things are going to be difficult in a pregnant patient.

You may not have as much experience with these things and so know your limits and know the limits of ultrasound in general when you're making the decision to do these things.

Dan Culver, DO: So, if I had to put all of this whole conversation into summary, it's somewhat reassuring. It's doing the ABCs, taking a deep breath and thinking about the basics and knowing your limits. Those are probably some of the main themes.

Marina Freiberg, MD: You're right. I think it is reassuring if you really think about it. You have the training, you have the education to do a lot of really great things, but realizing those limits and knowing when to call a friend for help and knowing that those friends are available here and happy to come help is incredibly important.

Dan Culver, DO: Wonderful. Anything else that you think is important to address today, that any exciting trends happening or topics that we missed commenting on?

Marina Freiberg, MD: Couple of things to just kind of keep a watch out for. There's some good literature coming out about the incidence of critical illness in pregnant patients in the United States, and we've got some pretty significant maternal morbidity and mortality. And with that literature coming out, I'm really hoping that we can better address the care of pregnant patients in our populations.

Dan Culver, DO: Yes, I think there's lots of work to do on that, as well as a lot of other at-risk populations.

Marina Freiberg, MD: Absolutely. And that's the wonderful part of being part of medicine today is there's a lot of work to do, a lot of really cool things that we can be a part of and I think it's important to not get overwhelmed by the volume of things that may need help. Just start somewhere.

[00:26:01]

Dan Culver, DO: Plenty for all of us to work on.

Marina Freiberg, MD: Yes, there is.

Dan Culver, DO: Well, Dr. Freiberg, it was really wonderful having you here today. Thank you for joining and sharing your expertise with us.

 Marina Freiberg, MD: Thank you so much for having me.

Dan Culver, DO: Thank you everybody for joining today's episode of Respiratory Exchange. We'll see you next time.

Raed Dweik, MD: Thank you for listening to this episode of the Respiratory Exchange Podcast. You can find additional podcast episodes on our website, clevelandclinic.org/podcasts, or wherever you get your podcasts.