Caring for Pregnant Women During Disasters and Evacuations

1. Caring for Pregnant Women During Disasters and Evacuations LCDR John Heusinkveld Chief, OBGYN Northern Navajo Medical Center

2. Introduction • About 2% of women, or 1% of the population as a whole, is pregnant at any given time • Any population affected by a disaster is likely to contain a significant number of pregnant women

3. Objectives • Define the problems posed by pregnancy during disasters

4. Objectives • Define the problems posed by pregnancy during disasters • Discuss types of disasters and how they affect pregnant women

5. Objectives • Define the problems posed by pregnancy during disasters • Discuss types of disasters and how they affect pregnant women • Focus on some common themes and make some suggestions

6. Objectives • Define the problems posed by pregnancy during disasters • Discuss types of disasters and how they affect pregnant women • Focus on some common themes and make some suggestions

7. Real Objective • Get potential responders thinking about this issue

8. My Background • Board Certified in OBGYN • Participated in Katrina Response

9. My Background • Board Certified in OBGYN • Participated in Katrina Response • 2 years training in Internal Medicine

10. Defining the Problem • Historically, up to 1 in 10 women died as a result of complications of pregnancy or childbirth • Today the number is more like 1 in 100,000 • Modern care has made pregnancy and childbirth 10,000 times safer

11. Defining the Problem • How do we maintain this level of safety during emergencies, when patients are unable to reach their usual care providers and facilities?

12. Types of Emergencies • Natural Disasters • Warfare • Terrorism • Epidemics

13. Natural Disasters • Damage to transportation infrastructure • Damage to healthcare infrastructure • Physical trauma • Exposure to pathogens and toxins

14. Warfare and Terrorism • Damage to transportation and healthcare infrastructure • CBR Agent exposure

15. Epidemics • Direct pathogen exposure • Healthcare facilities may be overwhelmed or closed due to contamination • Quarantines

16. Common Problems • Damage to transportation infrastructure • Damage to healthcare infrastructure • Physical trauma • Displacement • Exposures • Inectious Diseases

17. Damage to Infrastructure and Displacement • Patient can’t reach facility or facility is not operating • Most pregnant women can go without any care for a few days or even weeks • Exceptions: • Patients near delivery • Patients with pregnancy complications • Patients with chronic medical problems

18. Physical Trauma • May cause intra-uterine fetal demise or precipitate premature delivery • No intervention is possible until the age of viability • After viability, delivery in a tertiary care facility is vital • Ability to rapidly assess gestational age and fetal well-being is essential

19. Exposures • Chemical • Little known about teratogenic effects of most agents • Radiological • Exposure is cumulative for pregnancy • Less than 5 rads: probably no risk • Greater than 10 rads: significant risk • Risk probably decreases with gestational age • No intervention possible except minimize exposure

20. Epidemics • Most infectious diseases associated with disasters are unlikely to pose specific risk for pregnant women • Biggest risk is non-treatment • Responders need to know which medications are safe in pregnancy

21. The Challenge: Triage • How can non-specialists rapidly identify pregnant patients needing immediate care?

22. What Responders Need

23. What Responders Need

24. Scenario 1: Earthquake • Multiple trauma victims • 22 year-old woman who says she is pregnant and is having some bleeding • Stable vitals • No acute distress • Unsure of gestational age

25. Scenario 1: Earthquake • Ultrasound reveals 16-week gestation

26. Scenario 1: Earthquake • Ultrasound reveals 16-week gestation • Move on to next patient

27. Scenario 1: Earthquake • Ultrasound reveals 16-week gestation • Move on to next patient • Ultrasound reveals no fetal cardiac activity

28. Scenario 1: Earthquake • Ultrasound reveals 16-week gestation • Move on to next patient • Ultrasound reveals no fetal cardiac activity • Move on to next patient

29. Scenario 1: Earthquake • Ultrasound reveals 16-week gestation • Move on to next patient • Ultrasound reveals no fetal cardiac activity • Move on to next patient • Ultrasound reveals 28-week gestation with fetal cardiac activity

30. Scenario 1: Earthquake • Ultrasound reveals 16-week gestation • Move on to next patient • Ultrasound reveals no fetal cardiac activity • Move on to next patient • Ultrasound reveals 28-week gestation with fetal cardiac activity • Evacuate by air to tertiary care center

31. Scenario 2: Hurricane • Large number of patients in Medical Support Shelter • 22 year old woman says she is pregnant and has to take shots “for her blood”

32. Scenario 2: Hurricane • Syringes say: “insulin”

33. Scenario 2: Hurricane • Syringes say: “insulin” • Monitor blood sugar at relief center

34. Scenario 2: Hurricane • Syringes say: “insulin” • Monitor blood sugar at relief center • Syringes say: “Lovenox”

35. Scenario 2: Hurricane • Syringes say: “insulin” • Monitor blood sugar at relief center • Syringes say: “Lovenox” • Evacuate to tertiary care center • Responders need quick access to expert advice in order to make these decisions

36. What Responders Need • Ability to assess gestational age and fetal well-being • Ability to evacuate patients at risk • Tertiary care hospitals for acute problems • Communities with access to care for chronic problems • Access to expertise

37. Some Suggestions • Teams responding to disasters should have doppler and basic ultrasound capability • Identify consultants whom responders can easily reach with questions • Coordinate with tertiary care centers and communities to which patients can be dispersed