Stephanie Ogir - Student Research and Creativity Forum

Lactate and Creatine Kinase Levels in the Peri-partum Period

Dr. Gary L. Goldberg1, Dr. Abittan1 , Dr. Uppalapati1, Stephanie Ogir1

1Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

Background Aims & Hypothesis

Maternal Early Warning Systems (MEWS) are implemented to facilitate rapid recognition and intervention of illness in pregnant women in labor to avoid morbidity and mortality. Lactate, an indicator of anaerobic metabolism and cellular stress, is currently used as a MEWS criteria at Northwell LIJ as an indicator of increased morbidity and the need for a rapid response team RRT assessment. An abnormal lactate level as defined by this criteria is based on normal lactate levels seen across the general population. However, the levels of lactate are likely to be higher in healthy patients in labor due to uterine contractions, strenuous effort, and blood loss associated with normal vaginal and cesarian deliveries. Creatine Kinase levels also increase as a result of muscle breakdown during normal vaginal and cesarian deliveries. Research has shown that creatine kinase levels increase markedly during labor, reaching a peak of 2-4 fold baseline levels at 24 hours post-partum. [1] For these reasons, creatine kinase may have similar utility to lactate in the determination of risk of morbidity and mortality in pregnant women.

• Aims:

• To create a nomogram for normal lactate and creatine kinase levels throughout labor and the postpartum period

• To determine whether lactate or creatine kinase may be a better indicator of morbidity and mortality throughout labor and the postpartum period

• Hypothesis:

• Normal lactate and creatine kinase levels in labor and the postpartum period are greater than the normal lactate and creatine kinase levels in the non-pregnant population

• The maternal early warning systems may need to be changed to include more appropriate markers for morbidity and mortality

Methods

• Recruitment:

• Pregnant women presenting to labor and delivery at LIJ were screened and approached for consent

• Enrollment goals: 120 patients (60 vaginal deliveries and 60 cesarian sections)

• Eligibility Criteria:

• Adult women 18 years and older

• Primagravid women with singleton pregnancy

• Patients with scheduled induction or normal spontaneous labor

• Patients having elective cesarian sections

Results/ Conclusions

Delivery Method % of recruited patients Vaginal 38.2 Scheduled cesarian 56.4 Unscheduled cesarian 5.5

• TPAL demographics:

• 50 (36%) subjects had never been pregnant before

• 48 (34.5%) subjects had a previous full-term pregnancy

• 5 (3.6%) subjects had preterm pregnancies

• 36 (26%) subjects had a previous history of abortion

• 43 (31%) subjects had living children

• Average BMI: 32.1 (Range 22.1-49.9)

• Examine the difference in lactate and creatine kinase levels among healthy women in labor across various demographic groups including African American and Latino women

Figure 1.

Case

Figure 2. Serum CK levels as measured in 7 blood samples obtained at different time points throughout labor and delivery in 26 multiparous (empty bars) and 24 nulliparous (filled bars) women.

• Patients taking the following medications were excluded as they may influence lactate levels: Albuterol, Terbutaline, Epinephrine, Nitroglycerin, Nifedipine, Diltiazem, Valproic Acid, Linezolid, Nitrofurantoin, and Bactrim

• Research Procedures:

• According to standard of care procedures, a CBC was collected at time of admission

• Lactate and creatine kinase was drawn at 4 time points: on admission, <30 minutes postpartum, 2-3 hours post partum, and 6-7 hours postpartum

• A CBC was repeated at 6-7 hours postpartum

• Compare the lactate and creatine kinase levels among women with no labor complications in comparison to those that suffer postpartum hemorrhages

Resources

[1] Abramov et. Al, Acta Obstetricia et Gynecologica Scandinavica, 2005

[2] Nordström, L., Achanna, S., Naka, K., & Arulkumaran, S. (2001, March). Fetal and maternal lactate increase during active second stage of labour. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/11281466

[3] Li, S., Peng, K., Liu, F., Yu, Y., Xu, T., & Zhang, Y. (2013, October). Changes in blood lactate levels after major elective abdominal surgery and the association with outcomes: A prospective observational study. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23721936

profiles (n=33) of maternal venous lactate in cases with three or more blood samplings during second stage (of labor). M-0 indicates blood samplings before bearing down and M-1, M-2 etc. represent the repeat sampling for every 15 min of bearing down. The last value in each case is at crowning of the fetal head. [2]

[3]