Obstetrical Emergencies

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Obstetrical Emergencies

• James Ducey MD
• Director of Maternal-Fetal Medicine

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Definition

• A suddenly developing pathologic condition in a
  patient, due to accident or disease, which
  requires urgent medical or surgical therapeutic
  intervention

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Common Emergencies

• Hypertensive Disorders
• Hemorrhage
• Trauma
• Shoulder Dystocia
• Umbilical Cord Prolapse
• Acute Abdomen

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Uncommon Emergencies

• Sepsis
• Respiratory Failure
• Heart Failure
• Renal Failure
• Aplastic anemia
• ITP and HUS

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Immediate Obstetric Hemorrhage

• Cause
• Lacerations
• Atony
• Abruptio
• Retained placenta
• Previa Accreta
• Rupture
• Inversion

• Incidence
• 18
• 120-150
• 180-1150
• 1100-1160
• 1200
• 12000-12500
• 16400

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Lacerations

• First thing to be ruled out in bleeding post
  partum woman with a firm uterus
• Careful examination of the entire genital tract
• Rarely results in massive blood loss
• May be life threatening if extends to the retro
  peritoneum

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Atony

• Most common cause of significant blood loss and
  blood transfusion
• Generally responds to uterine massage and
  uterotonic drugs
• Hemabate 250 micrograms IM every 15 mins. very
  effective, not more than 8 doses

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Abruption

• Delivery is generally indicted unless the fetus
  is very premature and both the mother and fetus
  are stable
• DIC occurs in 4-10 of cases and usually is
  apparent by 8 hours after onset if symptoms
• Renal failure is the most common cause of
  maternal mortality

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Previa

• Transvaginal ultrasound is highly accurate in
  making diagnosis (PPV 93, NPV 98)
• Preterm delivery frequently needed due to
  excessive blood loss or fetal compromise
• Amniocentesis to documents fetal lung maturity at
  36 weeks in stable patients prior to c/section

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Accreta

• Absence of decidua basalis and imperfect
  formation of the fibrinoid layer (Nitabuch)
• Inccreta in myometrial invasion
• Perccreta the placenta goes through to the serosa
• Most frequently seen now when a woman with a
  previous c/section has placenta overlying the
  uterine scar.

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Rupture

• Frequently the result of uterine scar disruption
• Incidence has increased with the increase of
  c/sections and VBACs
• Blood loss is usually not severe
• Surgical repair usually satisfactory

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Inversion

• Usually occurs when the placenta is fundally
  implanted
• Dont attempt to deliver placenta until there
  have been signs of separation
• Prompt replacement is generally easier.
• Halothane or nitroglycerine are effective agents
• Uterotonics then needed to contract the uterus

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New Therapies

• B-Lynch Brace Suture
• Angiography and selective embolization
• Recombinant activated Factor VII

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B-Lynch Suture

• Br J Obstet Gynecol 1997 CB Lynch describes a
  simple technique that he and others have reported
  excellent success
• Patient is placed in a modified lithotomy
  position with the abdomen open to visually asses
  the bleeding
• If bimanual uterine compression controls the
  bleeding the suture is placed

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B-Lynch Suture

• 2 chromic on a rounded needle is used
• The suture punctures the uterus in the lower
  uterine segment 3 cm from the lateral edge,
  enters the endometrial cavity and emerge s 2 cm
  superior (in the region of the lateral edge of a
  low transverse c/s scar if that had been
  performed)

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B-Lynch Suture

• The suture is then passed over the fundus 3-4 cm
  medial to the cornua
• It is then placed through the posterior wall of
  the uterus transversely at the same level of the
  anterior placement
• It is the passed over the opposite cornua and
  through the anterior lower segment mirroring the
  opposite side and tied across the midline

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Arterial Embolization

• J Reproductive Med 1987 Feinberg etal reported a
  case of delayed postpartum bleeding successfully
  treated with this technique
• There have been several series now published that
  have established the effectiveness and safety

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Recombinant Activated Factor VII

• Novoseven is FDA approved for bleeding episodes
  in hemophilia patients
• It has been effective in nonhemophiliac patients
  with extensive organ damage, hemorrhage and
  coagulopathy that did not respond to transfusion

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Recombinant Activated Factor VII

• Arch Gynecol Obstet 2003 Segal etal Israel
• 3 Ob cases with severe bleeding unresponsive to
  surgery and massive transfusion
• Dose 90-100micrograms/kg
• Bleeding stopped in 2 cases and reduce in 1
• All patients survived

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Recombinant Activated Factor VII

• Obstet Gynecol 2004 Merchant etal New Mexico
• 3 cases of HELLP with liver hematoma
• Bleeding was controlled in all cases with
  Novoseven