Obstetrical Emergencies

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Obstetrical Emergencies

• July 28th 2011
• Oguchi Andrew Nwosu, MD FAAFPEmory Family
  Medicine

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OB EmergenciesLearning objectives

• Case based studies to learn the evaluation and
  management of OB emergencies

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OB Case 1

• 34 yr old G1P0 presents at 41 w 4 days for
  postdates induction. Cervix is 1 cm / long / -2.
• Uncomplicated pregnancy.
• 0900 1700 Misoprostol x 3 doses vaginally
• 1900 Regular UCtx 2 cm / 25 / -2
• 2300 Regular UCtx 4 cm / 50 / -1
• 0400 Regular UCtx 4 cm / 60 / -1
• 0430 Pitocin started

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OB Case 1

• 0800 8 cm / 90 / 0
• 1100 complete
• 1250 OA Delivery infant boy 3790 grams
• 1325 Delivery of placenta. Moderate bleeding
  responds to bimanual massage.
• 1340 2nd degree perineal tear repair done
• 1344 Mild bleeding intermittently
• 1430 P increase 102 to 125. Feels lightheaded.
  MD called back to room

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Postpartum Hemorrhage

• Defined as gt500 ml blood loss vaginal
• or gt1000 ml blood loss after c-section
• or
• Hemodynamic instability
• Lightheadedness / Tachycardia / Hypotension /
  Syncope
• HCT drop gt 10
• Need for blood transfusion

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Postpartum Hemorrhage

• Risk factors
• Antepartum
• Pre-eclampsia
• Multiparity
• Multiple gestation
• Previous PPH
• Previous C-section
• Intrapartum
• Pitocin augmented / induced labor
• Prolonged third stage
• Instrument assisted vaginal delivery
• Shoulder dystocia
• Episiotomy / Laceration

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PPH - Prevention

• Management of anemia in pregnancy
• Appropriate labor management
• Appropriate pt selection for induction
• Third stage management

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PPH - Cause

• Think of the 4 Ts
• Tone decreased uterine tone most common cause
• Trauma Laceration / Uterine inversion
• Tissue retained placental tissue
• Thrombin depleted coagulation factors

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PPH - Treatment

• Pitocin 20 units in 1 liter LR. IV bolus
  beginning with delivery of anterior shoulder of
  infant
• Massage uterus
• Inspect vaginal vault / cervix / placenta

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PPH - Treatment

• If not responding to above measures
• Methergine 0.2 mg IM. Can repeat 2 to 4 hrs
• Contraindication HTN disorders
• Carbaprost (Hemabate) 0.25 mg IM or IM
• Contraindication RAD
• Misoprostol 1000 mcg PR x 1, Also PO, SL,PV

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PPH Retained placenta

• Failure to deliver placenta in 30 minutes
• Treatment
• Gentle cord traction
• Consider injection of 20 units of pitocin in the
  umbilical vein (2 ml of pitocin in 20 ml saline)
• Manual extraction

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PPH Retained placenta

• Manual extraction
• Consider uterine relaxation (halothane /
  nitroglycerin 50 mcg IV / terbutaline 0.25 mg SQ.
  Bleeding will be a problem if you do this. You
  will need to reverse it afterward.
• Consider sedation (If no epidural) (Fentanyl)
• Find the cleavage plane b/t placenta and uterus
• Advance fingertips cleaving the placenta free.
• If no cleavage plane, consider abnormal
  placentation like accreta and need for OR

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Post partum Hemorrhage

• Retained placenta due to abn implantation
• Placenta accreta
• Firm attachment to myometrium. 4 of previas have
  this.
• Placenta increta
• Invasion of myometrium.
• Placenta percreta
• Invades through myometrium.

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PPH Uterine inversion

• Rare
• Cause Uterine atony / congenital weakness of
  uterus / ? Undue cord traction
• Prompt recognition What the heck is that?
• Do not remove the placenta use your fist to
  replace the uterus in the pelvis

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PPH Uterine inversion

• Uterus not replaceable due to contraction ring
• Nitroglycerin 100 mcg IV
• If this fails, needs to go to OR for general
  anesthesia

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PPH - Coagulopathy

• Treat cause
• Maintain fibrinogen gt 100 mg / dl with FFP /
  Cryoprecipitate
• Maintain Plt count gt 50,000
• Specific factor replacement for known coagulation
  diseases
• 4 Ts

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OB Case 2

• 27 yr G1P0 is in active labor. Her pregnancy was
  uncomplicated. She was complete at 1300. At
  1415 she delivers an OA Head over an intact
  perineum. A turtle sign is noted. You suction
  the fetal mouth and nose and then assist
  restitution of the head. Despite maternal
  pushing, you are unable to deliver the baby over
  the next minute.

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OB Case 2

• What do you do next?

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Shoulder Dystocia

• Definition Delivery in which the anterior
  shoulder of the baby is impacted against the
  maternal symphysis pubis and is not deliverable
  in 60 seconds.
• Common!!!
• Risk Factors - ???

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Shoulder Dystocia

• Risk Factors
• Prior shoulder dystocia
• Diabetes
• Prolonged gestation
• Fetal macrosomia
• Maternal obesity

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Erbs Palsy
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Shoulder Dystocia

• Fetal macrosomia
• Fetal wt 2500 4000 gm 0.3 1
• (Note that 50 of shoulder dystocias occur in
  this group)
• Fetal wt gt 4000gm ---gt RR 11
• Fetal wt gt 4500gm ---gt RR 22
• (EFW off by 3 lbs (!!!) in 6 patients in one
  study)
• (Ultrasound error is easily /- 10)

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Shoulder Dystocia

• Prevention
• Maintenance of good glycemic control in pregnant
  diabetic women decreases fetal macrosomia
• Elective C-section for fetal macrosomia?

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Shoulder Dystocia

• Elective C-section for EFW gt4500 grams in
  non-diabetic women
• 3600 C-sections to prevent one permanent brachial
  plexus injury

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Shoulder dystociaTreatment

• H
• E
• L
• P
• E
• R
• R

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Shoulder dystociaTreatment

• Help (call for)
• Episiotomy (consider)
• Legs (McRoberts Maneuver)
• Pressure (suprapubic)
• Enter vagina (Internal maneuvers)
• Remove the posterior arm
• Roll the patient

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Shoulder dystocia

• McRoberts position

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McRoberts / Suprapubic pressure
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Shoulder dystocia

• Treatment
• Enter vagina
• Rotate anterior shoulder (Apply pressure to
  posterior aspect of shoulder)
• Woods screw maneuver Apply pressure to the
  anterior aspect of the posterior shoulder while
  continuing to rotate the anterior shoulder also.
• Reverse Woods screw maneuver

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Shoulder dystocia

• Remove posterior arm
• Roll pt onto hands / legs
• Last resort measures
• Fracture clavicle
• Zavanelli maneuver
• Hysterotomy
• Symphysiotomy

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OB Case 3

• 27 yo female G2 P1001 at 40 2/7 is in spontaneous
  active labor.
• She complains of mod pain in between her
  contractions that was relieved with her epidural.
• Mild bleeding with contractions.
• PMHx uncomplicated
• Social Hx uncomplicated/normal/low risk

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OB Case 3

• On exam, Cx is 8-9cm / 100 / - 1 station
• Presentation is vertex
• Position is straight OA
• Last BP was 155/93 after a contraction
• Last Pulse was 100
• Urine no protein
• Fetal strip ? Baseline 140 Good longterm
  variability Noted variable decels to 110

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OB Case 3

• What are your concerns? Ddx?
• How would you manage this patient?

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Third trimester bleeding

• Placenta abruption
• Placenta previa
• Vasa previa
• Uterine rupture

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Placental Abruption

• Painful third trimester bleeding.
• 1120 pregnancies, approx. 1.
• Recurrence rate of 10.
• Port wine stained amniotic fluid.

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Placental Abruption
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Placental Abruption
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Placental AbruptionRisk factors

• Hypertensive diseases of pregnancy
• Trauma
• Drug use - cocaine
• Smoking/poor nutrition
• Twins/polyhydramnios

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Placental AbruptionTreatment

• Trauma - 2 large bore IVs for IVF / blood
  products as needed.
• Labs CBC / Type and screen / Coags
• Tape a red top tube to the wall and
  
• check for spontaneous clotting
• Consider ultrasound depending on clinical
  presentation - must have 200-300cc blood to be
  visible. If no prior U/S, you need to r/o
  placenta previa

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Placental Abruption
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Placental AbruptionTreatment

• If term, then deliver. Consider controlled
  induction if patients are stable.
• If preterm, weigh risks of continued pregnancy
  against risks of complications from preterm
  delivery.

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Placenta Previa

• Painless third trimester vaginal bleeding
• 1200 pregnancies in 3rd trimester
• 150 grand multiparas,11500 nulliparas
• Risks
• Prior c-section
• Prior uterine instrumentation
• High parity

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Placenta previaTreatment

• Complete
• C-section
• Marginal
• Vaginal delivery can be considered under a
  double setup status in the OR

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Placentation
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Vasa Previa

• Fetal vessel crosses presenting membranes
  (velamentous insertion)
• Occurs in pregnancies with low lying placenta
• Rare (13000)
• Bleeding is fetal
• Mortality is high

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Vasa Previa
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Vasa Previa

• Prevention
• Membrane palpation before amniotomy

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Special Labs

• Wright stain Blood from vagina.
• Look for nucleated rbcs
• Apt test Mix blood from vagina with tap water.
  Mix with NaOH.
• Fetal Hgb pink
• Maternal Hgb brown

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Special tests

• Kleihauer Betke test
• No role in diagnosis of abruption or vasa previa
  (slow test)
• Sample maternal blood
• Make smear
• Stain for cells with fetal hemoglobin
• Used to calculate dose of Rhogam in fetomaternal
  hemorrhage

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Kleihauer-Betke Test
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Uterine rupture

• Major risk is prior c-section
• Warning sign Variable deceleration
• Do not take lightly in a TOLAC patient

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OB Case 4

• 17 yr old G1P0 presents at 37 w 1 day with
  complaint of HA / nausea / upper abdominal pain.
• RN notes BP 170 / 115
• RN pages you to LD
• Within 5 seconds of your arrival, the pt has an
  obvious seizure

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OB Case 4

• What do you do?

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Pre-eclampsia

• Defined
• BP gt 140 systolic or gt 90 diastolic on two
  occasions more than six hours apart.
• Proteinuria of gt 300 mg / 24hours
• Affects 5-8 of pregnancies
• Risk factors include first pregnancy, multiple
  gestation, chronic HTN, pregestational diabetes.

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Severe Pre-eclampsia

• BP gt160 / 110
• Proteinuria gt 5 grams / 24 hours
• Oliguria (lt500 ml urine / 24 hours)
• Elevated Cr
• Pulmonary edema
• HELLP syndrome
• Symptoms indicating other end organ damage (RUQ
  pain / HA / Visual change) or
• Seizure (Eclampsia)

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Eclampsia

• Seizure in pregnancy at or near term usually
  associated with Pre-eclampsia
• May occur up to 48 hours after delivery. 70
  intrapartum / 30 postpartum.
• Risk factors Similar to Pre-eclampsia
• 1150 - 13500

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Eclampsia - Treatment

• Protect the airway
• Get Help
• Magnesium sulfate 6 grams IV over 20 minutes.
  Start gtt at 2gm/hr.
• If already on Magnesium sulfate, immediately
  bolus 2 grams IV over 20 minutes.
• Oxygen

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Eclampsia - Treatment

• What do you do when the seizure is over?

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Early decelerations
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Variable decelerations
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Variable decelerations - severe
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Late decelerations
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Late Decelerations
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Variable deceleration with late component
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Fetal Tachycardia
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Sinusoidal Pattern
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Non Stress Test (NST)

• 24 yr old G2P1 at 41 weeks. Post-dates NST

What is the expected outcome of this pregnancy?
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Why we do OB!!! ?