Obstetrical Emergencies

1. Obstetrical Emergencies James Ducey MD Director of Maternal-Fetal Medicine Stanen Island University Hospital

2. Definition A suddenly developing pathologic condition in a patient, due to accident or disease, which requires urgent medical or surgical therapeutic intervention Stanen Island University Hospital

3. Common Emergencies • Hypertensive Disorders • Hemorrhage • Trauma • Shoulder Dystocia • Umbilical Cord Prolapse • Acute Abdomen Stanen Island University Hospital

4. Uncommon Emergencies • Sepsis • Respiratory Failure • Heart Failure • Renal Failure • Aplastic anemia • ITP and HUS Stanen Island University Hospital

5. Cause Lacerations Atony Abruptio Retained placenta Previa Accreta Rupture Inversion Incidence 1:8 1:20-1:50 1:80-1:150 1:100-1:160 1:200 1:2000-1:2500 1:6400 Immediate Obstetric Hemorrhage Stanen Island University Hospital

6. 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 Stanen Island University Hospital

7. 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 Stanen Island University Hospital

8. 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 Stanen Island University Hospital

9. 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 Stanen Island University Hospital

10. 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. Stanen Island University Hospital

11. Rupture • Frequently the result of uterine scar disruption • Incidence has increased with the increase of c/sections and VBAC’s • Blood loss is usually not severe • Surgical repair usually satisfactory Stanen Island University Hospital

12. Inversion • Usually occurs when the placenta is fundally implanted • Don’t 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 Stanen Island University Hospital

13. New Therapies • B-Lynch Brace Suture • Angiography and selective embolization • Recombinant activated Factor VII Stanen Island University Hospital

14. 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 Stanen Island University Hospital

15. 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) Stanen Island University Hospital

16. 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 Stanen Island University Hospital

17. 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 Stanen Island University Hospital

18. 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 Stanen Island University Hospital

19. 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 Stanen Island University Hospital

20. 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 Stanen Island University Hospital