Obstetrical Emergencies

1. Obstetrical Emergencies 22 July 2008 Justin A. Glass, MDEmory Family Medicine

2. OB Emergencies:Learning objectives • Case based studies to learn the evaluation and management of OB emergencies (This presentation is a modification of a lecture initially prepared by Eddie Needham, MD. I extend my gratitude for his sharing of this work.)

3. OB Case #1 • 34 yr old G1P0 presents at 41 w 4 days for postdates induction. Cervix is 1 cm / long / -2. Uncomplicated pregnancy. PMH: RAD • 0900 – 1700 Misoprostil 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

4. 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

5. Postpartum Hemorrhage • Defined as >500 ml blood loss vaginal or >1000 ml blood loss after c-section or • Hemodynamic instability • Lightheadedness / Tachycardia / Hypotension / Syncope • HCT drop > 10 • Need for blood transfusion

6. 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

7. PPH - Prevention • Management of anemia in pregnancy • Appropriate labor management • Appropriate pt selection for induction • Third stage management

8. PPH - Cause • Think of the 4 T’s: • Tone – decreased uterine tone – most common cause • Trauma – Laceration / Uterine inversion • Tissue – retained placental tissue • Thrombin – depleted coagulation factors

9. 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

10. PPH - Treatment • If not responding to above measures: • Methergine 0.2 mg IM. Can repeat every 6-8 hrs. • Contraindication: HTN disorders • Carbaprost (Hemabate) 0.25 mg IM • Contraindication: RAD • Misoprostil 1000 mcg PR x 1

11. 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

12. 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 placental insertion problem and need for OR

13. 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.

14. 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

15. 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

16. PPH - Coagulopathy • Treat cause • Maintain fibrinogen > 100 mg / dl with FFP / Cryoprecipitate • Maintain Plt count > 50,000 • Specific factor replacement for known coagulation diseases

17. 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 head over the next minute.

18. OB Case #2 • What do you do next?

19. 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 - ???

20. Shoulder Dystocia • Risk Factors • Prior shoulder dystocia • Diabetes • Prolonged gestation • Fetal macrosomia • Maternal obesity

23. Erb’s Palsy

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

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

26. Shoulder Dystocia • Elective C-section for EFW >4500 grams in non-diabetic women • 3600 C-sections to prevent one permanent brachial plexus injury

27. Shoulder dystociaTreatment • H • E • L • P • E • R • R

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

29. Shoulder dystocia • McRoberts position

30. McRoberts / Suprapubic pressure

31. Shoulder dystocia • Treatment: • Enter vagina • Rotate anterior shoulder (Apply pressure to posterior aspect of shoulder) • Wood’s screw maneuver: Apply pressure to the anterior aspect of the posterior shoulder while continuing to rotate the anterior shoulder also. • Reverse Wood’s’ screw maneuver

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

33. 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

34. 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

35. OB Case #3 • What are your concerns? Ddx? • How would you manage this patient?

36. Third trimester bleeding • Placenta abruption • Placenta previa • Vasa previa • Uterine rupture

37. Placental Abruption • Painful third trimester bleeding. • 1:120 pregnancies, approx. 1%. • Recurrence rate of 10%. • Port winestained amniotic fluid.

38. Placental Abruption

39. Placental Abruption

41. Placental AbruptionRisk factors • Hypertensive diseases of pregnancy • Trauma • Drug use - cocaine • Smoking/poor nutrition • Twins/polyhydramnios

42. 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

44. Placental Abruption

45. 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.

46. Placenta Previa • Painless third trimester vaginal bleeding • 1:200 pregnancies in 3rd trimester • 1:50 grand multiparas,1:1500 nulliparas • Risks: • Prior c-section • Prior uterine instrumentation • High parity

47. Placenta previaTreatment • Complete • C-section • Marginal • Vaginal delivery can be considered under a “double setup” status in the OR

50. Placentation