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OB/GYN Emergencies

OB/GYN Emergencies. July 2010 Emory Family Medicine. Topics. Postpartum hemorrhage Shoulder dystocia Third trimester bleeding Eclampsia Ectopic pregnancy Miscarriage PID Ovarian pathology. Learning Objectives. OB Emergencies. Postpartum hemorrhage Shoulder dystocia

florrie-morris
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OB/GYN Emergencies

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  1. OB/GYN Emergencies July 2010 Emory Family Medicine

  2. Topics • Postpartum hemorrhage • Shoulder dystocia • Third trimester bleeding • Eclampsia • Ectopic pregnancy • Miscarriage • PID • Ovarian pathology

  3. Learning Objectives

  4. OB Emergencies • Postpartum hemorrhage • Shoulder dystocia • Third trimester bleeding • Eclampsia

  5. Postpartum Hemorrhage • Defined as >500 cc blood loss. • Risk factors • Overdistended uterus: polyhydramnios, twins • pitocin stimulated labor • general anesthesia • amnionitis • retained placental fragments

  6. Postpartum HemorrhageTreatment • Sweep uterus to remove retained parts. • Massage uterus. • Pitocin 10-20 units in 1 liter, bolus. • Methergine 0.2 mg IM, may repeat. • Consider not using in pre-eclamptic. • Hemabate (prost. F2alpha) 0.25 mg IM.

  7. Postpartum HemorrhageTreatment • Inspect for other causes of PPH - cervical/vaginal laceration, episiotomy. • Consider pelvic hematoma - may not initially be visible. • Treat blood loss like any other condition - fluids, blood products. • Get help!!!

  8. OB Emergencies • Postpartum hemorrhage • Shoulder dystocia • Third trimester bleeding • Eclampsia

  9. Shoulder Dystocia • Defined as a vaginal delivery in which the anterior shoulder of the baby is not readily deliverable. • 0.15 - 2% all deliveries - BE READY! • Risk Factors - ???

  10. Shoulder Dystocia • Risk Factors • Fetal macrosomia • Maternal obesity • Previous infant > 4000gm • Diabetes • Prolonged gestation

  11. Shoulder Dystocia • Fetal macrosomia • 50% infants < 4000gm. • Fetal wt > 4000gm ---> risk increased x11. • Fetal wt > 4500gm ---> risk increased x22. • EFW off by 3 lbs (!!!) in 6% patients in one study. • Ultrasound error is easily +/- 10%.

  12. Shoulder DystociaTreatment • ALSO Course mnemonic - HELPERR • Go get Dr. McRoberts !!! Get Help. • Suprapubic pressure - NOT FUNDAL. • Generous episiotomy. • Rotate posterior shoulder - Wood’s screw maneuver. May then deliver posterior arm first.

  13. Shoulder DystociaTreatment • Rotate anterior shoulder obliquely. • Fracture clavicle. • Symphysiotomy • Dr. Patil has done this at least 3 times. • Zavenelli maneuver • I precepted this maneuver while watching ER.

  14. Helperr • H - Help • E - Episiotomy • L - Legs into McRoberts • P - Pressure, suprapubic • E - Enter for rotational maneuvers • R - Remove posterior arm • R - Roll patient onto hands and knees

  15. OB Emergencies • Postpartum hemorrhage • Shoulder dystocia • Third trimester bleeding • Eclampsia

  16. Placental Abruption • Painful third trimester bleeding. • 1:120 pregnancies, approx. 1%. • Recurrence rate of 10%. • Port wine stained amniotic fluid. • Mark line at top of fundus at presentation and follow fundal height serially.

  17. Placental Abruption

  18. Placental Abruption

  19. Placental Abruption

  20. Placental AbruptionRisk factors • Increased blood pressure • Trauma • Drug use - cocaine • Smoking/poor nutrition • Chorioamnionitis • Twins/polyhydramnios

  21. Placental AbruptionTreatment • Trauma - 2 large bore IVs, labs, fluids, can take a red top tube for spontaneous clot - may check CBC/coags and fibrinogen serially. • Consider ultrasound - must have 200-300cc blood to be visible. May be able to see a retroplacental lucency

  22. Placental AbruptionTreatment • If term, deliver. Consider controlled induction if patients are stable. • If preterm, weigh risks of continued pregnancy against risks of complications from preterm delivery. • Need NICU backup. • Give steroids and vitamin K as usual.

  23. Placental AbruptionTreatment • Do not use beta mimetics to tocolyze. They may cause maternal hypotension - badness. They may also cause maternal tachycardia which may mask hypotension. • Use magnesium to tocolyze. • Get Help!!!

  24. OB Emergencies • Postpartum hemorrhage • Shoulder dystocia • Third trimester bleeding • Eclampsia

  25. Placenta Previa • Painless third trimester vaginal bleeding • 1:200 - 1:250 pregnancies average • 1:50 grand multiparas,1:1500 nulliparas • Undiagnosed third trimester bleeding, consider a double set-up in the OR. • Biggest risk factor is prior C-section, which confers a 1% risk.

  26. Placenta previaTypes • Total - needs operative delivery. • Partial and Marginal - may consider a vaginal delivery as the baby’s head may tamponade the placenta during descent • Consider fetal hemorrhage in addition to maternal hemorrhage.

  27. Special Labs • KB or Kleihauer-Betke test. Checks for amount of fetal cells in maternal circulation. • Apt test. Determines if blood is fetal or maternal. • Rh status. Mom needs rhogam if she is Rh negative. 1 amp = 300 micrograms which covers 30cc fetal hemorrhage.

  28. Placenta PreviaTreatment • If baby mature by amniocentesis (L/S ratio, PG - phosphotidylglycerol/ amniostat) or >36 wk EGA, then deliver. • If baby immature and maternal condition stable, give steroids/vitamin K. May tocolyze prn until mature or condition unstable. • Get help!!!

  29. Placental abnormalities • Placenta accreta • Firm attachment to myometrium. 4% of previas have this. • Placenta increta • Invasion of myometrium. • Placenta percreta • Invades through myometrium. • Placenta concreta - placenta hard as rock and well set.

  30. Placenta accreta

  31. Placenta Accreta

  32. Vascular Abnormalities • Vasa Previa - fetal vessel running in front of internal os. These may rupture causing painless third trimester vaginal bleeding. 1:3000 deliveries. • The Apt test may be used to differentiate fetal from maternal bleeding in this case.

  33. Vasa Previa

  34. Vasa Previa

  35. OB Emergencies • Postpartum hemorrhage • Shoulder dystocia • Third trimester bleeding • Eclampsia

  36. Eclampsia • Seizure in pregnancy at or near term usually associated with preeclampsia or hypertension. • May occur up to 48 hours after delivery. 70% at delivery, 30% postpartum. • Risk factors - primigravida, non-white, age>35. • 1:150 - 1:3500 (it happens, we’re not sure when).

  37. EclampsiaCommon symptoms • Headache - 82% • Visual changes - 44% • Epigastric/RUQ pain - 19%

  38. EclampsiaTreatment • Deliver - get help, not HELLP. • Bite stick, left lateral decubitus, prevent falls, suction PRN, O2. • Magnesium 4-6 gm over 15-20 minutes. May bolus an additional 2gm prn a second seizure. Run at 2gm/hr, check levels.

  39. EclampsiaTreatment • Diazepam - may cause apnea at high enough doses, may lead to fetal compromise. • Dilantin??? • Hydralazine to control hypertension. • Consider labs to assess HELLP, DIC.

  40. Healthy babies do exist!!! 

  41. GYN Emergencies • Ectopic pregnancy • Miscarriage • PID • Ovarian pathology

  42. Ectopic Pregnancy • 1:100 pregnancies on average. • 25% recurrence rate. • Future fertility rate = 50%. • Remember Rh status. • Risk factors ???

  43. Ectopic PregnancyRisk Factors • Prior ectopic. • Prior abdominal surgery, especially BTL. This confers a 50% ectopic rate. • Endometriosis • PID - 50% ectopics have this hx. Relative risk (RR) increased x 7. • IUD (?), DES, prior abortion. First Ab increases RR x 1.3, 2nd x 2.6.

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