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Obstetrical emergencies

Obstetrical emergencies. Nancy E Fay MD FACOG Division of Reproductive Medicine. Obstetrical Hemorrhage. Blood volume expands by 40% RBC’s increases by 30% = hemodilution Fibrinogen is double the non-pregnant level Uterine blood flow at term >500-700 cc/minute 15% of cardiac output

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Obstetrical emergencies

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  1. Obstetrical emergencies Nancy E Fay MD FACOG Division of Reproductive Medicine

  2. Obstetrical Hemorrhage • Blood volume expands by 40% • RBC’s increases by 30% = hemodilution • Fibrinogen is double the non-pregnant level • Uterine blood flow at term >500-700 cc/minute 15% of cardiac output • Blood loss for vaginal delivery <500 cc • Blood loss for c-section <1,000 cc

  3. First trimester bleeding • Light bleeding: • Implantation • Ectopic • Polyp or cervical irritation • Heavy • Threatened AB • Heavy bleeding: • Ectopic • Inevitable or incomplete AB

  4. Categories of hemorrhage • Class I • Loss of 15% of blood volume • No change in clinical status • BP, RR and HR unchanged • Class II • Loss of 15-35% blood volume • Tachycardic 100-120 • Tachypneic 20-24 • Cool, pale and clammy

  5. Categories of hemorrhage • Class III • 30-40% of blood volume • Altered mental status • Hypotensive, HR >120 • Class IV • >40% of blood volume • Altered mental status or minimal responsiveness • Hypotensive, tachycardic, no urine output

  6. Blood loss Soaked raytec=50 cc Soaked lap=100 cc Coke can=350 cc 2 cups=500 cc Weigh to measure

  7. Incidence of hemorrhage • 1-5% of deliveries and increasing a result of atony • Developed world 1/100,000 deliveries • Third world 1/1,000 deliveries • After delivery bleeding slows as a result of • Uterine contraction • Local PA-1 from decidua and clotting factors • Any alteration of above results in hemorrhage

  8. Uterine atony • Causes 80% of postpartum hemorrhage • Immediate most common • Delayed most likely from retained products of conception • Uterus not palpable postpartum

  9. Treatment of atony • Massage: external vs bimanual • Confirm no retained placental or membrane products • Empty the bladder • IV access if none, and bolus IV fluids • Medications • Oxytocin • Misoprostol • Methyl ergonovine • Hemabate/carboprost

  10. Surgical treatment • OB Alert/Massive transfusion protocol • Laparotomy: ligation of uterine arteries • B Lynch procedure • Other surgical control of atony • Uterine balloon or packing • Hysterectomy • Interventional radiology

  11. B Lynch Procedure

  12. Risk factors for Atony • Induction of labor • Prolonged labor or precipitous delivery • Over-distended uterus: macrosomia, multiples, polyhydramnios etc… • Prior hemorrhage*** • Preeclampsia, abruption, previa, trauma • Grand multiparity • Coagulopathy • Infection

  13. Delayed hemorrhage • Usually retained tissue • Other risk factors • Evacuate • Increased likelihood of infection • Asherman’s syndrome risk

  14. Anatomic causes for bleeding • Cervical lacerations • Vaginal lacerations • Vaginal hematoma • Uterine inversion • Cause • Replacement medication

  15. Placenta accreta • Abnormal decidualization allow villi invade myometrium • Accreta=myometrial superficial invasion • Increta=deep myometrial invasion • Percreta=serosal invasion and beyond • Incidence: In 1950 1/30,000 pregnancies • 1980 1/2,500 • 1990 1/500

  16. Placenta percreta

  17. Risk factors • Location of implantation: lower uterine segment, cervix, cornua • Scars in decidua: c-section, myomectomy, multiple D&C’s, Asherman’s Syndrome, septum resection • Uterine anomalies • Grand multiparity

  18. Accreta incidence • One prior section=0.3% • Two prior sections=0.6% • Three prior sections=2.4% • If concurrent previa: No scar 1-5% • One section 11-25% • Two sections 35-47% • Three sections >40%

  19. Diagnosis of accreta • Antepartum ultrasound, confirm with MRI • Treatment • Prior to delivery • How to deliver • When to deliver • Discovery after vaginal delivery

  20. Uterine rupture • With prior one low transverse c-section, incidence <1% • With two prior LTV c-sections? • With classical c-section? • First sign of uterine rupture in trial of labor or VBAC? • Trauma • Drug use/abuse

  21. Placenta Previa “________” third trimester vaginal bleeding

  22. Placenta previa Complete central, partial, marginal vs low lying Incidence at term 1%, in second trimester?

  23. Risk factors for previa • Prior section • Prior uterine surgery: D&C’s or myomectomies, septum resections etc… • Increasing parity • Multiple gestation • Prior previa

  24. Management of previa • Risk to fetus: IUGR, stillbirth, prematurity • Preterm labor risk • Mode of delivery….? • Timing of delivery: No bleeding • With bleeding • At hemorrhage… • Steroid use • Magnesium sulfate neuroprotection • Historic “double set-up”

  25. Placental abruption “____________” third trimester vaginal bleeding

  26. Placental abruption Marginal, concealed, complete

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