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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

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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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