Dr. A.Abudaber

Case based studies to learn the evaluation and management of OB emergencies

34 yr old G1P0 presents at 41 w 4 days for postdates induction. Cervix is 1 cm / long / -2.

Uncomplicated pregnancy. PMH: NAD

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

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

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

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

Management of anemia in pregnancy Appropriate labor management

Appropriate pt selection for induction Third stage management

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

Pitocin 20 units in 1 liter LR. IV bolus beginning with delivery of anterior shoulder of infant

Massage uterus Inspect vaginal vault / cervix / placenta

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

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

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

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.

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

Uterus not replaceable due to contraction ring: Nitroglycerin 100 mcg IV

If this fails, needs to go to OR for general anesthesia

Treat cause Maintain fibrinogen > 100 mg / dl with

FFP / Cryoprecipitate Maintain Plt count > 50,000 Specific factor replacement for known

coagulation diseases

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.

What do you do next?

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 - ???

Risk Factors Prior shoulder dystocia Diabetes Prolonged gestation Fetal macrosomia Maternal obesity

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 . Clinical Vs US

Prevention: Maintenance of good glycemic control in

pregnant diabetic women decreases fetal macrosomia

Elective C-section for fetal macrosomia?

Elective C-section for EFW >4500 grams in non-diabetic women 3600 C-sections to prevent one permanent

brachial plexus injury

H E L P E R R

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

McRoberts position

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

Remove posterior arm Roll pt onto hands / legs

Last resort measures Fracture clavicle Zavanelli maneuver Hysterotomy Symphysiotomy

27 yr female G2 P1 at 40 w 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

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

What are your concerns? Ddx? How would you manage this patient?

Placenta abruption Placenta previa Vasa previa Uterine rupture

Painful third trimester bleeding. 1:120 pregnancies, approx. 1%. Recurrence rate of 10%. Port wine stained amniotic fluid.

Hypertensive diseases of pregnancy Trauma Drug use - cocaine Smoking/poor nutrition Twins/polyhydramnios

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

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.

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

Complete C-section

Marginal Vaginal delivery can be considered under a

“double setup” status in the OR

What is the role of the digital vaginal exam?

Fetal vessel crosses presenting membranes (velamentous insertion)

Occurs in pregnancies with low lying placenta

Rare (1:3000) Bleeding is fetal Mortality is high

Prevention Membrane palpation before amniotomy

Wright stain: Blood from vagina. Look for nucleated rbc’s

Apt test: Mix blood from vagina with tap water. Mix with NaOH. Fetal Hgb: pink Maternal Hgb: brown

Kleihauer – Betke test No role in diagnosis of abruption or vasa

previa (slow test) Sample: maternal blood Make smear Stain for cells with fetal hemoglobin

Used to calculate dose of Rhogam in fetomaternal hemorrhage

Major risk is prior c-section Warning sign: Variable deceleration

Do not take lightly in a TOL patient

17 yr old G1P0 presents at 37 w 1 day with complaint of HA / nausea / upper abdominal pain.

RN notes BP 170 / 115 RN pages you to L&D Within 5 seconds of your arrival, the pt

has an obvious seizure

What do you do?

Defined BP > 140 systolic or > 90 diastolic on two

occasions more than six hours apart. Proteinuria of > 300 mg / 24hours

Affects 5-8% of pregnancies Risk factors include first pregnancy,

multiple gestation, chronic HTN, pregestational diabetes.

BP >160 / 110 Proteinuria > 5 grams / 24 hours Oliguria (<500 ml urine / 24 hours) Elevated Cr Pulmonary edema HELLP syndrome Symptoms indicating other end – organ

damage (RUQ pain / HA / Visual change) or

Seizure (Eclampsia)

Seizure in pregnancy at or near term usually associated with Pre-eclampsia

May occur up to 48 hours after delivery. 70% intrapartum / 30% postpartum.

Risk factors – Similar to Pre-eclampsia 1:150 - 1:3500

Protect the airway Get Help Magnesium sulfate 6 grams IV over 20

minutes. Start gtt at 2gm/hr. If already on Magnesium sulfate,

immediately bolus 2 grams IV over 20 minutes.

Oxygen Benzos?

What do you do when the seizure is over?

Review of common findings on fetal monitoring

24 yr old G2P1 at 41 weeks. Post-dates NST:

What is the expected outcome of this pregnancy?