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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
OB/GYN Emergencies

July 2010

Emory Family Medicine

topics
Topics
  • Postpartum hemorrhage
  • Shoulder dystocia
  • Third trimester bleeding
  • Eclampsia
  • Ectopic pregnancy
  • Miscarriage
  • PID
  • Ovarian pathology
ob emergencies
OB Emergencies
  • Postpartum hemorrhage
  • Shoulder dystocia
  • Third trimester bleeding
  • Eclampsia
postpartum hemorrhage
Postpartum Hemorrhage
  • Defined as >500 cc blood loss.
  • Risk factors
    • Overdistended uterus: polyhydramnios, twins
    • pitocin stimulated labor
    • general anesthesia
    • amnionitis
    • retained placental fragments
postpartum hemorrhage treatment
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.
postpartum hemorrhage treatment1
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!!!
ob emergencies1
OB Emergencies
  • Postpartum hemorrhage
  • Shoulder dystocia
  • Third trimester bleeding
  • Eclampsia
shoulder dystocia
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 - ???
shoulder dystocia1
Shoulder Dystocia
  • Risk Factors
    • Fetal macrosomia
    • Maternal obesity
    • Previous infant > 4000gm
    • Diabetes
    • Prolonged gestation
shoulder dystocia2
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%.
shoulder dystocia treatment
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.
shoulder dystocia treatment1
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.
helperr
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
ob emergencies2
OB Emergencies
  • Postpartum hemorrhage
  • Shoulder dystocia
  • Third trimester bleeding
  • Eclampsia
placental abruption
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.
placental abruption risk factors
Placental AbruptionRisk factors
  • Increased blood pressure
  • Trauma
  • Drug use - cocaine
  • Smoking/poor nutrition
  • Chorioamnionitis
  • Twins/polyhydramnios
placental abruption treatment
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
placental abruption treatment1
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.
placental abruption treatment2
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!!!
ob emergencies3
OB Emergencies
  • Postpartum hemorrhage
  • Shoulder dystocia
  • Third trimester bleeding
  • Eclampsia
placenta previa
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.
placenta previa types
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.
special labs
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.
placenta previa treatment
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!!!
placental abnormalities
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.
vascular abnormalities
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.
ob emergencies4
OB Emergencies
  • Postpartum hemorrhage
  • Shoulder dystocia
  • Third trimester bleeding
  • Eclampsia
eclampsia
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).
eclampsia common symptoms
EclampsiaCommon symptoms
  • Headache - 82%
  • Visual changes - 44%
  • Epigastric/RUQ pain - 19%
eclampsia treatment
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.
eclampsia treatment1
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.
gyn emergencies
GYN Emergencies
  • Ectopic pregnancy
  • Miscarriage
  • PID
  • Ovarian pathology
ectopic pregnancy
Ectopic Pregnancy
  • 1:100 pregnancies on average.
  • 25% recurrence rate.
  • Future fertility rate = 50%.
  • Remember Rh status.
  • Risk factors ???
ectopic pregnancy risk factors
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.
ectopic pregnancy diagnosis
Ectopic PregnancyDiagnosis
  • (+) hCG, unilateral abdominal/pelvic pain, vaginal bleeding.
  • Pain - 94%
  • Missed LMP - 89%
  • Vaginal bleeding - 80%
  • Palpable mass in only 50% - don’t squeeze too hard!!!
ectopic pregnancy1
Ectopic Pregnancy
  • Most present after rupture (by 10 weeks EGA)
  • Unruptured ectopics - 65% have a (+) culdocentesis
  • Ruptured ectopics - 85% have a (+) culdocentesis
discriminatory zone
Discriminatory Zone
  • This is the value of the hCG above which an intrauterine sac should be seen.
  • Transabdominal U/S - 6000-6500 hCG
  • Transvaginal (TV) U/S - 3000 (or less)
  • 50% of IUPs visible at an hCG of 1500
  • By TV U/S, fetal cardiac activity at 6 - 6.5 weeks EGA.
ectopic pregnancy treatment
Ectopic PregnancyTreatment
  • Get help!!!
  • Trauma - 2 large bore IV, fluids, CBC/ coags, ABO/Rh, type and screen/cross.
  • With “Chronic Ectopic” - consider methotrexate
  • If not sure in equivocal patient and U/S not helpful, observe and check “doubling” of hCG.
heterotopic pregnancy
Heterotopic pregnancy
  • Defined ???
  • Classically 1:30000
  • Now with advent of ovulation induction (clomid, pergonal, etc...) this risk is much higher, 1:900 is the lowest number I’ve seen, up to 1:7000.
spontaneous abortion
Spontaneous Abortion
  • Threatened Ab - uterine cramps with vaginal bleeding w/o cervical dilation.
    • Historically, 50% abort, 50% don’t.
    • Can’t predict who will abort, therefore, strict bedrest not necessary.
    • Demonstration of fetal cardiac activity decreases risk of SAb to 5% or less
spontaneous abortion1
Spontaneous Abortion
  • Inevitable Ab - cramps, vaginal bleeding, cervical dilation (not just parous cervix).
    • May note tissue in the os.
    • May be accompanied by a gush of fluid.
    • Rare case reports of salvaged pregnancies.
spontaneous abortion2
Spontaneous Abortion
  • Incomplete Ab - Vaginal bleeding, cramps, os dilated with tissue present.
    • Tissue may have already partially passed in patient with continued bleeding.
    • May remove tissue with ring forceps.
    • Suction curettage in unstable patient after demonstrating no fetal cardiac activity or Mom’s life in danger.
spontaneous abortion3
Spontaneous Abortion
  • Missed Ab - Dead fetus for several weeks without passage of tissue.
    • I see this most commonly in women without doptones at 10-12 weeks. Ultrasound then shows lack of fetal cardiac activity.
    • Most pass spontaneously. May need suction curettage.
pelvic inflammatory disease
Pelvic Inflammatory Disease
  • Clinically defined
    • Cervical motion tenderness, abdominal pain, adnexal pain (possibly mass - TOA).
    • Fever
    • Fullness in the posterior fornix - pus on culdocentesis, fluid in pouch of Douglas.
    • Elevated WBC, elevated ESR.
    • Positive gram stain/culture
pelvic inflammatory disease ddx
Pelvic Inflammatory DiseaseDDx
  • Acute appendicitis, especially ruptured.
  • Diverticulitis, especially abscess.
  • Septic abortion
  • Adnexal torsion
  • Others (Crohn’s exacerbation with fistula formation.)
pelvic inflammatory disease treatment
Pelvic Inflammatory DiseaseTreatment
  • Tubo-ovarian abscess - consult GYN, take to surgery and drain. May consider IV antibiotics in small abscess with stable patient.
  • Treat aggressively as this can predispose to future ectopics and infertility.
    • I was taught to hospitalize in first episode.
ovarian pathology
Ovarian Pathology
  • Painful cyst, especially hemorrhagic or ruptured.
  • Torsion. Recent case of torsed dermoid cyst requiring surgery in a pregnant woman.
  • Endometrioma - torsed or ruptured.
  • Adhesions.