4OB Emergencies Postpartum hemorrhage Shoulder dystocia Third trimester bleedingEclampsia
5Postpartum Hemorrhage Defined as >500 cc blood loss.Risk factorsOverdistended uterus: polyhydramnios, twinspitocin stimulated laborgeneral anesthesiaamnionitisretained placental fragments
6Postpartum Hemorrhage Treatment Sweep uterus to remove retained parts.Massage uterus.Pitocin 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.
7Postpartum Hemorrhage Treatment 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!!!
8OB Emergencies Postpartum hemorrhage Shoulder dystocia Third trimester bleedingEclampsia
9Shoulder DystociaDefined as a vaginal delivery in which the anterior shoulder of the baby is not readily deliverable.% all deliveries - BE READY!Risk Factors - ???
13Shoulder 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%.
14Shoulder Dystocia Treatment ALSO Course mnemonic - HELPERRGo get Dr. McRoberts !!! Get Help.Suprapubic pressure - NOT FUNDAL.Generous episiotomy.Rotate posterior shoulder - Wood’s screw maneuver. May then deliver posterior arm first.
15Shoulder Dystocia Treatment Rotate anterior shoulder obliquely.Fracture clavicle.SymphysiotomyDr. Patil has done this at least 3 times.Zavenelli maneuverI precepted this maneuver while watching ER.
16Helperr H - Help E - Episiotomy L - Legs into McRoberts P - Pressure, suprapubicE - Enter for rotational maneuversR - Remove posterior armR - Roll patient onto hands and knees
17OB Emergencies Postpartum hemorrhage Shoulder dystocia Third trimester bleedingEclampsia
18Placental 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.
25Placental Abruption Treatment 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 cc blood to be visible. May be able to see a retroplacental lucency
26Placental Abruption Treatment 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.
27Placental Abruption Treatment 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!!!
28OB Emergencies Postpartum hemorrhage Shoulder dystocia Third trimester bleedingEclampsia
29Placenta Previa Painless third trimester vaginal bleeding 1: :250 pregnancies average1:50 grand multiparas,1:1500 nulliparasUndiagnosed third trimester bleeding, consider a double set-up in the OR.Biggest risk factor is prior C-section, which confers a 1% risk.
30Placenta previa Types Total - needs operative delivery. Partial and Marginal - may consider a vaginal delivery as the baby’s head may tamponade the placenta during descentConsider fetal hemorrhage in addition to maternal hemorrhage.
34Special LabsKB 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.
35Placenta Previa Treatment 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!!!
36Placental abnormalities Placenta accretaFirm attachment to myometrium. 4% of previas have this.Placenta incretaInvasion of myometrium.Placenta percretaInvades through myometrium.Placenta concreta - placenta hard as rock and well set.
39Vascular 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.
42OB Emergencies Postpartum hemorrhage Shoulder dystocia Third trimester bleedingEclampsia
43EclampsiaSeizure 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: :3500 (it happens, we’re not sure when).
45Eclampsia Treatment Deliver - get help, not HELLP. Bite stick, left lateral decubitus, prevent falls, suction PRN, O2.Magnesium 4-6 gm over minutes. May bolus an additional 2gm prn a second seizure. Run at 2gm/hr, check levels.
46Eclampsia TreatmentDiazepam - may cause apnea at high enough doses, may lead to fetal compromise.Dilantin???Hydralazine to control hypertension.Consider labs to assess HELLP, DIC.
50Ectopic Pregnancy Risk Factors Prior ectopic.Prior abdominal surgery, especially BTL. This confers a 50% ectopic rate.EndometriosisPID - 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.
51Ectopic Pregnancy Diagnosis (+) 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!!!
52Ectopic Pregnancy Most present after rupture (by 10 weeks EGA) Unruptured ectopics - 65% have a (+) culdocentesisRuptured ectopics - 85% have a (+) culdocentesis
53Discriminatory ZoneThis is the value of the hCG above which an intrauterine sac should be seen.Transabdominal U/S hCGTransvaginal (TV) U/S (or less)50% of IUPs visible at an hCG of 1500By TV U/S, fetal cardiac activity at weeks EGA.
54Ectopic Pregnancy Treatment Get help!!!Trauma - 2 large bore IV, fluids, CBC/ coags, ABO/Rh, type and screen/cross.With “Chronic Ectopic” - consider methotrexateIf not sure in equivocal patient and U/S not helpful, observe and check “doubling” of hCG.
55Heterotopic pregnancy Defined ???Classically 1:30000Now 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.
56Spontaneous AbortionThreatened 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
57Spontaneous AbortionInevitable 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.
58Spontaneous AbortionIncomplete 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.
59Spontaneous AbortionMissed Ab - Dead fetus for several weeks without passage of tissue.I see this most commonly in women without doptones at weeks. Ultrasound then shows lack of fetal cardiac activity.Most pass spontaneously. May need suction curettage.
60Pelvic Inflammatory Disease Clinically definedCervical motion tenderness, abdominal pain, adnexal pain (possibly mass - TOA).FeverFullness in the posterior fornix - pus on culdocentesis, fluid in pouch of Douglas.Elevated WBC, elevated ESR.Positive gram stain/culture
61Pelvic Inflammatory Disease DDx Acute appendicitis, especially ruptured.Diverticulitis, especially abscess.Septic abortionAdnexal torsionOthers (Crohn’s exacerbation with fistula formation.)
62Pelvic Inflammatory Disease Treatment 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.
63Ovarian 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.