1. Stanen Island University Hospital Obstetrical Emergencies James Ducey MD Director of Maternal-Fetal Medicine

2. Stanen Island University Hospital Definition A suddenly developing pathologic condition in a patient, due to accident or disease, which requires urgent medical or surgical therapeutic intervention

3. Stanen Island University Hospital Common Emergencies Hypertensive Disorders Hemorrhage Trauma Shoulder Dystocia Umbilical Cord Prolapse Acute Abdomen

4. Stanen Island University Hospital Uncommon Emergencies Sepsis Respiratory Failure Heart Failure Renal Failure Aplastic anemia ITP and HUS

5. Stanen Island University Hospital Immediate Obstetric Hemorrhage Cause Lacerations Atony Abruptio Retained placenta Previa Accreta Rupture Inversion Incidence 1:8 1:20-1:50 1:80-1:150 1:100-1:160 1:200 1:2000-1:2500 1:6400

6. Stanen Island University Hospital Lacerations First thing to be ruled out in bleeding post partum woman with a firm uterus Careful examination of the entire genital tract Rarely results in massive blood loss May be life threatening if extends to the retro peritoneum

7. Stanen Island University Hospital Atony Most common cause of significant blood loss and blood transfusion Generally responds to uterine massage and uterotonic drugs Hemabate 250 micrograms IM every 15 mins. very effective, not more than 8 doses

8. Stanen Island University Hospital Abruption Delivery is generally indicted unless the fetus is very premature and both the mother and fetus are stable DIC occurs in 4-10% of cases and usually is apparent by 8 hours after onset if symptoms Renal failure is the most common cause of maternal mortality

9. Stanen Island University Hospital Previa Transvaginal ultrasound is highly accurate in making diagnosis (PPV 93%, NPV 98%) Preterm delivery frequently needed due to excessive blood loss or fetal compromise Amniocentesis to documents fetal lung maturity at 36 weeks in stable patients prior to c/section

10. Stanen Island University Hospital Accreta Absence of decidua basalis and imperfect formation of the fibrinoid layer (Nitabuch) Inccreta in myometrial invasion Perccreta the placenta goes through to the serosa Most frequently seen now when a woman with a previous c/section has placenta overlying the uterine scar.

11. Stanen Island University Hospital Rupture Frequently the result of uterine scar disruption Incidence has increased with the increase of c/sections and VBAC’s Blood loss is usually not severe Surgical repair usually satisfactory

12. Stanen Island University Hospital Inversion Usually occurs when the placenta is fundally implanted Don’t attempt to deliver placenta until there have been signs of separation Prompt replacement is generally easier. Halothane or nitroglycerine are effective agents Uterotonics then needed to contract the uterus

13. Stanen Island University Hospital New Therapies B-Lynch Brace Suture Angiography and selective embolization Recombinant activated Factor VII

14. Stanen Island University Hospital B-Lynch Suture Br J Obstet Gynecol 1997 CB Lynch describes a simple technique that he and others have reported excellent success Patient is placed in a modified lithotomy position with the abdomen open to visually asses the bleeding If bimanual uterine compression controls the bleeding the suture is placed

15. Stanen Island University Hospital B-Lynch Suture # 2 chromic on a rounded needle is used The suture punctures the uterus in the lower uterine segment 3 cm from the lateral edge, enters the endometrial cavity and emerge s 2 cm superior (in the region of the lateral edge of a low transverse c/s scar if that had been performed)

16. Stanen Island University Hospital B-Lynch Suture The suture is then passed over the fundus 3-4 cm medial to the cornua It is then placed through the posterior wall of the uterus transversely at the same level of the anterior placement It is the passed over the opposite cornua and through the anterior lower segment mirroring the opposite side and tied across the midline

17. Stanen Island University Hospital Arterial Embolization J Reproductive Med 1987 Feinberg etal reported a case of delayed postpartum bleeding successfully treated with this technique There have been several series now published that have established the effectiveness and safety

18. Stanen Island University Hospital Recombinant Activated Factor VII Novoseven is FDA approved for bleeding episodes in hemophilia patients It has been effective in nonhemophiliac patients with extensive organ damage, hemorrhage and coagulopathy that did not respond to transfusion

19. Stanen Island University Hospital Recombinant Activated Factor VII Arch Gynecol Obstet 2003 Segal etal Israel 3 Ob cases with severe bleeding unresponsive to surgery and massive transfusion Dose 90-100micrograms/kg Bleeding stopped in 2 cases and reduce in 1 All patients survived

20. Stanen Island University Hospital Recombinant Activated Factor VII Obstet Gynecol 2004 Merchant etal New Mexico 3 cases of HELLP with liver hematoma Bleeding was controlled in all cases with Novoseven