Obstetrical emergencies Nancy E Fay MD FACOG Division of Reproductive Medicine

Obstetrical Hemorrhage Blood volume expands by 40% RBC’s increases by 30% = hemodilution Fibrinogen is double the non-pregnant level Uterine blood flow at term >500-700 cc/minute 15% of cardiac output Blood loss for vaginal delivery <500 cc Blood loss for c-section <1,000 cc

First trimester bleeding Light bleeding: Implantation Ectopic Polyp or cervical irritation Heavy Threatened AB Heavy bleeding: Inevitable or incomplete AB

Categories of hemorrhage Class I Loss of 15% of blood volume No change in clinical status BP, RR and HR unchanged Class II Loss of 15-35% blood volume Tachycardic 100-120 Tachypneic 20-24 Cool, pale and clammy

Categories of hemorrhage Class III 30-40% of blood volume Altered mental status Hypotensive, HR >120 Class IV >40% of blood volume Altered mental status or minimal responsiveness Hypotensive, tachycardic, no urine output

Blood loss Soaked raytec=50 cc Soaked lap=100 cc Coke can=350 cc 2 cups=500 cc Weigh to measure

Incidence of hemorrhage 1-5% of deliveries and increasing a result of atony Developed world 1/100,000 deliveries Third world 1/1,000 deliveries After delivery bleeding slows as a result of Uterine contraction Local PA-1 from decidua and clotting factors Any alteration of above results in hemorrhage

Uterine atony Causes 80% of postpartum hemorrhage Immediate most common Delayed most likely from retained products of conception Uterus not palpable postpartum

Treatment of atony Massage: external vs bimanual Confirm no retained placental or membrane products Empty the bladder IV access if none, and bolus IV fluids Medications Oxytocin Misoprostol Methyl ergonovine Hemabate/carboprost

Surgical treatment OB Alert/Massive transfusion protocol Laparotomy: ligation of uterine arteries B Lynch procedure Other surgical control of atony Uterine balloon or packing Hysterectomy Interventional radiology

B Lynch Procedure

Risk factors for Atony Induction of labor Prolonged labor or precipitous delivery Over-distended uterus: macrosomia, multiples, polyhydramnios etc… Prior hemorrhage*** Preeclampsia, abruption, previa, trauma Grand multiparity Coagulopathy Infection

Delayed hemorrhage Usually retained tissue Other risk factors Evacuate Increased likelihood of infection Asherman’s syndrome risk

Anatomic causes for bleeding Cervical lacerations Vaginal lacerations Vaginal hematoma Uterine inversion Cause Replacement medication

Placenta accreta Abnormal decidualization allow villi invade myometrium Accreta=myometrial superficial invasion Increta=deep myometrial invasion Percreta=serosal invasion and beyond Incidence: In 1950 1/30,000 pregnancies 1980 1/2,500 1990 1/500

Placenta percreta

Risk factors Location of implantation: lower uterine segment, cervix, cornua Scars in decidua: c-section, myomectomy, multiple D&C’s, Asherman’s Syndrome, septum resection Uterine anomalies Grand multiparity

Accreta incidence One prior section=0.3% Two prior sections=0.6% Three prior sections=2.4% If concurrent previa: No scar 1-5% One section 11-25% Two sections 35-47% Three sections >40%

Diagnosis of accreta Antepartum ultrasound, confirm with MRI Treatment Prior to delivery How to deliver When to deliver Discovery after vaginal delivery

Uterine rupture With prior one low transverse c-section, incidence <1% With two prior LTV c-sections? With classical c-section? First sign of uterine rupture in trial of labor or VBAC? Trauma Drug use/abuse

Placenta Previa “________” third trimester vaginal bleeding

Placenta previa Complete central, partial, marginal vs low lying Incidence at term 1%, in second trimester?

Risk factors for previa Prior section Prior uterine surgery: D&C’s or myomectomies, septum resections etc… Increasing parity Multiple gestation Prior previa

Management of previa Risk to fetus: IUGR, stillbirth, prematurity Preterm labor risk Mode of delivery….? Timing of delivery: No bleeding With bleeding At hemorrhage… Steroid use Magnesium sulfate neuroprotection Historic “double set-up”

Placental abruption “____________” third trimester vaginal bleeding

Placental abruption Marginal, concealed, complete