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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
Feels lightheaded. 0800: 8 cm / 90% / 0 1100: complete 1250: OA Delivery infant boy 3790 grams 1325: Delivery of placenta. MD called back to room . Moderate bleeding responds to bimanual massage. 1340: 2nd degree perineal tear repair done 1344: Mild bleeding intermittently 1430: P increase 102 to 125.
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 Pitocin augmented / induced labor Prolonged third stage Instrument assisted vaginal delivery Shoulder dystocia Episiotomy / Laceration Intrapartum .
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 .
IV bolus beginning with delivery of anterior shoulder of infant Massage uterus Inspect vaginal vault / cervix / placenta . Pitocin 20 units in 1 liter LR.
2 mg IM. Can repeat every 6-8 hrs. If not responding to above measures: Methergine 0. 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 .
Bleeding will be a problem if you do this.25 mg SQ. consider placental insertion problem and need for OR . Manual extraction: Consider uterine relaxation (halothane / nitroglycerin 50 mcg IV / terbutaline 0. If no cleavage plane. Consider sedation (If no epidural) (Fentanyl) Find the cleavage plane b/t placenta and uterus Advance fingertips cleaving the placenta free. You will need to reverse it afterward.
Placenta increta Invasion of myometrium. Placenta percreta Invades through myometrium. Retained placenta due to abn implantation Placenta accreta Firm attachment to myometrium. 4% of previas have this. .
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 .
needs to go to OR for general anesthesia . Uterus not replaceable due to contraction ring: Nitroglycerin 100 mcg IV If this fails.
Treat cause Maintain fibrinogen > 100 mg / dl with FFP / Cryoprecipitate Maintain Plt count > 50.000 Specific factor replacement for known coagulation diseases .
you are unable to deliver the head over the next minute. She was complete at 1300. Despite maternal pushing. You suction the fetal mouth and nose and then assist restitution of the head. A “turtle sign” is noted. . Her pregnancy was uncomplicated. 27 yr G1P0 is in active labor. At 1415 she delivers an OA Head over an intact perineum.
What do you do next? .
Common!!! Risk Factors .??? . Definition: Delivery in which the anterior shoulder of the baby is impacted against the maternal symphysis pubis and is not deliverable in 60 seconds.
Risk Factors Prior shoulder dystocia Diabetes Prolonged gestation Fetal macrosomia Maternal obesity .
Fetal macrosomia Fetal wt 2500 – 4000 gm: 0. Clinical Vs US .3 – 1% (Note that 50% of shoulder dystocias occur in this group) Fetal wt > 4000gm ---> RR 11 Fetal wt > 4500gm ---> RR 22 EFW .
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 nondiabetic 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 .
Reverse Wood’s’ screw maneuver . 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.
Remove posterior arm Roll pt onto hands / legs Last resort measures Fracture clavicle Zavanelli maneuver Hysterotomy Symphysiotomy .
PMHx: uncomplicated Social Hx: uncomplicated/normal/low risk . 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.
Cx is 8-9cm / 100% / . On exam.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 .
approx. Port wine stained amniotic fluid. Painful third trimester bleeding. Recurrence rate of 10%. 1%. 1:120 pregnancies. .
cocaine Smoking/poor nutrition Twins/polyhydramnios . Hypertensive diseases of pregnancy Trauma Drug use .
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 . you need to r/o placenta previa .2 large bore IVs for IVF / blood products as needed. If no prior U/S. Trauma .must have 200-300cc blood to be visible.
Consider controlled induction if patients are stable. . weigh risks of continued pregnancy against risks of complications from preterm delivery. If preterm. If term. then deliver.
1:1500 nulliparas Risks: Prior c-section Prior uterine instrumentation High parity . Painless third trimester vaginal bleeding 1:200 pregnancies in 3rd trimester 1:50 grand multiparas.
Complete C-section Vaginal delivery can be considered under a “double setup” status in the OR Marginal .
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? .
Proteinuria of > 300 mg / 24hours Affects 5-8% of pregnancies Risk factors include first pregnancy. chronic HTN. multiple gestation. Defined BP > 140 systolic or > 90 diastolic on two occasions more than six hours apart. . 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) .
Risk factors – Similar to Pre-eclampsia 1:150 . Seizure in pregnancy at or near term usually associated with Pre-eclampsia May occur up to 48 hours after delivery. 70% intrapartum / 30% postpartum.1:3500 .
If already on Magnesium sulfate. Start gtt at 2gm/hr. Protect the airway Get Help Magnesium sulfate 6 grams IV over 20 minutes. 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 .
Post-dates NST: What is the expected outcome of this pregnancy? . 24 yr old G2P1 at 41 weeks.
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