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Obstetrical Emergencies

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Title: Obstetrical Emergencies


1
Obstetrical Emergencies
  • James Ducey MD
  • Director of Maternal-Fetal Medicine

2
Definition
  • A suddenly developing pathologic condition in a
    patient, due to accident or disease, which
    requires urgent medical or surgical therapeutic
    intervention

3
Common Emergencies
  • Hypertensive Disorders
  • Hemorrhage
  • Trauma
  • Shoulder Dystocia
  • Umbilical Cord Prolapse
  • Acute Abdomen

4
Uncommon Emergencies
  • Sepsis
  • Respiratory Failure
  • Heart Failure
  • Renal Failure
  • Aplastic anemia
  • ITP and HUS

5
Immediate Obstetric Hemorrhage
  • Cause
  • Lacerations
  • Atony
  • Abruptio
  • Retained placenta
  • Previa Accreta
  • Rupture
  • Inversion
  • Incidence
  • 18
  • 120-150
  • 180-1150
  • 1100-1160
  • 1200
  • 12000-12500
  • 16400

6
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
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
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
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
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
Rupture
  • Frequently the result of uterine scar disruption
  • Incidence has increased with the increase of
    c/sections and VBACs
  • Blood loss is usually not severe
  • Surgical repair usually satisfactory

12
Inversion
  • Usually occurs when the placenta is fundally
    implanted
  • Dont 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
New Therapies
  • B-Lynch Brace Suture
  • Angiography and selective embolization
  • Recombinant activated Factor VII

14
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
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
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
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
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
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
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
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