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Obstetrical Emergencies

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Third trimester bleeding Placenta abruption Placenta previa Vasa previa Uterine rupture Placental Abruption Painful third trimester bleeding. 1:120 pregnancies, ... – PowerPoint PPT presentation

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Title: Obstetrical Emergencies


1
Obstetrical Emergencies
  • July 28th 2011
  • Oguchi Andrew Nwosu, MD FAAFP Emory Family
    Medicine

2
OB Emergencies Learning objectives
  • Case based studies to learn the evaluation and
    management of OB emergencies

3
OB Case 1
  • 34 yr old G1P0 presents at 41 w 4 days for
    postdates induction. Cervix is 1 cm / long / -2.
  • Uncomplicated pregnancy.
  • 0900 1700 Misoprostol 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

4
OB Case 1
  • 0800 8 cm / 90 / 0
  • 1100 complete
  • 1250 OA Delivery infant boy 3790 grams
  • 1325 Delivery of placenta. Moderate bleeding
    responds to bimanual massage.
  • 1340 2nd degree perineal tear repair done
  • 1344 Mild bleeding intermittently
  • 1430 P increase 102 to 125. Feels lightheaded.
    MD called back to room

5
Postpartum Hemorrhage
  • Defined as gt500 ml blood loss vaginal
  • or gt1000 ml blood loss after c-section
  • or
  • Hemodynamic instability
  • Lightheadedness / Tachycardia / Hypotension /
    Syncope
  • HCT drop gt 10
  • Need for blood transfusion

6
Postpartum Hemorrhage
  • Risk factors
  • Antepartum
  • Pre-eclampsia
  • Multiparity
  • Multiple gestation
  • Previous PPH
  • Previous C-section
  • Intrapartum
  • Pitocin augmented / induced labor
  • Prolonged third stage
  • Instrument assisted vaginal delivery
  • Shoulder dystocia
  • Episiotomy / Laceration

7
PPH - Prevention
  • Management of anemia in pregnancy
  • Appropriate labor management
  • Appropriate pt selection for induction
  • Third stage management

8
PPH - Cause
  • Think of the 4 Ts
  • Tone decreased uterine tone most common cause
  • Trauma Laceration / Uterine inversion
  • Tissue retained placental tissue
  • Thrombin depleted coagulation factors

9
PPH - Treatment
  • Pitocin 20 units in 1 liter LR. IV bolus
    beginning with delivery of anterior shoulder of
    infant
  • Massage uterus
  • Inspect vaginal vault / cervix / placenta

10
PPH - Treatment
  • If not responding to above measures
  • Methergine 0.2 mg IM. Can repeat 2 to 4 hrs
  • Contraindication HTN disorders
  • Carbaprost (Hemabate) 0.25 mg IM or IM
  • Contraindication RAD
  • Misoprostol 1000 mcg PR x 1, Also PO, SL,PV

11
PPH Retained placenta
  • 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

12
PPH Retained placenta
  • Manual extraction
  • Consider uterine relaxation (halothane /
    nitroglycerin 50 mcg IV / terbutaline 0.25 mg SQ.
    Bleeding will be a problem if you do this. You
    will need to reverse it afterward.
  • Consider sedation (If no epidural) (Fentanyl)
  • Find the cleavage plane b/t placenta and uterus
  • Advance fingertips cleaving the placenta free.
  • If no cleavage plane, consider abnormal
    placentation like accreta and need for OR

13
Post partum Hemorrhage
  • Retained placenta due to abn implantation
  • Placenta accreta
  • Firm attachment to myometrium. 4 of previas have
    this.
  • Placenta increta
  • Invasion of myometrium.
  • Placenta percreta
  • Invades through myometrium.

14
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15
PPH Uterine inversion
  • 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

16
PPH Uterine inversion
  • Uterus not replaceable due to contraction ring
  • Nitroglycerin 100 mcg IV
  • If this fails, needs to go to OR for general
    anesthesia

17
PPH - Coagulopathy
  • Treat cause
  • Maintain fibrinogen gt 100 mg / dl with FFP /
    Cryoprecipitate
  • Maintain Plt count gt 50,000
  • Specific factor replacement for known coagulation
    diseases
  • 4 Ts

18
OB Case 2
  • 27 yr G1P0 is in active labor. Her pregnancy was
    uncomplicated. She was complete at 1300. At
    1415 she delivers an OA Head over an intact
    perineum. A turtle sign is noted. You suction
    the fetal mouth and nose and then assist
    restitution of the head. Despite maternal
    pushing, you are unable to deliver the baby over
    the next minute.

19
OB Case 2
  • What do you do next?

20
Shoulder Dystocia
  • Definition Delivery in which the anterior
    shoulder of the baby is impacted against the
    maternal symphysis pubis and is not deliverable
    in 60 seconds.
  • Common!!!
  • Risk Factors - ???

21
Shoulder Dystocia
  • Risk Factors
  • Prior shoulder dystocia
  • Diabetes
  • Prolonged gestation
  • Fetal macrosomia
  • Maternal obesity

22
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23
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24
Erbs Palsy
25
Shoulder Dystocia
  • Fetal macrosomia
  • Fetal wt 2500 4000 gm 0.3 1
  • (Note that 50 of shoulder dystocias occur in
    this group)
  • Fetal wt gt 4000gm ---gt RR 11
  • Fetal wt gt 4500gm ---gt RR 22
  • (EFW off by 3 lbs (!!!) in 6 patients in one
    study)
  • (Ultrasound error is easily /- 10)

26
Shoulder Dystocia
  • Prevention
  • Maintenance of good glycemic control in pregnant
    diabetic women decreases fetal macrosomia
  • Elective C-section for fetal macrosomia?

27
Shoulder Dystocia
  • Elective C-section for EFW gt4500 grams in
    non-diabetic women
  • 3600 C-sections to prevent one permanent brachial
    plexus injury

28
Shoulder dystocia Treatment
  • H
  • E
  • L
  • P
  • E
  • R
  • R

29
Shoulder dystocia Treatment
  • Help (call for)
  • Episiotomy (consider)
  • Legs (McRoberts Maneuver)
  • Pressure (suprapubic)
  • Enter vagina (Internal maneuvers)
  • Remove the posterior arm
  • Roll the patient

30
Shoulder dystocia
  • McRoberts position

31
McRoberts / Suprapubic pressure
32
Shoulder dystocia
  • Treatment
  • Enter vagina
  • Rotate anterior shoulder (Apply pressure to
    posterior aspect of shoulder)
  • Woods screw maneuver Apply pressure to the
    anterior aspect of the posterior shoulder while
    continuing to rotate the anterior shoulder also.
  • Reverse Woods screw maneuver

33
Shoulder dystocia
  • Remove posterior arm
  • Roll pt onto hands / legs
  • Last resort measures
  • Fracture clavicle
  • Zavanelli maneuver
  • Hysterotomy
  • Symphysiotomy

34
OB Case 3
  • 27 yo female G2 P1001 at 40 2/7 is in spontaneous
    active labor.
  • She complains of mod pain in between her
    contractions that was relieved with her epidural.
  • Mild bleeding with contractions.
  • PMHx uncomplicated
  • Social Hx uncomplicated/normal/low risk

35
OB Case 3
  • On exam, Cx is 8-9cm / 100 / - 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

36
OB Case 3
  • What are your concerns? Ddx?
  • How would you manage this patient?

37
Third trimester bleeding
  • Placenta abruption
  • Placenta previa
  • Vasa previa
  • Uterine rupture

38
Placental Abruption
  • Painful third trimester bleeding.
  • 1120 pregnancies, approx. 1.
  • Recurrence rate of 10.
  • Port wine stained amniotic fluid.

39
Placental Abruption
40
Placental Abruption
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42
Placental Abruption Risk factors
  • Hypertensive diseases of pregnancy
  • Trauma
  • Drug use - cocaine
  • Smoking/poor nutrition
  • Twins/polyhydramnios

43
Placental Abruption Treatment
  • Trauma - 2 large bore IVs for IVF / blood
    products as needed.
  • 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 - must have 200-300cc blood to be
    visible. If no prior U/S, you need to r/o
    placenta previa

44
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45
Placental Abruption
46
Placental Abruption Treatment
  • If term, then deliver. Consider controlled
    induction if patients are stable.
  • If preterm, weigh risks of continued pregnancy
    against risks of complications from preterm
    delivery.

47
Placenta Previa
  • Painless third trimester vaginal bleeding
  • 1200 pregnancies in 3rd trimester
  • 150 grand multiparas,11500 nulliparas
  • Risks
  • Prior c-section
  • Prior uterine instrumentation
  • High parity

48
Placenta previa Treatment
  • Complete
  • C-section
  • Marginal
  • Vaginal delivery can be considered under a
    double setup status in the OR

49
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50
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51
Placentation
52
Vasa Previa
  • Fetal vessel crosses presenting membranes
    (velamentous insertion)
  • Occurs in pregnancies with low lying placenta
  • Rare (13000)
  • Bleeding is fetal
  • Mortality is high

53
Vasa Previa
54
Vasa Previa
  • Prevention
  • Membrane palpation before amniotomy

55
Special Labs
  • Wright stain Blood from vagina.
  • Look for nucleated rbcs
  • Apt test Mix blood from vagina with tap water.
    Mix with NaOH.
  • Fetal Hgb pink
  • Maternal Hgb brown

56
Special tests
  • 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

57
Kleihauer-Betke Test
58
Uterine rupture
  • Major risk is prior c-section
  • Warning sign Variable deceleration
  • Do not take lightly in a TOLAC patient

59
OB Case 4
  • 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 LD
  • Within 5 seconds of your arrival, the pt has an
    obvious seizure

60
OB Case 4
  • What do you do?

61
Pre-eclampsia
  • Defined
  • BP gt 140 systolic or gt 90 diastolic on two
    occasions more than six hours apart.
  • Proteinuria of gt 300 mg / 24hours
  • Affects 5-8 of pregnancies
  • Risk factors include first pregnancy, multiple
    gestation, chronic HTN, pregestational diabetes.

62
Severe Pre-eclampsia
  • BP gt160 / 110
  • Proteinuria gt 5 grams / 24 hours
  • Oliguria (lt500 ml urine / 24 hours)
  • Elevated Cr
  • Pulmonary edema
  • HELLP syndrome
  • Symptoms indicating other end organ damage (RUQ
    pain / HA / Visual change) or
  • Seizure (Eclampsia)

63
Eclampsia
  • Seizure in pregnancy at or near term usually
    associated with Pre-eclampsia
  • May occur up to 48 hours after delivery. 70
    intrapartum / 30 postpartum.
  • Risk factors Similar to Pre-eclampsia
  • 1150 - 13500

64
Eclampsia - Treatment
  • Protect the airway
  • Get Help
  • Magnesium sulfate 6 grams IV over 20 minutes.
    Start gtt at 2gm/hr.
  • If already on Magnesium sulfate, immediately
    bolus 2 grams IV over 20 minutes.
  • Oxygen

65
Eclampsia - Treatment
  • What do you do when the seizure is over?

66
Early decelerations
67
Variable decelerations
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69
Variable decelerations - severe
70
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71
Late decelerations
72
Late Decelerations
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74
Variable deceleration with late component
75
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77
Fetal Tachycardia
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79
Sinusoidal Pattern
80
Non Stress Test (NST)
  • 24 yr old G2P1 at 41 weeks. Post-dates NST

What is the expected outcome of this pregnancy?
81
Why we do OB!!! ?
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