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Dr. A.Abudaber
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
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
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
Intrapartum Pitocin augmented / induced labor Prolonged third stage Instrument assisted vaginal delivery Shoulder dystocia Episiotomy / Laceration
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
Pitocin 20 units in 1 liter LR. IV bolus beginning with delivery of anterior shoulder of infant
Massage uterus Inspect vaginal vault / cervix / placenta
If not responding to above measures: Methergine 0.2 mg IM. Can repeat every 6-8
hrs. 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
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 placental
insertion problem and need for OR
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.
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
Uterus not replaceable due to contraction ring: Nitroglycerin 100 mcg IV
If this fails, needs to go to OR for general anesthesia
Treat cause Maintain fibrinogen > 100 mg / dl with
FFP / Cryoprecipitate Maintain Plt count > 50,000 Specific factor replacement for known
coagulation diseases
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 head over the next minute.
What do you do next?
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 - ???
Risk Factors Prior shoulder dystocia Diabetes Prolonged gestation Fetal macrosomia Maternal obesity
Fetal macrosomia Fetal wt 2500 – 4000 gm: 0.3 – 1% (Note that 50% of shoulder dystocias occur in
this group) Fetal wt > 4000gm ---> RR 11 Fetal wt > 4500gm ---> RR 22
EFW . Clinical Vs US
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 non-diabetic 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
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.
Reverse Wood’s’ screw maneuver
Remove posterior arm Roll pt onto hands / legs
Last resort measures Fracture clavicle Zavanelli maneuver Hysterotomy Symphysiotomy
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. PMHx: uncomplicated Social Hx: uncomplicated/normal/low risk
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
What are your concerns? Ddx? How would you manage this patient?
Placenta abruption Placenta previa Vasa previa Uterine rupture
Painful third trimester bleeding. 1:120 pregnancies, approx. 1%. Recurrence rate of 10%. Port wine stained amniotic fluid.
Hypertensive diseases of pregnancy Trauma Drug use - cocaine Smoking/poor nutrition Twins/polyhydramnios
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
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.
Painless third trimester vaginal bleeding 1:200 pregnancies in 3rd trimester 1:50 grand multiparas,1:1500 nulliparas Risks:
Prior c-section Prior uterine instrumentation High parity
Complete C-section
Marginal Vaginal delivery can be considered under a
“double setup” status in the OR
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?
Defined BP > 140 systolic or > 90 diastolic on two
occasions more than six hours apart. Proteinuria of > 300 mg / 24hours
Affects 5-8% of pregnancies Risk factors include first pregnancy,
multiple gestation, chronic HTN, 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)
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 1:150 - 1:3500
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 Benzos?
What do you do when the seizure is over?
Review of common findings on fetal monitoring
24 yr old G2P1 at 41 weeks. Post-dates NST:
What is the expected outcome of this pregnancy?