OBSTETRIC EMERGENCIES

OBSTETRIC EMERGENCIES Maternal Fetal Both mother and fetus at risk

HEMORRHAGE PREPARTUM/INTRAPARTUM: Placenta previa Placenta accreta/increta/percreta Placental abruption Uterine rupture POSTPARTUM: Retained placenta Uterine atony Uterine inversion Birth trauma/laceration

NON REASSURING FETAL HEART RATE ANTEPARTUM: Umbilical cord prolapse Umbilical cord compression Uteroplacental insufficiency AT DELIVERY: Shoulder dystocia Vaginal breech delivery (head entrapment)

PLACENTA PREVIA 1 in 200-250 deliveries Complete, partial or marginal Most diagnosed early resolve by third trimester ETIOLOGY: Unknown Previous uterine scar Previous placenta previa Advanced maternal age Multiparity

PLACENTA PREVIA Painless vaginal bleeding-third trimester Vaginal bleeding in 3rd trimester should be considered previa until proven otherwise Ultrasound has eliminated the need of double set up to diagnose previa as in the past Cesarean delivery Expectant management if fetus immature and no active bleeding Urgent/emergent cesarean delivery for active or persistent bleeding or fetal distress

PLACENTA ACCRETA/ INCRETA/PERCRETA Placenta accreta, increta and percreta difficult to diagnose antepartum Usually diagnosed when placenta doesn’t separate after cesarean or vaginal delivery Color Doppler imaging or magnetic resonance imaging may diagnose the condition antepartum Preoperative balloon catheters in internal iliac can be considered in cases diagnosed antepartum. Prompt decision for hysterectomy

PLCANTA ACCRETA/ INCRETA/PERCRETA Good IV access/ A line Cross matched blood FFP/Cryo/Factor VII/Platelets Emergency hysterectomy more blood loss than elective hysterectomy Hemodilution/red cell salvage can be considered.

PLACENTAL ABRUPTION I ETIOLOGY: Cocaine Hypertension: Chronic or pregnancy induced Trauma Heavy maternal alcohol use Smoking Advanced age and parity Premature rupture of membranes History of previous abruption

PLACENTAL ABRUPTION Vaginal bleeding-Classical presentation May not always be obvious 3000 ml or more blood can be sequestered behind placenta in concealed bleeding Uterus can’t selectively constrict abrupted area Decreased placental area-fetal asphyxia 1 in 750 deliveries-fetal death Severe neurological damage in some surviving infants Upto 90% abruptions-mild to moderate

PLACENTAL ABRUPTION Problems: Hemorrhage, Consumptive coagulopathy, Fetal hypoxia, Prematurity Low fibrinogen/ Factor V, Factor VII and platelets and increased fibrin split products Management depends on severity of situation Vaginal delivery-Fetus and mother stable Urgent/Emergent LSCS- Fetal distress or severe hemorrhage Be prepared for massive blood loss. uterus may not contract after delivery On rare occasions, internal iliac ligation/hysterectomy may be necessary

UTERINE RUPTURE Prepartum, intrapartum or postpartum ETIOLOGY: Prior cesarean delivery especially classical cesarean scar Rupture of myomectomy scar Precipitous labor Prolonged labor with cephalopelvic disproportion Excessive oxytocin stimulation Abdominal trauma Grand multiparity Iatrogenic Direct uterine trauma-forceps or curettage

UTERINE RUPTURE Severe uterine or abdominal pain or shoulder pain Disappearance of fetal heart tones Vaginal or intraabdominal bleeding Hypotension VBAC: Change in uterine tone or contraction pattern and FHR changes and not pain during uterine rupture Emergent SURGERY may be necessary Uterine repair/Hysterectomy depending on situation

RETAINED PLACENTA 1% of deliveries Ongoing blood loss Manual exploration for removal You need uterine relaxation and analgesia anesthesia depending on clinical situation

UTERINE ATONY Most common cause of postpartum hemorrhage Follows 2-5% deliveries ETIOLOGY: Multiparity Polyhydramnios Macrosomia Chorioamnionitis Precipitous labor or excessive oxytocin use during labor Prolonged labor Retained placenta Tocolytic agents Halogenated agents >0.5 MAC

UTERINE ATONY Vaginal bleeding > 500 ml Manual examination of uterus Volume resuscitation Infusion of oxytocics + bimanual compression of uterus Evaluation for retained placenta

OXYTOCIC DRUGS Oxytocin:20-40U/L-Vasodilation, hypotension, hyponatremia, no benefit after 40 U Methylergonovine:0.2 mg IM, Max. 0.4 mg- Vasoconstriction, ↑PA pressures, coronary artery vasospasm, hypertension, CVA, nausea and vomiting Carboprost or hemabate (prostaglandin F2α analog): 0.25 mg IM or IU, Max 1.0 mg – Vasoconstriction, systemic and pulmonary hypertension, bronchospasm, V/Q mismatch, nausea, diarrhea Misoprostol 800 mg PR. Minimal side effects

UTERINE INVERSION Uncommon problem Results from inappropriate fundal pressure or Excessive traction on umbilical cord especially if placenta accreta is present Mass in the vagina Uterine atony Maternal shock and hemorrhage Volume replacement Analgesia for the procedure Uterine relaxation for replacement Oxytocics following replacement

BIRTH TRAUMA/LACERATIONS Lesions range from laceration to retroperitoneal hematoma requiring laparotomy Can result from difficult forceps delivery/ Precipitous vaginal delivery/ Malpresentation of fetal head (OP)/ Laceration of pudendal vessels/ Clinical presentation of postpartum bleeding with contracted uterus Anethesia depending on the clinical scenario

FETAL HEART RATE Baseline fetal heart rate, variability, decelerations or accelerations Normal FHR: 110-160 bpm Tachycardia: Maternal fever, infection, terbutaline, atropine, hyperthyroidism, tachyarrythmia, hypoxemia Bradycardia: Fetal autonomic response to baroreceptor or chemoreceptor stimulation Fetal cardiac output: Rate dependent Variability: Most reliable index of fetal well being; variability is baseline fluctuations in FHR over 2 cycles/min Can be absent, minimal (<5 bpm), moderate (6-25 bpm) or marked (>25 bpm)

NON REASSURING FETAL HEART RATE (INTRAPARTUM) UMBILICAL CORD PROLAPSE: Acute fetal bradycardia Cord palpable in vagina Membrane rupture with head not well applied to cervix-High station/breech presentation Push presenting part away from cervix Emergency section.

NON REASSURING FETAL HEART RATE UMBILICAL CORD COMPRESSION: Variable decelerations Nonreassuring if slow return to baseline or severe (<60 bpm from baseline for over 60 seconds) and repetitive May be associated with ↓ amniotic fluid from ruptured membranes or oligohydramnios Changing maternal position, oxygen, amnioinfusion, discontinuation of oxytocin may help Expeditious delivery may be necessary Regional/GAdepending on clinical scenario

NON REASSURING FETAL HEART RATE UTEROPLACENTAL INSUFFICIENCY: Late decelerations Cause for concern if repetitive Postdates, preeclampsia, diabetes, IUGR Uterine resuscitation: change of maternal position, IV fluids, oxygen, discontinuation of oxytocin and administration of tocolytic agents (terbutaline) Regional/GA depending on clinical scenario

NON REASSURING FETAL HEART RATE(AT DELIVERY) SHOULDER DYSTOCIA: Postterm pregnancy, diabetes, maternal obesity, macrosomia and shoulder dystocia in previous pregnancy Extension of episiotomy/flexion of mother’s legs against abdomen, suprapubic pressure, fractures of clavicles Anticipation: Epidural-relaxed perineum surgery

NON REASSURING FETAL HEART RATE BREECH (HEAD ENTRAPMENT): True obstetric emergency Smaller body pushed through partially dilated cervix trapping aftercoming head Vaginal breech delivery-Discouraged 5% vs.1.6% deaths-Vaginal vs. C/D (Study in 2000 women) Incisions in cervix to enlarge opening or skeletal muscle and cervical relaxation or CD Epidural-prevents early pushing before cervix is fully dilated and relaxes the perineum GA may be necessary for uterine and perineal relaxation

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