1. Obstetrical emergencies
Nancy E Fay MD FACOG
Division of Reproductive Medicine

2. Obstetrical Hemorrhage
Blood volume expands by 40%
RBC’s increases by 30% = hemodilution
Fibrinogen is double the non-pregnant level
Uterine blood flow at term > cc/minute 15% of cardiac output
Blood loss for vaginal delivery <500 cc
Blood loss for c-section <1,000 cc

3. First trimester bleeding
Light bleeding:
Implantation
Ectopic
Polyp or cervical irritation
Heavy
Threatened AB
Heavy bleeding:
Inevitable or incomplete AB

4. Categories of hemorrhage
Class I
Loss of 15% of blood volume
No change in clinical status
BP, RR and HR unchanged
Class II
Loss of 15-35% blood volume
Tachycardic
Tachypneic 20-24
Cool, pale and clammy

5. Categories of hemorrhage
Class III
30-40% of blood volume
Altered mental status
Hypotensive, HR >120
Class IV
>40% of blood volume
Altered mental status or minimal responsiveness
Hypotensive, tachycardic, no urine output

6. Blood loss Soaked raytec=50 cc Soaked lap=100 cc Coke can=350 cc
2 cups=500 cc
Weigh to measure

7. Incidence of hemorrhage
1-5% of deliveries and increasing a result of atony
Developed world 1/100,000 deliveries
Third world 1/1,000 deliveries
After delivery bleeding slows as a result of
Uterine contraction
Local PA-1 from decidua and clotting factors
Any alteration of above results in hemorrhage

8. Uterine atony Causes 80% of postpartum hemorrhage
Immediate most common
Delayed most likely from retained products of conception
Uterus not palpable postpartum

9. Treatment of atony Massage: external vs bimanual
Confirm no retained placental or membrane products
Empty the bladder
IV access if none, and bolus IV fluids
Medications
Oxytocin
Misoprostol
Methyl ergonovine
Hemabate/carboprost

10. Surgical treatment OB Alert/Massive transfusion protocol
Laparotomy: ligation of uterine arteries
B Lynch procedure
Other surgical control of atony
Uterine balloon or packing
Hysterectomy
Interventional radiology

11. B Lynch Procedure

12. Risk factors for Atony Induction of labor
Prolonged labor or precipitous delivery
Over-distended uterus: macrosomia, multiples, polyhydramnios etc…
Prior hemorrhage***
Preeclampsia, abruption, previa, trauma
Grand multiparity
Coagulopathy
Infection

13. Delayed hemorrhage Usually retained tissue Other risk factors Evacuate
Increased likelihood of infection
Asherman’s syndrome risk

14. Anatomic causes for bleeding
Cervical lacerations
Vaginal lacerations
Vaginal hematoma
Uterine inversion
Cause
Replacement medication

15. Placenta accreta
Abnormal decidualization allow villi invade myometrium
Accreta=myometrial superficial invasion
Increta=deep myometrial invasion
Percreta=serosal invasion and beyond
Incidence: In /30,000 pregnancies
1980 1/2,500
1990 1/500

16. Placenta percreta

17. Risk factors
Location of implantation: lower uterine segment, cervix, cornua
Scars in decidua: c-section, myomectomy, multiple D&C’s, Asherman’s Syndrome, septum resection
Uterine anomalies
Grand multiparity

18. Accreta incidence One prior section=0.3% Two prior sections=0.6%
Three prior sections=2.4%
If concurrent previa: No scar 1-5%
One section %
Two sections %
Three sections >40%

19. Diagnosis of accreta Antepartum ultrasound, confirm with MRI Treatment
Prior to delivery
How to deliver
When to deliver
Discovery after vaginal delivery

20. Uterine rupture
With prior one low transverse c-section, incidence <1%
With two prior LTV c-sections?
With classical c-section?
First sign of uterine rupture in trial of labor or VBAC?
Trauma
Drug use/abuse

21. Placenta Previa
“________” third trimester vaginal bleeding

22. Placenta previa Complete central, partial, marginal vs low lying
Incidence at term 1%, in second trimester?

23. Risk factors for previa
Prior section
Prior uterine surgery: D&C’s or myomectomies, septum resections etc…
Increasing parity
Multiple gestation
Prior previa

24. Management of previa Risk to fetus: IUGR, stillbirth, prematurity
Preterm labor risk
Mode of delivery….?
Timing of delivery: No bleeding
With bleeding
At hemorrhage…
Steroid use
Magnesium sulfate neuroprotection
Historic “double set-up”

25. Placental abruption
“____________” third trimester vaginal bleeding

26. Placental abruption
Marginal, concealed, complete