1. Dr. A.Abudaber

2.  Case based studies to learn the evaluation and management of OB emergencies

3.  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

4.  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: 2 nd degree perineal tear repair done  1344: Mild bleeding intermittently  1430: P increase 102 to 125. Feels lightheaded. MD called back to room

5.  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

6.  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.  Management of anemia in pregnancy  Appropriate labor management  Appropriate pt selection for induction  Third stage management

8.  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

9.  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.  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

11.  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.  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

13.  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.  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

15.  Uterus not replaceable due to contraction ring:  Nitroglycerin 100 mcg IV  If this fails, needs to go to OR for general anesthesia

16.  Treat cause  Maintain fibrinogen > 100 mg / dl with FFP / Cryoprecipitate  Maintain Plt count > 50,000  Specific factor replacement for known coagulation diseases

17.  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.

18.  What do you do next?

19.  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 - ???

20.  Risk Factors  Prior shoulder dystocia  Diabetes  Prolonged gestation  Fetal macrosomia  Maternal obesity

22.  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

23.  Prevention:  Maintenance of good glycemic control in pregnant diabetic women decreases fetal macrosomia  Elective C-section for fetal macrosomia?

24.  Elective C-section for EFW >4500 grams in non- diabetic women  3600 C-sections to prevent one permanent brachial plexus injury

25. HELPERRHELPERR

26.  Help (call for)  Episiotomy (consider)  Legs (McRoberts Maneuver)  Pressure (suprapubic)  Enter vagina (Internal maneuvers)  Remove the posterior arm  Roll the patient

27.  McRoberts position

29.  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

30.  Remove posterior arm  Roll pt onto hands / legs  Last resort measures  Fracture clavicle  Zavanelli maneuver  Hysterotomy  Symphysiotomy

31.  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

32.  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

33.  What are your concerns? Ddx?  How would you manage this patient?

34.  Placenta abruption  Placenta previa  Vasa previa  Uterine rupture

35.  Painful third trimester bleeding.  1:120 pregnancies, approx. 1%.  Recurrence rate of 10%.  Port wine stained amniotic fluid.

39.  Hypertensive diseases of pregnancy  Trauma  Drug use - cocaine  Smoking/poor nutrition  Twins/polyhydramnios

40.  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

43.  If term, then deliver. Consider controlled induction if patient s are stable.  If preterm, weigh risks of continued pregnancy against risks of complications from preterm delivery.

44.  Painless third trimester vaginal bleeding  1:200 pregnancies in 3 rd trimester  1:50 grand multiparas,1:1500 nulliparas  Risks:  Prior c-section  Prior uterine instrumentation  High parity

45.  Complete  C-section  Marginal  Vaginal delivery can be considered under a “double setup” status in the OR

48.  What is the role of the digital vaginal exam?

49.  Fetal vessel crosses presenting membranes (velamentous insertion)  Occurs in pregnancies with low lying placenta  Rare (1:3000)  Bleeding is fetal  Mortality is high

50.  Prevention  Membrane palpation before amniotomy

51.  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

52.  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

54.  Major risk is prior c-section  Warning sign: Variable deceleration  Do not take lightly in a TOL patient

55.  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

56.  What do you do?

57.  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.

58.  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)

59.  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

60.  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?

61.  What do you do when the seizure is over?

62.  Review of common findings on fetal monitoring

77.  24 yr old G2P1 at 41 weeks. Post-dates NST: What is the expected outcome of this pregnancy?