Download Obstetrical Emergencies

Obstetrical Emergencies
James Ducey MD
Director of Maternal-Fetal Medicine
Stanen Island University Hospital
Definition
A suddenly developing pathologic
condition in a patient, due to accident
or disease, which requires urgent
medical or surgical therapeutic
intervention
Stanen Island University Hospital
Common Emergencies
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Hypertensive Disorders
Hemorrhage
Trauma
Shoulder Dystocia
Umbilical Cord Prolapse
Acute Abdomen
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Uncommon Emergencies
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Sepsis
Respiratory Failure
Heart Failure
Renal Failure
Aplastic anemia
ITP and HUS
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Immediate Obstetric Hemorrhage
Cause
• Lacerations
• Atony
• Abruptio
• Retained placenta
• Previa Accreta
• Rupture
• Inversion
Incidence
• 1:8
• 1:20-1:50
• 1:80-1:150
• 1:100-1:160
• 1:200
• 1:2000-1:2500
• 1:6400
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Lacerations
• First thing to be ruled out in bleeding post
partum woman with a firm uterus
• Careful examination of the entire genital
tract
• Rarely results in massive blood loss
• May be life threatening if extends to the
retro peritoneum
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Atony
• Most common cause of significant blood
loss and blood transfusion
• Generally responds to uterine massage and
uterotonic drugs
• Hemabate 250 micrograms IM every 15
mins. very effective, not more than 8 doses
Stanen Island University Hospital
Abruption
• Delivery is generally indicted unless the
fetus is very premature and both the mother
and fetus are stable
• DIC occurs in 4-10% of cases and usually is
apparent by 8 hours after onset if symptoms
• Renal failure is the most common cause of
maternal mortality
Stanen Island University Hospital
Previa
• Transvaginal ultrasound is highly accurate
in making diagnosis (PPV 93%, NPV 98%)
• Preterm delivery frequently needed due to
excessive blood loss or fetal compromise
• Amniocentesis to documents fetal lung
maturity at 36 weeks in stable patients prior
to c/section
Stanen Island University Hospital
Accreta
• Absence of decidua basalis and imperfect
formation of the fibrinoid layer (Nitabuch)
• Inccreta in myometrial invasion
• Perccreta the placenta goes through to the
serosa
• Most frequently seen now when a woman
with a previous c/section has placenta
overlying the uterine scar.
Stanen Island University Hospital
Rupture
• Frequently the result of uterine scar
disruption
• Incidence has increased with the increase of
c/sections and VBAC’s
• Blood loss is usually not severe
• Surgical repair usually satisfactory
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Inversion
• Usually occurs when the placenta is fundally
implanted
• Don’t attempt to deliver placenta until there have
been signs of separation
• Prompt replacement is generally easier.
• Halothane or nitroglycerine are effective agents
• Uterotonics then needed to contract the uterus
Stanen Island University Hospital
New Therapies
• B-Lynch Brace Suture
• Angiography and selective embolization
• Recombinant activated Factor VII
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B-Lynch Suture
• Br J Obstet Gynecol 1997 CB Lynch
describes a simple technique that he and
others have reported excellent success
• Patient is placed in a modified lithotomy
position with the abdomen open to visually
asses the bleeding
• If bimanual uterine compression controls
the bleeding the suture is placed
Stanen Island University Hospital
B-Lynch Suture
• # 2 chromic on a rounded needle is used
• The suture punctures the uterus in the lower
uterine segment 3 cm from the lateral edge,
enters the endometrial cavity and emerge s
2 cm superior (in the region of the lateral
edge of a low transverse c/s scar if that had
been performed)
Stanen Island University Hospital
B-Lynch Suture
• The suture is then passed over the fundus 3-4 cm
medial to the cornua
• It is then placed through the posterior wall of the
uterus transversely at the same level of the anterior
placement
• It is the passed over the opposite cornua and
through the anterior lower segment mirroring the
opposite side and tied across the midline
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Arterial Embolization
• J Reproductive Med 1987 Feinberg etal
reported a case of delayed postpartum
bleeding successfully treated with this
technique
• There have been several series now
published that have established the
effectiveness and safety
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Recombinant Activated Factor VII
• Novoseven is FDA approved for bleeding
episodes in hemophilia patients
• It has been effective in nonhemophiliac
patients with extensive organ damage,
hemorrhage and coagulopathy that did not
respond to transfusion
Stanen Island University Hospital
Recombinant Activated Factor VII
• Arch Gynecol Obstet 2003 Segal etal Israel
• 3 Ob cases with severe bleeding
unresponsive to surgery and massive
transfusion
• Dose 90-100micrograms/kg
• Bleeding stopped in 2 cases and reduce in 1
• All patients survived
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Recombinant Activated Factor VII
• Obstet Gynecol 2004 Merchant etal New
Mexico
• 3 cases of HELLP with liver hematoma
• Bleeding was controlled in all cases with
Novoseven
Stanen Island University Hospital