5 3 Obstetrical Emergency M

Obstetrical Emergency Management I
Department of Emergency Medicine Johns Hopkins University Center for International Emergency Disaster and Refugee Studies
Objective
Pregnancy Hyperemesis gravidum Ectopic pregnancy Spontaneous Abortions Placenta previa Abruptio placenta Prolapsed cord
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Center for International Emergency Disaster and Refugee Studies Obstetrical Emergency Management
Introduction
In Tanzania, the maternal mortality rate per 100,000 deliveries was 180 for all of Tanzania yet this varied from a high of 514 in Lindi to 56 in Mtwara. The rate of deliveries at antenatal clinics in Tanzania is 86.2%. The percent of deliveries at health facilities by trained traditional birth attendants was 39.4% for all of Tanzania. Patients returning with complications (at health facilities under the care of traditional birth attendants) is 39.2%. These statistics demonstrate that obstetrical problems like gynecological - are leading forms of morbidity and mortality and also probably underreported yet remain among the 20 health problems in Tanzania.
Pregnancy
Any woman of childbearing age presenting to the ED is pregnant until proven otherwise Signs and symptoms Missed, light, or late menstrual period Breast swelling and tenderness at 4 weeks Fatigue, nausea, and frequency at 5-6 weeks Cervical softening Chadwicks sign Uterus enlarged and soft at 6-8 weeks
Center for International Emergency Disaster and Refugee Studies
Obstetrical Emergency Management
Pregnancy: Physiologic changes
Cardiac

Increased: heart rate, cardiac output Decreased: blood pressure

Normalizes 3rd trimester
Respiratory

Increased: respiratory rate, tidal volume Decreased: functional residual volume, pCO2
Blood composition

Increased: blood volume, WBCs, clotting factors Decreased: hematocrit

Emergency Delivery
Emergency Delivery
Emergency Delivery
Emergency Delivery
Emergency Delivery
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Medications for Emergency Delivery and Indications for Use

Medication oxytocin 10u/cc Dose infuse two liters of 20 units/liter 0.9 NS solution. 0.2 mg IM 5-10mg IVP q 3-5 min to treat diastolic BP > 110 mm-hg bolus 4-6 grams IV over several minutes 1 amp (10cc) IVP 10mg/kg loading, followed by second loading dose of 5mg/kg 2 hours later 0.25 SC q 3 hours 50 mics (1cc) q hour 1-10cc locally 5-10 mg IV 0.8 mg to 2 mg IV Indication give routinely for uterine contraction and hemostasis immediately post partum control of post partum hemorrhage control of hypertensive crisis (to diastolic BP 80-90 mm-hg) first line control of eclamptic seizures magnesium toxicity second line drug for eclamptic seizures tocolysis short acting narcotic analgesic local anesthetic nausea and vomiting** (see below) narcotic overdose
methyl ergonovine (Methergine) hydralazine 20mg/cc magnesium sulfate (50% solution: 5grams/10cc, ) calcium gluconate 10% phenytoin terbutaline sulfate 1mg/cc fentanyl (50mics/cc) lidocaine (Xylocaine) 1% prochlorperazine (Compazine) 10mg/2cc naloxone (Narcan) 0.4 mg/cc
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Tanzanian guidelines
For uterine stimulation after delivery

5 units of oxytoicin after delivery of the infant is acceptable after routine deliveries. If no response occurs then oxytocin IV infusion of 10-20 units in 1 liter of NS running at 10-20 dpm.
Second line medication: ergometrine IM 0.5 mg after delivery of the infant, in the absence of myometrial contraction and to prevent postpartum hemorrhage.
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Emergency Delivery
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Complications of pregnancy
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Preterm Delivery:

A major cause of precipitous childbirth and is often the cause of emergency delivery. Preterm infants also more often present in the breech position and are associated with greater incidence of infant morbidity and mortality. Care must be taken to deliver the infant slowly and immediately dry and warm the infant while performing the initial assessment, as the premature infant is much more likely to require resuscitation.
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Preterm Delivery:
In the event that the delivery of a newborn whose gestation is less than 36 weeks is anticipated, the casualty officer should advise and facilitate steroid therapy to prevent respiratory distress syndrome. Tanzanian national guideline advise:
Drug of choice: hydrocortisone IV 250 mg and repeat after 24 hours Second choice: dexamethasone IV 12 mg, two does at an interval of 12 hours
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Maternal Complications:

Immediately after the delivery of the infant, the umbilical cord is clamped and the placenta is delivered. The placenta should be allowed to separate spontaneously, assisted with gentle traction only. Aggressive traction on the cord risks uterine inversion, tearing of the cord or disruption of the placenta which can result in severe vaginal bleeding. After the removal of the placenta, the uterus should be gently massaged to promote contraction. Oxytocin (20 units in 1 liter 0.9 NS at a moderate rate) is infused to maintain uterine contraction. Uterine atony may follow a precipitous delivery and may lead to excessive vaginal bleeding.
Additional oxytocin may be administered, as well as methyl ergonovine (Methergine) 0.2mg (IM only) or prostaglandin F-2 alpha (Hemabate) 0.25mg IM.
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Hyperemesis gravidum
Intractable vomiting with weight loss Hypokalemia and/or ketonemia Cause is unknown Treatment: IV hydration, anti-emetics, correction of electrolyte abnormalities Monitor urinary ketones
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Tanzanian treatment guidelines

If vomiting is not excessive, advise women to take small but frequent meal and drinks In persistent vomiting cases search for other reasons such as UTI, multiple or molar pregnancy. Otherwise give: Drug of choice: promethazine (O) 25 mg at night OR chlorpheniramine (O) 4 mg at night Second choice (severe cases only): prochlorperazine (O) 5 mg up to 3 times per day For hyperemesis gravidum (with vomiting and dehydration): Admit and give dextrose 5% IV and add, Promethazine (IM) 25 mg twice daily OR prochlorperazine (IM) 12.5 mg twice daily
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Ectopic pregnancy
Leading cause of maternal death in 1st trimester Usually: 5-8 weeks after LMP Classic triad (only present in 15%)
Amenorrhea, followed by Abdominal pain Abnormal vaginal bleeding
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2% of all pregnancies
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Ectopic pregnancy
Risk factors (present in < 50%) History of PID, previous ectopic, tubal surgery or sterilization procedure Endometriosis, Use of superovulating agents/reproduction techniques IUD
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Ectopic pregnancy
Diagnosis Pregnancy test Pelvic ultrasound Serial quantitative hcGs Culdocentesis
http://www.advancedfertility.com/pics/ectopicuterus132.jpg
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Ectopic pregnancy
Laparoscopic visualization of ampullary ectopic pregnancy

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Ectopic pregnancy
Treatment Large bore IV and fluid resuscitation Lab work (CBC, Rh type, crossmatch) Rhogam, if appropriate Definitive therapy
Methotrexate Laparoscopic salpingectomy Laparotomy
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Spontaneous abortions

Vaginal bleeding in first half of pregnancy 30-40% of women have 1st trimester bleeding 50% miscarry Most in first 8 weeks Risk factors:
Advanced maternal age, previous abortions, infections (syphilis, HIV), anatomic abnormalities, exposure to tobacco, drugs, toxic agents
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Diagnositic modalities Lab tests
CBC Blood type and Rh B-HCG quantitative Urinalysis
Ultrasound
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Threatened abortion Inevitable abortion Incomplete abortion Complete abortion Missed abortion
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Threatened abortion

Vaginal bleeding without passage of products of conception or cervical dilation Cervical os closed Most common cause of bleeding in primiparous Treatment:

Bedrest and pelvic rest, Rhogam if needed, Follow-up with obstetrician in 2 to 3 days
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Inevitable abortion
Vaginal bleeding without passage of products of conception (POC) Cervical os open, Treatment:
Dilation and curretage Rhogam
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Incomplete abortion
Vaginal bleeding with POC at os or in vaginal canal Cervical os open Treatment:
Visible POC should be gently removed to control bleeding Dilation and curretage Rhogam
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Complete abortion

Passage of all POC Cervical os closed Bleeding almost stopped Uterus contracted Treatment:
Dilation and curretage

Unless complete expulsion confirmed by inspection of passed POC or ultrasound
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Rhogam
Missed abortion

In utero death of embryo or fetus with retained POC Cervical os closed

Blighted ovum, anembryonic pregnancy, or fetal demise Pregnancy test converts from positive to negative
Treatment:

Induction of labor Dilation and curretage Rhogam

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Vaginal bleeding in the second half of pregnancy
Potentially life-threatening to mother and fetus Delay pelvic speculum and digital exam Differential Placenta previa Abruptio placenta Others: cervicovaginal lesions, Premature Rupture of Membranes
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Placenta previa

Implantation of the placenta in the lower uterine segment Covers all or part of cervical os Presentation: Painless bright red bleeding 3rd trimester Risk Factors:
Prior C/S, grand multiparity, previous placenta previa, multiple gestations, multiple induced abortions, maternal age > 40
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Placenta previa
http://www.drapplebaum.com/images/Placenta_Previa.JPG
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Placenta previa
Treatment IV access, lab work (CBC, T&C), IVF Establish cardiac and fetal monitoring Emergent OB/GYN consult Ultrasound for placental location, if stable Pelvic exam (digital and speculum) should not be done* Unstable patients require immediate delivery by C-section Rhogam
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Abruptio placenta
Premature separation of normally implanted placenta from the uterine wall causing visible or hidden bleeding
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Abruptio placenta
Presentation:

Painful bright red bleeding 3rd trimester Sometimes only pain is present
HTN, smoking, chronic alcohol, cocaine, multiparity, increased maternal age, previous abruption, abdominal trauma
Risk Factors:
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Abruptio placenta
Treatment IV access, lab work (CBC, T&C, DIC profile), IVF Establish cardiac and fetal monitoring Emergent OB/GYN consult Ultrasound to R/O placenta previa, if stable Stable patients may be observed in the hospital Unstable patients require immediate delivery by C-section Rhogam
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Prolapsed cord
Protrusion of the umbilical cord through the cervical os. May occur up to 19% of the time in a footling breech delivery
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Prolapsed cord
Presentation:

Fetal distress Umbilical cord in the vagina or through cervical os at time of vaginal exam
Malpresentation, polyhydramnios, multiple gestation, ROM without head engagement, prematurity
Associated with:
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Prolapsed cord
Treatment
Check the fetus for fetal heart tones Place patient in deep trendelenberg Lift the presenting part off cord & cervix Do NOT remove hand or palpate cord Emergent OB/GYN consult for CSection
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Case
23 year old female G0P0 presents with vaginal spotting and lower abdominal pain. Vital signs: normal blood pressure, slightly tachycardic PE: abdominal tenderness in the LLQ, small amount of blood in the vaginal vault, left adnexal tenderness, no mass felt Urine pregnancy +
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What is your differential diagnosis?

Case
Management
Lab tests
CBC: within normal limits Type and Rh: O+ Urinalysis: negative for infection B-HCG: 6500
Ultrasound
No intrauterine pregnancy, + gestational sac in left adnexa, not ruptured
What is diagnosis? How would you manage it?

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Obstetrical Emergency Management II

Department of Emergency Medicine Johns Hopkins University Center for International Emergency Disaster and Refugee Studies
Overview
Hypertension in pregnancy Preeclampsia HELLP syndrome Eclampsia Postpartum Hemorrhage Uterine inversion Amniotic fluid embolus Endometritis
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Hypertension in pregnancy
Blood pressure

> 140/90 20 mmHg rise in systolic blood pressure 10 mmHg rise in diastolic blood pressure
All hypertensive pregnant women need to be evaluated Associated with several dangerous complications Difficult to differentiate transient hypertension from others
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Preeclampsia
Definition
20th week to 1-2 weeks postpartum Elevated blood pressure
Systolic: 140 or 20 above baseline Diastolic: 90 or 10 above baseline
Proteinuria Edema
Hands, face, or generalized
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7% of pregnancies
Preeclampsia
Presentation Headache, visual disturbances, abdominal pain, edema

Predisposing factors Primigravida- > 60% of cases Age: extremes (<17 or >35) Pregnancies associated with a large placenta History of chronic HTN or renal disease Family history of preeclampsia or PIH
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Preeclampsia
Treatment
HTN is only finding

Order 24 urine, Decrease activity, Home BP monitoring, OB follow up in 2-3 days
Other findings present (proteinuria)

Hospitalization
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Preeclampsia
Prevent seizures
Magnesium sulfate
Antihypertensive therapy
Systolic BP > 170 or diastolic BP >110 Hydralazine Labetolol
Definitive treatment: delivery

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HELLP syndrome
Severe form of preeclampsia with

Hemolysis Elevated Liver enzymes Low Platelets (<100,000)
Multigravidas 5-10% of preeclamptic patients
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HELLP syndrome
Presentation
RUQ pain with nausea and vomiting +/- elevated blood pressure
Treatment
Admission Antihypertensive medication Definitive: Delivery
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Eclampsia
Definition
Preeclampsia plus generalized seizure or coma
May occur up to 10 days postpartum Major cause of maternal death is ICH Warning signs
HA, visual disturbances, hyperreflexia, and abdominal pain

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Eclampsia
Treatment
Control seizures
Magnesium sulfate Phenytoin in lower doses
Control hypertension
Hydralazine Labetolol
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No diuretics Definitive treatment: delivery

Eclampsia
Tanzanian treatment guidelines advise:
that to stop convulsions use Diazepam IV infusion 40 mg diluted in 100 ml of NS infused over 6 hours If diastolic pressure still > 110 mm, give antihypertensive:
hydralazine (IM) 12.5 mg intermittently Nifedpine (SL) 10 mg
Plan urgent delivery
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Postpartum hemorrhage
Definition
Hemorrhage: > 500cc post vaginal delivery
Most common complication of labor and delivery 5-8% of all deliveries 25% of obstetric deaths Immediate or delayed types

<24 hours >24 hours 6 weeks postpartum

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Causes
Uterine atony (most common) Uterine rupture/inversion Obstetric trauma, vaginal tears Retained products of conception Abnormal placental attachment
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Presentation
Signs of trauma Enlarged, doughy uterus Vaginal mass Uterine bleeding with good uterine tone and normal size: retained POC.
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Treatment
IVF and/or packed RBCs Oxytocin Local repair of lacerations OB/GYN consult
Evaluation Operative repair
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Uterine inversion
Definition
Inversion of uterus through the cervix or vaginal introitus
Associated with immediate hemorrhage Rare: 1 of 2000 to 2500 deliveries Risk factors

Traction on umbilical cord during labor Primiparity, fundal implantation of uterus, fundal pressure during delivery, use of oxytocin
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Uterine inversion
Presentation

Sudden onset severe pain Tenderness with absence of uterine corpus Visualization of uterus in vault or introitus Manual repositioning Do NOT remove placenta if still attached Uterine relaxing agents: terbutaline, MgSO4 Surgical repositioning
Treatment

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Manual repositioning of a uterine inversion

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Amniotic fluid embolus
Definition

Release of amniotic fluid into the maternal circulation during intense contractions Anaphylactoid-like maternal response
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Most common during labor Leading cause of death in induced abortions and miscarriages Rare: 1/8000 - 1/80,000 births Mortality 60%
Amniotic fluid embolus
Classic Pentad

Respiratory distress Cardiovascular collapse Cyanosis Hemorrhage Coma Cardiovascular resuscitation Intubation and oxygenation Treatment for DIC
Treatment

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Endometritis
Definition
Ascending infection of the uterus
3% vaginal deliveries Usually 2-3 days postpartum Most polymicrobial causes Minor illness to sepsis Risk factors
C/S, PROM, prolonged labor, excessive pelvic examination, obesity, diabetes, hypertension
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Endometritis
Presentation

Fever Malaise Lower abdominal pain Foul-smelling lochia Look for retained POC Lab tests: CBC, urinalysis, cervical and blood cultures Broad spectrum antibiotic Hospitalization
Treatment

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Case
23 year old female G0P0 presents with facial, hand, and leg swelling over the past week. Also states that she has had a headache for the same amount of time Vital signs: BP170/100 HR 90 RR 14 PE:+ edema generalized, mild abdominal discomfort Urinalysis: 2+ protein What are the three most important hypertensive diseases in pregnancy?
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Case
Lab studies
CBC, electrolytes, LFTs, PT/PTT, 24 urine Hospitalization Begin antihypertensive therapy

Hydralazine 2.5mg initially, then 5-10mg
Treatment

Prevent seizures with MgSO4 No diuretics
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Obstetrical Emergency Management I

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Pregnancy: Physiologic changes

Increased: heart rate, cardiac output Decreased: blood pressure

Increased: blood volume, WBCs, clotting factors Decreased: hematocrit

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Medications for Emergency Delivery and Indications for Use

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

For uterine stimulation after delivery

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Tanzanian treatment guidelines

Amenorrhea, followed by Abdominal pain Abnormal vaginal bleeding

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Diagnosis Pregnancy test Pelvic ultrasound Serial quantitative hcGs Culdocentesis

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Laparoscopic visualization of ampullary ectopic pregnancy

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

CBC Blood type and Rh B-HCG quantitative Urinalysis

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Dilation and curretage Rhogam

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Dilation and curretage

In utero death of embryo or fetus with retained POC Cervical os closed

Induction of labor Dilation and curretage Rhogam

Vaginal bleeding in the second half of pregnancy

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies

Obstetrical Emergency Management

Center for International Emergency Disaster and Refugee Studies