1 / 26

Obstetrical emergencies

Obstetrical emergencies. Nancy E Fay MD FACOG Division of Reproductive Medicine. 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 >500-700 cc/minute 15% of cardiac output

igantt
Télécharger la présentation

Obstetrical emergencies

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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 >500-700 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: • Ectopic • 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 100-120 • 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 1950 1/30,000 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 11-25% • Two sections 35-47% • 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

More Related