Post on 01-Aug-2020
OB/GYN EMERGENCIESElyse Watkins, DHSc, PA-C, DFAAPA
DISCLOSURES
I have no financial relationships to disclose.
TOPICS
Ovarian torsion
Ruptured ectopic pregnancy
Acute menorrhagia
Placental abruption
Postpartum hemorrhage
Acute uterine inversion
Amniotic fluid embolism
OVARIAN TORSION
OVARIAN TORSION
Tumors (benign and malignant) are implicated in 50-60% of cases of torsion
20% occur during pregnancy (corpus luteum cyst)
Unilateral or bilateral abdominal-pelvic pain, usually sudden onset
Exercise or movement exacerbates pain
Nausea and vomiting 70%
Pathophys: reduced venous return, stromal edema, internal hemorrhage, and infarction → necrosis
OVARIAN TORSION
Physical exam variable
Ultrasonography with color Doppler
Surgical referral
RUPTURED ECTOPIC PREGNANCY
RUPTURED ECTOPIC PREGNANCY
All patients of reproductive age with a hx of missed menses and pelvic pain should be considered to have an ectopic pregnancy until proven otherwise.
A patient with missed menses, irregular vaginal bleeding, pelvic pain, syncope, abdominal pain, and/or dizziness should be managed as a ruptured ectopic pregnancy until proven otherwise.
RUPTURED ECTOPIC PREGNANCY
Physical exam of pts with a ruptured ectopic can reveal pelvic tenderness, an adnexal mass, and evidence of hemodynamic compromise.
A transvaginal ultrasound will often show an adnexal mass and/or fluid in the pouch of Douglas.
The serum qualitative βHCG will be > 5 mIu/mL.
RUPTURED ECTOPIC PREGNANCY
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RUPTURED ECTOPIC PREGNANCY
Immediately order an H/H, type and cross, and place large bore IV access for fluid support.
Laparotomy is performed when patients are hemodynamically unstable or if visualization during laparoscopy was difficult.
Patients with a ruptured ectopic pregnancy must be managed emergently and surgically!
ACUTE MENORRHAGIA
ACUTE MENORRHAGIA
Abnormal uterine bleeding (AUB) can result in acute blood loss that causes hemodynamic compromise so prompt evaluation of vital signs is important.
Can occur as a single episode or in a pt with a hx of AUB.
The hx should focus on duration of bleeding and a quantification of bleeding:
How many pads and/or tampons are being used and how frequently the patient is changing them.
ACUTE MENORRHAGIAA careful physical examination must include a pelvic exam to locate the source of bleeding.
Use the PALM-COEIN system:
P: polyps
A: adenomyosis
L: leiomyoma
M: malignancy
C: coagulopathy
O: ovulatory dysfunction
E: endometrial
I: iatrogenic
N: not otherwise classified
ACUTE MENORRHAGIAIf consistent heavy menses since menarche, abnormal surgical or dental bleeding, hx of postpartum hemorrhage, unexplained epistaxis or bruising, and/or a fam hx of blood dyscrasia should be evaluated for a platelet or coagulation disorder.
Young women, particularly adolescents, should be tested for Von Willebrand’s disease.
Laboratory tests must include a CBC with differential, serum β-HCG, and type and cross.
Hemostatic disorders: include PTT, aPTT, and fibrinogen
Von Willebrand disease: include VWF antigen
ACUTE MENORRHAGIAPharmacologic interventions include:
Conjugated equine estrogen 25 mg IV every 4 – 6 hours for a max of 24 hours in the absence of contraindications.
Medroxyprogesterone acetate 20 mg orally TID x 7 days (can be used if the patient cannot use estrogen but has no contraindications to progestins).
Tranexamic acid (TXA) is an important component of managing acute hemorrhage!
TXA 1.3 grams orally or 10 mg/kg IV for a maximum of 600 mg every 8 hours x 5 days.
TXA should NOT be used in patients with a hx of a thrombotic/thromboembolic event and used with caution in patients currently taking hormonal contraception.
ACUTE MENORRHAGIA
Fluid support is essential.
•2 L of isotonic sodium chloride solution or lactated Ringer’s solution
Is it necessary to provide supplemental O2?
ACUTE MENORRHAGIATransfusion:
4 U of packed red blood cells (PRBCs) with 4 U of fresh frozen plasma (FFP).
2 units O-negative noncrossmatched blood (start type-specific blood when available).
Pts who require large amounts of transfusion likely will develop a coagulopathy.
If not already given: FFP when the pt shows signs of coagulopathy, usually after 6-8 U of PRBCs.
Platelets become depleted with large blood transfusions.
Platelet transfusion is also recommended if a coagulopathy develops.
ACUTE MENORRHAGIA
Surgical/interventional options include dilation and curettage, uterine artery embolization, and hysterectomy.
Endometrial ablation and insertion of a progestin-secreting IUS can help prevent further episodes of bleeding.
PLACENTAL ABRUPTION
PLACENTAL ABRUPTION
Premature separation of a normally implanted placenta
PLACENTAL ABRUPTIONMay present with vaginal bleeding, pain, and evidence of fetal distress on external monitor.
The absence of vaginal bleeding does not rule out an abruption as the hemorrhage can remain uterine!
Maternal hypertension is the leading cause of placental abruption.
An abruption can be seen in patients with acute trauma, such as a motor vehicle accident, assault, or a fall.
Tobacco use and cocaine use are strongly associated with risk of placental abruption.
Placental abruption is associated with DIC.
PLACENTAL ABRUPTION
Do not perform a digital exam on a pregnant patient with vaginal bleeding in the late 2nd
or 3rd trimester without first assessing the location of the placenta!
PLACENTAL ABRUPTION
Ultrasound: used to rule out placenta previa and to find a retroplacental hematoma
(classic for placental abruption)
PLACENTAL ABRUPTION
Classification is based on extent of separation (ie, partial vs complete) and the location of separation (ie, marginal vs central).
Class 0 - Asymptomatic
Class 1 - Mild (48% of all cases)
Class 2 - Moderate (27% of all cases)
Class 3 - Severe (24% of all cases)
PLACENTAL ABRUPTIONClass 1: Mild
•No sign of vaginal bleeding or a small amount of vaginal bleeding.
•Slight uterine tenderness
•Maternal blood pressure and heart rate WNL
•No signs of fetal distress
Class 2: Moderate
•No sign of vaginal bleeding to moderate amount of vaginal bleeding
•Significant uterine tenderness with tetanic contractions
•Change in vital signs: maternal tachycardia, orthostatic changes in blood pressure.
•Evidence of fetal distress
•Clotting profile alteration: hypofibrinogenemia
Class 3: Severe
•No vaginal bleeding to heavy vaginal bleeding
•Tetanic uterus/ board-like consistency on palpation
•Maternal shock
•Clotting profile alteration: hypofibrinogenemia and coagulopathy
•Fetal death
PLACENTAL ABRUPTIONManagement: Conservative
1. Expectant management with continuous fetal monitoring
Indications: when both mother and fetus are stable and the fetus is < 34 weeks gestation
2. Vaginal delivery
Indications:
fetus is ≥ 36 weeks gestation, vaginal delivery is preferable if there are no indications for cesarean delivery
if the patient is not in active labor then amniotomy and oxytocin administration can be used
PLACENTAL ABRUPTION
Operative:
Immediate delivery via cesarean (vertical incision is usually the incision of choice as it is associated with less blood loss and preferred for preterm pregnancies).
Indications:
non-reassuring fetal status
hemodynamic instability of the mother
PLACENTAL ABRUPTIONEmergency management of moderate to severe:
Administer supplemental O2
Continuous fetal monitoring
IV fluids: aggressive fluid resuscitation if needed
Labs: Hemoglobin, Hematocrit, Platelets, Prothrombin time/activated partial thromboplastin time, Fibrinogen, Fibrin/fibrinogen degradation products, D-dimer, Blood type/Rh, BUN
Monitor vital signs and urine output
Crossmatch 4 units of PRBCs; transfuse if necessary
Amniotomy to decrease intrauterine pressure, extravasation of blood into the myometrium, and entry of thromboplastic substances into the circulation
Amniotomy video: https://www.youtube.com/watch?v=nJJmjKQeSs4
Treatment of coagulopathy or DIC
PLACENTAL ABRUPTIONMain ideas
Potentially a medical/surgical emergency
Suspect in any gravid patient with third trimester bleeding
Differentiate between abruption and placenta previa
Previa is painless
Never perform a pelvic/digital exam without first assessing location of placenta
Fetal demise and maternal hypovolemic shock/death can result
Prompt recognition and management is essential
POSTPARTUM HEMORRHAGE
POSTPARTUM HEMORRHAGE (PPH)
PPH is the leading cause of morbidity and mortality among pregnant patients worldwide.
The most common causes of primary PPH include uterine atony, lacerations, placenta accrete, retained placenta, coagulopathy, and uterine inversion.
Definition: cumulative blood loss ≥1000 mL, or blood loss with evidence of hypovolemia that occurs within 24 hours after the intrapartum and/or postpartum period independent of mode of delivery.
Video: Quantifying blood loss https://youtu.be/F_ac-aCbEn0
POSTPARTUM HEMORRHAGE (PPH)
As soon as a PPH is suspected, the rapid response team should be notified.
Uterine massage should continue.
If not already in place, two large-bore IV catheters should be inserted and high-flow oxygen (10-15 L/min via face mask) should be administered.
Isotonic crystalloids are the preferred fluids to help maintain urine output >30 mL/hour.
POSTPARTUM HEMORRHAGE (PPH)
A balloon tamponade can be inserted if the patient is hemodynamically stable.
Pharmacologic tx includes:
Oxytocin, methylergonovine, carboprosttromethamine, and tranexamic acid.
POSTPARTUM HEMORRHAGE (PPH)Oxytocin: 10 units IM with an expected response in 3 -5 minutes.
If given intravenously, use 40 units in 1 liter of NS or LR but avoid a bolus injection of oxytocin.
Tranexamic acid TXA: 1 gram intravenously every 24 hours.
should be given with within three hours of delivery
Methylergonovine: 200 mcg IM.
Can be injected directly into the myometrium as well.
Do not administer methylergonovine intravenously.
If no response in 3 – 5 minutes/no improvement is seen, add carboprosttromethamine 250 mcg IM every 15 minutes for a maximum of 8 doses.
Carboprost should never be given intravenously and should be avoided in asthmatic patients
POSTPARTUM HEMORRHAGE (PPH)
Blood products: 2 units of packed red blood cells with plasma and platelets.
Most institutions use a 1:1:1 ratio of RBCs:FFP:platelets.
If DIC is suspected, cryoprecipitate should be administered.
Surgical options include arterial embolization, laparotomy, and hysterectomy.
ACUTE UTERINE INVERSION
ACUTE UTERINE INVERSION
Will appear as a bleeding mass at the introitus after a vaginal delivery.
Caused by manual pulling force on the umbilical cord during delivery of the placenta.
Inversion can also occur with a short umbilical cord, excessive fundal pressure, or rapid removal of the placenta.
Massive hemorrhage and pain will be present.
ACUTE UTERINE INVERSION
Manual replacement of the uterus should be attempted but may require the use of anesthesia, tocolysis, and Pitocin
Manual replacement involves using the palm or fist of one hand and placing upwards pressure with the fingers.
In refractory cases, hysterectomy may be required
AMNIOTIC FLUID EMBOLISM
AMNIOTIC FLUID EMBOLISM
Rare, but mortality around 90%
Typical presentation: acute respiratory distress after pushing during delivery or immediately after the delivery.
Early signs include cough, altered mental status, cyanosis and hypoxia, fetal bradycardia and hypoxia, and hypotension.
Causes pulmonary vascular obstruction, pulmonary hypertension, cor pulmonale and left ventricular failure, shock, hypoxia, and DIC/hemorrhage
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AMNIOTIC FLUID EMBOLISM
Management:
Delivery of infant if not done yet
O2, CPR/ACLS
Evaluate for coagulopathy → massive transfusion protocol
Evaluate RV failure with transthoracic echo
Norepineprhine to maintain BP and dobutamine if RV failure occurs
Avoid over-hydrating as RV failure occurs
LV failure follows RV failure → cardiogenic pulmonary edema
AMNIOTIC FLUID EMBOLISM
The following must be present to diagnose AFE:Cardiac arrest or hypotension
Acute hypoxia
Severe hemorrhage or coagulopathy when other etiologies have been ruled out
Occurring during labor and delivery, cesarean, dilation and evacuation, or within the 30 minutes postpartum, when other etiologies have been ruled out
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