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

HTTPS://YOUTU.BE/TNN1FPWHOXS

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

HTTP://WWW.JOACC.COM/ARTICLE.ASP?ISSN=2249-4472;YEAR=2015;VOLUME=5;ISSUE=1;SPAGE=3;EPAGE=8;AULAST=SADERA;TYPE=3

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

THE END! THANK YOU!