OB Emergencies

Question 1

T Reasons for Hemorrhage

Answer 1

Tone (uterine)
Trauma (rupture, laceration of cervix)
Tissue (retained products)
Thrombin ( ex, coagulopathy)
Turned inside out (uterine inversion)

TELEPHONE CALL for help MTP!!!

Question 2

4 risk factors for highest odds of predicting massive transfusion

Answer 2

Abnormal Placentation (1.6/10K deliveries)
Placental Abruption (1.0/10K deliveries)
Severe Preeclampsia (.8/10K deliveries)
Intrauterine fetal demise (.7/10K deliveries)

Question 3

Why do we check a fibrinogen level?

Answer 3

Low is MOST predictive variable for EARLY Hemorrhage
Goal is greater than 200mg/dl
GIVE EARLY!!!!

Question 4

TXA for PPH

Answer 4

Tranexamic acid –give within 3 hours
Lysine analogue
Prevents fibrinolysis
Competitively blocks plasminogen and plasmin
TXA half life is 2-3 hours with normal renal fxn
1 gram in 100cc over 10min
1 gram in 250cc over 8hr infusion

Question 5

OB Emergencies

Answer 5

Maternal Hemorrhage:
- Antepartum/Intrapartum
- Placental abruption
- Uterine rupture
- Location of placenta

Fetal Injury
- Prolapsed cord
- Shoulder Dystocia

Question 6

Umbilical Cord Prolapse

Answer 6

Acute fetal bradycardia
ROM+palpated cord in vagina
STAT C/S
May be on all fours

Question 7

What is placental abruption?

Answer 7

Premature separation of normally implanted placenta
1 in 86 deliveries
Blood loss can be concealed
DIC in 4-10% deliveries
15% 3rd trimester still births

Question 8

Placental Abruption: Risk Factors

Answer 8

Multiparity
Age>35
Preeclampsia
Chronic HTN
ETOH abuse
Cocaine use
Smoking/PROM/Abdominal Trauma
Previous history of abruption

Question 9

Placental Abruption: Clinical Presentation

Answer 9

Vaginal bleeding dark blood/clots
Shock with minimal visible blood loss
Abdominal pain
hypertonicity
U/S=clot
Often concealed

Fetal distress

GOOD NEWS:
90% are mild or moderate
SEVERE= Stat C/S

Question 10

Uterine Rupture Risk Factors

Answer 10

1 in 2000-2500 deliveries
3 ruptures in 1000 deliveries in pt with prev c/s
Leading cause is previous uterine scar
VBAC (most common UR- prev C/S)
Multiparity
Previous uterine surgery-myomectomy
Previous uterine rupture
Hx prior c/s and induction of labor
“Classical” c/s with vertical incision
Fetal macrosomia/malposition
Rapid labor
Prolonged labor with CPD
Parity >7 increased incidence of rupture is 20 times that of lower parity women

STAT C/S + Control hemorrhage

Question 11

Uterine Rupture symptoms

Answer 11

INITIAL signs sudden /individualized
Fetal bradycardia /variable decel (70%)
Hypotension (5-10%)
Vaginal bleeding (3-5%)
Uterine atony/ recession fetal head- rarer
severe abdominal/uterine pain
pain that does not decrease with ctx
STAT C/S + MTP

Question 12

TOLAC and uterine rupture

Answer 12

RARE TOLAC with uterine rupture of those:
1 in 4 serious outcome:
hysterectomy /vented/blood transfusion/death/5 min Apgar<4 or vented

Question 13

Different types of abnormal placentation

Answer 13

Placental Previa
Placenta accreta, increta, percreta

Question 14

Placenta Previa –location r/t OS

Answer 14

Implantation over or too close to the cervical os
Dx with Transvaginal U/S
1 in 250 deliveries
Most detected early U/S

Question 15

Placenta Previa -

Answer 15

BRIGHT RED painless bleeding
Usually 3rd trimester
For stable placenta previa elective C/S with blood products available
2 large bore IVs and blood products in room etc

Question 16

Abnormally Implanted Placenta

Answer 16

Accreta = absence of decidua basalis
Increta = invades myometrium
Percreta =thru serosa

U/S and confirmed by MRI

Undiagnosed if placenta does NOT separate at vaginal delivery or C/S

Earlier diagnosis allows plan development/tertiary care center

Question 17

Abnormal Implantation- PAS

Answer 17

Adherent placenta leads to significant hemorrhage
Average EBL for PAS cases 2-5 liters
40% of cases require more than 10 units of blood products
Neuraxial anesthesia pros and cons/ planned conversion to general at time if needed study by Markley has conversion rate of 21%

Question 18

Risk Factors-abnormal implantation

Answer 18

Accreta(76%)
Increta(18%)
Percreta(6%)
Multiparity
Previous C/S
Current PL. PREVIA
IVF pregnancy
Elevated 2nd trimester alpha fetal protein and Bhcg
Hx Post partum Hemmorhage,uterine surgery,
AMA

Question 19

Silver RM etal. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology. 2006.107(6):1226-1232……????? why…

Answer 19

Red flag: in cases of previa there is INCREASING risk of Accreta w each c/s

1999-2002
30,132 c/sections without labor 19 institutions
Placenta accreta
1st c/s=15(.24%) 4th c/s=31(2.13%)
2nd c/s=49(.31%) 5th c/s=6 (2.33%)
3rd c/s=36(.57%) 6th c/s=6 (6.74%)

Now in those 723 with known PREVIA….
1st c/s risk of accreta 3%
2nd c/s risk of accreta 11%
3rd c/s risk of accreta 40%
4th c/s risk of accreta 61%

Question 20

Placenta Accreta Spectrum Acog consensus no 7

Answer 20

Most accepted approach is cesarean hysterectomy with the placenta in situ
Multidiscipinary team- designated maternity centers
Delivery at 34 weeks -35 6/7 weeks is optimal
Corticosteroids for lung maturity
MT planned
?Post delivery MT uterine artery embolization
(rate increasing noted acog 2021 reaffirmed… cites 2016 study as 1 in 272 USA deliveries)

Question 21

Should have how many units ready with PAS?

Answer 21

T&C for 6 units is recommended by recent retrospective studies(published Jan 2023)

Designated Maternity Tertiary Care Center

Question 22

AFE: Anaphylactoid Syndrome of Pregnancy

Answer 22

1941 1st described by Steiner and Lusbaugh
Limitations… self reporting and limited pts 2 early registries
Change of term Anaphylactoid syndrome of pregnancy

Question 23

Pathophysiology of AFE

Answer 23

1st described as presence of amniotic fluid debri,squamous fetal cells in pulmonary circulation of the mother…embolic “theory”
Immune response in mother to fetal antigens
Amniotic fluid contains vasoactive and procoagulant substances(thromboxane, bradykinin,cytokines etc)…immunologic “theory”

Question 24

NEW-2 phase model of AFE

Answer 24

1st phase rapid respiratory and cardiac arrest
2nd phase hemorrhagic
Bleeding wound site: placental attachment or cesarean incision
Rapidly DIC
Dx of exclusion

Question 25

AFE diagnostic criteria basics

Answer 25

Sudden onset of cardioresp arrest or hypotension with evidence of respiratory compromise
DIC (scoring sxn Plt, INR, fibrinogen low)
Clinical onset during labor or within 30 minutes of placental delivery
Absence of fever(> 38 degrees c) during labor
(1/4 of all cases of AFE are atypical cases)

Question 26

Amniotic Fluid Embolism? risk factors ?

Answer 26

AMA
Preeclampsia/ Placenta Previa
C/S
Uterine Rupture
Manual removal of placenta
Endocervical laceration
CONSIDER RiaSTAP(IV fibrinogen)2gram

Question 27

Summary AFE clinically seen by

Answer 27

Resp and cardiac arrest
PEA, Pulmonary HTN, Right sided heart failure, RV Failure with severe Tricuspid Regurg
Seizures
Platelet degranulation/Pulmonary HTN due to serotonin/thromboxane
DIC

Question 28

AFE– USA updated: stats

Answer 28

1: 14,000-1:16,000
Majority at time of delivery (can occur <48hr after delivery and others)
Could be via labor or c/s- “distress”
Mortality rate 20-22%
Most babies survive neurologically intact
Pulmonary vasoconstrictors lead to right heart failure….hypoxia… tissue factors from
amniotic fluid cause DIC

Question 29

AFE update review

Answer 29

Mast cell degranulation/Complement activation
*Mast cell degranulation in aternal lunges in fatal AFE cases-serum tryptase levels in fatal cases AFE 7-10 times that of controls
*
Hypothesis immunologic mechanism-release vasoactive substances-fetal antigens
Tx coagulopathy promptly:FFP, cryo, fibrinogen concentrate and antifibrinolytics
Serum tryptase levels in fatal cases 7-10 times higher than controls

Question 30

Society for MFM special statement

Answer 30

Cognitive aid checklist /immed CPR/MANUAL LUD/differential dx /ABCs
Time keeper one minute intervals
No pulse at 4 minutes PMCD resuscitative hysterotomy “splash prep- location”
Interosseous line humerus uterotonics /MTP
Cryo preferred over FFP
Reduce volume overload/ TXA if DIC
Manage Pulmonary HTN/ Right Heart failure
Consider early TTE or TEE
Avoid overload 500cc bolus reassess
1st line pressor is Norepi .05-3.3mcg/kg/min
Inotropes(Dobutamine/Milrinone)
Then Pulmonary vasodilator…. ECMO

Question 31

A-OK case reports

Answer 31

Atropine 1mg atropine
Ondansetron 8mg
Ketolorac 15mg
Others have added Metoclopramide
Baylor College of Medicine registry for AFE
307-363-2337 tel support; registry@afesupport.org
(Rezai etal Case Rep Obstet Gynecol 2017 Atypical AFE case report .2mg Atropine, Ondansetron 8mg and Ketolorac 15mg)

Question 32

Manual LUD

Answer 32

Question 33

AHA website comments-updated 2015 ACLS

Answer 33

Back board +Two handed Manual LUD
Emergency Cesarean Delivery in Cardiac Arrest individualized
PMCD may be considered part of maternal resuscitation regardless of fetal viability
***
Survival of mother has been reported after 15 minutes of cardiac arrest
Neonatal survival has been documented with PMCD performed up to 30 minutes after maternal arrest
Not recommended to have cricoid pressure in maternal resuscitation-cardiac arrest-no data to support
*

Question 34

ACLS goals

Answer 34

High quality CPR AND Relief of aortocaval compression- 2cm
Continuous Manual LUD if fundus height at or above level of umbilicus
IV access above diaphragm/ remove internal monitors/stop IV Magnesium give Calcium chloride or calcium gluconate
NO DELAY Perimortem cesarean delivery considered at 4 minutes after onset of maternal arrest—ie futile maternal trauma

Question 35

AHA updated 2015

Answer 35

Survival of mother has been reported after 15 minutes of cardiac arrest
Neonatal survival has been documented with PMCD performed up to 30 minutes after maternal arrest
Post arrest care -targeted temp management and multidisciplinary team

32-36 degrees for 1st 24 hours post ROSC// and onward/ focus hemostasis TTM and multidisciplinary team

Question 36

ACLS for Obstetric cardiac/resp arrest: BEAUCHOPS

Answer 36

Bleeding/DIC
Embolism: coronary/pulmonary/AFE
Anesthetic complications
Uterine atony
Cardiac disease (MI/aortic diss/cardiomyopathy)
HTN- PEC with severe features
Other-5Hs 5Ts
Placenta Abruption/Placenta Previa/PAS
Sepsis

Question 37

Def: Pregnancy –Related Death

Answer 37

Death of a woman during or within one year of pregnancy that was caused by a pregnancy complication, a chain of events initiated by pregnancy, or the agravation of an unrelated condition by the physiologic effects of pregnancy

Question 38

Maternal Mortality

Answer 38

Estimated 25% of maternal deaths are due to hemorrhage/uterine atony

Risk of death increases w/maternal age >35

African American race more likely to die
Overall Maternal Mortality rates in the USA
17.4 per 100,000 live births

Nonhispanic black 37.1 per 100K live births
Nonhispanic white 14.7 per 100k live births
Hispanic 11.8 per 100K live births

Question 39

Maternal Mortality Trends

Answer 39

Maternal Mortality rates 2.5 times higher in Non hispanic Blacks

Trends 1999-2018
PEC and Eclampsia are declining
Chronic HTN increasing
Rise and fall with diabetes mellitus
AFE is declining

Question 40

Severe Maternal Morbidity

Answer 40

New trends looking at 2012-2014 National Inpatient sample- has 20% of hospitalizations in US
Obstetric readmissions racial disparities
Of 11 million births 1.8% admitted post partum- most common dx transfusion
nonhispanic black women had 80% higher risk of postpartum readmission
Pulmonary edema and acute heart failure
SUMMARY:
Estimated 35-40% cases of maternal mortality or severe maternal mortality are preventable
Only 5.5% of anesthetics OB for c/s are GA in US- think regional first
Centers for Excellence team approach for AIP abnormal invasive placenta (PAS)
Obesity increases the risk of venous thromboembolism, c/s del, endometritis. failed trial of labor