Obstetric emergencies Flashcards
Etiology of postpartum hemorrhage
Primary
Secondary
Consider the 40s, tone, trauma, tissue, thrombin Atony 70-80% Vaginal laceration Retained placenta Morbidly adherent placenta Coagulation defects Uterine inversion
Secondary causes include Subinvolution of the placenta site Retained POC Infection Inherited coagulation defects
What causes acute coagulopathy in obstetric patients?
Placental abruption and amniotic fluid embolism
Medical management of PPH
TXA 1 g every three hours
Oxytocin 10 to 40 units IV or 10 units IM
Methylergonovine 0.2 mg every 2 to 4 hours
15-methyl PGF2alpha 0.25 mg every 15 to 90 minutes
Miso 600 to 1000 µg Oral, sublingual, rectal
Surgical and procedural interventions for PPH
Uterine artery embolization, success rate 89%, 43% infertility
Vascular ligation 92%
Uterine compression sutures, B Lynch, 60 to 75%, number one chromic suture
Hysterectomy associated with a bladder injury right up to 12% and ureteral injury rate of up to 41%
Rest of placenta accreta in women with a previa after one through five C-section
3% 11% 40% 61% 67%
What is the appropriate management for placenta accret With ongoing vaginal bleeding after vaginal delivery
Plan for hysterectomy, activate massive transfusion
patient to the OR, attempt a D&C
Laparotomy may be required.
Hysterectomy is recommended Due to 20% risk of recurrent
Management of inverted uterus
If it occurs before the placenta detaches, do not remove the placenta
Administer uterine relaxant such as terbutaline, mag sulfate, nitroglycerin (50 mcg). Manual replacement with a closed fist exerting upward pressure circumferentially towards the fundus
Huntington procedure, progressive upper traction on the inverted uterus using Babcock or Alice forcep
Haultain procedure- Inside the cervix posteriorly
Went to initiate massive transfusion protocol
Ongoing bleeding with estimated blood loss of 1500 mL and women with abnormal vital signs
What is the appropriate initial transfusion ratio for RBC and FFP?
When should cryo-precipitate be administered
1:1
If DIC is suspected or fibrinogen is low. This is commonly in the setting of placental abruption and amniotic fluid embolism
What causes Erb palsy?
Klumpke?
Injury to C5-6 (waiter’s tip)
C8-T1
Describe management of shoulder dystocia
Call for help
Assigned someone to time maneuvers
Reassure the patient and encourage her to relax and listen for instructions
Placed the patient and McRoberts position and administer suprapubic pressure
Release of posterior arm
If this doesn’t work, try Rubin maneuver (place hand on back of fetal shoulder and rotate anteriorly) or Wood screw (front of fetal shoulder)
Gaskin maneuver
Zavenelli
Symptoms of lidocaine toxicity
Metallic taste Perioral numbness TINNITUS Slurred speech and blurred vision Altered consciousness Convulsions Cardiac arrhythmias Cardiac arrest
Mouth>ears>eyes>CNS>heart
Management of diabetic ketoacidosis during pregnancy
- Fluids, total replacement 4-6 L in the first 12 hours. Electrolytes hourly
- Correct abnormal potassium
<3.3, hold insulin and give 20-30 meq
>3.3 but <5 add 20-30 meq per 1L fluid - Insulin. Start a regular insulin IV, load .1 to .2 units per KG and begin continuous infusion at .1 units per KG per hour until Glucose <200
- Bicarbonate if pH<7
Maternal complications of Shoulder dystocia
Postpartum hemorrhage
Higher degree perineal lacerations
Lateral femoral cutaneous neuropathy
Symphyseal separation
Risk factors for shoulder dystocia
Excessive Maternal weight or weight gain Pitocin use Operative vaginal delivery Epidural use Prolonged second stage
