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Pregnant Women Are Scary! Objectives Take a Deep Breath…

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Pregnant Women Are Scary! Objectives Take a Deep Breath… 4/2/2020 Expert Management of OB Emergencies for PAs: Pregnant Women are Scary! Kristin Lyerly, MD, MPH, FACOG Women’s Care of Wisconsin 1 Objectives Diagnosis and initial management of common obstetrical emergencies Birth Bleeding Leaking fluid Headache Respiratory illness Chest pain/Shortness of breath Trauma 2 take a deep breath… 3 1 4/2/2020 Basic Emergency Care ABCs History Physical Vital Signs Labs? Imaging? Blood? 4 Obstetric Assessment Gestational age ‐ report, ultrasound or fundal height Viability ‐ Doppler or ultrasound Bleeding? Pain? Labor? Do you need an ultrasound for viability, presentation or gestational age? 5 Fetal Assessment Do you have the resources to deliver a baby? gestational age comorbidities Fetal monitoring Interventions: tocolysis, betamethasone, GBS 6 2 4/2/2020 The Miracle of Birth! 7 Normal Birth don’t panic call for help coach mom to breathe catch the baby wrap/stimulate the baby on mom deliver the placenta 8 Abnormal Birth presenting part is not the head excessive bleeding unconscious or seizing patient pulsating umbilical cord comes first shoulder dystocia preterm birth 9 3 4/2/2020 Shoulder Dystocia shoulder is typically wedged behind the pubic symphysis or sacrum maneuvers (repeat, if necessary): have mom stop pushing McRoberts’ maneuver (straighten, then flex thighs) suprapubic (not fundal!) pressure deliver the posterior arm rotate the baby Gaskin (all‐fours) maneuver 10 Preterm Birth <37 weeks gestational age what is causing it? unknown 50% of the time can you stop it? magnesium sulfate betamethasone for lungs Group B Strep prophylaxis ‐ usually penicillin deliver vs stabilize and transfer? 11 Bleeding Intercourse! Early Pregnancy Miscarriage Ectopic Pregnancy Mid to Late Pregnancy Placenta Previa Placental Abruption Postpartum Hemorrhage Uterine Inversion 12 4 4/2/2020 Miscarriage stable or unstable? gestational age? history/physical ultrasound, serum B‐hCG support and follow up 13 Ectopic Pregnancy typically presents with pain and bleeding pregnancy is located somewhere other than the uterus ultrasound and serum B‐hCG management: stable ‐ may manage expectantly or with medication unstable or worrisome ‐ to the OR! 14 Placenta Previa 15 5 4/2/2020 Placenta Previa patients who have received care often know should you do an exam? ultrasound ‐ low lying vs previa management: stable ‐ fluids and blood products if needed unstable ‐ cesarean delivery 16 Placental Abruption 17 Placental Abruption common presentation is sudden pain and bleeding acute vs chronic risk factors include trauma, hypertension, smoking, PROM, infection workup: CBC, fibrinogen, KB, type and screen, PT/PTT, creatinine, ultrasound, fetal monitoring management based on fetal status and bleeding: stable: expectant management unstable: delivery (by cesarean or vaginal) 18 6 4/2/2020 Postpartum Hemorrhage PRIMARY: redefined as “cumulative blood loss greater than or equal to 1,000 mL or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process” uterine atony (80%) ‐ massage, remove clots, uterotonics, tamponade lacerations ‐ exam and suture retained placenta ‐ manual extraction vs curettage with ultrasound placenta accreta ‐ hysterectomy may be necessary coagulation defects ‐ blood product replacement uterine inversion CBC, type and screen ‐ consider need for transfusion 19 Uterine Inversion 20 Postpartum Hemorrhage SECONDARY PPH can occur up to 12 weeks postpartum subinvolution of placental site ‐ uterotonics (often methergine) coagulation defects ‐ dx and directed treatment retained products of conception ‐ US, uterotonics vs D&C infection ‐ gentamicin & clindamycin, other options 21 7 4/2/2020 Leaking Fluid Amniotic fluid…or urine? 22 How to tell the difference: history and physical avoid a vaginal exam unless the patient appears to be laboring sterile speculum exam pooling ferning pH (blue could be amniotic fluid) +/‐ fetal fibronectin (helpful to confirm negative) and Group B strep ultrasound, “AmniSure” may be helpful, but not diagnostic 23 Premature Rupture of Membranes determine gestational age fetal presentation fetal well‐being assess for infection, abruption management depends on gestational age and maternal/fetal status 24 8 4/2/2020 Headache unresponsive to usual medical treatment history & physical blood pressure: >140/90 if urine protein/creatinine > 0.3 mg/dL, preeclampsia labs: platelets, creatinine, LFTs, urine protein/creatinine head imaging? 25 Preeclampsia (severe) new onset headache without other known etiologies visual disturbances BP >160/110 platelets < 100K impaired liver function (LFTs double + pain) renal insufficiency (Cr 1.1 or doubled from baseline) pulmonary edema 26 COVID-19 information is evolving respiratory infections tend to be more severe in pregnant women no definitive evidence for vertical transmission usual recommendations, limited office visits, testing as needed, additional precautions at time of delivery care is supportive ‐ prevention is key 27 9 4/2/2020 Chest Pain/ Shortness of Breath common in pregnancy worrisome disease may present with uncommon symptoms: vomiting, diaphoresis, reflux must consider cardiovascular disease heart failure, MI, arrhythmia, aortic dissection risk factors include non‐Hispanic black race, age > 40, hypertension, and obesity pulmonary etiologies including edema and embolism 28 Workup H&P, VS, exam BNP troponins EKG vs CT CXR echocardiogram 29 Trauma treatment is the same as for non‐pregnant women care for the mother first, then the baby bedside ultrasound very helpful 30 10 4/2/2020 Transport left lateral decubitus if patient is unstable or delivery is possible, send a physician 31 In closing Take a deep breath Remember the basics Call for help 32 “Birth takes a woman’s deepest fears about herself and shows her that she is stronger than them.” 33 11.
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