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Home , Ectopic pregnancy, Uterine inversion

OB/GYN EMERGENCIES Elyse Watkins, DHSc, PA-C, DFAAPA DISCLOSURES

I have no financial relationships to disclose. TOPICS

Ovarian torsion Postpartum hemorrhage Ruptured ectopic Acute Acute menorrhagia OVARIAN TORSION .Tumors (benign and malignant) are implicated in 50-60% of cases of torsion .20% occur during pregnancy () .Unilateral or bilateral abdominal-, usually sudden onset .Exercise or movement exacerbates pain . and 70% .Pathophys: reduced venous return, stromal , internal hemorrhage, and infarction → necrosis OVARIAN TORSION

.Physical exam variable .Ultrasonography with color Doppler .Surgical referral

RUPTURED 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 , pelvic 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 , 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. . is performed when patients are hemodynamically unstable or if visualization during 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 loss that causes hemodynamic compromise so prompt evaluation of 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 MENORRHAGIA .A 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 MENORRHAGIA .If 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 MENORRHAGIA .Pharmacologic 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 MENORRHAGIA .Transfusion: .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 , uterine artery embolization, and . .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 PLACENTAL ABRUPTION .May present with vaginal bleeding, pain, and evidence of 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 ABRUPTION Class 1: Mild Class 3: Severe •No sign of vaginal bleeding or a small amount of vaginal bleeding. •No vaginal bleeding to heavy •Slight uterine tenderness vaginal bleeding •Maternal blood pressure and heart rate •Tetanic / board-like WNL consistency on palpation •No signs of fetal distress •Maternal Class 2: Moderate •No sign of vaginal bleeding to moderate •Clotting profile alteration: amount of vaginal bleeding hypofibrinogenemia and •Significant uterine tenderness with tetanic coagulopathy contractions •Fetal death •Change in vital signs: maternal , orthostatic changes in blood pressure. •Evidence of fetal distress •Clotting profile alteration: hypofibrinogenemia PLACENTAL ABRUPTION .Management: Conservative .1. Expectant management with continuous fetal monitoring .Indications: when both mother and 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 ). .Indications: .non-reassuring fetal status .hemodynamic instability of the mother PLACENTAL ABRUPTION .Emergency 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 ABRUPTION Main 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 /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 , 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 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, carboprost tromethamine, 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 carboprost tromethamine 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

.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 . .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: . 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!