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Abcs of OB/GYN Outline OB Emergencies I 1. Pre/eclampsia 2. Shoulder dystocia 3. Cord Prolapse CLERKSHIP TEACHING SERIES Topics Objectives Pre/eclampsia • Define pre eclampsia and eclampsia and list 4 risk factors for developing it. • Describe the pathophysiology of pre eclampsia/eclampsia and symptoms, physical findings and lab abnormalities. • Describe an approach to management and some maternal and fetal complications of PET. Topics Open Discussion CLASSIFICATION OF HDP Who has seen a case of pre/eclampsia already? What happened? What were the symptoms, signs, management, and outcome? PREEXISTING HTN OR/AND • WITH COMORBID CONDITIONS • WITH PRE ECLAMPSIA Tell me everything you know about pre/eclampsia GESTATIONAL HTN • WITH COMORBID CONDITIONS • WITH PRE ECLAMPSIA PRE ECLAMPSIA = NEW OR WORSENING PROTEIN OR RESISTANT HTN OR ADVERSE CONDITIONS Topics 1 Diagnosis of HTN Clinically Significant Proteinuria Systolic > 140 should be followed closely Proteinuria should be strongly suspected when Diastolic > 90 avg 2 measurements dipstick> 2+ Proteinuria defined as > >.3g per 24 hrs or >30mg/mmol urinary creatinine in a spot urine Severe HTN = systolic >160, diastolic> 110 sample Not clear whether there is a role for quantification of Office (whitecoat) HTN defined as office proteinuria for prognosis diastolic>90 but home BP<135/85 Topics Topics PET Risk Factors for PET Incidence 3-14% worldwide Risk factors clinical manifestations= the result of micrangiopathy of target organs eg brain, liver, kidney, placenta pathogenesis Topics Topics Pathogenesis of PET Severe Preeclampsia Impaired trophoblast invasion abN trophoblast differentiation Placental ischemia Immunologic factors Genetic factors(2-5X risk w fam hx) Systemic endothelial dysfunction Treatment=delivery Topics Topics 2 Severe Pre eclampsia Complications of PET Severe pre eclampsia should be defined as pre Seizures eclampsia with onset < 34 wks with heavy Abruption proteinuria or with one or more adverse conditions Thrombocytopenia Cerebral hemorrhage The term PIH should be abandoned Pulmonary edema Liver hemorrhage/rupture Renal failure Topics Topics Eclampsia Treatment of HDP Generalized seizures in the setting of preeclampsia Lifestyle changes 4-5/10,000 births in developed countries Insufficient evidence on exercise, workload reduction antepartum-38-53% or stress reduction intrapartum-18-36% Some bedrest may be useful in gestational HTN <48 hrs pp-5-39% Strict bedrest is NOT recommended in pre eclampsia >48 hrs pp-5-17% Topics Topics Antihypertensive Therapy Antihypertensive Therapy Severe HTN > 160/110 Non severe HTN(140-159/90-109) BP should be lowered to < 160 systolic and < 110 Without comorbid conditions BP should be kept at diastolic 130-155/80-105 Initial rx with labetolol, nifedipine caps, nifedipine With comorbid conditions, BP should be 130- PA tabs or hydralazine 139/80-89 MgSO4 is no an anti hypertensive Initial rx with methyldopa,labetolol, other beta- Continuous FHR monitoring until BP stable blockers, ca channel blockers ACE inhibitors, ARBs, atenolol, prazosin not recommended Topics Topics 3 Steroids and Mode of Delivery Anesthesia and Fluids Antenatal corticosteroids should be considered in Inform anesthesia of PET and plt count any pre eclampic < 34 wks Regional anesthesia is appropriate with plts > 75, May be considered in gest HTN <34 wks even with low dose ASA Vag delivery unless ob indications Epidural OK 12 hrs after prophylactic dose of LMWH Cx ripening if necessary and 24 hrs after a therapeutic dose Maintain BP < 160/110 thru labor Early epidural recommended for pain control Ergometrine contraindicated Topics Topics Anesthesia and Fluids Antihypertensives Minimize iv/oral fluids to avoid pul edema Don’t routinely treat oliguria (<15 ml/hr) with fluids hydralazine 5 mg iv, 5-10 q 30 min Dopamine and lasix not recommended for persistent oliguria labetolol 20 mg iv, 20-80 q 20 min Central line not routinely recommended nifedipine 5-10 mg cap q 30 min Pul art cath not recommended diazepam 5-10 mg iv Topics Topics MgSO4 MgSo4 First line treatment of eclampsia Cochrane reviews: MgSo4 safer and more effective Mech of action is unclear than diazepam or phenytoin for prevention of Impedes acetylcholine release? recurrent seizures Decr sens of the motor end plate? SE: Mg toxicity Central anticonvulsant effect? Loss of DTRs @ 8-10 mEq/L Recommended as prophylaxis against eclampsia in Respiratory paralysis @10-15 mEq/L severe pre eclampsia Cardiac arrest @ 20-25 mEq/L May be considered in non severe PET—decreased eclampsia but increased C/S rates and expense Topics Topics 4 MgSo4 Case PET Monitor: You are called to the antenatal floor to see a pt with a BP of RR hourly 160/110 Patellar reflexes hourly 18 y/o primip U/O <20cc/hr--decrease dose Admitted at 37 wks 2 days ago Serum Mg levels q 4 hrs 94-8mEq/L) BP 140/90, 150/98, 2+ prot Crosses the placenta freely--rarely NN depression 24 hr urine pending Calcium gluconate--1g iv over 3-5 min(10cc of 10% BW N soln) antidote! Topics Topics Hx and PEx Case PET BP 160/114 HR 92 Management? BP control Feels awful, headache Repeat bloodwork Delivery-induction vs c-section? RUQ tender MgSo4? Reflexes 3+ Pv 2 cm 70% Topics Topics Case 1 PET Prior to the antihypertensive you were going to give Shoulder Dystocia the pt, she begins to seize… Management: Call for help MgSO4 4g bolus iv>>1g/hr O2 Pt on her side Mouth guard Topics 5 Objectives Case – Shoulder Dystocia List risk factors for shoulder dystocia You arrive to take call at 5 pm. The pt in room 1 has Describe 4 immediate management steps for been laboring since yesterday morning. shoulder dystocia. 32 y/o G2P1 induced for postdates at 41 weeks. Healthy pregnancy, no GDM Previous SVD 8 lb 4 oz babe Fully dilated since noon Topics Topics Case Case The nurses have taken her to the back room for Management: forceps Call for help, anesthesia, episiotomy Deliver the head over 2 contractions with T-M McRobert’s maneuvre forceps Suprapubic pressure Post shoulder to oblique “turtle” sign Deliver the posterior arm You can’t reach the anterior shoulder and the baby’s Wood’s corkscrew maneuvre face is getting bluer… Zavanelli maneuvre (cephalic replacement) Topics Topics Shoulder Dystocia Shoulder Dystocia 0.2-2% births Definition=difficulty delivering the shoulders Obstetrical emergency (subjective) Most occur in the absence of risk factors Time to delivery? Avg time from del of head to expulsion of body—24 sec Be prepared! 24 + 2SD=60 sec Goal to prevent fetal asphyxia and avoid trauma Prosp series—del of head to body expul time>60—descr a subpop of incr BW, sh dystand low 1 min Apgar Topics Topics 6 Shoulder dystocia Macrosomia Pathophysiology Can be defined as Risk Factors (50% cases have NO risk factors) EFW >4500g (1.5%) Macrosomia EFW >4000g (10%) DM EFW > 90th%ile for GA Operative vaginal delivery Previous sh dystocia Clinical EFW as accurate as U/S biometry at upper Postdates wt ranges Male fetal gender 95% of infants > 4000g will NOT have sh dystocia 50% cases occur in BW < 4000g Topics Topics Macrosomia Diabetes Review of the literature: labor induction for Maternal diabetes increases the rate of sh dystocia 2- suspected macrosomia does NOT decr rate of sh 6 X dystocia but does incr C/S rates Chest to head and shoulder to head ratios are Prophylactic C/S for EFW > 5000 g in non diabetic increased in infants of diabetic mothers pts and > 4500g in diabetic pts is not unreasonable Topics Topics 7 Op Vag Delivery Previous Sh Dystocia Combination of macrosomia, prolonged second stage Incidence of recurrence 1-17% and mid-pelvic delivery----associated with a 21% inc May be an underestimate—many mothers choose of shoulder dystocia C/S for next delivery Birth trauma more likely in the recurrent episode 29 Classic study Benedetti, Gabbe O&G 1978 vs 19% Incr mat pre preg wt Incr mat wt gain in preg Incr BW Topics Topics Postdates Male Fetal Gender A large proportion of sh dystocia cases occur in Freq of males 55-68% in sh dystocia cases posterm pregnancies Freq males 51% in overall birth pop The majority of postterm preg are uncomplicated 70% babies > 4500g are male Cohort study of term and postterm births from Shoulder dimensions? As in IDM? Norway reported a RR 1.3 for sh dystocia in the postterm group Topics Topics Management of Sh Dystocia Management After del of the head umb art pH falls .04 pH units per Suprapubic pressure—down and lateral to adduct the min shoulders and disimpact the ant shoulder 7 min to deliver a previously well-oxygenated infant before asphyxia occurs McRobert’s maneuvre-hyperflex the pt’s legs DON’T! pull on the neck/head Straightens the lumbosacral lordosis put fundal pressure Widens the pelvis to it’s max dimension Call for help Incr pushing efficency Re-position mom Successful alone in 42% cases episiotomy Topics Topics 8 Management Complications of Sh Dystocia Delivery of the post arm Fetal Wood’s corkscrew maneuvre Gaskin all-fours Brachial plexus injury-<10% permanent disabilty Fractures-clavicular, humeral, heal readily Clavicular fracture-shortens the bisacromial diameter, risk to subclavians Asphyxia-hypoxic brain damage Death is rare Zavanelli maneuvre Symphysiotomy-rare Topics Topics Complications of Sh Dystocia Maternal Cord prolapse Pph Genital tract lacerations Topics 9 Objectives Case List 4 risk factors for cord prolapse Your resident in the DR
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