HARRY SINGH, MDDEPT. OF ANESTHESIOLOGYUTMB

MaternalFetalBoth mother and fetus at riskMortality can be 200%

PREPARTUM/INTRAPARTUM:Placenta previaPlacenta accreta/increta/percretaPlacental abruptionUterine rupturePOSTPARTUM:Retained placentaUterine atonyUterine inversionBirth trauma/laceration

ANTEPARTUM:Umbilical cord prolapseUmbilical cord compressionUteroplacental insufficiencyAT DELIVERY:Shoulder dystociaVaginal breech delivery (head entrapment)

1 in 200-250 deliveriesComplete, partial or marginalMost diagnosed early resolve by third trimesterETIOLOGY:UnknownPrevious uterine scarPrevious placenta previaAdvanced maternal ageMultiparity

Painless vaginal bleeding-third trimesterVaginal bleeding in 3rd trimester should be considered previa until proven otherwiseUltrasound has eliminated the need of double set up to diagnose previa as in the pastCesarean deliveryExpectant management if fetus immature and no active bleedingUrgent/emergent cesarean delivery for active or persistent bleeding or fetal distressRegional/GETA

Linearly related to number of previous scars in presence of placenta previa PP+unscarred uterus-5 % risk of accretaPP+one previous C/D-24% risk of accretaPP+two previous C/D-47% risk of accretaPP+three previous C/D-40% risk of accretaPP+four previous C/D-67% risk of accretaCombination of placenta previa and previous C/D-Dangerous

Placenta accreta, increta and percreta difficult to diagnose antepartumUsually diagnosed when placenta doesnt separate after cesarean or vaginal deliveryColor Doppler imaging or magnetic resonance imaging may diagnose the condition antepartumPreoperative balloon catheters in internal iliac can be considered in cases diagnosed antepartum.Prompt decision for hysterectomyPercreta may require surgeons skilled in pelvic dissection

GETA/Regional (CSE)Good IV access/ A line Level 1 or equivalent warmerCross matched bloodFFP/Cryo/Factor VII/Platelets Emergency hysterectomy more blood loss than elective hysterectomyHemodilution/red cell salvage can be considered in Jehovahs witnessRegional may be associated with reduced blood loss but may complicate treatment of hypotension in a bleeding patient.

I in 77 to 1 in 86 deliveriesETIOLOGY:CocaineHypertension: Chronic or pregnancy inducedTraumaHeavy maternal alcohol useSmokingAdvanced age and parityPremature rupture of membranesHistory of previous abruption

Vaginal bleeding-Classical presentationMay not always be obvious 3000 ml or more blood can be sequestered behind placenta in concealed bleeding Uterus cant selectively constrict abrupted areaDecreased placental area-fetal asphyxia1 in 750 deliveries-fetal deathSevere neurological damage in some surviving infantsUpto 90% abruptions-mild to moderate

Problems: Hemorrhage, Consumptive coagulopathy, Fetal hypoxia, PrematurityLow fibrinogen/ Factor V, Factor VII and platelets and increased fibrin split productsManagement depends on severity of situation Vaginal delivery-Fetus and mother stableUrgent/Emergent C/D- Fetal distress or severe hemorrhageBe prepared for massive blood loss with C/DCouvelaire uterus may not contract after deliveryOn rare occasions, internal iliac ligation/hysterectomy may be necessary

Prepartum, intrapartum or postpartumETIOLOGY:Prior cesarean delivery especially classical cesarean scarRupture of myomectomy scarPrecipitous laborProlonged labor with cephalopelvic disproportionExcessive oxytocin stimulationAbdominal traumaGrand multiparity IatrogenicDirect uterine trauma-forceps or curettage

Severe uterine or abdominal pain or shoulder painDisappearance of fetal heart tonesVaginal or intraabdominal bleedingHypotensionVBAC: Change in uterine tone or contraction pattern and FHR changes and not pain during uterine ruptureVBAC: Consider low conc . local anestheticsEmergent C/D may be necessaryUterine repair/Hysterectomy depending on situation

1% of deliveriesOngoing blood lossManual exploration for removalYou need uterine relaxation and analgesiaSAB/Epidural/ GETA/MAC depending on clinical situationUterine relaxation: inhalational agents in pts receiving GETANitroglycerin: 100 ug boluses-relaxation within 30-45 seconds lasting 60-90 secondsOxytocics after removal of placenta

Most common cause of postpartum hemorrhageFollows 2-5% deliveriesETIOLOGY:MultiparityPolyhydramniosMacrosomiaChorioamnionitisPrecipitous labor or excessive oxytocin use during laborProlonged laborRetained placentaTocolytic agents Halogenated agents >0.5 MAC

Vaginal bleeding > 500 mlManual examination of uterusVolume resuscitationInfusion of oxytocics + bimanual compression of uterusEvaluation for retained placenta

Oxytocin:20-40U/L-Vasodilation, hypotension, hyponatremia, no benefit after 40 UMethylergonovine:0.2 mg IM, Max. 0.4 mg-Vasoconstriction, PA pressures, coronary artery vasospasm, hypertension, CVA, nausea and vomitingCarboprost or hemabate (prostaglandin F2 analog): 0.25 mg IM or IU, Max 1.0 mg Vasoconstriction, systemic and pulmonary hypertension, bronchospasm, V/Q mismatch, nausea, diarrheaMisoprostol 800 mg PR. Minimal side effects

Uncommon problem Results from inappropriate fundal pressure orExcessive traction on umbilical cord especially if placenta accreta is presentMass in the vaginaUterine atonyMaternal shock and hemorrhageVolume replacementAnalgesia for the procedureUterine relaxation for replacementOxytocics following replacement

Lesions range from laceration to retroperitoneal hematoma requiring laparotomyCan result from difficult forceps delivery/Precipitous vaginal delivery/Malpresentation of fetal head (OP)/Laceration of pudendal vessels/Clinical presentation of postpartum bleeding with contracted uterusSaddle (SAB)/Epidural/MAC/GETA depending on the clinical scenario

Baseline fetal heart rate, variability, decelerations or accelerationsNormal FHR: 110-160 bpmTachycardia: Maternal fever, infection, terbutaline, atropine, hyperthyroidism, tachyarrythmia, hypoxemiaBradycardia: Fetal autonomic response to baroreceptor or chemoreceptor stimulationFetal cardiac output: Rate dependentVariability: Most reliable index of fetal well being; variability is baseline fluctuations in FHR over 2 cycles/minCan be absent, minimal (25 bpm)

UMBILICAL CORD PROLAPSE:Acute fetal bradycardiaCord palpable in vaginaMembrane rupture with head not well applied to cervix-High station/breech presentationPush presenting part away from cervixEmergency C/DGETA most appropriate

UMBILICAL CORD COMPRESSION:Variable decelerationsNonreassuring if slow return to baseline or severe (

UTEROPLACENTAL INSUFFICIENCY:Late decelerationsCause for concern if repetitivePostdates, preeclampsia, diabetes, IUGRUterine resuscitation: change of maternal position, IV fluids, oxygen, discontinuation of oxytocin and administration of tocolytic agents (terbutaline)Regional/GETA depending on clinical scenarioMaternal mortality more common with GETAACOG: Cesarean deliveries performed for a nonreassuring fetal heart rate pattern do not necessarily preclude the use of regional

SHOULDER DYSTOCIA:Postterm pregnancy, diabetes, maternal obesity, macrosomia and shoulder dystocia in previous pregnancyExtension of episiotomy/flexion of mothers legs against abdomen, suprapubic pressure, fractures of claviclesAnticipation: Epidural-relaxed perineumC/D

BREECH (HEAD ENTRAPMENT):True obstetric emergencySmaller body pushed through partially dilated cervix trapping aftercoming headVaginal breech delivery-Discouraged by ACOG5% vs.1.6% deaths-Vaginal vs. C/D (Study in 2000 women)Incisions in cervix to enlarge opening or skeletal muscle and cervical relaxation or CDEpidural-prevents early pushing before cervix is fully dilated and relaxes the perineumGETA may be necessary for uterine and perineal relaxation

Hawkins J. Obstetric Emergencies, 2004 IARS Meeting Review Course Lectures.Palmer C. Obstetric Emergencies and Anesthetic Management (Lecture #201), 2005 ASA Annual Meeting Refresher Course Lectures.

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