Case One: Postpartum Hemorrhage
25 yo G2P2 presents to the ED with continued vaginal bleeding s/p delivery. She delivered her baby at home with the help of a midwife but has had prolonged vaginal bleeding for the past 4 hours after her delivery and was brought to the ED with orthostatic dizziness. She has no significant past medical conditions and takes no medications. Her vitals are HR 115, BP 95/65, RR 18, T 98.4F, pulse ox 99% RA.
What are the 4 "T's" that cause postpartum hemorrhage?
Tone, Trauma, Tissue, Thrombin
What are the key portions of the physical exam to help differentiate the causes of hemorrhage?
Uterine tone/bogginess, vaginal tears, placental exam (if available) to ensure entire placenta is present, uterine height or protruding uterus (uterine inversion)
How are vaginal tears classified? Which types of vaginal tears require OB surgical repair?
1st degree - through vaginal mucosa
2nd degree - through vaginal muscular layer
3rd degree - into rectal sphincter
4th degree - through rectal mucosa
3rd and 4th degree tears require surgical repair
What diagnostic method is used to evaluate for retained products of conception? Which findings have a high negative predictive value for retained products? What is the treatment?
Ultrasound; empty or fluid filled uterus has a high negative predictive value. Treatment is blunt digital dissection. Further remnants are removed by curettage in the OR by OB.
What is the risk associated with forceful pulling of the umbilical cord during delivery? What is the treatment of this complications?
Uterine inversion: before further removal of the placenta, pressure is applied to the uterine fundus through the introitus. Tocolytics are used initial to relax uterine musculature then uterotonic agents (oxytocin) should be started once the uterus is appropriately repositioned.
What methods are available to the emergency physician to decrease further bleeding after tears and retained products have been evaluated for and bleeding continues? What are the contraindications of prostaglandins and ergot alkaloids? What may ultimately be required to treat postpartum hemorrhage?
A - Uterine massage
B - Uterotonic agents (oxytocin, prostaglandins, methergine). Methergine/ergotamine can cause HTN (avoid in preeclampsia), F class prostaglandins are contraindicated in asthma.
C - Uterine packing using 15-20 yards of 4-inch packing gauze with ringed forceps in a layering fashion.
D - Hysterectomy (by OB)
25 yo G2P2 presents to the ED with continued vaginal bleeding s/p delivery. She delivered her baby at home with the help of a midwife but has had prolonged vaginal bleeding for the past 4 hours after her delivery and was brought to the ED with orthostatic dizziness. She has no significant past medical conditions and takes no medications. Her vitals are HR 115, BP 95/65, RR 18, T 98.4F, pulse ox 99% RA.
What are the 4 "T's" that cause postpartum hemorrhage?
Tone, Trauma, Tissue, Thrombin
What are the key portions of the physical exam to help differentiate the causes of hemorrhage?
Uterine tone/bogginess, vaginal tears, placental exam (if available) to ensure entire placenta is present, uterine height or protruding uterus (uterine inversion)
How are vaginal tears classified? Which types of vaginal tears require OB surgical repair?
1st degree - through vaginal mucosa
2nd degree - through vaginal muscular layer
3rd degree - into rectal sphincter
4th degree - through rectal mucosa
3rd and 4th degree tears require surgical repair
What diagnostic method is used to evaluate for retained products of conception? Which findings have a high negative predictive value for retained products? What is the treatment?
Ultrasound; empty or fluid filled uterus has a high negative predictive value. Treatment is blunt digital dissection. Further remnants are removed by curettage in the OR by OB.
What is the risk associated with forceful pulling of the umbilical cord during delivery? What is the treatment of this complications?
Uterine inversion: before further removal of the placenta, pressure is applied to the uterine fundus through the introitus. Tocolytics are used initial to relax uterine musculature then uterotonic agents (oxytocin) should be started once the uterus is appropriately repositioned.
What methods are available to the emergency physician to decrease further bleeding after tears and retained products have been evaluated for and bleeding continues? What are the contraindications of prostaglandins and ergot alkaloids? What may ultimately be required to treat postpartum hemorrhage?
A - Uterine massage
B - Uterotonic agents (oxytocin, prostaglandins, methergine). Methergine/ergotamine can cause HTN (avoid in preeclampsia), F class prostaglandins are contraindicated in asthma.
C - Uterine packing using 15-20 yards of 4-inch packing gauze with ringed forceps in a layering fashion.
D - Hysterectomy (by OB)
Case Two: Abnormal Presentations
A 19 yo G3P2 presents to the ED in labor. She is unsure of her gestational date as she has not seen an OB/Gy during the pregnancy and does not know her LMP. She has been having regular contractions for an hour and had spontaneous rupture of membranes, which prompted her to come to the ED. Her vitals are HR 101, BP 109/74, RR 16, T 99.1F, pulse ox 97% RA.
What needs to be done prior to taking the patient to labor and delivery?
Pelvic exam to determine stage of labor, dilation and effacement
You are able to see fetal crowning and prepare for emergent delivery and after delivery of the head you are unable to deliver a shoulder. Which maneuvers are available to deal with shoulder dystocia?
Episiotomy
McRoberts' maneuver (maternal knee-to-chest postion)
Suprapubic pressure
Rubin's maneuver (pushing shoulders anteriorly)
Wood's corkscrew maneuver (accessible shoulder is rotated toward the chest and fetus is rotated 180 degrees)
Arm deliver (should be attempted last, hand is introduced posteriorly of the posterior arm, arm is swept across the chest and hand is brought toward the chin, splint the humerus and sweep the hand across the face)
HELPER mnemonic (call for Help, Episiotomy, Legs flexed, Pressure, Enter vagina, Remove posterior arm)
What is the proper technique for episiotomy? What are the risks of each technique?
Mediolateral - 2% lidocaine local anesthesia, use tissue scissors to extend incision through the skin, subQ tissues and vaginal mucosa lateral to the anal sphincter. Results in greater blood loss, repair is more difficult and healing is more painful.
Median - should be avoided due to extension into/through anal sphincter causing 3rd/4th degree lacerations. Is easiest to repair, bleeds less, heals more rapidly with less pain and is preferred??? (per R&H)
What are the difference breech presentations? Which presentations have the highest and lowest incidence of cord prolapse? What is the method for safe breech deliver?
Frank - helps flexed, knees extended; 0.4% cord prolapse
Incomplete - hips and knees flexed; 5% cord prolapse
Complete - since or footling; 10% cord prolapse
For breech delivery, perform an episiotomy, deliver the posterior hip, then anterior hip by sweeping the legs away from the midline. Then grab the pelvis with both hands with the thumbs on the sacrum and fingers on the ASIS. Wrap the body in a towel and apply gentle downward pressure. Rotate the fetus so the anterior shoulder is at the vulva then rotate in the reverse direction to deliver the other arm beneath the pubic symphysis. Use the Maurice maneuver (place the index and middle fingers over the maxilla - NOT mandible - and the other hand over the fetal neck and apply gentle downward pressure) with assistance of suprapubic pressure to deliver the head.
How is umbilical cord prolapse managed? Cord entanglement?
Umbilical cord prolapse - mother is placed in knee-to-chest position and bed in Trendelenburg and the presenting part is lifted off of the cord. Emergent cesarean section should be performed, but if unavailable, the cord should be reduced and rapid vaginal delivery performed.
Cord entanglement - nuchal cords should be reduced at the perineum by slipping them over the head. Loose body cords usually reduce spontaneously. If loops are too tight to be reduced and impede delivery, then they should be cut and clamped with rapid fetal delivery.
A 19 yo G3P2 presents to the ED in labor. She is unsure of her gestational date as she has not seen an OB/Gy during the pregnancy and does not know her LMP. She has been having regular contractions for an hour and had spontaneous rupture of membranes, which prompted her to come to the ED. Her vitals are HR 101, BP 109/74, RR 16, T 99.1F, pulse ox 97% RA.
What needs to be done prior to taking the patient to labor and delivery?
Pelvic exam to determine stage of labor, dilation and effacement
You are able to see fetal crowning and prepare for emergent delivery and after delivery of the head you are unable to deliver a shoulder. Which maneuvers are available to deal with shoulder dystocia?
Episiotomy
McRoberts' maneuver (maternal knee-to-chest postion)
Suprapubic pressure
Rubin's maneuver (pushing shoulders anteriorly)
Wood's corkscrew maneuver (accessible shoulder is rotated toward the chest and fetus is rotated 180 degrees)
Arm deliver (should be attempted last, hand is introduced posteriorly of the posterior arm, arm is swept across the chest and hand is brought toward the chin, splint the humerus and sweep the hand across the face)
HELPER mnemonic (call for Help, Episiotomy, Legs flexed, Pressure, Enter vagina, Remove posterior arm)
What is the proper technique for episiotomy? What are the risks of each technique?
Mediolateral - 2% lidocaine local anesthesia, use tissue scissors to extend incision through the skin, subQ tissues and vaginal mucosa lateral to the anal sphincter. Results in greater blood loss, repair is more difficult and healing is more painful.
Median - should be avoided due to extension into/through anal sphincter causing 3rd/4th degree lacerations. Is easiest to repair, bleeds less, heals more rapidly with less pain and is preferred??? (per R&H)
What are the difference breech presentations? Which presentations have the highest and lowest incidence of cord prolapse? What is the method for safe breech deliver?
Frank - helps flexed, knees extended; 0.4% cord prolapse
Incomplete - hips and knees flexed; 5% cord prolapse
Complete - since or footling; 10% cord prolapse
For breech delivery, perform an episiotomy, deliver the posterior hip, then anterior hip by sweeping the legs away from the midline. Then grab the pelvis with both hands with the thumbs on the sacrum and fingers on the ASIS. Wrap the body in a towel and apply gentle downward pressure. Rotate the fetus so the anterior shoulder is at the vulva then rotate in the reverse direction to deliver the other arm beneath the pubic symphysis. Use the Maurice maneuver (place the index and middle fingers over the maxilla - NOT mandible - and the other hand over the fetal neck and apply gentle downward pressure) with assistance of suprapubic pressure to deliver the head.
How is umbilical cord prolapse managed? Cord entanglement?
Umbilical cord prolapse - mother is placed in knee-to-chest position and bed in Trendelenburg and the presenting part is lifted off of the cord. Emergent cesarean section should be performed, but if unavailable, the cord should be reduced and rapid vaginal delivery performed.
Cord entanglement - nuchal cords should be reduced at the perineum by slipping them over the head. Loose body cords usually reduce spontaneously. If loops are too tight to be reduced and impede delivery, then they should be cut and clamped with rapid fetal delivery.
Case Three: Postpartum Cardiomyopathy
A 31 yo G3P3 postpartum day 17 presents with exertional dyspnea and fatigue. She had an uncomplicated vaginal delivery and has no significant past medical conditions. She denies chest pain or history of PE and does not have a cough or significant symptoms at rest, but has been sleeping on 3 pillows at night to help with sleep. Vitals are HR 89, BP 115/78, RR 18, T 98.2F, pulse ox 94% RA.
What is the incidence of postpartum cardiomyopathy and which populations are more at risk? What is the typical time frame for onset?
1/4000 pregnancies are affected but may be more frequent due to missed milder forms. PPCM is more common in African Americans and multiparous women. Onset is usually days to weeks after delivery.
What are treatment options for PPCM during pregnancy? After pregnancy?
Oxygen, diuretics (HCTZ), and vasodilators during pregnancy
ACE inhibitors and amlodipine after pregnancy
What is the natural sequela of PPCM? How does this affect the recommendations for further pregnancies?
50% have normal cardiac function within 6 months, while some have residual deficits in function and have an 85% 5 year mortality rate. It is generally recommended to avoid further pregnancies, though PPCM after one pregnancy does not predict recurrence in the future.
A 31 yo G3P3 postpartum day 17 presents with exertional dyspnea and fatigue. She had an uncomplicated vaginal delivery and has no significant past medical conditions. She denies chest pain or history of PE and does not have a cough or significant symptoms at rest, but has been sleeping on 3 pillows at night to help with sleep. Vitals are HR 89, BP 115/78, RR 18, T 98.2F, pulse ox 94% RA.
What is the incidence of postpartum cardiomyopathy and which populations are more at risk? What is the typical time frame for onset?
1/4000 pregnancies are affected but may be more frequent due to missed milder forms. PPCM is more common in African Americans and multiparous women. Onset is usually days to weeks after delivery.
What are treatment options for PPCM during pregnancy? After pregnancy?
Oxygen, diuretics (HCTZ), and vasodilators during pregnancy
ACE inhibitors and amlodipine after pregnancy
What is the natural sequela of PPCM? How does this affect the recommendations for further pregnancies?
50% have normal cardiac function within 6 months, while some have residual deficits in function and have an 85% 5 year mortality rate. It is generally recommended to avoid further pregnancies, though PPCM after one pregnancy does not predict recurrence in the future.
Submitted by Dr. Dan Montgomery
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