Third Trimester and Postpartum Disasters

1
Third Trimester and Postpartum Disasters

• Jason Knight, MD
• Maricopa Medical Center Emergency Medicine
  Residency
• Phoenix, AZ

2
Third Trimester and Postpartum Disasters

• Preeclampsia
• HELLP
• Third Trimester Bleeding
• Preterm Labor
• Premature Rupture of Membranes
• Postpartum Hemorrhage
• Endometritis

3
Case 1

• 32 year old female arrives via military
  helicopter after crossing the border in labor
• Patient is a G1P0 at 34 weeks by dates with
  regular uterine contractions
• BP 168/110 110 22 37.4 96 No PNC
• Patient had a generalized tonic clonic seizure in
  the helicopter
• Asking for medical direction
• ETA 10 min

4
Preeclampsia and Eclampsia

• Background
• Multisystem disease of unknown etiology
• 5-7 of pregnancies
• Significant cause of maternal and fetal morbidity
  and mortality
• Definition
• Blood Pressure gt 140/90 after 20 weeks gestation
• Proteinuria gt 0.3 gms/24 hours
• Eclampsia preeclampsia seizures

5
Preeclampsia

• Risk Factors
• Primigravida
• HTN, Renal Disease, DM
• Hydatidiform Mole
  (may get preeclampsia lt 20 weeks)
• Multiple gestations
• Family History
• Lupus/Antiphosphlipid/Connective Tissue Disorders
• Age lt 20 or gt 35

6
Risk Factors Preeclampsia

• First time Father
• Father of a preeclamptic pregnancy in ANOTHER
  WOMAN

7
Preeclampsia

• Signs and Symptoms
• Headache
• Visual Changes
• Weight gain gt 5 lbs per week
• Peripheral Edema
• Pulmonary Edema
• Oliguria (UOP lt 500 cc in 24 hours)
• RUQ Pain
• Severe Preeclampsia
• BP gt 160/110 and 5 gms Protein in 24 hours

8
(No Transcript)
9
Pathophysiology

• Intense systemic vasospasm decreased perfusion
  to virtually all organ systems
• Third spacing of fluid and hemoconcentration
• Activation of coagulation cascade

10
Preeclampsia Treatment

• Delivery
• Delivery
• Delivery
• Steroids for fetal lung maturity is GA lt 34 weeks
• BP control
• Seizure prophylaxis/control
• Bed Rest
• Maintain UOP gt 30 cc/hour

11
Pharmacology Seizures

• Magnesium 4-6 gm IV (slow) followed by 2 gm per
  hour drip
• Witlin Obstet Gynecol Magnesium is superior to
  phenytoin (Dilantin) and diazepam (Valium) for
  eclamptic seizures

12
Pharmacology Blood Pressure

• Immediately treat BP gt 160/100 Goal BP SBP
  140-150 and DBP 90-100
• Hydralizine 5 mg IV then 2.5 to 5mg Q 20 min
• Labetolol 20 mg IV (slow) and escalate dose Q 10
  min
• Alternatives Nitroprusside, Nitroglycerine,
  Nifedipine

13
Order Sheet

• IV, O2, Monitor
• Maternal Fetal Monitor
• Hydralizine 5 mg IV x 1
• Magnesium 6 gm IV (slow) x 1 then 2 mg per hour
  drip
• Bolus 1 L NS then 125 cc/hour
• CBC, CMP, Uric Acid, UA, Dimer, Coags, Fibrinogen
• Seizure precautions
• OB/GYN Consult

14
Pitfall 1

• Rapid blood pressure reduction may decrease
  uterine blood flow and lead to fetal distress
• Clinical Pearl see what happens to the blood
  pressure after the magnesium before giving BP
  control medication

15
Literature on Prevention

• NEJM and ACOG Committee
• ASA therapy does NOT work
• Except cases of abnormal uterine arteries on US
• NEJM and ACOG Committee
• Calcium supplementation does NOT work
• Current trend Antioxidants

16
HELLP Syndrome

• Hemolysis
• Elevated Liver Enzymes
• Low Platelets
• Frequently misdiagnosed at initial presentation
• Up to 25 mortality rate

17
Classification of HELLP

• Full vs. Partial HELLP
• The lower the platelets the higher the
  morbidity and mortality
• The more symptoms you have the higher the
  morbidity and mortality

18
Recognition is Key

• HELLP a challenging diagnosis to make
• 90 General malaise
• 65 Epigastric/RUQ pain
• 30 Nausea/vomiting
• 31 Headache

19
HELLP Orders

• Platelet count
• Liver Function
• CBC
• Lactate
• D-Dimer

• Type and Screen
• Fibrinogen
• Urine protein
• Uric Acid

20
Laboratory Studies

• Platelets less than 150
• Transaminases up to 4000
• Coags usually normal
• Fibrinogen less than 300 suspect DIC

21
HELLP Treatment

• Supportive management
• Seizure prophylaxis
• Blood pressure control
• Women at term should be delivered
• Transfusion if necessary
• Corticosteroids for fetal lung maturity
• Rarely plasmaphoresis

22
Complications

• Subcapsular Liver hematoma or rupture.
• Bleeding if platelets below 20,000
• 50,000 for C-Section
• Placental Abruption
• DIC
• ARDS
• Infant mortality 10-60

23
Current Literature

• Sibai Am J Obstet Gynecol Conservative therapy
  prolonged the pregnancy by 15 days and resulted
  in less NICU time, decreased incidence of NEC,
  and decreased respiratory distress syndrome
• Recurence rate 19-27

24
Indications for Delivery
Mom Fetus

• GA gt 38 weeks
• Eclampsia
• Suspected placental abruption
• Platelets lt 100
• Severe Signs/Symptoms
• HA, Liver, Renal
• HELLP

• Severe IUGR
• Ugly Strip
• Oligohydramnios

25
Pre-Term Labor

• Definition Regular uterine contractions with
  cervical dilation or effacement after 20 weeks
  and before 37 weeks
• Leading cause of perinatal morbidity and
  mortality
• Diagnosis
• Maternal/Fetal Monitor
• Pelvic Exam
• Fetal Fibernectin

26
Risk Factors Preterm Labor

• Previous preterm delivery
• Low socioeconomic status
• Age lt18 or gt 40
• PROM
• Multiple gestations
• H/O second/third trimester abortions

27
Risk Factors for Preterm Labor

• Maternal behaviors T/E/D
• Structural Causes Uterus, Cervix, Placenta and
  Retained IUD
• Infectious Causes Chorioamnionitis, BV,
  Asymptomatic bacteruria, Pyelo
• Fetal Causes IUFD, IUGR, Congenital

28
Preterm Labor Management

• Hydration and Bed Rest
• Never shown to be helpful
• Tocolytic Agents
• Magnesium, Terbutaline, Nifedipine, Indomethacin
• Corticosteroids for fetal lung maturity
• Dexamethasone or Betamethasone
• Admit vs. D/C after Obs per OB consult

29
Tocolytics

• Magnesium 4-6 gm IV (slow) then 2gm/Hr
• Terbutaline 0.25 -0.5 mg SC Q3-4
• Nifedipine 5-10 mg SL Q 15 min
• Incomethacin 25-50 mg PO
• Risks of tocolytics Huge list of badness so call
  OB first
• Benefits buy time for steroids to work and fetus
  to grow

30
Corticosteroids

• Betamethasone 12 mg IM
• Dexamethasone 6-10 mg IM

31
Premature Rupture of Membranes

• Definition
• Signs and Symptoms
• Leakage of amniotic fluid prior to onset of labor
• Oligohydramnios
• Diagnosis
• Pooling of amniotic fluid in vagina
• Nitrazine paper test Turns Blue (False with
  lube)
• Ferning

32
(No Transcript)
33
PROM

• Treatment
• Fetus gt 37 weeks Deliver within 24 hours
• Fetus lt 37 weeks OB to weigh risks vs. benefits
  of delivery now vs. later
• Fetus lt 34 weeks corticosteroids for lung
  maturity

34
PROM and GBS

• Any risk factors present?
• GBS screen
• Delivery lt 37 weeks
• PROM gt 18 hours
• Temp gt 38 (100.4)
• Yes Rx PCN or Clindamycin

35
Third Trimester Bleeding

• Placental Abruption
• Placenta Previa
• NO PELVIC EXAM UNTIL AFTER THE ULTRASOUND

36
Key Concept

• NO PELVIC EXAM UNTIL AFTER THE ULTRASOUND

37
Placental Abruption

• Premature separation of the placenta from the
  uterus
• Risk Factors
• Previous Abruption
• Trauma
• HTN
• Cocaine
• Smoking
• Multiple Gestations

38
Placental Abruption

• Signs and Symptoms
• Vaginal bleeding with clots (third trimester)
• Abdominal Pain
• Uterine irritability/contractions
• Uterus may feel soft of firm
• Diagnosis
• US is not particularly useful

39
Placental Abruption

• Orders
• Call for Help
• CBC, Type and Cross 6 U, Fetal Monitoring, 2
  large bore IVs
• Treatment
• Emergency OB consult/ Delivery if viable
• Maternal/Fetal Monitoring
• RhoGAM if needed
• Outcome rarely good

40
Placenta Previa

• Call from resident moonlighting in rural Arizona
  hospital
• I have a 25 year old female G2P1 who is 36 weeks
  and came in for painless vaginal bleeding for 30
  minI put the speculum in and a whole lot of
  bright red blood came out

41
Placenta Previa

• Definition Implantation of the placenta
  overlying internal os
• Risk factors
• Previous placenta previa
• Prior C-Section
• Multiple Gestations
• Advanced maternal age

42
Placental Previa

• Signs and Symptoms
• Painless Vaginal Bleeding
• Soft, nontender uterus
• Diagnosis
• Ultrasound to confirm placental location (FIRST)
• Orders Call for Help
• CBC, Type and Cross 6 U, IVF, 2 large bore IVs,
  NO PELVIC UNTIL AFTER US, Rh, Fetal monitoring

43
Is the BABY OK?
Maternal Fetal Monitoring

• Up and down and up and down
• Accelerations with contractions are normal

44
Early Deceleration
45
Variable Decel Intermittent cord compression
46
Late Decel Uteroplacental Insufficiency
47
Fetal Monitoring Summary

• Accelerations with contractions are normal
• Early decelerations head compression
• Variable decelerations intermittent cord
  compression
• Late decelerations uteroplacental insufficiency
• Fetal Tachycardia infection
• Fetal Bradycardia Bad

48
Third Trimester Documentation

• BP
• UA
• Headache
• Visual Changes
• RUQ Pain
• Vaginal Bleeding
• Loss of Fluid
• Fetal Movement
• /- Fetal Monitoring

49
Post Partum Hemorrhage

• Definition
• gt500 cc blood loss vaginal delivery
• gt1000 cc blood loss C-Section
• Early (lt24 hours), Late (up to 1-2 weeks)
• Signs and Symptoms
• Vaginal Bleeding
• /- Soft atonic uterus

50
Post Partum Hemorrhage

• Causes of Early Hemorrhage
• Uterine Atony
• Trauma/Lacerations
• Retained products of conception
• Uterine Inversion
• Causes of Late Hemorrhage
• Endometritis
• Retained Products of Conception

51
Post Partum Hemorrhage

• Lacerations fix it
• Bimanual massage
• Manual removal of placenta
• IV oxytocin (Pitocin) to stimulate uterine
  contractions
• 10 Units IM x 1 or
• 10- 40 Units per L
• Methylergonovine (Methergine)
• 0.2 mg IM x 1 or
• 0.2 mg PO TID

52
Post Partum Endometritis

• Definition Infection of the endometrium
• Causes
• Enterococci, Strep, Anaerobes
• Signs and Symptoms
• Fever
• Tender Uterus
• Foul Smelling Lochia

53
Post Partum Endometritis

• Differential
• Pelvic Abscess
• Retained Foreign Body Guaze/Instrument
• Pelvic Thrombophlebitis
• Treatment
• Broad spectrum antibiotics
• Admission

54
Summary

• Preeclampsia
• HELLP
• Third Trimester Bleeding
• Preterm Labor
• Premature Rupture of Membranes
• Postpartum Hemorrhage
• Postpartum Endometritis

55
Summary by Symptom

• Bleeding Placental abruption, placenta previa
• BP pre-eclampsia and/or HELLP
• RUQ pain Pre-eclampsia, HELLP, fatty liver of
  pregnancy, Appy
• Headache pre-eclampsia
• Seizures Eclampsia
• Gush of fluid PROM
• Fever Chorio, pyelo, UTI, Appy, Endometritis
• Trauma Placental Abruption

56
Thank You!