Obstetric Emergencies

Contents

Foreword ix

William F. Rayburn

Preface xi

James M. Alexander

Umbilical Cord Prolapse 1

Bradley D. Holbrook and Sharon T. Phelan

Umbilical cord prolapse is an obstetric emergency that can have negativeoutcomes for the fetus. It is diagnosed by a palpable or visible cord and isoften accompanied by severe, rapid fetal heart rate decelerations. Casesof cord prolapse should be delivered as soon as possible, usually by ce-sarean section. While awaiting delivery, the fetal presenting part shouldbe elevated off the cord either manually or by filling the bladder. Althoughan untreated case of umbilical cord prolapse can lead to severe fetalmorbidity and mortality, prompt and appropriate management leads togood overall outcomes.

Intrapartum Hemorrhage 15

James M. Alexander and Alison C. Wortman

Intrapartum hemorrhage is a serious and sometimes life-threatening event.Several etiologies are known and include placental abruption, uterineatony, placenta accreta, and genital tract lacerations. Prompt recognitionof blood loss, identification of the source of the hemorrhage, volume resus-citation, including red blood cells and blood products when required, willresult in excellent maternal outcomes.

Pulmonary Embolism and Amniotic Fluid Embolism in Pregnancy 27

Matthew C. Brennan and Lisa E. Moore

Amniotic fluid embolism and pulmonary embolism are 2 of the most com-mon causes of maternal mortality in the developed world. Symptoms ofpulmonary embolism include tachycardia, tachypnea, and shortness ofbreath, all of which are common complaints in pregnancy. Heightenedawareness leads to rapid diagnosis and institution of therapy. Amnioticfluid embolism is associated with maternal collapse. There are currentlyno proven therapies, although rapid initiation of supportive care maydecrease the risk of mortality.

Emergency Cesarean Delivery: Special Precautions 37

Joey E. Tyner and William F. Rayburn

Anemergent cesareandelivery is performed to immediately intervene to im-prove maternal or fetal outcome for such indications as fetal distress, pro-lapsed cord, maternal hemorrhage from previa or trauma, uterine rupture,and complete placental abruption. It is paramount to reduce morbidityand mortality by preparing health care providers for special precautions.

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Trauma During Pregnancy 47

Steffen Brown and Ellen Mozurkewich

Traumatic injuries in pregnancy are both common and burdensome.Optimal management includes proper triage, maternal resuscitation, fetalmonitoring, and diagnostic imaging.

Shoulder Dystocia 59

William Grobman

The frequency of shoulder dystocia in different reports has varied, ranging0.2-3% of all vaginal deliveries. Once a shoulder dystocia occurs, even ifall actions are appropriately taken, there is an increased frequency ofcomplications, including third- or fourth-degree perineal lacerations, post-partum hemorrhage, and neonatal brachial plexus palsies. Health careproviders have a poor ability to predict shoulder dystocia for most patientsand there remains no commonly accepted model to accurately predict thisobstetric emergency. Consequently, optimal management of shoulderdystocia requires appropriate management at the time it occurs. Multipleinvestigators have attempted to enhance care of shoulder dystocia byutilizing protocols and simulation training.

Maternal Sepsis 69

Jamie Morgan and Scott Roberts

Maternal sepsis is relatively common. Most of these infections are the re-sult of tissue damage during labor and delivery and physiologic changesnormally occurring during pregnancy. These infections, whether directlypregnancy-related or simply aggravated by normal pregnancy physiology,ultimately have the potential to progress to severe sepsis and septicshock. This article discusses commonly encountered entities and septicshock. The expeditious recognition of commonmaternal sepsis andmetic-ulous attention to appropriate management to prevent the progression tosevere sepsis and septic shock are emphasized. Also discussed are prin-ciples and new approaches for the management of septic shock.

Hypertensive Emergencies of Pregnancy 89

James M. Alexander and Karen L. Wilson

Hypertension is commonly encountered in pregnancy and has both mater-nal and fetal effects. Acute hypertensive crisis most commonly occurs insevere preeclampsia and is associated with maternal stroke, cardiopulmo-nary decompensation, fetal decompensation due to decreased uterineperfusion, abruption, and stillbirth. Immediate stabilization of the motherincluding the use of intervenous antihypertensives is required and oftendelivery is indicated. With appropriate management, maternal and fetaloutcomes can be excellent.

Seizures and Intracranial Hemorrhage 103

Karen L. Wilson and James M. Alexander

Seizures and intracranial hemorrhage are possible medical diseases thatany obstetrician may encounter. This article reviews the cause, treatment,

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and medical management in pregnancy for seizures and intracranial hem-orrhage, and how the two can overlap into preeclampsia or eclampsia.This article also highlights some challenging management issues fromthe obstetrician’s perspective.

Endocrine Emergencies 121

Scott A. Sullivan and Christopher Goodier

Several potentially fatal endocrine emergencies in relation to obstetricsand gynecology are discussed in the article. Rates of case fatality varyin different series, but range from 10% to 30%. Rapid recognition, promptsupportive care, and intervention likely maximize maternal and fetaloutcomes.

Placenta Accreta, Increta, and Percreta 137

Alison C. Wortman and James M. Alexander

Placenta accreta is an abnormal adherence of the placenta to the uterinewall that can lead to significant maternal morbidity and mortality. The inci-dence of placenta accreta has increased 13-fold since the early 1900s anddirectly correlates with the increasing cesarean delivery rate. The prenataldiagnosis of placenta accreta by ultrasound along with risk factors includ-ing placenta previa and prior cesarean delivery can aid in delivery planningand improved outcomes. Referral to a tertiary care center and the use ofa multidisciplinary care team is recommended.

Index 155