What I Wish I Learned in Medic School: Part 1 OB/GYN by Michael Defilippo
What I Wished I Learned in Medic School:
Obstetric Emergencies and Management
Michael DeFilippo, MS-III, MICP
On this first installation of The Overrun’s What I Wished I Learned in Medic School, I’m going to discuss topics I was introduced to during my Obstetrics and Gynecology clerkship in medical school, or those that were refreshed from my medic school time. I chose topics that I think can either have a direct impact on your prehospital care, or that you can recognize and understand what is going on in your patient while you’re with them before you transfer care at the Labor and Delivery unit or the ED. I tried to steer clear of topics that are normally covered routinely during classes or refreshers (except a couple) – to give you all something new and exciting!
In the ObGyn world, care and management is divided into the prepartum (pregnancy before labor), intrapartum (during labor), and postpartum (after labor) and that’s the layout we’ll use here.
Prepartum Emergencies
Pre-Eclampsia (PEC), PEC with Severe Features, HELLP Syndrome, Eclampsia
Symptoms/Exam Findings
PEC is the onset of hypertension after the 20thweek of pregnancy alongside the presence of excess protein in the urine (BP in ≥140/≥90, proteinuria >300 mg/dL). While PEC itself is not a prehospital emergency, its sequelae – PEC with severe features, eclampsia, and HELLP syndrome – are.
PEC with severe features is an acute episode defined as BP ≥160/≥110, alongside any“alarm symptoms”. Alarm symptoms that you can see in the prehospital environment are right upper quadrant pain or epigastric pain (due to liver damage), pulmonary edema, headache, and visual disturbances (scotomas, painful vision).
HELLP Syndrome is sometimes argued as a subtype of preeclampsia and is defined as Hemolysis (destruction of red blood cells within the arteries and veins), Elevated Liver enzymes, and LowPlatelets. While you can’t measure any of these things prehospitally, you can be aware of how it presents. Most commonly, this presents with signs of liver dysfunction (RUQ pain, jaundice) and nausea or vomiting. Other less common signs include bruising, petechiae, and ascites.
All of these pathologies can culminate in one of the most feared events of pregnancy – eclampsia. These are seizures that develop due to the excessive vasospasm and reperfusion that occurs from the hypertension seen in PEC.
Management / Treatment
You should always treat hypertension in an obstetric emergency where PEC is suspected. The agents of choice are antihypertensives that are safe in pregnancy and have proven efficacy in PEC care (labetalol, hydralazine). This is usually done in-patient with mom under observation under specific regiments.
The real intervention where you as an EMS provider can come in is with the administration of Magnesium Sulfate - it is both an anti-hypertensive and anti-epileptic. While it isn’t needed in the management of PEC, it is the standard of care for PEC with severe features and eclampsia. You can use benzodiazepines to abort the frank seizure activity seen in eclampsia, but recall the seizure is due to repetitive vasospasm and reperfusion – thus, to treat the underlying cause of the seizure you want to relax the arteries with magnesium sulfate administration.
For patients with suspected HELLP syndrome, management includes management of hypertension and correction of coagulopathies with fresh frozen plasma, platelets, or a blood transfusion.
The only “cure” for all of these obstetric pathologies related to PEC is delivery – women who are stable can still be induced to have a normal vaginal delivery, but if at any time they become unstable they will need to have an emergent cesarean section. If the patient is preterm (i.e., less than 37 weeks), there are some medications that can be administered depending on more specific gestational age to help either protect the fetus or accelerate some organ development prior to emergent section. One of these medications we should have given already – magnesium sulfate; it provides the fetus with neuroprotection at less than 32 weeks gestational age (reducing the risk of cerebral palsy, for instance). Likewise, steroids are routinely given to accelerate fetal lung maturity in women <34 weeks gestation.
The bottom line is: Any pregnant woman at 20 weeks of gestation or over, you should have a high index of suspicion for PEC with severe features and its adverse sequelae in the presentation of hypertension and abdominal pain.
Second and Third Trimester Bleeding
Symptoms / Exam Findings
The exam findings here are pretty self-explanatory – vaginal bleeding, which can vary from some spotting/trickling, to gross hemorrhage. Your differential is largely based upon what the mom is experiencing.
If the mom is experiencing painfulhemorrhage, you want to think of placental abruption or uterine rupture.
Placental abruption results from the premature separation of the placenta from the wall of the uterus – if more than 50% of the placenta is abrupting, there is a high risk of fetal death and maternal disseminated intravascular coagulopathy (DIC). Some abruptions may present with only severe abdominal or back pain withoutvaginal bleeding – these are termed concealed abruptions, wherein the blood collects within the uterus. Additional findings can include lack of fetal movement (signs of fetal distress) and uterine tenderness with severe contractions. Abruptions are most common following a motor vehicle collision, in the setting of extreme hypertension, or after maternal ingestion of cocaine.
Uterine rupture results from the tearing of the uterus prior to delivery or at the beginning of labor. These mostly occur in women who are attempting a vaginal delivery afterhaving a previous C-section on their prior pregnancy (but this can also occur in the setting of trauma). The major sign of this is palpating fetal parts in the abdomen or near the chest wall. If the mom is in labor, the major sign is losing fetal station (meaning the baby gets sucked back up in the vagina / uterus and disappears!).
If the mom is experiencing painless hemorrhage, you want to think of placenta previa or vasa previa (previas are painless).
Placenta previa occurs when the placenta implants over the cervical opening, thereby preventing the baby from exiting the uterus because the door to the outside world is blocked! Vasa previa is when the fetal blood vessels cover the cervical opening, also preventing the baby from exiting. Since this is the baby’s blood, it is painless and mom happens to notice bleeding.
Management / Treatment
The treatment for all of these is straight-forward: C-section. The role of EMS comes in recognizing the patient with suspected placental abruption, uterine rupture, placenta previa, or vasa previa and providing fluid resuscitation.
With all of these, NEVER perform a digital vaginal exam. In the setting of undifferentiated vaginal bleeding in a second or third trimester patient, you want to ULTRASOUND the uterus first. You don’t know if this patient with vaginal bleeding is a potential placenta previa even with their presentation, so you don’t want to potentially further perforate the placenta.
Intrapartum Emergencies
Shoulder Dystocia
Symptoms / Exam Findings
Imagine you’re delivering your first baby in the field – an exciting time to be sure. But what the heck, the baby’s head is stuck? Every time mom contracts, the baby’s head gets pulled back in just a little bit too.
A common complication during normal labor is shoulder dystocia – a failure of the fetal shoulders to deliver after delivery of the fetal head. The anterior shoulder becomes impacted behind the maternal pubic bone (pubic symphysis). This can result in fetal asphyxia, traumatic injury to the nerves in the arm, and humeral / clavicle fracture. A common presentation is the turtle sign– with the fetal head pulled tight against the perineum due to the impaction of the shoulder, the head is retracted back into the vaginal canal with each contraction.
You should be suspicious for a shoulder dystocia in diabetic or obese mothers. The excess glucose present in diabetes can make a larger fetus (macrosomia), thus these babies are more prone to getting stuck along their passage down the vaginal canal.
Management / Treatment
The first maneuver in management is the McRoberts Maneuver: sharply flex the maternal hips and legs and apply firm suprapubic (notfundal) pressure. This maneuver straightens the maternal sacrum while applying pressure to the anterior shoulder in an attempt to dislodge it. The McRoberts maneuver without suprapubic pressure alleviates shoulder dystocia upwards of 42% of the time.
If that doesn’t work, there are other maneuvers to attempt: Woods Corkscrew Maneuver (reaching in behind the posterior shoulder and pushing it forward), Rubin Maneuver (just leave to eat a delicious Reuben sandwich and call it a day… or, pushing the fetal shoulder anteriorly in an attempt to adduct them and deliver through the vaginal canal), or fracture of the clavicle in attempt to break the shoulder and extract the fetus.
In the event that none of these work, the last resort maneuver is the Gunn-Zavanelli-O’Leary Maneuver. The provider flexes the fetal head from its extended position and pushes it back into the vaginal canal – in layman’s terms: you put the baby back in the oven. The mom is emergently prepped for C-section and emergency surgery is performed. Over 100 of these procedures have been reported, with a high rate of success (meaning that it is rare and it shouldn’t be the first thing you jump to in the field!).
Amniotic Fluid Embolism
Symptoms / Exam Findings
During labor mom suddenly becomes severely short of breath and is showing signs of rapid cardiovascular collapse.
In the setting of a sudden change in maternal respiratory status during labor, you want to build a quick differential: amniotic fluid embolism, pulmonary embolism, anaphylaxis, acute MI, or sepsis. Since we know intimately about most of these differentials from being paramedics except one, I’m going to focus on amniotic fluid embolism.
During the labor process, amniotic fluid can be released into the maternal circulation causing a rapid pulmonary arterial obstruction. Furthermore, the amniotic fluid can trigger several inflammatory markers leading to disseminated intravascular coagulopathy, and it can also lead to direct embolization of amniotic debris in the brain leading to neurologic collapse.
When should you suspect this? A mom who is in labor and becomes rapidly short of breath with catastrophic hypoxia, altered mental status, and hemodynamic collapse.
Management / Treatment
In any labor emergency, you always treat the mom first. The infant should be emergently delivered if possible.
The treatment for amniotic fluid embolism is supportive – most cases present with sudden cardiorespiratory failure or arrest; therefore, intubation and advanced cardiac life support protocols should be followed.
Hemodynamic support in these patients should be cautious with fluid administration. The release of amniotic fluid into the systemic circulation results in cardiogenic shock due to acute pulmonary hypertension and right ventricular failure (rapidly leading to left ventricular failure). This is difficult to determine in the prehospital arena – thus fluids are typically administered until hypotension resolves or pulmonary edema becomes apparent. Initiation of vasopressor therapy (typically norepinephrine) is appropriate.
The coagulopathy, if present, is corrected with blood transfusion where appropriate. Excessive postpartum hemorrhage in these patients should be investigated as normal postpartum hemorrhage is (discussed below), and not automatically assumed to be as a sequelae of the amniotic fluid embolism.
Postpartum Emergencies
Postpartum Hemorrhage
Symptoms / Exam Findings
This is exactly as it sounds – bleeding and hemorrhage following delivery of the infant. This is the most common postpartum complication and accounts for up to 1 out of every 4 obstetric-related deaths.
Assessment of the uterus is a big factor in determining the cause of the hemorrhage.
If the patient’s uterus is soft or boggy, highly suspect uterine atony (i.e., the uterus is not responsive). After delivery, the uterus should clamp down and control bleeding from the recent evacuation of the fetus. A tired uterus, or one that has been working long to push the baby out, is not going to want to contract (like an overworked muscle).
If the patient’s uterus is firm, there is something still inside (retained products of conception). Typically this is part of the placenta that is either embedded into the uterus itself or has migrated through the uterine wall.
If the patient’s uterus is normal, you want to inspect the vagina for lacerations to make sure there was no tearing during the birthing procedure (be highly suspicious of this in cases of dystocia or macrosomia). You should also consider DIC if there is unresolved vaginal bleeding in the setting of a normal uterus and no overt lacerations.
If the patient’s uterus is missing (absent), and there’s a flesh-colored bag hanging out of the vagina, then you have a uterine inversion. Sometimes the uterus can contract so forcefully (especially in the setting of uterine tonic medications such as Oxytocin), that it can push itself inside out after delivering the infant and placenta.
Management / Treatment
The management here is dependent upon the type of uterus your patient has.
If the patient has uterine atony, you want to first perform a uterine massage by massaging the fundus – this can stimulate the atonic uterus to contract. Medication management includes oxytocin (which is a medication that is the same as the body’s oxytocin to stimulate uterine contractions) and other uterotonic medications. As a last line, an intrauterine balloon can be inserted to directly tamponade the uterus.
If the patient has retained products of conception, the management is either a dilation and curettage (surgically going into the uterus to remove the retained placental parts) or a hysterectomy (removal of the uterus).
The management of vaginal lacerations is direct pressure and suturing the wounds closed. If DIC is suspected, manage the coagulopathy as previously discussed.
Lastly, uterine inversion can become complicated to manage. If there are uterotonic medications being given (such as oxytocin), discontinue them. The first step includes manual replacement of the uterus – take a gloved hand and push the fundus along the long axis of the vagina toward the umbilicus. After replacement, restart the oxytocin to help the uterus control bleeding since uterine atony is common after manual replacement. Manual replacement is effective upwards of 66% of the time.
If manual replacement is unsuccessful, give a uterine relaxing medication – nitroglycerin 50 mcg IV is an excellent agent since it has a short half-life and works very well to relax the uterus. Once relaxation has been achieved, attempt manual replacement again as above. If manual replacement is unsuccessful, surgery is required.
-Michael is a third year osteopathic medical student. Michael will be providing periodic pieces about "What I wish I had learned in medical school" to The Overrun.
