Week 25: Pregnancy, Delivery, and Vaginal Bleeding

Perform Vigorous Bimanual massage and administer IV oxytocin.

The most common cause of post partum hemorrhage is uterine atony. Methylergonovine and prostaglandins are additional treatments that can be used. Maternal resuscitation should occur simultaneously, starting with NS fluid bolus and packed RBCs. Other less common causes of early postpartum hemorrhage include lacerations of lower genital tract, retained placenta, uterine rupture, and uterine inversions.

This patient has an inevitable abortion due to her open OS and products of conception in the vault. Expectant management is the most appropriate treatment. A dilation and curettage procedure would also be an appropriate option in this instance.

Significant risk factors of ectopic pregnancy include previous history of ectopic pregnancy, history of infection such as pelvic inflammatory disease, history of tubal surgery (leading to scar formation), the presence of IUD, and assisted reproductive therapy.

The correct answer is magnesium sulfate. This patient’s presentation is concerning for eclampsia. Magnesium sulfate is the mainstay of treatment because it will help to prevent future seizures. The recommendation is to give 4-6 g IV over 15-20 min. An alternative is to give 5 g IM into each buttock. After initial magnesium administration, a drip can be started at 2g/hr.
This patient’s presentation is concerning for ecclampsia. While persistently uncontrolled hypertension increase the risk of stroke, this patient should receive magnesium sulfate first to prevent recurrent seizures (which in turn may increase the blood pressure further).
This patient’s presentation is concerning for eclampsia. Lorazepam can be given for a prolonged seizure, but magnesium is the mainstay of treatment and will prevent future seizures.

This patient presents with abdominal pain and a positive pregnancy test raising the concern for an ectopic pregnancy. Ectopic pregnancy complicates about 1.5 – 2.0% of pregnancies and is potentially life threatening. There are a number of risk factors for ectopic pregnancy including pelvic inflammatory disease, prior tubal surgery, and previous ectopic pregnancy. This patient has an early pregnancy based on the low beta hCG. The transvaginal ultrasound shows an early gestational sac without a yolk sac or fetal pole within the uterus. This ultrasound does not rule out the diagnosis of an ectopic pregnancy as an ectopic pregnancy can cause a decidual reaction in the uterus, which appears similar to an early gestational sac. The definitive ultrasound finding for an intrauterine pregnancy would be the presence of a yolk sac or fetal pole. It is expected that above the discriminatory hCG zone of 1500-2500 mIU, a definitive IUP should be identified. Patients with a beta hCG below the discriminatory zone without a definitive IUP can be managed conservatively with a repeat hCG level in 48 hours (the level should double every 48 hours) and repeat ultrasound.

Rhogam (B & C) is recommended for patients who are Rh negative and have vaginal bleeding. If the mother is exposed to fetal blood, she may develop antibodies that threaten future pregnancies. This patient does not have vaginal bleeding and is Rh positive obviating the need for Rhogam. Methotrexate (A) is a chemotherapeutic agent that can be used for the treatment of early ectopic pregnancy. This approach is not indicated in a wanted pregnancy with a beta hCG below the discriminatory zone as repeat testing may show a viable intrauterine pregnancy.

Postpartum endometritis is the most common puerperal infection, usually developing on the 2nd or 3rd day postpartum. Typically, the lochia has a foul odor, and the patient develops a leukocytosis. The infection begins in the endometrium and can extend to the myometrium or parametrium. It is a serious infection that can lead to complications such as peritonitis, septic thrombophlebitis, and necrotizing fasciitis. The pathogens involved are typically the flora of the bowel, perineum, vagina, and cervix. The strongest risk factor for endometritis is a cesarean section.

In lactating women, mastitis typically presents within a few weeks postpartum, and occurs in 2-10% of breastfeeding women. The infection is almost always unilateral. The most common causative agent is Staphylococcus aureus, which actually originates mainly from the newborn’s pharynx. The antibiotic of choice for non-severe disease is a penicillinase resistant agent, such as dicloxacillin or cephalexin. If the patient has beta lactam sensitivity, clindamycin is recommended. If there is concern for maternal methicillin-resistant staphylococcus aureus (MRSA) colonization, trimethoprim-sulfamethoxazole or clindamycin is recommended. If the patient is unstable, inpatient intravenous vancomycin should be initiated after local and blood cultures are obtained.

Compression of the cord can be life threatening to the fetus. To reduce the risk of cord compression, the examiner should manually elevate the presenting part. An obstetrician should be called immediately because the patient needs an emergent cesarean section. The examiner’s hand should remain in the vagina, elevating the presenting part, while the patient is transported to the operating room and prepared for surgery.

Terbutaline (A) is a tocolytic and is not indicated for treatment of prolapsed umbilical cord. The provider should never try to reduce the cord (B) because this may cause compression and fetal distress. The provider should never cut the cord (C) and attempt delivery because this will cut off the fetus’s blood supply during delivery.

Symptoms of hypermagnesemia are not often seen unless significantly elevated (> 4 meq/L). Neurological symptoms are the most commonly seen symptoms of hypermagnesemia. The initial clinical manifestation of this problem is diminished deep tendon reflexes usually first noted when the plasma magnesium concentration reaches 4–6 meq/L. More severe hypermagnesemia can result in somnolence, loss of deep tendon reflexes, and muscle paralysis, potentially leading to flaccid quadriplegia and, because smooth muscle function is also impaired, decreased respiration and eventual apnea. Parasympathetic blockade—inducing fixed and dilated pupils, thereby mimicking a central brain-stem herniation syndrome—can also be seen in this setting. Treatment is based on renal function and ranges from withdrawal of the magnesium drip to treating with IV fluids, intravenous calcium, and/or dialysis.
Clonus (A) is less likely because hyperexcitability or upper motor neuron lesions typically cause clonus. Tachypnea (D) is also less likely, given magnesium also impairs smooth muscle, which can lead to respiratory depression and eventually apnea. Hypocalcemia, not hypercalcemia (B), is typically seen with hypermagnesemia because magnesium can inhibit the secretion of parathyroid hormone.

Rapid delivery of the head can result in 3rd- and 4th-degree perineal tears. Applying pressure at the perineum can help prevent rapid delivery. As the head emerges from the introitus, the perineum should be supported by a sterile towel placed along the inferior aspect, held in place with one hand. The other hand should support the fetal head. As the infant’s head presents, the inferior hand may then be used to control the fetal chin while the superior hand remains on the crown of the head, supporting the delivery. Once the head delivers, the fetus should be evaluated for nuchal cord.

Although the performance of episiotomies (B) remains controversial, prophylactic episiotomy in the ED is not routinely indicated. Upward pressure on the inferior portion of the head (C) may result in injuries to the anterior structures of the perineum, including the urethra and clitoris. Vigorous stretching of the perineum (D) can predispose patients to perineal tears.