What are the key OBGYN (Obstetrics and Gynecology) emergencies that Physician Assistant (PA) students should know how to manage?

OBGYN Emergencies: 2-Hour PowerPoint Presentation for PA Students

Slide Structure Overview

Module 1: Postpartum Hemorrhage (30 minutes)

Definition and Recognition

• Define PPH as blood loss >500 mL after vaginal delivery or >1000 mL after cesarean delivery, though clinical estimation often underestimates actual blood loss 1
• Recognize that PPH is the leading cause of maternal deaths worldwide and requires immediate systematic response 1
• Monitor for signs of hemodynamic instability: tachycardia, hypotension, altered mental status, oliguria 2

The "4 T's" Framework for Diagnosis

• Tone (70%): Uterine atony - soft, boggy uterus on palpation 1
• Trauma (20%): Lacerations, hematomas, uterine inversion, uterine rupture 1
• Tissue (10%): Retained placenta or placental fragments 1
• Thrombin (<1%): Coagulopathy - inherited or acquired bleeding disorders 1

Immediate Management Protocol

• Establish large-bore IV access (at least two sites) and initiate aggressive crystalloid resuscitation immediately 3
• Activate massive transfusion protocol without delay 4
• Ensure blood bank resources are immediately available with type-specific or O-negative blood acceptable in emergencies 4
• Perform bimanual uterine compression and vigorous uterine massage 1

Pharmacologic Management

• First-line: Oxytocin 10-40 units in 1000 mL non-hydrating solution, infused at rate necessary to control atony 5
• Second-line: Methylergonovine (Methergine) 0.2 mg IM for routine management after placental delivery and postpartum atony 6
• Avoid methylergonovine in hypertensive patients due to vasoconstrictive effects 1

Surgical Interventions

• If medical management fails, proceed to intrauterine balloon tamponade (Bakri balloon) as next step 1
• Surgical options if tamponade fails: uterine compression sutures (B-Lynch), uterine artery ligation, hypogastric artery ligation, or hysterectomy 1
• Consider interventional radiology for uterine artery embolization when patient is stable enough for transfer 1

Equipment Requirements

• Large-bore IV catheters, fluid warmer, forced-air body warmer 4
• Rapid infusion devices: hand-squeezed fluid chambers, hand-inflated pressure bags, automatic infusion devices 4
• Massive transfusion protocol with immediate blood bank access 4

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Module 2: Hypertensive Emergencies in Pregnancy (25 minutes)

Preeclampsia with Severe Features

• Recognize severe features: BP ≥160/110 mmHg, thrombocytopenia <100,000, elevated liver enzymes, renal insufficiency, pulmonary edema, new-onset headache, visual disturbances 7
• Severe preeclampsia requires immediate treatment to prevent progression to eclampsia and maternal stroke 7

Eclampsia Management

• Eclampsia is defined by new-onset grand mal seizures in a woman with preeclampsia and represents a life-threatening emergency 8, 7
• Immediate priorities: protect airway, prevent maternal injury during seizure, administer magnesium sulfate 8
• Position patient in left lateral decubitus to prevent aspiration and improve uteroplacental perfusion 7

Magnesium Sulfate Protocol

• Loading dose: 4-6 grams IV over 15-20 minutes 7
• Maintenance: 1-2 grams/hour continuous infusion 7
• Monitor for magnesium toxicity: loss of deep tendon reflexes (first sign), respiratory depression, cardiac arrest 7
• Keep calcium gluconate 1 gram IV at bedside as antidote for magnesium toxicity 7

Acute Blood Pressure Management

• Treat sustained BP ≥160/110 mmHg immediately to reduce stroke risk 7
• First-line agents: labetalol 20 mg IV bolus, then 40-80 mg every 10 minutes (max 300 mg), or hydralazine 5-10 mg IV every 20 minutes 7
• Goal: reduce BP to 140-150/90-100 mmHg range, avoiding precipitous drops that compromise uteroplacental perfusion 7

Delivery Timing

• Eclampsia or preeclampsia with severe features at ≥34 weeks requires delivery after maternal stabilization 7
• Below 34 weeks, consider corticosteroids for fetal lung maturity if time permits, but maternal safety takes priority 7

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Module 3: Ectopic Pregnancy (20 minutes)

Initial Assessment

• Up to 13% of symptomatic ED patients with first-trimester bleeding and pain are at risk for ectopic pregnancy 9
• Assess vital signs immediately to determine hemodynamic stability 9
• Classic triad: abdominal pain, vaginal bleeding, amenorrhea - but not always present 9

Diagnostic Approach

• Obtain quantitative β-hCG and perform transvaginal ultrasound regardless of β-hCG level 9
• Critical pitfall: Do not defer ultrasound because β-hCG is "too low" - sensitivity is only 33% below 1,500 mIU/mL, but still provides valuable risk stratification 9
• Check blood type and Rh status immediately 9

Unstable Patient Management

• Establish IV access immediately and initiate resuscitation with fluids and blood products for hemorrhagic shock 9
• Activate massive transfusion protocol 9
• Proceed directly to emergency laparotomy without delay for additional imaging 9
• Notify surgical team immediately for ruptured ectopic pregnancy 9

Stable Patient Management

• Medical management with methotrexate for hemodynamically stable patients with unruptured ectopic pregnancy 9
• Surgical management (laparoscopy preferred) for unstable patients, failed medical management, or patient preference 9

Critical Discharge Planning

• Never discharge without concrete follow-up plans within 24-48 hours 9
• Administer anti-D immunoglobulin (RhoGAM) to Rh-negative patients 9
• Provide explicit return precautions: worsening pain, dizziness, syncope, heavy bleeding 9

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Module 4: Amniotic Fluid Embolism (20 minutes)

Recognition

• Consider AFE in any postpartum woman with sudden cardiorespiratory collapse - it remains a clinical diagnosis with no confirmatory laboratory test 10
• Classic triad: sudden hypoxia, hypotension, and coagulopathy 10
• Mortality remains up to 50% despite optimal management, requiring aggressive and prompt intervention 10

Immediate Resuscitation

• Initiate high-quality CPR following standard BCLS and ACLS protocols immediately if cardiac arrest occurs 10
• Provide 100% oxygen and proceed to early endotracheal intubation for respiratory distress 10
• Activate multidisciplinary team: anesthesia, respiratory therapy, critical care, maternal-fetal medicine 10

Hemodynamic Management

• Initial phase typically presents with right ventricular failure, followed by left ventricular failure 10
• Use echocardiography if available to evaluate ventricular function 10
• Administer inotropes: dobutamine 2.5-5.0 μg/kg/min and milrinone 0.25-0.75 μg/kg/min for right ventricular support 10

Coagulopathy Management

• DIC is the hallmark laboratory finding, though it may have immediate or delayed onset 10
• Obtain immediately: PT/INR, aPTT, fibrinogen, platelet count, D-dimer 10
• Expected findings: low fibrinogen, thrombocytopenia, elevated D-dimer 10
• Implement massive transfusion protocols aggressively for clinical bleeding 10

Advanced Interventions

• Consider ECMO for prolonged CPR without return of spontaneous circulation 10
• Transfer to ICU for continued management once initially stabilized 10

Critical Pitfall

• AFE is often misdiagnosed initially - maintain high clinical suspicion in any postpartum woman with sudden cardiorespiratory collapse 10

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Module 5: Cesarean Delivery Emergencies (25 minutes)

Impacted Fetal Head

• Impacted fetal head complicates up to 1 in 10 emergency cesarean deliveries and is defined as inability to deliver the fetal head with usual delivering hand, requiring additional maneuvers 4
• Risk factors: full cervical dilatation, prolonged labor, deep engagement of fetal head 4
• Maternal risks: hemorrhage, bladder injury, uterine extension 4
• Neonatal risks: skull fractures, brain hemorrhage, hypoxic brain injury 4

Prevention Techniques

• Manual vaginal disimpaction before uterine incision: introduce hand into vagina to elevate fetal head into abdomen 4
• Fetal Pillow device: inflatable device placed vaginally to elevate fetal head before uterine incision 4

Management During Cesarean

• Administer tocolysis to relax uterus and facilitate disimpaction 4
• Reverse breech extraction: deliver baby feet first 4
• Assistant pushes head up from vagina while surgeon delivers from above 4

Cesarean Scar Rupture

• Proceed directly to emergency laparotomy without delay for additional imaging or stabilization attempts 3
• Obtain large-bore IV access at two sites minimum 3
• Initiate aggressive crystalloid resuscitation immediately - large volumes potentially necessary 3
• Activate massive transfusion protocol and ensure blood products readily available 3

Surgical Approach for Rupture

• Use midline vertical incision for optimal access and visualization 3
• Avoid forced placental removal - can result in profuse hemorrhage 3
• Maintain vigilance for ongoing bleeding postoperatively with low threshold for reoperation 3

Postoperative Monitoring

• Monitor for: renal failure, liver failure, infection, unrecognized ureteral/bladder/bowel injury, pulmonary edema, DIC 3
• Counsel patients about significantly increased risks in future pregnancies: recurrent cesarean scar pregnancy, placenta accreta spectrum, repeat uterine rupture 3

Airway Management Resources

• Labor and delivery units must have personnel and equipment readily available to manage airway emergencies 4
• Required equipment: rigid laryngoscope blades of alternate design, videolaryngoscopic devices, endotracheal tubes of assorted sizes, tube guides 4
• Emergency airway devices: supraglottic airways (LMA), equipment for cricothyrotomy 4
• Pulse oximeter and carbon dioxide detector mandatory 4

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Module 6: Simulation and Team Training (20 minutes)

Importance of Simulation

• Obstetric emergencies are unpredictable and high-risk, requiring multiprofessional team coordination 4
• Simulation training improves recognition, response times, and team communication 4

Key Scenarios to Practice

• Postpartum hemorrhage with progression to massive transfusion 1
• Eclamptic seizure with airway management 7
• Shoulder dystocia with McRoberts maneuver and suprapubic pressure 11
• Maternal cardiac arrest with perimortem cesarean delivery 10
• Impacted fetal head at cesarean delivery 4

Team Communication

• Use closed-loop communication: receiver repeats back orders 1
• Designate clear team leader and roles 1
• Use checklists and protocols to reduce cognitive load during crisis 1

Debriefing

• Conduct structured debriefing after simulations and real emergencies 1
• Focus on systems issues, not individual blame 1
• Identify opportunities for protocol improvement 1

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Key Takeaways for PA Students

Critical equipment must be immediately available on all labor and delivery units: large-bore IV catheters, fluid warmers, forced-air body warmers, blood bank resources, massive transfusion protocols, rapid infusion devices, and airway management equipment including videolaryngoscopes and emergency surgical airway supplies 4

The most common OBGYN emergencies requiring immediate recognition are: postpartum hemorrhage (leading cause of maternal death worldwide), eclampsia, ruptured ectopic pregnancy, amniotic fluid embolism, and cesarean delivery complications including impacted fetal head and uterine rupture 4, 3, 10, 9, 1, 7

Multidisciplinary team activation is essential for all major obstetric emergencies - never hesitate to call for help early, including anesthesia, critical care, blood bank, and surgical teams 10, 1