What are the key OBGYN (Obstetrics and Gynecology) emergencies that PA (Physician Assistant) students should know about in order to manage women of reproductive age, pregnant women, and postpartum women?

OBGYN Emergencies: A Comprehensive Two-Hour Presentation for PA Students

Module 1: Hemorrhagic Emergencies (30 minutes)

Postpartum Hemorrhage (PPH)

Administer oxytocin 5-10 IU via slow IV or IM injection at shoulder release or immediately postpartum as first-line prophylaxis for all deliveries. 1

Immediate Management Protocol

• Activate massive transfusion protocol immediately when blood loss exceeds 1,500 mL or patient shows signs of hemodynamic instability 1, 2
• Transfuse packed red blood cells, fresh frozen plasma, and platelets in a fixed 1:1:1 ratio—do not wait for laboratory results in acute hemorrhage 3, 2
• Administer tranexamic acid 1 gram IV within 1-3 hours of bleeding onset (NNT: 276 to prevent one maternal death); effectiveness drops significantly after 3 hours 1, 2
• Establish large-bore IV access (two 16-gauge or larger catheters) and begin aggressive fluid resuscitation 1

Critical Monitoring Parameters

• Obtain baseline platelet count, PT, PTT, and fibrinogen levels immediately—fibrinogen <200 mg/dL in pregnancy predicts severe PPH 2
• Maintain maternal temperature >36°C using forced-air warmers, as clotting factors function poorly at lower temperatures 3, 2
• Avoid acidosis through adequate ventilation and perfusion, as this further impairs coagulation 2
• Re-dose prophylactic antibiotics if blood loss ≥1,500 mL 3, 2

Pharmacologic Management Beyond Oxytocin

• If oxytocin fails, use methylergonovine or carboprost (15-methyl PGF2α) as second-line agents 1
• Avoid prostaglandin F2α in patients with asthma due to risk of severe bronchospasm 3
• Avoid ergometrine in patients with hypertension or cardiovascular disease 3

Placenta Accreta Spectrum

Cesarean hysterectomy with placenta left in situ is the definitive management for confirmed placenta accreta spectrum—attempts at manual placental removal cause catastrophic hemorrhage. 3, 4, 1

Risk Stratification

• Risk increases 7-fold after one prior cesarean delivery and 56-fold after three cesarean deliveries 4
• Additional risk factors include advanced maternal age, high parity, prior uterine surgery, prior PPH, Asherman syndrome, uterine anomalies, smoking, and hypertension 4
• All women with placenta previa and prior cesarean deliveries must be evaluated for placenta accreta spectrum 4

Delivery Planning

• Schedule delivery at 34 0/7 to 35 6/7 weeks gestation at a level III or IV maternal care facility 4, 1
• Do not delay beyond 36 0/7 weeks—approximately 50% require emergent delivery for hemorrhage after this point 4
• Coordinate preoperatively with maternal-fetal medicine, gynecologic oncology or pelvic surgery, urology, interventional radiology, anesthesiology, critical care, and blood bank 3, 4

Intraoperative Approach

• If placenta accreta is unexpectedly discovered, pause the case immediately if maternal and fetal status allow 3
• Alert anesthesia team, obtain additional IV access, order blood products, mobilize cell salvage technology, and summon experienced surgical team 3
• After fetal delivery, leave placenta in situ if abnormal attachment is evident—rapid uterine closure followed by hysterectomy is preferred 3
• Consider ureteric stent placement and urologic surgeon involvement if bladder invasion suspected 4

Postoperative Management

• Transfer to ICU for intensive hemodynamic monitoring in early postoperative period 3
• Maintain low threshold for reoperation if ongoing bleeding suspected 3
• Monitor for renal failure, liver failure, infection, unrecognized ureteral/bladder/bowel injury, pulmonary edema, and DIC 3
• Consider possibility of Sheehan syndrome (postpartum pituitary necrosis) given potential for hypoperfusion 3

Placenta Previa

Digital pelvic examination must be avoided until placenta previa has been excluded to prevent triggering catastrophic hemorrhage. 4

Diagnosis

• Transvaginal ultrasound is the gold standard with 90.7% sensitivity and 96.9% specificity 4
• Perform transabdominal ultrasound initially, followed by transvaginal for accurate assessment 4
• Use Doppler ultrasound to identify vasa previa and assess placental blood flow 4

Delivery Timing

• Deliver at 34 0/7 to 35 6/7 weeks for uncomplicated placenta previa 4
• Earlier delivery indicated for persistent bleeding, preeclampsia, labor, rupture of membranes, or fetal compromise 4
• Administer antenatal corticosteroids when delivery anticipated before 37 0/7 weeks 4

Intraoperative Considerations

• Inspect uterus after peritoneal entry to determine placental location and optimize uterine incision placement 4
• Make uterine incision away from placenta when possible 4
• Consider dorsal lithotomy positioning to allow vaginal access and optimal surgical visualization 4

Placental Abruption

Immediately activate massive transfusion protocol with 1:1:1 ratio of packed red blood cells, fresh frozen plasma, and platelets in severe abruption with hypotension. 2

Critical Management Points

• Monitor fibrinogen levels closely—levels <200 mg/dL associated with severe PPH 2
• Transfuse cryoprecipitate if fibrinogen <100 mg/dL, though pregnancy target should be >200 mg/dL 2
• Consider tranexamic acid 1g IV, though evidence strongest when given within 3 hours of birth 2
• Do not underestimate blood loss—clinical estimation is notoriously inaccurate in obstetric hemorrhage 2

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Module 2: Hypertensive Emergencies (25 minutes)

Severe Preeclampsia and Eclampsia

Administer magnesium sulfate as first-line therapy for eclamptic seizures and seizure prophylaxis in severe preeclampsia. 1

Magnesium Sulfate Protocol

• Loading dose: 4-6 grams IV over 15-20 minutes 1
• Maintenance: 1-2 grams/hour continuous infusion 1
• Monitor deep tendon reflexes, respiratory rate (>12/min), and urine output (>25 mL/hour) 1
• Have calcium gluconate 1 gram IV available as antidote for magnesium toxicity 1

Blood Pressure Management

• Initiate antihypertensive treatment immediately when systolic BP ≥160 mmHg or diastolic BP ≥110 mmHg to prevent intracranial hemorrhage 1
• First-line agents: labetalol 20 mg IV bolus (can repeat and escalate), hydralazine 5-10 mg IV bolus, or immediate-release nifedipine 10-20 mg PO 1
• Goal: reduce BP to 140-150/90-100 mmHg range—avoid precipitous drops that compromise uteroplacental perfusion 1

Delivery Considerations

• Definitive treatment is delivery—timing depends on gestational age, maternal condition, and fetal status 1
• Coordinate with emergency services for rapid response capability 1
• Continue magnesium sulfate for 24 hours postpartum 1

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Module 3: Ectopic Pregnancy (20 minutes)

Diagnosis and Risk Stratification

Ectopic pregnancy should be suspected in any woman of reproductive age with abdominal pain, vaginal bleeding, or both, regardless of contraceptive use. 3

Diagnostic Approach

• Obtain quantitative β-hCG and transvaginal ultrasound 3
• With β-hCG >2,000 mIU/mL and no intrauterine gestational sac, ectopic pregnancy rate is 57% 3
• With β-hCG <2,000 mIU/mL and no intrauterine gestational sac, ectopic pregnancy rate is 28% 3
• Indeterminate ultrasound findings include empty uterus, anechoic intrauterine fluid, echogenic intrauterine material, or abnormal gestational sac 3

Management Based on Stability

• Hemodynamically unstable patients require immediate surgical intervention (diagnostic laparoscopy or laparotomy) 3, 5
• Stable patients with confirmed ectopic pregnancy: consider medical management (methotrexate) vs. surgical management based on β-hCG level, mass size, presence of fetal cardiac activity, and patient reliability for follow-up 3
• Ruptured ectopic pregnancy accounts for approximately 61% of acute surgical abdomen presentations in reproductive-age women 5

Surgical Considerations

• Salpingectomy is performed in approximately 47.8% of ectopic pregnancy cases requiring surgery 5
• Salpingostomy may be considered in select cases when future fertility desired and contralateral tube appears abnormal 5

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Module 4: Cardiopulmonary Emergencies (20 minutes)

Amniotic Fluid Embolism (AFE)

Use cognitive aid checklists focusing on ABC principle: Airway, Breathing, Circulation for AFE management. 1

Recognition

• Classic triad: sudden hypotension, hypoxia, and coagulopathy during labor, delivery, or immediate postpartum period 1, 6
• May present with seizure-like activity, altered mental status, or cardiac arrest 1

Immediate Management

• Secure airway immediately if respiratory distress and seizure activity occur to prevent aspiration 1
• Designate timekeeper to call out times at 1-minute intervals 1
• Start CPR with manual uterine displacement or lateral tilt if no pulse present 1
• Administer 100% oxygen, establish large-bore IV access, and initiate massive transfusion protocol 1, 6

Perimortem Cesarean Delivery

• Prepare for emergency cesarean delivery at 4 minutes regardless of gestational age if uterus at or above umbilicus 1
• Goal: delivery within 5 minutes of maternal cardiac arrest to optimize maternal and fetal outcomes 1
• Continue CPR throughout procedure 1

Maternal Cardiac Arrest

Pregnancy-Specific Modifications

• Perform manual left uterine displacement or place patient in 27-30 degree left lateral tilt to relieve aortocaval compression 1
• Hand placement for chest compressions may need to be slightly higher on sternum 1
• Ensure all staff educated about pregnancy-specific resuscitation modifications 1

Team Mobilization

• Identify contact details to mobilize entire maternal cardiac arrest response team including obstetrics, anesthesia, neonatology, and surgery 1
• Ensure availability of equipment for cesarean delivery and neonatal resuscitation 1
• Establish direct contact between on-call obstetrician and EMS 1

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Module 5: Delivery-Related Emergencies (15 minutes)

Shoulder Dystocia

Shoulder dystocia is an unpredictable and unpreventable obstetric emergency requiring prompt recognition and systematic intervention. 7

Recognition

• "Turtle sign": fetal head retracts against perineum after delivery 7
• Failure of shoulders to deliver with routine gentle downward traction 7

Management Algorithm (McRoberts Maneuver First)

1. Call for help immediately—announce "shoulder dystocia" to mobilize team 7
2. McRoberts maneuver: hyperflexion of maternal hips against abdomen (successful in majority of cases) 7
3. Suprapubic pressure: apply downward pressure above pubic symphysis (never fundal pressure) 7
4. Deliver posterior arm: sweep posterior arm across fetal chest and deliver 7
5. Rotational maneuvers: Woods screw or Rubin maneuver to rotate shoulders into oblique diameter 7
6. All-fours position (Gaskin maneuver): if patient able to move 7
7. Consider episiotomy if soft tissue dystocia suspected, though does not relieve bony obstruction 7

Documentation

• Document time of head delivery, maneuvers performed in sequence, time of body delivery, and personnel present 7
• Examine neonate for clavicular fracture and brachial plexus injury 7

Impacted Fetal Head at Cesarean Delivery

Manual vaginal disimpaction and fetal pillow are effective prevention techniques for impacted fetal head during cesarean delivery. 1

Prevention Strategies

• Avoid prolonged second stage before cesarean decision 1
• Consider fetal pillow placement vaginally before cesarean incision if head deeply engaged 1

Management Techniques

• Assistant pushing head up from vagina while surgeon delivers from above 1
• Reverse breech extraction: deliver feet first, then body and head 1
• Tocolysis (nitroglycerin 50-100 mcg IV or terbutaline 0.25 mg IV/SQ) to relax uterus 1
• Patwardhan technique: push head up through uterine incision, then deliver through enlarged incision 1

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Module 6: Gynecologic Emergencies (15 minutes)

Ovarian Torsion

Ovarian torsion requires urgent surgical intervention to preserve ovarian function—delay increases risk of ovarian necrosis. 5, 6

Clinical Presentation

• Sudden onset severe unilateral lower abdominal pain, often with nausea and vomiting 6
• May have history of ovarian mass or cyst 5
• Pain may be intermittent if torsion is incomplete 6

Diagnosis

• Transvaginal ultrasound with Doppler: enlarged ovary with peripheral follicles, absent or decreased blood flow 6
• Presence of arterial flow does not exclude torsion due to dual blood supply 6
• CT or MRI may show enlarged ovary with edema 6

Management

• Diagnostic laparoscopy is both diagnostic and therapeutic 5, 6
• Detorsion should be attempted even if ovary appears necrotic—ovarian function often recovers 6
• Cystectomy or oophorectomy performed as indicated 5
• Twisted ovarian cyst accounts for approximately 7.64% of acute surgical abdomen presentations 5

Ruptured Hemorrhagic Ovarian Cyst

Management Approach

• Hemodynamically stable patients: conservative management with pain control and serial hemoglobin monitoring 6
• Hemodynamically unstable patients or those with significant hemoperitoneum require surgical intervention 6
• Laparoscopy preferred over laparotomy when feasible 6

Pelvic Inflammatory Disease (PID) with Tubo-Ovarian Abscess (TOA)

Diagnosis

• Clinical diagnosis: lower abdominal pain, cervical motion tenderness, adnexal tenderness 6
• Imaging: transvaginal ultrasound shows complex adnexal mass with thick walls and internal debris 6

Management

• Broad-spectrum IV antibiotics: cefoxitin or cefotetan plus doxycycline, or clindamycin plus gentamicin 6
• Surgical intervention (drainage or excision) indicated for: ruptured TOA, failed medical management after 48-72 hours, or abscess >9 cm 6

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Module 7: Airway Management in Obstetrics (10 minutes)

Physiologic Changes Affecting Airway Management

Pregnant patients are at significantly higher risk for difficult intubation and rapid desaturation due to physiologic changes of pregnancy. 1

Key Anatomic and Physiologic Changes

• Decreased functional residual capacity and increased oxygen consumption lead to rapid desaturation 1
• Airway edema and capillary engorgement increase risk of difficult intubation and bleeding with instrumentation 1
• Increased gastric pressure and decreased lower esophageal sphincter tone increase aspiration risk 1

Preparation Requirements

• Have rigid laryngoscope blades, videolaryngoscopic devices, and endotracheal tubes of assorted sizes immediately available 1
• Prepare for difficult airway: have bougie, laryngeal mask airway, and cricothyrotomy kit readily accessible 1
• Consider neuraxial techniques over general anesthesia when possible 1

Aspiration Prophylaxis

• Administer non-particulate antacid (sodium citrate 30 mL PO) before induction 1
• Consider H2-receptor antagonist (ranitidine 50 mg IV) and metoclopramide 10 mg IV 1
• Use rapid sequence induction with cricoid pressure (though efficacy debated) 1

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Module 8: System-Level Preparedness and Common Pitfalls (15 minutes)

Essential Equipment and Resources

All facilities performing deliveries must have hemorrhage resources immediately available and plans for managing or stabilizing placenta accreta spectrum cases. 3, 1

Hemorrhage Cart Contents

• Large-bore IV catheters (14-16 gauge), rapid infusion devices, fluid warmers 1
• Uterotonic medications: oxytocin, methylergonovine, carboprost, misoprostol 1
• Tranexamic acid 1
• Bakri balloon or other intrauterine tamponade devices 1
• Surgical instruments for B-Lynch suture, uterine artery ligation 1

Blood Bank Coordination

• Establish massive transfusion protocol with 1:1:1 ratio of PRBC:FFP:platelets 1, 2
• Ensure blood bank capability for rapid release of uncrossmatched O-negative blood 1
• Stock adequate cryoprecipitate for fibrinogen replacement 2

Critical Pitfalls to Avoid

Hemorrhage Management Errors

• Do not underestimate blood loss—visual estimation typically underestimates actual loss by 30-50% 2
• Do not delay tranexamic acid beyond 3 hours—effectiveness drops significantly 1, 2
• Do not attempt forced placental removal with suspected accreta—causes catastrophic hemorrhage 3, 1
• Do not wait for laboratory results before initiating massive transfusion protocol in acute hemorrhage 3, 2

Resuscitation Errors

• Do not underestimate physiological changes of pregnancy—normal vital signs may mask significant blood loss 1
• Do not forget to maintain maternal temperature >36°C during resuscitation 3, 2
• Recognize the 4-minute window for perimortem cesarean—do not delay decision-making 1

Medication Errors

• Do not use prostaglandins in patients with respiratory distress or cardiovascular disease 3, 1
• Do not use oxytocin for labor induction in cases of placenta previa, cord prolapse, or other contraindications 8
• Avoid ergometrine in hypertensive patients 3

Simulation-Based Training

Simulation-based training is significantly more effective than conventional didactic teaching for obstetric emergency management. 9

Benefits of Simulation

• Provides real-life-like experiences without patient risk 9
• Leads to better knowledge retention and understanding 9
• More interactive and motivates self-directed learning 9
• Allows practice of rare but critical events (eclampsia, shoulder dystocia, maternal cardiac arrest) 9

Implementation Recommendations

• Conduct regular multidisciplinary simulation drills for common emergencies 9
• Use cognitive aid checklists during simulations and real emergencies 1
• Debrief after each simulation to reinforce learning and identify system gaps 9

Multidisciplinary Team Coordination

Complex obstetric emergencies require immediate mobilization of multidisciplinary teams including obstetrics, anesthesia, surgery, critical care, and neonatology. 3, 1, 10

Team Roles and Communication

• Designate clear team leader for each emergency type 1
• Use closed-loop communication: receiver repeats back orders 1
• Assign specific roles: timekeeper, medication administrator, recorder 1
• Acute Care/Trauma Surgeons play key role in cases of overwhelming hemorrhage requiring damage control techniques 10

Damage Control Surgery Principles

• Damage control packing used in approximately 76% of cases requiring trauma surgery involvement 10
• Average blood loss in cases requiring surgical intervention: 6.8 ± 5.5 L 10
• Patients typically receive 21 ± 14 units of blood products during deliveries with severe hemorrhage 10

Transfer Protocols

Facilities unable to manage placenta accreta spectrum or other complex cases must have established transfer agreements with higher-level centers. 3

When to Transfer

• Suspected placenta accreta spectrum diagnosed antenatally 3
• Unexpected intraoperative recognition of accreta with maternal hemodynamic stability 3
• Lack of surgical expertise, blood bank resources, or ICU capability 3

Stabilization Before Transfer

• Temporizing maneuvers: abdominal packing, tranexamic acid infusion 3
• Transfuse with locally available products 3
• Coordinate with receiving facility before transport 3

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Key Takeaways for PA Students

1. Hemorrhage kills quickly—activate massive transfusion protocol early, transfuse in 1:1:1 ratio, give tranexamic acid within 3 hours 1, 2

2. Placenta accreta spectrum requires specialized care—deliver at tertiary center, never attempt manual removal, hysterectomy is definitive treatment 3, 4

3. Eclampsia management is straightforward—magnesium sulfate for seizures, aggressive BP control to prevent stroke, delivery is definitive treatment 1

4. Ectopic pregnancy can be subtle—maintain high index of suspicion, use β-hCG and ultrasound together for diagnosis 3

5. Maternal cardiac arrest requires immediate perimortem cesarean—prepare at 4 minutes, deliver by 5 minutes if uterus at umbilicus 1

6. Shoulder dystocia follows algorithm—McRoberts first, then suprapubic pressure, then internal maneuvers 7

7. Airway management in pregnancy is high-risk—prepare for difficult intubation, use aspiration prophylaxis, prefer neuraxial when possible 1

8. System preparedness saves lives—have protocols, equipment, and trained teams ready before emergencies occur 1, 9