7. Organisation and targets of the women’s health practice.Emergency obstetric care. Flashcards
what does perinatal mean ?
starts at 20-28th gestation week and ends are 1-4 week after birth
Majority of the maternal and early newborn deaths can be avoided by ensuring availability of?
EmONC (emergency obstetric and newborn care) services.
and timing is critical
why are peripartum haemorrhages very dangerous?
Peripartal haemorrhage kills women in less than 2 hours - for other cases the women has 6 hours or or more
most perinatal death occurs when ?
during labour and delivery and the following 48 hour
what is essential for a functional EmONC ?
have atleast two skilled attendants and trained support staff on duty all times
availability of treatment is very crucial
Basic EmONC has seven components and comprehensive EmONC has three additional ones , name all of them :
1) parenteral treatment for infections
2) parenteral treatment of severe pre-eclampsia / eclampsia (MgSO4)
3) treatment of PPH (postpartum hemorrage) - uteronitics oxytocin
4) manual aspiration of retained products of conception
5) assisted vaginal delivery - eg vacuums assisted delivery
6) manual removal of placenta
7) newborn resuscitation station
add 3
8) surgical capability including anaesthesia and cesarian
9) blood transfusions
10) contraceptive services including sterilization and facilities of referral with transport
what are the obstetric emergencies during pregnancy ?
miscarriage
Ectopic pregnancy
Placental abruption
placenta praaevia
-preeclampsia (pregnancy induced blood pressure) / eclampsia (seizures)
PROM - premature rupture of membranes
Abnormalities of the placenta ,membranes and umbilical cord
in miscarriage the death of the baby cannot be stopped before what gestational week
otherwise called spontaneous abortion
loss of a baby before the 24th week of gestation cannot be stopped
if the baby dies after 24th week it is known as still birth
common symptoms of miscarriage
vaginal bleeding/ and tissue substance pass through
Abdominal cramping and pain
septic abortion -rise of temperature of at least for 24 hours or more,
offensive or purulent vaginal discharge
other evidences of pelvic infection such as lower abdominal pain and tenderness.
what are the risk factors /causes miscarriage
IUD in situ
miscarriages occur before the 16th week and of these about 80% occur before the 12th week of pregnancy
first trimester : 1) majorly chromosomal abnormalities = Autosomal trisomy / trisomy 16 = Polyploidy = Monosomy X
2) Endocrine disorders
= Luteal Phase Defect (LPD) Deficient progesterone secretion from corpus luteum or poor endometrial response to progesterone is the cause.
thyroid abnormalities, diabetes
3) Immunological autoimmune -
>antiphospholipid syndrome = lupus anticoagulant
anticardiolipin antibodies
> Th1 response is the production of proinflammatory cytokines
Women with recurrent miscarriage have more Th 1 response
4) Infection - TORCH
^numbered in order of highest incidence ^
inherited thrombophilia
smoking - formation of carboxyhemoglobin and decreased oxygen transfer to fetus
radiation
alcohol
second trimester-
(1) Anatomic abnormalities
- Cervical incompetence (congenital or acquired).
-Müllerian fusion defects
bicornuate uterus, septate uterus.
- Uterine synechiae.( uterine adhesions)
- Uterine fibroid esp submucous variation
miscarriage should be diagnosed only if any of the following criteria are met what are they ?
Low levels hCG
Internal examination reveals dilated internal os of the cervix and products of conception which escaped examined to confirm or
through which the products of conception are felt
Crown-rump length of 7 mm or > and no heartbeat.
Mean gestational sac diameter of 25 mm or > and no embryo
Absence of embryo with heartbeat at least 2 weeks after an ultrasound scan that showed a gestational sac without a yolk sac.
Absence of embryo with heartbeat at least 11 days after an ultrasound scan that showed a gestational sac with a yolk sac
what is the management of miscarriages ?
the clinical management of miscarriage is that if it is in the beginning of pregnancy it usually passes by itself - complete miscarriage
In cases of an incomplete miscarriage, empty sac, or missed abortion there are three treatment options: watchful waiting, medical management(misoprosto/mifepristonel), and surgical treatment (dilation vacuum aspiration/currettage)
however if it has passed viable gestational age then cervical dilation - prostaglandin , saline infusion
misoprostol / prostaglandin , oxytocin and other uterine contractors are given to delivery the baby and the retained products of conception are suctioned and curettage
septic abortion - Broad-spectrum intravenous antibiotics should be given until the fever is gone if septic abortion first then go onto the rest
rh immunisation
what are the two classifications for spontaneous abortion
isolated (sporadic)
or
recurrent
expulsion of miscarriage before 8 weeks ?
embryo surrounded by the villi with the decidual coverings, is expelled out intact.
Sometimes, the external os fails to dilate so that the entire mass is accommodated in the dilated cervical canal= cervical miscarriage
expulsion of miscarriage 8-14 weeks ?
Expulsion of the fetus commonly occurs leaving behind the placenta and the membranes.
A part of it may be partially separated with brisk hemorrhage or remains totally attached to the uterine wall
what is expulsion of miscarriage after 14 weeks ?
process of expulsion is similar to that of a “mini labor”. The fetus is expelled first followed by expulsion of the placenta after a varying interval
what is threatened miscarriage ?
process of miscarriage has started but has not progressed to a state from which recovery is impossible
what is the clinical features of threatened miscarriage ?
Bleeding per vaginam which is painless and stops spontaneously
Pain appears usually following hemorrhage
mild backache or dull pain in lower abdomen
treatment of threatened miscarriage ?
bed rest till bleeding stops
Relief of pain may be ensured by diazepam
some evidence that treatment with progesterone improves the outcome (hcg not preferred)
RH negative patients
anti-D gamma globulin injection intramuscularly
diagnosis of threatened miscarriage (also bad prognosis ) ?
vaginal Speculum inspection reveals—bleeding if any, through the external os
CERVICAL OS closed
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Blood—for hemoglobin, hematocrit, ABO and Rh grouping.
falling serum b-hCG,
serum progesterone value of 25 ng/mL or more generally indicates a viable pregnancy
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golden
TRANSVAGINAL ULTRASOUND
normal - gestational sac well formed with central echogenicity and fetal cardiac signs
decreasing size of the fetus,
irregular shape of the gestational sac and smaller mean gestational sac
decrease in fetal movement
decreasing fetal heart rate
progressing to INEVITABLE MISCARRIAGE
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If the pregnancy continues, there is increased frequency of preterm labor, placenta previa, intrauterine growth restriction of the fetus and fetal anomalies.
clinical features of inevitable miscarriage ?
in comparison to threatened miscarriage
Increased vaginal bleeding.
Aggravation of pain in the lower abdomen which may be colicky in nature
CERVICAL OS OPEN
second trimester, it may start with rupture of the membranes or intermittent lower abdominal pain -mini labor
what is the management of inevitable miscarriage ?
Excessive bleeding -Methergine 0.2 mg if the cervix is dilated and the size of the uterus is less than 12 weeks.
blood loss is corrected by intravenous (IV) fluid therapy and blood transfusion.
under strict aseptic conditions
Before 12 weeks : Suction evacuation -6-12weeks (dilation and curettage) suction aspiration vacuum aspiration (explained in induced abortion)
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After 12 weeks:
(1) cervical preparation and uterine contraction is accelerated by oxytocin drip
If the fetus is expelled and the placenta is retained, it is removed by ovum forceps, if lying separated. If the placenta not separated, manual and evacuation under general anesthesia
suction evction , folllowed by opher forceps , followed by curettage
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RH negative patients
anti-D gamma globulin injection intramuscularly
what is complete miscarriage ?
all the pregnancy tissue has left your uterus.
what is the clinical features for complete miscarriage ?
expulsion of a fleshy mass per vaginam
subsidence of abdominal pain
vaginal bleeding absent
what is the diagnosis of complete miscarriage ?
internal examination
cervical os is closed
bleeding trace
examination of expelled fleshy mass is found complete
US - empty uterine cavity
what is incomplete miscarriage ?
entire products of conception are not expelled, instead a part of it is left inside the uterine cavity
clinical features of incomplete miscarriage
expulsion of a fleshy mass per vaginam followed by
Continuation of pain in lower abdomen.
Persistence of vaginal bleeding.
what is the diagnosis of incomplete miscarriage ?
internal examination - cervical os open
examination of fleshy material is incomplete
US - revels echogenic products of the conception
what are complications where there is retained products of conception ?
profuse bleeding
sepsis
placental polyp
blood coagulation - less likely
what is the management of incomplete miscarriage?
expectant management if pain levels are tolerable
dilation and suction evacuation under general anaesthesia
placenta products can also be ovum forceps
blunt curette is used to scrap on the walls after the procedure
medical management by giving misprostol in the posterioir fornix of the vagina = there is less complication
what is the MANAGEMENT of missed miscarriage when the fetus is dead inside the uterus for a variable period ?
uterus less than 12 weeks -
be expectant - expulsion spontaneously
then
medial manegmnet - misoprostol put in the posterioir fornix and repeated if needed products are expelled
then dilation and suction evacuation can be done under general anaesthesia
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uterus more than 12 weeks
misoportsol vaginally for expulsion
general anaesthesia
dilation then evacuation
what is septic abortion?
and what are the typical microorganism causing it ?
Any abortion associated with clinical evidences of infection of the uterus
(a) Anaerobic—Bacteroides group (fragilis), anaerobic Streptococci,
(b) Aerobic—Escherichia coli (E. coli), Klebsiella, Staphylococcus,
what are the clinical features of septic abortion ?
fever for 24hrs and more
offensive purulent vaginal discharge / pelvic abcess
other incidence f pelvic infection such as lower abdominal pain
persistent tachycardia
tachypnea
endotoxic shock - hypotension
Diarrhea and/or vomiting
what is the diagnosis of septic abortion ?
cervical and high vaginal swab - culture
blood - leukocytosis
CRP
serum lactate
Ultrasound -
grade 3 - peritonitis
what are the complications of septic abortion ?
most fatal complications comes from illegal induced abortions of grade 3 type
= hemorrhage
= injury of the uterus and adjacent tissues
= spread of the infection- sepsis and peritonitis
endotoxic shock - ecoli
DIC
=thrombophelbitis
= remote complications: dyspareunia , ectopic pregnancy , secondary infertility
what is the management of septic abortion ?
hospitalisation and isolation
grade 1 - infection localised to uterus
-antibiotics
-Analgesics and sedatives
-evacuation should be performed at a convenient time within 24 hours following antibiotic therapy
excessive bleeding - immediate evacuation
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grade 2 - spread beyond uterus , parametric , tubes and ovaries
combination of either piperacillin-tazobactam or carbapenem plus clindamycin (IV) gives broadest range of microbial coverage
as empirical therapy
Evacuation of the uterus
is withheld for at least 48 hours when the infection is controlled and is localized, the only exception being excessive bleeding then in all cases evacuation
Posterior colpotomy—When the infection is localized in the pouch of Douglas, pelvic abscess is formed. It is evidenced by spiky rise of temperature, rectal tenesmus (frequent loose stool mixed with mucus) and boggy mass felt through the posterior fornix.
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grade 3
Generalized peritonitis and/or endotoxic shock or jaundice or acute renal failure.
antibiotics as grade 2
generalized peritonitis by vigorous intravenous crystalloids infusion
laparotomy- is needed to perform a full exploration and lavage of the peritoneum
laparotomy to remove uterus indications :
Injury to the uterus or bowel
Unresponsive peritonitis
Septic shock or oliguria not responding to the conservative treatment.
WHAT IS PROM?
Spontaneous rupture of the membranes any time beyond 28th week of pregnancy but before the onset of labor
what are the different types of prom ?
occur beyond 37th week but before the onset of labor, it is called term PROM
occurs before 37 completed weeks, it is called preterm PROM.
Rupture of membranes for > 24 hours before delivery is called prolonged rupture of membranes.
what is the cause of PROM
cause of PROM is not clearly understood
risk factors
Infections: urinary tract infection, sexually transmitted diseases, lower genital tract infections (e.g. bacterial vaginosis),
chorioamnionitis
Tobacco
Illicit drug use
Having had PROM or preterm
Polyhydramnios
Multiple gestation
what is the signs and symptoms of PROM
experience a painless leakage of fluid out of the vagina
diagnosis of PROM
prove that the fluid leaking from the vagina is amniotic fluid,
History: a person with PROM typically recalls a sudden “gush” of fluid loss
Speculum examination : called the Pooling test: collection of amniotic fluid seen in the posterior vaginal fornix
Sometimes leakage of fluid from the cervical opening can be seen when the person coughs or performs a valsalva maneuver
this is the put under tests :
Nitrazine test: A sterile cotton swab is used to collect fluid from the vagina and place it on nitrazine paper. Amniotic fluid is mildly basic (pH 7.1–7.3) compared to normal vaginal secretions which are acidic (pH 4.5–6).Basic fluid, like amniotic fluid, will turn the nitrazine paper from orange to dark blue.
Fern test: A sterile cotton swab is used to collect fluid from the vagina and place it on a microscope slide. After drying, amniotic fluid will form a crystallization pattern called arborization which resembles leaves of a fern plant when viewed under a microscope.
====need to monitor these below=====
US - also fetal biophysical profile
pulmonary maturity
phosphatidyl glycerol and L: S ratio
Cardiotocography for nonstress test
cervical swab and urine culture
what is the management of PROM ?
near term
37 weeks - observation for 12-24 hours in which labour starts that is if no fetal distress , no signs of infections
if not labour does not start
oxytocin induction
and preparation of cervix with prostaglandins
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36-34 weeks -
watch for onset of labour for max 48hrs
give prophylactic antibiotics
if not induction of labour begins with oxytocin
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less than 34 weeks
Delivery before 32 weeks’ gestation is associated with a significant risk of neonatal morbidity and death. Because of this, attempts to prolong pregnancy if there is no maternal indication for immediate delivery.
In the presence of active labor, intrauterine infection, or evidence of fetal compromise, delivery is required
corticosteroids
broad spectrum prophylactic antibiotics
tocolytic drugs - magnesium sulfate (MgSO4), indomethacin, and nifedipine
elective delivery at 34 weeks
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below 24 weeks - careful observation ONLY,
NO medication is given
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C SECTION of ANY OF IT NOT CEPHALIC PRESENTTION
complication of prom ?
premature baby and its complication - RDS , pulmonary hypoplasia
ascending infection if labour starts to fail in 24hrs = chorioamonitis = fetal infection
cord prolapse esp when associated to malpresentation
dry labour -
mother - placental abruption , retained placental , endometritis, maternal sepsis
why is it recommended to deliver at 34 weeks in prom?
perinatal mortality from prematurity is less compared to infection
Obstetric emergencies during labour /after vaginal delivery ?
during labour :
shoulder dystocia
prolapse of umbilical cord
rupture of uterus
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post partum
inversion of uterus (birth trauma of mother)
uterine atony - (post partum hemorrhage )
amniotic fluid
embolism-DIC
Hypotension without significant external bleeding
retained products of conception
what is prolapse of umbilical cord
the umbilical cord gets push down to vagina or cervix before birth of the baby - leading to cord being compressed - fetes does not receive oxygen - brain damage and even death of fetes
what are the other types of cord descend ?
occult prolapse - the cord is placed to the side of the presenting part
it is not felt through the fingers on internal examination
but COULD BE seen in US
cord presentation - cord slipped below the presenting part and its pulsations ar felt through vaginal examinations of an intact membrane
what is the aetiology of cord prolapse ?
malpresentation - transverse and breech
contracted pelvis
prematurity
trins
hydroaminos
what is the diagnosis of cord descend ?
occult prolapse - difficult to diagnose should be suspected if there is variable deceleration cardiotochography
cord presentation - vaginal internal examination , pulsate of the cord through INTACT membranes
cord prolapse - cord palpated directly through the fingers if the fetus is alive - but no pulsation does not necessarily mean fetal death
what is the management of different cord descend?
cord presentation
c section
exaggerated sim position to minimise cord compression
cord prolapse
baby living - c section - tocolysis if there is a wait
prior to making the abdominal incision feat hr should be checked one more time to avoid c section of dead baby
immediate safe vaginal delivery - if head is engaged delivery by forceps
bladder filling with foley catheter with saline solution- raise the presenting part from the cord
lift the presenting part of the cord through fingers introduced into he vagina and pushing the presenting part upwards remove the hand from the vagina once the presenting part is above the pelvic brim and apply continuo suprpubicpressure
SIMS position with pillow under the hips
cord replacement not advised
if the baby is dead - labour is proceeded
what causes hypotension without significant external bleeding
uterine inversion,
IMPROPER sutured episiotomy,
genital tract lacerations,
retained product of conception
sort tissue hematoma - usually of vulva occur during delivery in the absence of any episiotomy
how is the proper suturing of episiotomy done ?
inccoperate the cut and retracted arterioles - they can continue to bleed - creating hematoma
hypotension without significant external bleeding is dealt how
blood transfusion with ringers solution
what is the definition of recurrent miscarriage ?
defined as a sequence of three or more consecutive spontaneous abortion before 20 weeks.
causes for recurrent miscarriage ?
infection in genital tract
genetic factors
Endocrine and metabolic:
(1) Poorly controlled diabetic
Presence of thyroid autoantibodies
Luteal phase defect (LPD) with less production of progesterone
Polycystic ovary syndrome (PCOS
Inherited thrombophilia
second trim
congenital or acquired.
Congenital anomalies may be due to defects in the Müllerian duct fusion or resorption
(e.g. unicornuate, bicornuate, septate or double uterus).
Acquired anomalies are: intrauterine adhesions, uterine fibroids and endometriosis and cervical incompetence.
