Clinical: Obstetric Complications Flashcards
6 obstetric emergencies
- Massive obstetric hemorrhage
- Non-hemorrhagic shock
- Shoulder dystocia
- Eclampsia
- Cord prolapse
- Malpresentation
3 massive obstetric hemorrhages
- Praevia
- Abruption
- PPH
2 non-hemorrhagic shocks
- Amniotic fluid embolism
- Acute uterine inversion
Define massive obstetric hemorrhage
Blood loss requiring replacement of patient’s total blood volume
3 potential locations of concealed bleeding
- Uterus (couverlaire uterus of abruption)
- Broad ligament hematoma
- Peritoneal cavity
What is disseminated intravascular coagulation characterized by?
Activation of the coagulation sequence –> systemic micro-thrombi (sequelae of tissue hypoxia)
2 triggering pathways of disseminated intravascular coagulation
- Release of tissue factor/thromboplastic factors into circulation
- Widespread endothelial injury
2 mechanisms of disseminated intravascular coagulation
- Activated monocytes –> release IL-1 and TNF alpha –> increase expression of tissue thromboplastic factor on endothelial cels + increase thrombomodulin
- Consumption of coagulation factors, platelets, and activation of fibrinolytic pathways
4 sources of thromboplastic substances that may cause DIC
- Leukemic cell granules
- Placenta in obstetric complications
- Carcinomas (Mucin-secreting adenocarcinomas)
- Bacterial endo and exotoxins
3 organs damaged by micro-thrombi in DIC
- Kidney
- Adrenals
- Brain
- Heart and anterior pituitary
Kidney damage due to micro thrombi
Microinfarcts in the renal cortex (severe - bilateral renal cortical necrosis)
Adrenal damage due to micro thrombi
Bilateral adrenal hemorrhage (resembles Waterhouse-Friderichsen syndrome)
Brain damage due to microthrombi
Microinfarcts surrounded by foci of hemorrhage
DIC clinical manifestation (9)
- Acute = bleeding tendency (i.e. obstetrical complications and trauma)
- Chronic = thrombotic complications (i.e. cancer0
- Minimal to profound shock
- Renal failure
- Dyspnea
- Cyanosis
- Convulsions
- Coma
- Hypotension
Lab findings of DIC (4)
- PT and PTT typically prolonged
- Thrombocytopenia
- Low fibrinogen
- Elevated plasma fibrin split products
Define placenta praevia
The placenta covers the internal cervical os completely or partially (0.5% to 1% of all births)
4 risk factors of placenta praevia
- Previous cesarean sectrion (x6)
- Mulitparity (x2.6)
- Previous uterine surgery
- IVF
4 different scenarios that predict placenta praevia management
- Preterm fetus and no indication for delivery (observe)
- Mature fetus and bleeding does not stop (C section)
- Patient in labor (C section)
- Severe bleeding and immature fetus (C section)
Management of placental abruption if no symptoms (no bleeding)
Observe mother and fetus
Management of placental abruption if severe bleeding and fetus is alive
Cesarean section
Management of placental abruption if bleeding and fetus is dead
- Amniotomy + pakced red cells + coagulatoin factors + labor induction (vaginal birth)
- If bleeding too severe –> C section
When to consider vasa praevia
If bleeding occurs after amniotomy
3 points of management of post-partum hemorrhage
- Detect and treat antenatal anemia
- Active management of third stage
- IV access plus collect blood for group and cross match if assessed as at risk
3 elements of active management of third stage for post-partum hemorrhage
- Administration of a prophylactic oxytocic agent
- Early cord clamping
- Controlled cord traction of the umbilical cord
2 prophlactic oxytocic agents
Ergometrine and Carboprost
Define amniotic fluid embolism
Anaphylactic reaction to fetal antigens, mainly during delivery
6 risk factors for amniotic fluid embolism
- Multiparity
- Abruption
- Blunt abdominal trauma
- External version
- Fetal death
- Amniocentesis
13 clinical manifestations of amniotic fluid embolism
- Rigors
- Perspiration
- Restlessness
- Coughing
- Cyanosis
- Hypotension
- Bronchospasm
- Tachypnea
- Tachycardia
- Arrhythmia
- Convulsions
- MI
- DIC
Diagnosis of amniotic fluid embolism (4)
- Clinical manifestations
- Chest X ray
- ECG
- Blood gas analysis
Usual presentation of amniotic fluid embolism
Sudden coughing attack after cesarean or vaginal birth
When might uterus inversion occur?
If the fundal placenta is pulled out incautiously and forcefully
Describe the events of shoulder dystocia (4)
- Fetal head is born
- Contraction ceases –> fetal head slips back into vagina (turtle phenomenon)
- Blue livid color of face caused by venous congestion (not hypoxia)
- Interruption of arterial perfusion –> fetal hypoxia and cerebral injury
Shoulder dystocia management (4 maneuvers)
- McRoberts maneuver
- Woods maneuver
- Jacqumiere maneuver
- Rubin maneuver
Describe the McRoberts maneuver
- Flex thighs sharply up onto the abdomen
- Suprapubic pressure
Describe the Wood Maneuver
The posterior sohulder is rotated 180 degrees in a corkscrew manner so that the anterior shoulder is released
Describe the Jacqumiere maneuver
Delivery of the posterior shoulder
Describe the Rubin maneuver
The impacted anterior shoulder is rotated in abdomen direction
3 methods of management for shoulder dystocia if all 4 maneuvers do not work
- Fracture of the clavicula (upward direction)
- Zavanelli maneuver
- Abdominal rescue after O,Leary & Cuva.
Describe Zavanelli maneuver
Put the fetal head into the vagina and cesarean section
Describe abdominal rescue
Lap + uterotomy: release the impacted anterior shoulder abdominally and the posterior sohulder vaginal and deliver the fetus vaginally
7 risk factors for umbilical cord prolapse
- Long umbilical cord
- Breech
- Transverse lie
- Small fetus
- Multiparity
- Twins
- Amniotomy
8 clinical manifestations of eclampsia
- Headaches
- Blurred vision
- Confusion
- Severe HTN
- Proteinuria
- Edema
- Hyper-reflexia
- Eclamptic fit (seizure)
6 points of management for eclampsia
- Turn woman on side
- Oxygen
- Magnesion sulphate (IM or IV)
- Anti-hypertensives (hydrallazine, labetolol)
- Anti-seizure meds
- DELIVER THE PLACENTA (and the baby!)
6 potential consequences of eclampsia
- Fetal death
- Maternal asphyxia
- Respiratory distress
- Hemorrhage (thrombocytopenia/DIC)
- Multi-organ failure
- ICU
2 malpresentations
- Breech presentation
- Transverse/oblique lie
5 potential consequences of malpresentation
- Prematurity
- Multiple pregnancy
- Obstruction (i.e. fibroids)
- Fetal malformation (i.e. hydrocephaly)
- Placenta praevia
