Emergencies Flashcards

1
Q

Discuss amniotic fluid embolism
-Incidence (2)
-Case fatality rate (1)
-Perinatal mortality rate (1)
-Risk factors (6)

A
  1. Incidence
    -1.7:100,000
    -Second most common cause of maternal mortality in NZ
  2. Case fatality rate - 14-19%
  3. Perinatal mortality rate - 67:1000
  4. Risk factors
    -Advanced maternal age
    -Polyhydramnios
    -Placenta praevia
    -Placental abruption
    -Operative delivery
    -Induction of labour
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2
Q

Discuss presentation of amniotic fluid embolism (5)

A

-Acute hypotension
-Fetal distress
-Pulmonary oedema
-Cardiopulmonary arrest
-Coagulopathy

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3
Q

Discuss the pathophysiology of AFE (6)

A
  1. Thought to be an anaphylactoid process to amniotic fluid and debris in maternal circulation
  2. Vascular occlusion and vasoconstricition leading to pulmonary HTN
  3. Increased R ventricular pressures leading to acute dilation and poor filling and reduced cardiac output
  4. Left heart failure due to R heart dilation and pulmonary oedema
  5. DIC secondary to thromboplastin release and bleeding
  6. Hypotension leading to reduced uterine perfusion and fetal distress and death.
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4
Q

Discuss AFE
-Diagnosis (3)
-Management (3)

A
  1. Diagnosis
    -No definite diagnostic criteria
    -Suspect if acute cardiopulmonary collapse and coagulopathy without another reason
    -Can find fetal debris in R ventricle on autopsy.
  2. Management
    -Supportive care
    -Advance life support
    -Manage coagulopathy
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5
Q

Discuss cord prolapse
-Types (3)
-Incidence (3)
-Perinatal mortality rate (1)

A
  1. Types
    -Overt - decent of cord past presenting part in context of ruptured membranes
    -Occult - decent of cord alongside presenting part in context of ruptured membranes
    -Cord between the cervix and fetal presenting part with or without ROM
  2. Incidence
    -1:1000
    -1:100 Breech
    -50% associated with obstetric intervention
  3. Perinatal mortality 9%
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6
Q

Discuss risk factors for cord prolapse
-General risk factors (9)
-Procedure related (6)

A
  1. General risk factors
    -Multiparity
    -Low birth weight (<2.5kg)
    -Non-cephalic presentation
    -PTL
    -Fetal congenital abnormalities
    -Second twin
    -Polyhydramnios
    -Low lying placenta
    -Unengaged presenting part
  2. Procedure based
    -ARM with high presenting part
    -Vaginal manipulation of fetus with ruptured membranes
    -ECV
    -Internal podalic version
    -Stabilising IOL
    -Balloon catheter for IOL
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7
Q

Discuss methods to prevent or mitigate effects of cord prolapse (6)

A
  1. Consider selective screening e.g. for breech women choosing vaginal birth (No role for routine antenatal detection)
  2. Admission after 37/40 for transverse, oblique or unstable lie
  3. Admission of PPROM where non-cephalic
  4. Avoid ARM with high presenting part
  5. Avoid ARM when cord palpable below presenting part
  6. Avoid upward pressure on fetal head with VE to avoid dislodging
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8
Q

Discuss management of cord prolapse
1. In a primary setting (5)
2. In a secondary setting (5)
3. When peri-viable

A
  1. Primary setting
    -Call ambulance
    -Transfer in exaggerated Sims position
    -Transfer to nearest facility with CS available
    -Elevate presenting part manually or by filling bladder
    -Minimise handling of cord to avoid vasospasm
  2. Secondary setting
    -Elevate the presenting part manually or with filling bladder
    -Position woman - knees to chest
    -Consider tocolysis if recurrent fetal HR abnormalities
    -Avoid touching cord. No evidence to wrap it in warm swabs or replace it above presenting part
    -Assess for route of delivery and timing of delivery
    _Can consider regional anaesthetic
    -Can consider delayed cord clamping
  3. When peri-viable
    -Expectant management can be considered between 23-24 weeks
    -Replacement of cord not supported
    -Discuss options of TOP vs continuation
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9
Q

Discuss management of eclampsia (5)

A
  1. DRS ABCD
  2. MgSO4
    ->4g over 20mins then 1g.hr infusion
    -If recurrent seizure further 2g bolus
    -If AKI halve dose
    -Risk of seizure despite MgSO4 10-15%
  3. Control BP
  4. Monitor for MgSO4 toxicity
    -Loss of deep tendon reflexes
    -Reduced respiratory rate
    -Manage with 10% calcium gluconate 10ml IV
  5. Delivery once stable
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10
Q

Discuss the physiological changes in pregnancy which impact resus (9)

A
  1. Dilutional anemia = reduced O2 capacity
  2. Increased HR and CO = Increased CPR circulation demands
  3. Decreased SVR = reduced preload, therefore increased CPR demand
  4. Increased O2 consumption = Earlier onset of hypoxia
  5. Laryngeal oedema, large breasts, weight gain = Difficult intubation
  6. Increased RR and decreased residual capacity = decreased buffering ability and faster onset of acidosis
  7. Decreased gastric motility and increased oesophageal sphincter laxity = Risk of aspiration
  8. Large uterus = reduced CO 2’ to aortocaval compression, impairs CPR
  9. Diaphragm splinting makes ventilation more difficult
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11
Q

Discuss perimortem CS
-Who should have one (1)
-When to do (1)
-Where to do (1)
-How to do (2)
-Benefits of doing (4)

A
  1. Who should have one
    -Maternal collapse requiring CPR without ROSC and after 20/40
  2. When to do. Start if no ROSC by 4 mins and finish by 5 mins
  3. Where to do
    -At the site of resus
  4. How to do
    -Way surgeon is most comfortable with
    -Midline and classical is fastest approach
  5. Benefits
    -Reduces placental O2 consumption
    -Increased pre load and CO
    -Facilitates chest compressions
    -Facilitates internal chest compressions
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12
Q

Discuss shoulder dystocia
-Definition
-Incidence

A
  1. Definition
    -Vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the fetus
    -Usually due to boney impaction of the anterior shoulder on the pelvic brim or the posterior shoulder on the sacral promontory
    -Associated with prolonged time between head and delivery time >60 seconds
  2. Incidence
    1:200
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13
Q

Discuss risk factors for shoulder dystocia
-Predictive quality of risk factors
-Pre-labour risk factors (4)
-Intra-partum risk factors (3)

A
  1. Predictive value of risk factors
    -50% of shoulder dystocia occurs in women without risk factors
    -Risk factors predict about 15% of shoulder dystocia
  2. Pre-labour risk factors
    -Maternal obesity >30 BMI
    -Fetal macrosomia (2-5%)
    -Maternal diabetes (2-4 x increased risk compared to same weight babies of non-diabetic mothers)
    -Previous shoulder dystocia (10 x BL rate 1-25%)
  3. Intrapartum risk factors
    -IOL or augmentation
    -Prolonged first and second stage
    -Instrumental delivery
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14
Q

How can shoulder dystocia be prevented (6)

A
  1. Only proven way to reduce shoulder dystocia is ELCS at term for diabetic women with LGA babies (NNT 443)
  2. NNT in nondiabetic population is 4000
  3. IOL for LGA reduces Shoulder dystocia by 40%.
    -Best if done 37-38 weeks
    -Data for IOO at >39/40 unclear
  4. Consider offering CS to women with previous shoulder dystocia
  5. Consider offering CS to women with EFW >5kg
  6. Prophylactic McRoberts doesn’t work
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15
Q

What are the signs of shoulder dystocia (4)

A

-Difficulty delivering head and chin
-Head remaining tightly applied to vulva or retracting (Turtle sign)
-No restitution of fetal head
-Anterior shoulder palpable abdominally

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16
Q

Discuss management of shoulder dystocia (9 steps and 3 points)

A

1 Call for help
2. Advise woman to stop pushing
3. McRoberts flexion and adduction of hips (Knees to nipples). Increases AP diameter
4. Suprapubic pressure to posterior surface of anterior shoulder
5. Evaluate for episiotomy (If more space required for manoeuvres
6. Delivery posterior arm by flexing at elbow and sweeping across fetal face - ass with humeral #
7. Attempt internal manoeuvres: Rubin II (push anterior shoulder into oblique position
Rubin II + Corkscrew manoeuvre (Push anterior shoulders anticlockwise and posterior shoulder clockwise into oblique position)
Reverse corkscrew (Push posterior shoulder clockwise)
8. Roll onto all fours and try manoeuvres again
9. Last resort manoeuvres: Fracture fetal clavicle, symphisiotomy, Zanavelli
-Each manoeuvre should be done for 30-60 seconds
-Aim to delivery baby by 5 mins (47% of babies die in 5 mins
-80-90% of shoulder dystocia is resolved with McRoberts and suprapubic pressure

17
Q

Discuss complications associated with shoulder dystocia
-Maternal (7)
-Fetal (7)

A
  1. Maternal complications
    -3rd and 4th degree tears 4%
    -PPH 11%
    -Vaginal lacerations
    -Uterine rupture
    -Bladder rupture
    -Symphyseal separation
    -Sacroilliac joint separation
    -PTSD
  2. Fetal complications
    -Intraventricular haemorrhage
    -HIE
    -CP
    -Brachial plexus (10%) injury (Erbs 90% recover, Klumpke’s 40% recover)
    -Cervical spine injury
    -Humeral fracture <10%
18
Q

What is the definition of shock

A

Shock is a life threatening condition secondary to circulatory failure where by there is an inability for oxygen to be supplied to tissues to meet their metabolic requirements.