Emergencies Flashcards
Where is pain from an ectopic pregnancy referred?
Tip of the shoulder
What is the most common location for an ectopic pregnancy?
Ampulla of the fallopian tube
Fallopian tube 95%
How is an ectopic pregnancy surgically managed?
Laparoscopic salpingectomy
- Salpingostomy (removal of the ectopic only) carries a risk of retained trophoblastic tissue and recurrent ectopic*
- Does not increase risk of future infertility*
What is eclampsia?
New-onset generalised tonic-clonic seizure in women with pre-eclampsia
What’s the definition of an antepartum haemorrhage (APH)?
Any vaginal bleeding following 20/40
What’s the definition of a postpartum haemorrhage (PPH)?
Vaginal bleeding > 500 mL after delivery (1L for C-section)
Primary: within 24 hours
Secondary: after 24 hours
PROM
Prelabour rupture of membranes at term
PPROM
Preterm prelabour rupture of membranes
What is the most common cause of PPH?
Uterine atony
Failure of the uterus to effective contract and retract after delivery
What are the four Ts of PPH?
- Tone
- Tissue
- Thrombin
- Trauma
What is a placental abruption?
Partial or complete separation of the placental from the uterus prior to delivery
What is the most significant risk factor for placental abruption?
Maternal hypertension
What are the clinical features of placental abruption?
- Dark, vaginal bleeding
- Abdominal pain
- Uterine tenderness
- Hypertonic contractions, rigid uterus, premature labour
- Foetal distress (decelerations + diminished/absent heart beat)
What are three complications of PROM?
- Umbilical cord prolapse or compression
- Placental abruption
- Chorioamnionitis
- Maternal/foetal sepsis
- Maternal DVT
- Foetal infection
What is placental previa?
The placenta obstructs the neck of the uterus
How is placenta previa classified?
Low-lying placenta (2cm from internal os)
Marginal (touches internal os)
Partial (partially covers internal os)
Complete (completely covers internal os)
What is vasa previa?
Foetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture
How is vasa previa managed?
Emergency caesarean
Painless vaginal bleeding that occurs suddenly after rupture of membranes suggests what?
Vasa previa
What is the most common cause of umbilical cord prolapse?
Rupture of membranes when the presenting part is not engaged
What are 4 risk factors for umbilical cord prolapse?
- Presentation anomalies e.g. breech, transverse
- SROM
- PPROM
- Polyhydramnios
- Multiple pregnancy
- Long umbilical cord
What CTG abnormality is seen with umbilical cord prolapse?
Variable deceleration
What is uterine rupture?
A full thickness tear through the uterine myometrium and serosa
What are 3 risk factors for a uterine rupture?
- Classical caesaream incision
- Myomectomy (removal of fibroids)
- Uterine anomalies
- Cocaine abuse
- Malpresentation
- Placenta increta/percreta (chorionic villi invade the myometrium and beyond)
What is placenta accreta?
Chorionic villi attach to the myometrium rather than the decidua basalis
Vessels do not invade or penetrate the myometrium
What is placenta increta?
Chorionic villi invade or penetrate into the myometrium
What is placenta percreta?
Chorionic villi penetrate through the myometrium, penetrate the serosa, and in some cases, adjacent organs e.g. rectum or bladder
Why is magnesium sulfate administered to women at imminent risk of preterm birth?
Neuroprotection
Decreases risk of cerebral palsy and motor dysfunction
What are the steps in managing a PPH from uterine atony?
- General (IV access, monitor, fluid, oxygen)
- Uterine massage and external compression
- Tranexamic acid
- Uterotonic agents e.g. oxytocin
- Speculum to examine extrauterine bleeding
- Intracavitary prostaglandin
- Blood transfusion
- Hysterectomy
How is PPH from abnormal placental separation treated?
- General (IV access, fluid, oxygen)
- Brandt-Andrews manoevre
- Uterotonic agents e.g. oxytocin
- Removal of RPOC under anaesthesia
- Hysterectomy
What is the most significant risk factor for PROM?
Infection e.g. chorioamnionitis, STIs, UTIs
Also cigarette smoking
Without intervention, when do mothers with PROM go into labour?
50% within 24 hours
75% within 48 hours
Why are antibiotics given in PPROM?
GBS
Treat triggering infection
Prevent chorioamnionitis
Delays labour by up to a week
What tests are performed on spectulum examination for PROM?
- Positive pool: amniotic fluid pooling in the vagina
- Litmus/nitralazine: strips turn blue
- Fern test: amniotic fluid reveals a fern-like pattern under microscopy
What clinical features carry a high suspicion of chorioamnionitis?
Maternal fever
Maternal tachycardia
Uterine tenderness
Foetal tachycardia
What are the steps in managing shoulder dystocia?
- Suprapubic pressure
- McRobert’s manoeuvre (knees to chest)
- Corkscrew manoeuvre
- Episiotomy
- Caesarean section
Why does placental abruption confer a high risk of DIC?
The placenta is rich in thromboplastin which is released in abruption
Following delivery, a woman has massive bleeding and fails to complete the third stage. What is the likely diagnosis?
Placenta accreta, in which the placenta is firmly attached to the myometrium and is not expelled after delivery of the foetus
Name two risk factors for placenta previa
- Prior pregnancy
- Maternal age > 35
- Previous caesarean
- Previous placental previa
What anticonvulsant is used to treat eclampsia?
Magnesium sulfate
In an umbilical cord prolapse, if the cervix is fully dilated what is the management?
Vaginal delivery
In an umbilical cord prolapse, if the cervix is NOT fully dilated what is the management?
- Cease syntocinon
- Consdier terbutaline
- Turn the woman into the left lateral, Trendelenberg or all fours
- Place Foley catheter and fill bladder with 500 mL normal saline
- Monitor CTG and if not improving
- Caesarean
* If the cord is visibly outside of the vagina push it back in, minimising contact where possible*
What is terbutaline?
A tocolytic
Beta-2 agonist → smooth muscle relaxant → inhibits contractions
What is a Bakri balloon?
Balloon catheter used to treat PPH
What are the most common causative agents in puerperal sepsis?
GAS (Streptococcus pyogenes)
- Escherichia coli*
- Staphylococcus aureus*
- Streptococcus pneumoniae*
MRSA
How is acute severe hypertension managed in pregnancy?
IV labetalol
At what BP are patients with pre-eclampsia treated?
>160 SBP
>100 DBP
May prevent severe hypertension which is an indication for delivery
What proportion of PPHs are caused by each of the 4 T’s?
Tone - 70%
Trauma - 20%
Tissue - 10%
Thrombin - 1%
What is the mneumonic for shoulder dystocia management?
H - help
E - evaluate for episiotomy
L - legs to nipples
P - pubic pressure
E - enter: rotational manoeuvres
R - remove the posterior arm
R - roll the patient onto all fours
Up to what gestational age are antenatal corticosteroids given?
34+6
How long until labetalol IV exerts its maximal effect?
5 minutes
How long until nifedipine exerts its maximal effect?
Oral tablet (no IV preparation)
30-45 minutes
What are the most common adverse effects of nifedipine?
Headache
Flushing
What is severe hypertension in pregnancy?
BP > 170 systolic or 110 diastolic
Acute blood pressure lowering therapy is required
Increased risk of maternal morbidity and mortality
Which clinical features are most suggestive of uterine rupture over placental abruption?
Cessation of contractions
Recession of presenting part
What are the risk factors for umbilical cord prolapse?
Presenting part high or ill-fitting
Malpresentation (breech or transverse)
Low lying placenta
Polyhydraminios
Prematurity, LBW, second twin
Use of cervical ripening balloon
Obstetric manipulation
