Emergencies Flashcards
CXR findings of a PE
Normal wedge-shaped infarction, pleural effusion, atelectasis, area of translucency in underperfused lung
Give 3 causes of painful uterine contractions in early pregnancy
1) Threatened miscarriage
2) Inevitable or incomplete miscarriage (more painful + more bleeding)
3) Septic miscarriage (+ fever)
4) Pregnancy in a uterine horn (colicky pain)
Give 3 causes of painful uterine contractions in late pregnancy
1) Late miscarriage
2) Preterm labour (uterine over distension e.g. multipreg, polyhydraminos, fibroids)
3) Uterine irritability (abruption, chorioamnionitis pyelonephritis)
Give 3 causes of painful uterine contractions during labour
1) Uterine hyperstimulation (too much oxytocin)
2) Placental abruption
3) Uterine scar rupture
4) Intrapartum infections (chorioamnionitis, pyelonephritis)
Give 3 causes of painful uterine contractions after delivery
1) Retained products of conception
2) Acute inversion of the uterus (bradycardia and hypotension)
When might a fluid thrill be heard over a tender gravid uterus?
Polyhydraminos
Sharp uterine pain + late/prolonged CTG decelerations
Acute fetal compromise secondary to placental abruption or scar rupture
Pain + increased contraction frequency (>6-10 per min)
uterine hyperstimulation/
irritability
Pain + increased baseline tone of contractions
Placental abruption, impending uterine
rupture. After rupture, the contractions may not be recordable
How to Tx uterine hyperstimulation?
- Stop oxytocin
- IV fluids
- Left lateral postition
- Acute tocolysis
Dx of greyish frothy discharge + strawberry punctation of the cervix
Trichomoniasis
Treat with metronidazole
Dx urinary frequency
> 7 day + 1 night
**Exclude infection and then reassure, normal in pregnancy even before the 1st period missed
Mx of urinary retention in pregnancy
- Catheter
- ## Test for UTI
Causes of low UO intrapartum?
- Dehydration
- Retention - Descent of fetal head + epidural
How does urinary frequency change following delivery?
Increased UO D2-5 due to dieresis of increased extracellular fluid vol.
Enlarged uterus can continue to give frequency and urgency symptoms
Why is monitoring postpartum UO important?
Over distention can lead to serious longstanding voiding difficulties, chronic infection and renal damage
**If UO on catheterisation is >800mls keep catheter in for at least 24hours + after removal measure until >100mls per void
What is the significance of reduced fetal movements?
- Not particularly useful
- Historically theorized that reduced fetal movements = hypoxic fetus trying to save energy 12-24hrs prior to fetal death
- However, this doesn’t show benefits in outcome when considering increased interventions + anxiety
- Should prompt monitoring
If you are investigating reduced fetal movements, why would you ask about previous pregnancies and the father?
- Placental insufficiency is more common in first pregnancy and uncommon if previous baby was well grown + same father
Assessment of reduced fetal movements
- Establish risk
- BP
- SFH
- Fetal movements
- Fetal heart beat may reassure parents
- US for growth + liquor volume
- Umbilical artery + middle cerebral artery doppler as an indicator of uteroplacental insufficiency (at term this isn’t useful)
- CTG
What is the sequence of placental dysfunction?
1) Slowing of growth (small size)
2) Increased resistance in umbilical artery
3) Doppler (reduced end- diastolic frequencies)
4) Absent/ reversed enddiastolic frequencies in umbilical artery Doppler
5) Abnormal venous Doppler (ductus venosus Doppler)
6) Intrauterine death.
Is it worth doing daily umbilical artery dopplers?
A loss of end-diastolic frequency will not occur in <7days so weekly monitoring is acceptable
What does loss of end-diastolic frequency indicate?
Only occurs when >75% of the placental vascular bed is obliterated. It indicates a 85% chance the fetus is hypoxic + 50% chance the fetus is acidaemic
What does reversed end-diastolic frequency suggest?
Pre-terminal, will not survive without delivery
What parameters are assessed in a biophysical profile?
- Fetal accelerations/ HR (non-stress test)
- Fetal breathing movements
- Fetal movements
- Fetal limb extension and flexion
- Amniotic fluid index
Which features on CTG are reassuring?
- At least 2 accelerations (.15bpm for >15 sec) in 20mins
- Baseline HR 110-160bpm
- Baseline HR variability 5-25bpm
- Absence of decelerations
- Sporadic decelerations <40bpm, for <15sec is acceptable or <30 sec if followed by an acceleration
- Moderate tachycardia 160-180bpm is reassuring
- Bradycardia (100-110) without decelerations is reassuring
Which features on CTG are suspicious?
- Non-reactive (no accelerations) for 40mins
- Baseline heart rate tachy 140-160 or brady 100-110
- Reduced baseline variability (5– 10 bpm for >40 min)
- Baseline variability >25 bpm in the absence of accelerations
- Sporadic decelerations of any type unless severe
***Interpretation/ action— continue or repeat CTG within 24 hours/
AFI/ BPP / fetal Doppler flow velocity waveform analysis.
What are pathological features on CTG?
- Baseline heart rate <100 bpm or >180 bpm
- Silent pattern (baseline variability <5 bpm) for >40 min
- Sinusoidal pattern (oscillation frequency <2– 5 cycles/ min, amplitude
of >10 bpm for >40 min with no accelerations and no area of normal
baseline variability) - Repeated late, prolonged (>1 min) and severe variable (>40 bpm)
decelerations
**Interpretation/ action— further evaluation (VAS, AFI, BPP , Doppler). Deliver if clinically appropriate.
What are the most common causes of stillbirth
1) Unknown (27%)
2) Placental conditions (12%)
3) Antepartum haemorrhage (11%)
4) Congenital abnormalities
Give 3 RF for stillbirth
1) Obesity
2) Smoking
3) >35
4) Nulliparity
5) Illicit drug use
What are the mandatory investigations for the mother following SB or IUD
FBC, coag, fibinogen - DIC
BGL and HbA1C - DM
TFTs and T4
Causes of prolonged decelerations
1) Cord compression - oligohydramnios, cord prolapse, knots
2) Uteroplacental insufficiency - uterine hyperstimulation or prolonged contractions, placental abruption or uterine rupture
3) Maternal hypoxia - Hypotension, amniotic fluid embolism, seizures, valsalva manoeuvre
4) Fetal haemorrhage - vasa praevia, aminocentesis
5) Fetal vagal reaction - cervical exam, fetal scalp electrode placement, fetal blood sampling and impending birth
You are called to a woman with prolonged decelerations, what do you do?
- Assess immediate risk, senior?
- left lateral position
- stop oxytocin
- IV bolus
- Check obs; BP, pulse, temp
- Review CTG
- Abdo/vaginal ex
- FBC/G&S
- ?theatres
What is an abnormal (borderline) fetal blood sample?
lactate >4.9 (4.2)
pH <7.2 (7.24)
Signs/Sx of scar rupture
- Change to severe pain and continuous
- Cessation of contractions
- PV bleeding
- Abnormal CTG
- Maternal tachy/hypotension
- Loss of presenting part from the pelvis
- Peritonism
- fluid resus + blood
- laparotomy
RF for abruption in labour
- Hx antepartum haemorrhage
- Pre-eclampsia
- IUGR
- Polyhydraminos
Si/Sx abruption in labour
Severe and continuous pain PV bleeding Abnormal CTG Maternal tachy/hypotension Hard uterus
What is fetal distress?
A condition of significant impairment of oxygen transport resulting in progressive fetal hypoxia, acidosis, and asphyxia.
It is the second commonest cited indication for instrumental delivery in the second stage of labour, after prolonged second stage. Fetal pH falls quicker in the
second stage so delivery should be completed within 20–30 minutes of
decision to deliver for ‘fetal distress’
Indications for instrumental delivery for fetal distress
- Prolonged bradycardia
- Abnormal CTG
- Non-reassuring CTG with fresh meconium or abnormal FBS results
- Acute event (e.g. abruption, cord prolapse).
Contraindications for instrumental delivery
• Fetal malpresentation (brow, face mento-posterior)
• Unengaged fetal head (fetal head is above the ischial spines or more
than one-fifth of the head palpable abdominally)
• Cephalopelvic disproportion
• Fetal coagulopathy or bone demineralization disorder
• Not fully dilated cervix
What is shoulder dystocia?
A vaginal cephalic delivery that requires the use of additional obstetric
manoeuvres, following delivery of the head and failure to deliver using
gentle traction. Shoulder dystocia is a bony obstruction, which occurs
when the fetal shoulder impacts on the symphysis pubis (anteriorly) or,
less commonly, the sacral promontory (posteriorly).
HELPERR algorithm for the management of shoulder dystocia
• Help— SOAPS: Senior midwife, Obstetrician, Anaesthetist,
Paediatrician, & Scribe.
• Evaluate for episiotomy—increases room available for further manoeuvres.
• Legs (McRoberts manoeuvre)—hyperflexion of thighs onto abdomen
increases the ‘pelvic space’ available.
• Pressure (directed suprapubic)—aims to rotate anterior shoulder
forward off symphysis. ‘CPR grip’ to be used behind the fetal back.
• Enter the pelvis (Wood’s screw manoeuvre)—aims to internally rotate anterior shoulder to become posterior and bring the new
‘anterior’ shoulder below symphysis in a ‘corkscrew’ fashion.
• Remove posterior arm—posterior arm flexed and swept over fetal chest to exteriorize and then perform rotation as above.
• Roll onto all fours—change in position may improve pelvic diameters
and space available.
