Emergencies in O&G Flashcards
main obstetric causes of emergencies 3
PPH
APH
eclampsia
main incidental cuases of emregnecies in obsteics 4
massive VTE
ruptured aneuryms
ruptured spleen/liver
MI
emergenceis in gynaecologyy 3
ectopic pregnacy
miscarriage
post-op/intra-abdominal bleeding
define postpartum haemorrhage
any bleeding from or in to the genital tract following delivery of the infant
define primary post-partum haemorrhage
occuring within 24hours of delivery
define secondary postpartum haemorrhage
occuring betweeen 24hrs and 12 weeks postnatally
define the values assocateid with quantiy of blood loss in types of post partum haemorrhage
Postpartum haemorrhage (PPH) is defined as blood loss of > 500 ml after a vaginal delivery and may be primary or secondary.
minor- loss of 500-1000ml
moderate loss of 1000-2000ml
severe- loss of >2000ml
(BOTH DEFINED AS MAJOR BLEEDS)
define acute blood loss in postpartum haemorrhage
500ml/min
-acute loss of large blood volume
causes of primary postpartum haemorrhage 4
thrombin
tissue
tone
trauma
types of thrombin disorders causing primary postpartum haemorrhage 3
pre-exisitng
pregnancy induced
iatrogenic
antenatal risk factors for postpartum haemorrhage 8
suspected or proven placental abruption
known placenta praevia
multiple pregnancy
pre-eampsia/ HT
previous PPH
asian
BMI >35
anaemia
intrapartum risks associated with postpartum haemorrhage 7
C section
induced labour
retained placenta
episiotomy
prolonged labour
big baby
age >40
4 components of immediate postpartum haemorrhage managemnt
communcation
resusciation
monitoring and investigations
arresting the bleeding
ALL SIMULTANEOUSLY
aspcts of immediate postpartum haemorrhage immediate action and resus 5
blood loss>1000ml
call for help- senior midwife, obesterician, aneathetics, blood transfusion
resus
-ABC
-O2
-fluid
-blood products
-keep patient warm
aspects of minitoring and investgiaons in postpartum haemorrhage management 6
2 cannula
FBC, coag, U&Es, LFTs
cross match
ECG
foley ceehte
weigh all swabs and estimate blood loss
medical treatment of postpartum haemorrhage managemnt 2
-what drugs can be used
bimanual uterine compression
empty bladder
-oxytocin
-ergometrine
-carboprost
-misoprostol
define bimanual uterine compression compression
the clinician places one hand on the abdomen and the other hand inside the vagina then compresses the uterus between the two hands. These techniques cause the uterus to contract, which treats atony and assists with expulsion of retained placenta or clots.
what medications can be used to promote uterine contractility 4
syntocinon- injection and infusion
ergometrine- injection
carboprost IM
misoprostol
what immediate tecniqures can be considered in theatre for postpartum haemorrhage 2
intrauterine balloon tamponade
brace suture
?interventional radiology
what surgery can be used for postpartum haemorrhage 4
bilateral uterine artery ligation
bilateral internal iliac ligation
hysterectomy
uterine artery embolisation
steps in manual removal of placenta (just pictures)
[25,26,27]
balloon tamponate for postpartum haemorrhage (picture)
[28]
b-lynch suture for tamponade for postpartum haemorrhage (picture)
[29]
importance of uterine inversion (picture)
[30]
what is secondary postpartum haemorrhage usually associated with
infection (endometritis) ± retained tissue
managemnt of secodnary postpartum haemorrhage
treat infection
consider removal of tissue
-postnatal surgical evacuation risks
consider balloon tamponade
how does bleeding in ectopic vs miscarriage differ
ectopic- most likely concealed
miscarriage- most likely visulaised vaginally
important point with ectopic
can become unstable very quickly
important point with miscarriage
remeber cervical shock if products of conception or clot in cervical os
immediate Managemnt of miscarriage and ecotpic
if haemodynamically unstable- EMERGENCY
-ABC resus
-early senior involvement
prepare for theatre
define maternal collapse
acute event involving cardiorespiraroty systeem ± brain
resulting in reduced or absent conscious level (and potentially death)
when can maternal collapse happen
any stage of prengnacy and up to six weeks after delivery
incidence of maternal collapse
estimate between 0.14-6/1000 births
how does preganncy impact on resusication procedure
have reduced oxygen carrying capcacity therefore:
-increasd CPR circulation demands
potential rapid massive haemorage
blood can sequester during CPR
decreased BP reserve
how can prengnacy impact respiratory system if in maternal collapse
decreased buffering capacity- acidosis more likely
-hypoxia may develop more quickly
-can have difficult intubation
other resuscitaion considerations for pregant woemn
increased risk of aspriation
large nbreasts may interfere w intubation and make ventilation more difficult
when is a premortem C section performed
if no response to CPR after 4 minutes and uterus appox 20 week size
-aim for delivery by 5 minutes
aim of premortem C section
save mothers life
-increase venous return
-imrpove ease of ventilation
allow CPR in supine posiotn
reduced O2 requirements
causes of collapse (resus collapse) in all patients (including O&G)
4 Hs , 4 Ts
Hypoxia
hypovolaemia
hypo/hyperkalaemia
Hypothermia
Thromboembolism
Toxic
Tamponade
Tension pneumothorax
pregnancy specific resusitation collapse causes 4
eclampsia (incld magneussim toxicitiy)
amniotic fluid embolism
splecic artery ruptue
antepartum/post partum haemorrhae
incidence of preeclampsia in pregnancy
affects approx 3% of pregnnacies
largest cause of death from pre-eclampsia
intracranial haemorrage secodnary to uncontrolled hypertension indicating a failure in antihypertensive therapy
what blood pressure value should be treated as a medical emergency in pre-eclampsia
> 160mmHG
maternal complications of pre-eclampsia 7
intracranial haemorrhage
placental abruption and DIC
eclampsia
HELLP syndrome
renal failure
pulmonary oedema
acute respiratory arrest
define HELLP syndrome
severe form of eclampsia
Haemolysis, elevated liver enzymes, low platelets
fetal complicatiosn fo pre-eclampsia 5
intrauterine growth restriction
oligohydramnios
hypoxia from placental insufficiency
placental abruption
premature delivery
managemnt of moderatee pre-eclapmsia
oral labetaol if systolic BP reaches 150-160mmHg
how is severe pre-eclampsia defined
systolic BP >180mmHg
manamegant of severe preeclampsia (>180mmHg) 3
oral/IV labetalol
oral nifedipine
IV hydralazine
usually oral labetolor or nifedipine
-repeat oral if unsuccessful
-maintenance oral ehrapy or IV therapy ± infusion of labetoalol or hydrazline
what is the aim of antihypertensivee meds in pre-eclapmisa 1
lower systolic BP to <150mmHG
observations for motheres with severe pre-eclampsia
IV access, urine output
BP check
-15 mins if on treatemtn
-30 mins when stabilised
reviewed 4hrly by obstetrician
if not delivered-> continuous CTG
fluid balance managemnt in preeclampsia
input 1ml/kg/hr or 80ml/hr
-unless ongoing fluid loss (haemorrhage)
hourly urine output measurements
->100ml/4hr
if oral intake is adequate do not need IV
do not preload w IV fluids if epidural neeeded
define eclampsia
one or more convulsions in assocation with pre-eclampsia
-HOWEVER- MOST women in UK will not have established hypertension or proteinuria prior to seizure
when does eclampsia happen in pregnacy by percentage
44% postpartum
38% antepartum
18% intrapartum
5-30% recurrent seizure
management of pre-eclapmisa seizures
drug of choice magneisum sulphate
-fewer recurrent seziures than diazepam or phenytoin
DO NOT use diazepam, phenytoin or lytic cocktails as alternative to MgSO4
management of pre-eclapmisa seizures
drug of choice magneisum sulphate
-fewer recurrent seziures than diazepam or phenytoin
DO NOT use diazepam, phenytoin or lytic cocktails as alternative to MgSO4i
how does MgSo4 work for eclampsia
acts primarl by reducing cerebral vasospasm
can also prevent eclampsia
when should MgSO4 be considered for eclampsia management 2
*how long should it be used for
primary prophylaics
-women with severe-preeclampsia where birht is planned within next 24 hours
secondary prophylaxis
-after eclamptic fit
*-given for 24hours form time of commencement or for 24 hours after delivery
immediate managemnt of elampsia
call for help-> ABC
control seizures-> MgSO4 loading dose-> maintenance dose_> recurrent seziures?->MgSO4 bolus
then follow severe pre-eclpamisa guidelines
magnesium sulphate observations 3
hourly urine measurements
-MgSO4 exreted by kidnyes therefore risk of toxicity is higher with oliguria
hourly deep tendon reflexes
hourly RR
signs of MgSO4 toxicity 4
loss of deep tendon reflexes
respriaoty depression
respriaitoy arrest
cardiac arrest
what can cuase MgSO4 toxicitiy 2
if oliguria or renal impairment
emergency managemnt of MgSO4 toxicity 5
call for help
stop MgSO4
start BLS
give IV calcium gluconate (1g (10ml of10%)
intubate early and ventilate until respiration resumes
long term implciations of pre-eclampsia/eclampisa 2
increased risk of preeclampsia in future prectnacies
increased risk of hypertension adn its complications later in life
which syxs antenatallly is pre-eclampsia until otherrwise
Headache of sufficient severity to seek medical advice is pre-eclampsia until proven otherwise
Epigastric pain ≥ 20/40 is pre-eclampsia until proven otherwise
what should be measured to check for preeclampsia 2
BP
urinalysis
what should be used in the third stage of labour if concerns over BP
syntocinon
what additional maneuver cna be required for resuscitaiton of a pregnant women
manual left lateral uterine displacemtn [31]
define amniotic fludi embolus
catastophic complcation of pregnancy
-amniotic fluid, fetal cells, hair or other debris enters maternal pulmonary circulation and causes cardiovascular collapse
