Emergencies in O&G Flashcards
What is MBRRACE?
Mothers and babies: Reducing Risk through Audits and Confidential Enquiries.
It performs surveillance of all maternal and perinatal deaths, confidential enquireies into maternal deaths, still births, infant deaths and serious maternal morbidity.
What are the definitions of the following:
Direct maternal death
Indirect maternal death
Coincidental maternal death
Late maternal death
Direct maternal death - Consequence of a disorder to pregnancy
Indirect maternal death - resulting from previous existing disease or diseases which developed during pregnancy
Coincidental maternal death - Incidental/accidental deaths not due to pregnancy.
Late maternal death - Deaths occuring more than 42 days but less than 1 year after end of pregnancy
What are the most common causes of maternal mortality
Most common to least common:
Heart disease,
Blood clots,
Epilepsy and stroke,
Other physical condition,
Sepsis,
Mental health,
Bleeding,
Cancer,
Pre-eclampsia
Enthicity and mortality in pregnancy
Asian women 2x likely to die in pregnancy.
Mixed ethnicity = 3x likely
Black women = 5x more likely to die in pregnancy
WHat are some emergencies in obstetrics?
PPH,
APH - placental praevia, vasa praevia, abruption, uterine rupture,
Eclampsia,
Amniotic fluid embolus,
Uterine inversion,
Uterine rupture,
Intra-abdominal bleeding,
Genital tract haematoma,
Fetal malpresentation
Fetal distress.
Incidental causes - Massive VTE, aneurysm rupture, ruptured liver or spleen, MI, cardiac, CV accident, anaphylactic shock, septic shock, substance misuse.
Definitions and classifications of PPH
Primary - within 24 hours of delivery.
Secondary - Between 24 hours and 12 weeks postnatally.
Minor - 500-1000ml
Moderate - 1000-2000ml
Severe > 2000ml
How much blood can a pregnant woman lose by her usterus?
500ml/min
Causes of PPH?
Thrombin - clotting disorders,
Tissue - retained placenta
Tone - Uterine atony (most common)
Trauma - perineal tear
What are the risk factors for PPH?
Previous PPH,
Multiple pregnancies,
Obesity,
Large baby,
Failure to progress in second stage,
Prolonged third stage,
Pre-eclampsia,
Placental accreta,
Retained placenta,
Instrumental delivery,
GA,
Episiotomy or perineal tear
What is the initial management of PPH
Call 2222 - major obstetric haemorrhage. Also call senior help.
Resuscitation - ABCDE approach
15L non rebreather mask,
Lie flat and keep warm,
Two large IV cannula - take bloods for FBC, UEs, clotting, group and xmatch 4 units.
Warmed IV fluids and blood as requires.
FFP if clotting abnormalities or after 4 units of blood
Then move to medical and/or surgical management
What is the medical management of PPH?
Bimanual uterine compression.
Empy bladder
Syntocinon - oxytocin infusion 40 units in 500ml
Ergometrine 500 mcg
Carboprost 250 mcg every 15mins up to 8 times
Misoprostol 100 mcg suppository (rectally)
What is the surgical management of PPH?
Manual removal of placenta
Intrauterine balloon tamponade,
Brace solution
B-lynch suture
Uterine artery ligation.
Hysterectomy - last resort.
Causes and treatment of secondary PPH
Causes: Retained tissue or infection (endometritis)
Ix: US to look for retained products, and take swabs for infection.
Management: treat infection, consider removal of tissue and consider balloon tamponade.
Causes of bleeding in early pregnancy?
Ectopic pregnancy
Miscarriage
What is maternal collapse?
Acute event involving cardiorespiratory system and/or brain resulting in reduced or absent conscious level at any stage in pregnancy and up to 6wks after devlivery.
Describe features of a perimortem caesarean section
Performed if no response to CRP after 4mins and uterus is approx 20wks size. Aim to delivery baby in 5 minuets. No anesthetic is required .
This is done primarily to save mothers life, it improves venous return, ease of ventilation and allows CPR in supine position.
What are the maternal complications of pre-eclampsia?
Intracranial haemorrhage - leading cause of death from severe PET.
Placental abruption and DIC.
Eclampsia.
HELLP syndrome
Renal failure,
Pulmonary oedema,
Acute respiratory arrest
What are the fetal complications of pre-eclampsia
IUGR,
Oligohydramnios,
Hypoxia from placental insufficiency,
Placental abruption,
Premature delivery
What is the management of HTN in pre-eclampsia
Moderate - oral labetalol is systolic BP 150+
Severe (systolic >180) then oral/IV labetalol, oral nifedipine and IV hydralazine.
May need to manage in labour ward with IV access, urine output and BP checks every 15-30mins. Obstetrician review every 4 hours
What is the fluid balance in pre-eclampsia
Input - 1ml/kg/hour or 80ml per hour.
Urine output - Aim > 100ml/4 hours.
If oral intake is adequate then may not need IV
Management of eclampsia?
Magnesium sulphate is drug of choice. Do not use diazepam or phenytoin.
Consider primary prophylaxis in women with severe pre-eclampsia where birth is planned in next 24hr
Secondary prophylaxis after eclamptic fit
What observations are required for magnesium sulphate?
Hourly urine measurements.
Hourly deep tendon reflexes.
Hourly respiratory rate
Explain the presentation and management of magensium sulphate toxicity
Signs - loss of deep tendon reflexes, respiratory depression, respiratory arrest and cardiac arrest.
Management - Stop Mg and call for help. Start BLS and give IV calcium gluconate 1g
What are the risk factors for uterine rupture?
Previous caesarean section,
Vaginal birth after caesarean,
Previous uterine surgery,
Increased BMI,
High partiy,
Increades age,
Induction of labour,
Use of oxytocin
What is the presentation of uterine rupture?
Abdominal pain,
Vaginal bleeding,
Ceasing of uterine contractions,
Hypotension,
tachycardia,
Collapse
Management of uterine rupture
Emergency caesarean
What is shoulder dystocia?
Anterior shoulder of the baby becomes stuck behind pubic symphysis.
It is often caused by macrosomia secondary to gestational diabetes
What is the presentation of shoulder dystocia?
Difficulty delivering the face and hear followed by obstruction of shoulders.
Failure of retitution (head remains occipitoanterior and doesn’t turn sideways.
Turtle neck sign - head delivers and then retracts back into vagina
What is the management of shoulder dystocia?
Callfor senior help as soon as identified.
McRoberts manoeuvre -Hyperfelxion of mothers hips.
Episiotomy,
Pressure to anterior shoulder - pressure on suprapubic of abdomen.
Rubins manoever - Hand into vagina to put pressure on posterior aspect of baby’s anterior shouder.
Wood’s screw manoeuver
Zavanelli manoeuver.
What are the complications of shoulder dystocia?
Fetal hypoxia
Brachial plexus injury and Erb’s palsy.
Perineal tears,
Postpartum haemorrhage
What is umbilical cord prolapse and its causes
It is when the umbilical cord descends below presenting part of the fetus and through the cervix into vagina after the rupture of fetal membranes.
Most common cause is abnormal fetal lie after 37 wks gestationW
What is the diagnosis and management of umbilical cord prolapse
Diagnosis - Suspect if signs of fetal distress on CTG. Prolapsed cord then diagnosed by vaginal exam.
Management - Emergency caesarean section as pushing the cord back in is not recommended. In the meantime woman can lie on left lateral position or on all fours to reduced compression of the cord. Tocolytic medication can minimise contractions
Describe features of uterine inversion
Fundus of uterus drops through uterine cavity and cervix.
Incomplete - Decends inside uterus or vagina but not as far as introitus.
Complete - Uterus decends through vagina to the introitus.
May be caused by pulling on umbilical cord too hard.
What is the presentation and management of uterine inversion?
Presentation - PPH, maternal shock or colapse.
Management - Johnson manoevure, hydrostatic methods or surgery
What is amniotic fluid embolism and its risk factors
Where amniotic fluid passes into maternal blood stream.
RFs - Increasing maternal age, induction of labour, caesarean section and multiple pregnancy.
What is the presentation of amniotic fluid embolism?
Acute onset of SOB, hypoxia, hypotension, coagulopathy, haemorrhage, tachycardia, confusion, seizures and cardiac arrest.
What is the management of amniotic fluid embolism?
A-E examination and get senior help.
Supportive treatment
