Intrapartum Care: Amniotic Fluid Embolus, Uterine Rupture & Uterine Inversion Flashcards
What is an amniotic fluid emoblism?
A rare but severe condition where the amniotic fluid passes into the mother’s blood. This usually occurs around labour and delivery.
The amniotic fluid contains fetal tissue, causing an immune reaction from the mother.
This immune reaction to cells from the fetus leads to a systemic illness.
It has more similarities to anaphylaxis than venous thromboembolism.
Mortality rate of amniotic fluid embolism?
> 20%
What are the 2 key risk factors for amniotic fluid embolus?
1) increasing maternal age
2) induction of labour
When does amniotic fluid embolism usually present?
Amniotic fluid embolisation usually presents around the time of labour and delivery, but can be postpartum.
Presentation of amniotic fluid embolisation?
It can present similarly to sepsis, pulmonary embolism or anaphylaxis, with an acute onset of symptoms of:
1) Chills
2) Shivering
3) Sweating
4) Anxiety
5) Coughing
Signs:
1) SOB
2) Hypoxia
3) Hypotension
4) Coagulopathy
5) Haemorrhage
6) Tachycardia
7) Confusion
8) Seizures
9) Cardiac arrest
Management of amniotic fluid embolism?
Supportive (no specific treatments).
Medical emergency - likely transferral to ICU.
ABCDE approach:
A – Airway: Secure the airway
B – Breathing: Provide oxygen for hypoxia
C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage
D – Disability: Treat seizures and consider other neurological deficits
E – Exposure
What is uterine rupture?
A complication of labour, where the muscle layer of the uterus (myometrium) ruptures.
What are the 2 main types of uterine rupture?
1) Incomplete
2) Complete
What is an incomplete uterine rupture (or uterine dehiscence)?
Where the uterine serosa (perimetrium) overlying the uterus remains intact.
In this case, the uterine contents remain within the uterus.
What is a complete uterine rupture?
The serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.
What are some risk factors for uterine rupture?
Risk factors that generally make the uterus inherently weaker:
1) Previous c-secton (greatest risk factor for uterine rupture)
2) Previous uterine surgery e.g. myomectomy
3) Induction - (particularly with prostaglandins) or augmentation of labour.
4) Obstruction of labour: important risk factor to consider in developing countries.
5) Multiple pregnancy
6) Multiparity
What is the greatest risk factor for uterine rupture?
Previous c-section
What incision in c-section carries the highest risk for uterine rupture?
Classical (vertical) incisions.
Clinical features of uterine rupture?
Non-specific, which makes diagnosis and prompt management difficult.
1) Sudden & severe abdo pain (most common presenting symptom)
- pain persists between contractions
2) May also experience shoulder-tip pain (from diaphragmatic irritation)
3) May have vaginal bleeding.
4) May be signs of significant haemorrhage & hypovolaemic shock:
- tachycardia
- hypotension.
5) Ceasing of uterine contractions
On examination, what may be seen in uterine rupture?
There may be regression of the presenting part, with abdominal palpation revealing scar tenderness and palpable fetal parts.
What are the 3 main differentials to consider in uterine rupture?
1) Placental abruption:
- presents with abdominal pain +/- vaginal bleeding
- uterus is often described ‘woody’ and tense on palpation.
2) Placenta praevia:
- typically causes a painless vaginal bleeding.
3) Vasa praevia:
- characterised by a triad of ruptured membranes, painless vaginal bleeding, and fetal bradycardia.
What is a key investigation in women at risk of uterine rupture?
Intrapartum monitoring with cardiotocography (CTG) is vital.
What are early foetal indicators for uterine rupture?
1) Changes in fetal heart rate pattern (such as recurrent or late decelerations)
2) Prolonged fetal bradycardia
Management of uterine rupture?
Obstetric emergency.
In many cases, a pathological CTG prompts an emergency section – with uterine rupture noted intra-operatively.
If there is a suspicion of uterine rupture in the pre-labour setting, what investigation can be done?
US for diagnosis
What features may be seen on an US in uterine rupture?
- abnormal fetal lie or presentation
- haemoperitoneum
- absent uterine wall
What should the decision-incision interval in operative intervention in uterine rupture be?
<30 minutes
What is uterine inversion?
A rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out.
It is a very rare occurrence, and you are unlikely to see one in your career unless you become a midwife or obstetrician.
It is a life-threatening obstetric emergency.
What are the 2 types of uterine inversion?
1) Incomplete (partial)
2) Complete
