O+G Flashcards
Cord Prolapse
OBS EMERGENCY
Def: ruptured membrane + cord infront/beside presenting part
RF
- Multiuparity
- Pre-term labour
- Multiple birth (esp 2nd twin)
- Polyhydramnios
- Malpresentation
- Obstetric manipulation
Mx
- Prevent cord compression
- Elevate presenting part
- Deep Trendelenberg
- Left lateral with 2 pillows
- Fill bladder
- Minimal cord handling
- Elevate presenting part
- Calls to make
- Obs / Delivery suite
- Anaesthetics
- Paeds/NICU
- Tocolyticcs to be considered
- Terbutaline 250mcg stat
- Nifedipine
- MGSO4
Shoulder Dystocia
- Help: O+G, peads, anaesthetics
- Episiotomy
- Lithotomy - McRobert’s - supine, nipples to knees
- Pressure - Rubins I - suprapubic pressure and push shoulder downwards
- Enter vagina - Rubins II + Woodscrew
- Remove post arm - splint humerus, sweep post arm across chest, grasp hand and pull to extension, may free posterior shoulder
McRobert’s Manoeuvre
Mother lies head down, supine in extreme lithotomy, hips hyperflexed w/ knees to nipples
+/- suprapubic pressure
Open pelvic inlet by : cephalic rotation of pubic symphysis, flattens lumbar lordosis and allows for passage of one shoulder at a time
Wood’s Corkscrew Manoeuvre
The accoucheur places two fingers on the posterior aspect of the anterior shoulder of the fetus (internally) and two fingers on the anterior aspect of the posterior shoulder, then rotates the fetus forward through 180o so the posterior shoulder will now be anterior
Gaskin Manoeuvre
Position mother onto all 4s
May allow posterior shoulder to descend
Tocolytics Contraindications
- Intrauterine Fetal Demise or lethal fetal anomaly
- Fetal Compromise
- Fetal Bradycardia
- Fetal Tachycardia
- Severe Eclampsia or Preeclampsia
- Maternal bleeding + hemodynamic instability
- Maternal cardiopulmonary symptoms (CP or SOB)
- Chorioamnionitis
- 24 < gestation > 34 weeks
Tocolytic Therapies
General Indications
a. Stops labour for 24-48 hours
b. Allow maternal transport and steroid
Considerations for Management
1. A = Antibiotics
a. Benpen 1.2g or CLindamycin 600mg
2. B = Betamethasone 11.4 mg IM BD for 48 hours
a. Reduces Foetal Resp Distress Syndrome - max effect 48 hours
3. CCB = Nifedipine
a. 20-30mg loading, then 10-20mg QID
b. NB high risk of maternal adverse events when combined with MGSO4
4. D = Magnesium (tocolysis + neurprotection)
a. 4g IV over 20 mins
b. 2g/hr IV infusion
5. Other tocolytic therapies
a. PGI - Indomethacin < 32/40 gestation
i. 50-100mg PO/PR
ii. Avoid > 48 hours (risk of oligohydramnios, premature closure ductus arteriosus)
iii. Not recommended > 32/40 due to DA constriction
b.Salbutamol / Terbutaline
Placental abruption
25% APH
Most lifethreatening
Separation of placenta from uterus prior to second stage of labour
Concealed or Revealed
Painful PV bleeding
Clinical diagnosis + CTG
USS - placenta and abruption same echogenicity
RF - trauma, HTN, Pre-elampsia, Drugs - cocaine, amphetamine, Sudden reduction in uterine size (ROM with polyhydramnios, multiple births)
Uterus - tone increased, increased size
Mx
- Supportive and resuscitative
- IVF / Blood
- Steroids if urgent deilvery
- CTG
- Conisder Anti-D
- Emergent referral to O+G
- Monitor for and reverse coagulopathy
Complications
* Preterm labour
* Foetal distress
* Maternal Haemorrhagic shock - APH and PPH
* Coagulopathy / DIC
* Amniotic Fluid Embolism
Placenta Praevia
30% APH
Placenta implanting over internal os of cervix
Grade 1 - lower segment, not reaching os
Grade 2 - reaches margin of internal os
Grade 3 - partially covers internal os
Grade 4 - completely covers internal os
Also classified by adherance to uterus - accreta (superficial), increta ( into muscle), percreta (through muscle)
Painless PV bleeding
Mx
* Supportive and resuscitative
* IVF / Blood
* Steroids if urgent deilvery
* CTG
* Conisder Anti-D
* Emergent referral to O+G
Complications
* APH
* Foetal malpresentation
* IUGR
* PPROM
Vasa Praevia
Rare (<0.3%)
Foetal blood vessels cross or run near internal os. Risk of rupture when supporting membranes rupture as they are not supported byy umbilical cord or placental tissue.
Mother fine
Foetal distress - decelrations on CTG
75% foetal mortality rate!
Mx
Immediate C- section
Uterine Rupture
RF
Previous C-Section 40%, grand multip, small for dates
Trauma - forceps, shoulder dystocia
XS oxytocin
Clinical
Maternal shock
Abdominal Pain ++
Easily palpated foetal parts
Foetal distress or death
Possible decreased amplitude CTG
USS
ID protruding portion of amniotic sac
Endometrial or myometrial defect
Extra-uterine haematoma
Haemoperitoneum
APH Mx considerations
Resus - Monitor / IV access x 2 / O2
Bloods - FBE, UEC, VBG, G+S, coags, Kleihauer
Consider activating MTP
Pain - ? Abruption ? labour
CTG
PV - contraindicated
Anti-D
Foetus
- Steroids <34 weeks
- MgSO4 < 30 weeks
Refer - O+G, Paed, anaesthetics, haem
4 Ts
PPH - causes
- Tone
- Tissue
- Trauma
- Thrombin - coagulopathy
Ectopic USS findings
- Uterus
- No IUP
- Gestational sac with no foetal pole
- Extra-uterine pregnancy
- Tube/Ovary
- Complex extra-adnexal mass
- Tubal ring sign
- Haemosalpinx
- Pelvis
- Free fluid POD
- Free fluid Morrison’s pouch (higly likely)
IUP pregnancy USS findings
- 0-4.3 weeks: no ultrasound findings
-
4.3-5.0 weeks:
- possible small gestational sac
- possible double decidual sac sign (DDSS)
- possible intradecidual sac sign (IDSS)
-
5.1-5.5 weeks:
- gestational sac should be visible by this time
-
5.5-6.0 weeks
- yolk sac should be visible by this time
- gestational sac should be ~6 mm in diameter
- double bleb sign (yolk sac + amnion
-
>6.0 weeks
- fetal pole may be identifiable on endovaginal ultrasound (1-2 mm)
- fetal heart rate (FHR) should be ~100-115 bpm
- gestational sac should be ~10 mm in diameter
-
6.5 weeks
- crown rump length (CRL) should be ~5 mm
Failed pregnancy
CRL 6-10mm and NO foetal activity
Gestational sac >20-25mm and no foetal pole
Pregnancy Physiology
Cardiovascular
- 1st tirmester
- SVR decreased
- CO begins to rise
- 2nd trimester
- CO continues to increase
- 3rd trimester
- CO peaks
- Inc HR
Respiratory
- Chest wall - Diaphragm moves up 4cm but excursion increased by 2cm
- Lung volumes - decreased FRC 20%
- Ventilation - resting minute ventilation inc by 25% due to inc VT 40%
- Gas exchange
- inc alveolar ventilation → dec PaCO2 (27-32) → resp alkalosis
- Compensatory renal excretion of bicarbonate so pH slightly alkalotic 7.40-7.45
- O2 consumption - inc 20-40% due to myocardial and renal O2 demand
- Upper Resp tract - inc oedema
Renal
Blood
NEEDS FINISHING
Anti - D recommendations
RANZCOG
Rubin’s Manoeuvre
Hand is inserted into the anterior vagina and digital pressure is applied to the posterior aspect of the anterior shoulder pushing it towards the fetal chest. This rotates the shoulders forward into the more favourable oblique diameter
Then attempt deilvery
HELLP Syndrome
Haemolysis + Elelvated LIver enzymes + Low Platelets
MAHA leads to liver damage
1% of pregnancies, mortality 1-2%
Typically 28-36/40, but can be earlier or even post partum
Considered to be severe form of pre-eclampsia
Risk of hepatic rupture
Symptoms
HA
N/V
Malaise
Visual distrubance
RUQ pain
Exam
HTN
RUQ
Jaundice, ascites
Proteinuria
Ix
MAHA - Bloods film schistocytes
PLT <
Br > 20
AST > 2x upper limiti normal
Coags - 40% dvp DIC
Mx
As per pre-eclampsia
- HTN Mx
- Seizure Mx w/ MgSO4
Supportive
- PLT transfusion
- PRBC
- Bethmethasone 11.4 g IM
ICU / O+G / Paeds referral
Prognosis
1-2% mortality
Prematurity
70% require pre-term delivery
IUGR
Complications
DIC, ICH, Placental abruption + spontaneous hepatic or splenic hemorrhage.
Hepatic hemorrhage can progress to hepatic rupture - asoc with 50% maternal + foetal mortality.
Diagnosing Preterm Rupture of Membranes
HTN in Pregnancy
RF PPH
H
Foetal Radiation
