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
PPH Mx
Def:
* > 500mls post-delivery
- Primary = <24 hours post deivery
- Seconary = 24hrs to 12 weeks post delivery
* MAJOR > 1000mls
Mx
* MOVIE
* G+S
* MTP / correct coagulopathy
* Call O+G, OT, anaesthetics early
* Check for mulptiple pregnancy
* IDC to empty bladder
TONE
* Deliver placenta - controlled cord contraction
* In/out IDC to empty bladder
* Uterine massage / bimanual uterine compression
* Bakri balloon w/ 500ml saline
* Manual aortic compression
* Drugs
* Syntocin 5-10 units IV/IM + 40 units over 4 hrs infusion 500ml saline
* Ergometrine 0.25mg up to 1mg IV - ONLY if placenta delivered
TRAUMA
* Inspect - trauma, lacerations and repair
* Vaginal vault packing with adrenaline soaked gauze
TISSUE
* Remove placenta and RPOC
THROMBIN
* TXA 1g IV
* Early replacement of platelets / clotting factors
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
Pre-eclampsia risk factors
Age > 40 or young
FHx
Obstetric Hx
* Previous PET Hx
* Previous gestational HTN
* Multiple pregnancy
* Primagravida
Pre-existing conditions
* Chronic HTN
* CRF
* DM
* APL syndrome
* BMI > 35 at booking
Pre-eclampsia Mx
HTN + proteinuria + end organ dysfunction
BP 140/90 - mild
BP 160/110 - severe
Clinical features
Neuro - headache, drowsy, Hyper-reflexia
Vision - blurred, visual scotoma
Hepatic dysfunction - RUQ pain
Mx
Resus, left lateral
Bloods
CTG
MgSO4
BP control
- IV labetolol or hydralazine
Urgent O+G referral for delivery
Pre-eclampsia complications
Eclampsia
Hypertensive crisis
- SAH or ICH
Renal
- ARF
- Oliguria
Haematological
- DIC
- HELLP syndrome
Resp
- APO
Foetal
- FDIU
- Placental aburption / infarct
- Growth retardation
Anti - D recommendations
RANZCOG
AbN Uterine Bleeding - Chronic
- Progestins
a. Norethisterone 5-10mg PO TDS for 1/52 then 5mg TDS for 2/52 - Anti-fibrinolytic agents
a. TXA PO 1g TDS 3-5d, then 500mg TDS - Anti-PG
a. Ibuprofen
b. Naproxen 250mg 3-4 x daily
c. Mefanamic acid 500mg PO TDS - COCP
a. Oestrogen containing (35 mcg) BD up to 7 days - IUD - Mirena
AbN Uterine Bleeding - Acute Severe
- MOVIE
- Inspect cervix for products + remove
- Uterine compression - Foley
- Vaginal packing
a. Bakri Balloon
b. Adrenline soaked gauze - Pharmacological
a. Pregnant - syntocinon/ ergometrine
b. Non-pregnant - premarin (conj oestrogen) 25mg IV
NB Avoid oestrogen containing products:
- Thromboembolic events
- Active liver disease
- Pregnancy
- Smokers
- Oestrogen dependent tumours
Pre-Term Labour
- A - Antibiotics Benpen 1.2g
- Betamethasone 11.4g
- Calcium antagonist - Nifedipine 20mg (up to 3 doses q30min)
- D = MgSO4 IV 4g loading - neuroprotection for foetus
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
Rubin’s I
An assistant applies pressure above the symphysis pubis in a downward and lateral
motion over the fetal shoulder to attempt to release the anterior shoulder from the pubic bone.
A rocking action can also be applied with this manoeuvre.
Rubin’s II
The accoucheur places two fingers on the anterior shoulder of the fetus
(internally) and pushes in a forward and downward direction to attempt to disimpact the anterior shoulder from the pubic bone.
HTN in Pregnancy
Vaginal Breech Delivery
Lithotomy
Evaluate- ROM / prolapsed cord.
If the cord is presenting with the breech, pull out a 10–15 cm loop to provide room to work.
Consider episiotomy
Allow the delivery to happen spontaneously
Support the fetus’s body after the umbilicus appears
(Wrapping a towel around the fetus provides for better traction after the legs deliver)
Pull out the 10–15 cm loop of umbilical cord after the umbilicus delivers if not yet already done.
Keep the fetal sacrum anterior with the fetal face and abdomen away from the symphysis.
Encourage the mother to bear down strongly until the scapulae are visible.
Sweep the flexed arms across the chest to deliver each. Rotate the body to deliver the arms, each from an anterior position.
Perform the Mauriceau-Smellie-Veit maneuver to deliver the head once the fetal chin is at the pelvic inlet.
The provider’s arm is placed under the fetus with the middle fingers on the fetal maxilla and the fetal legs straddling the forearm.
The maxillary fingers plus occipital pressure with the other hand promote head flexion and descent as the body is slightly elevated [22].
The fetus should be delivered well within 10 minutes, as the umbilical cord will be compressed during delivery causing acidosis.
Methotrexate in Ectopic
Indications:
Asymptomatic
Highly compliant
HCG < 3500 (inc risk of failure HCG > 5000)
Tubal size < 3cm
No FHB on USS
No medical CI (allergy, hepatic/renal impairment
Willing to use contraception for next 3 months
RF PPH
H
Foetal Radiation
CTG
https://geekymedics.com/how-to-read-a-ctg/
Approach to CTGs
Dr - Define risk
C - Contractions
BRA - Baseline Rate
V - Variability
A - Accelerations
D - Decelerations
O - Overall Impression
Define Risk
Maternal and obstetric as well as social complications
Contractions
Should be 2 in 10 mins
Baseline Rate
FHR should be 110-160
Fetal tachycardia causes include fetal hypoxia, chorioamnionitis, hyperthyroidism, fetal or maternal anaemia, fetal tachyarrhythmia
Fetal bradycardia causes include prolonged cord compression, cord prolapse, epidural and spinal anaesthesia, maternal seizures, rapid fetal descent
Variability
Should be 5-25 beats per minute
Categorised as reassuring, non-reassuring or abnormal
Abnormal
< 5 bpm for more than 50 minutes
> 25 bpm for more than 25 minutes
sinusoidal
Causes
Fetal sleeping: this should last no longer than 40 minutes (this is the most common cause)
Fetal acidosis (due to hypoxia): more likely if late decelerations are also present
Fetal tachycardia
Drugs: opiates, benzodiazepines, methyldopa and magnesium sulphate
Prematurity: variability is reduced at earlier gestation (<28 weeks)
Congenital heart abnormalities
Accelerations
Increase in FHR >15bpm for more than 15seconds = Reassuring
Decelerations
Decrease in FHR < 15 bpm for > 15 seconds
Early, variable and late, prolonged and sinosoidal
Late = BAD
Begins at peak of uterine contraction and ends after contraction finished
Sign of decreased uterin blood flow
- Maternal hypotension
- Pre-eclampsia
- Uterine hyperstimulation
Overall Impressison
Reassuring, vs suspicious vs abnormal
