Ob/Gyn Emergencies Flashcards
Describe first trimester bleeding:
Common – 30-40%
50% will miscarry
What are some of the causes of first trimester bleeding?
Causes: Spontaneous abortion Incomplete abortion Blighted ovum Ectopic pregnancy Molar pregnancy Normal pregnancy Cervical polyps Infections Cervical erosions Cervical cancer
Most miscarriages are due to _____.
a genetic anomaly
What are the signs of a spontaneous abortion?
- intrauterine pregnancy at <20 weeks
- low or falling levels of hCG (hCG should normally double every 2-3 days in pregnancy)
- Bleeding, midline cramping pain
- open cervical os
- complete or partial expulsion of products of conception
If someone has had an abortion, then what do you need to check on in that states of the mother?
Rh status. If Rh neg, give Rho-gam
What are signs of ectopic pregnancy?
- amenorrhea or irregular bleeding and spotting
- pelvic pain, usually adnexal. SUDDEN ONSET, DOES NOT RADIATE.
- adnexal mass by clinical examination or U/S
- failure of serum level of beta-hCG to double EVERY 48 HOURS.
- no intrauterine pregnancy or transvaginal u/s with serum beta-hCG >2000 mu/mL
How do you treat ectopic pregnancy?
stable patient= watch and give methotrexate
unstable= hospitalize and surgery
What is placenta previa?
placenta grows into the opening of the mother’s cervix. PAINLESS vaginal bleeding in the 3rd trimester is placenta previa until proven otherwise. bleeding may stop on own, otherwise weigh considerations.
What is placenta abruption?
The placenta tear away from the lining of the uterus and can deprive the baby of oxygen. Vaginal bleeding in the presence of abdominal pain or back pain with a firm, tender uterus. Sometimes, hemorrhage is concealed. DIC can occur. If abruption is severe enough, then a c-section is indicated.
What is pre-eclampsia?
newly elevated blood pressure and proteinuria during pregnancy.
Blood pressure > 140/90 after 20 weeks
Proteinuria of >.3 gm in 24 hours.
Describe severe pre-clampsia?
BP >160/110 protineuria >5g in 24 hours thrombocytopenia HELLP pulmonary edema IUGR
What is the cure for pre-eclampsia?
the only true cure is delivery of the fetus
what are the 6 areas of the body that pre-eclampsia effects?
- CNS
- kidney
- liver
- hematologic
- vascular
- fetal-placental unit
What is eclampsia?
the occurrence of seizures with the other features of pre-eclampsia.
What is HELLP syndrome?
hemoloysis
elevated liver enzymes
low platelets
How are you going to prevent seizures in the mom with eclampsia?
you must give MgSO4
If BP increases, give hydrazine or Nifedipine
give IV D5 1/2 NS TRA 100-250 cc/hr with accurate I’s and O’s
What is postpartum hemorrhage?
It is the most common maternal morbidity
Major cause of death worldwide
traditionally define as blood loss >500ml
What are some risk factors for postpartum hemorrhage?
Antepartum: history of PPH, fetal macrosomia, multiple pregnancies
Intrapartum: prolonged third stage, episiotomy, c-section
How should PPH be managed?
- await placental separation
- leave cord uncut until pulsation stops
- allow spontaneous placental delivery
- give oxytocin
What are the 4 T’s of PPH?
- tone= soft, boggy uterus
- trauma= genital tract tear, inversion of uterus
- tissue= placenta retained
- thrombin= blood not clotting
What is the most common cause of PPH?
loss of tone
How do you manage loss of tone in regards to PPH?
bimanual uterine massage and compression
give oxytocic agents:
1. oxytocin
2. PG
What are some of the causes of trauma that cause PPH?
- uterine inversion: suspect if shock is disproportionate to blood loss, replace uterus immediately
- uterine rupture: risk is prior uterine surgery/no vaginal delivery. fetal bradycardia is first sign.
- vaginal or cervical lacerations
- hematoma
What are some of the reasons “tissue” can cause PPH?
- retained placenta that is not delivered within 30 minutes.
- invasive placenta (accreta)
what is placenta accreta?
general term used to describe an abnormally adherent palcenta. It can invade into or beyond the myometrium ( increta) or into the serosa (percreta). After delivery of an infant, the placenta does not separate correctly. Hysterectomy can somtimes be required to stop the bleeding.
How do you manage placental removal?
- STOP UTERINE MASSAGE! perhaps give anesthetic
- identify the “cleavage plane”
- cup edge in hand and remove
- explore uterine cavity to make sure it is all gone
- give oxytocin to stimulate contraction.
What are the indicators of “thrombin” PPH?
- lack of response to usual PPH treatment
- no blood clot formation
- oozing from puncture sites
What causes “thrombin” PPH?
ITP, TTP, von Willebrand’s, Hemophilia, HELLP, preclampsia, Disseminated intravascular coagulation
Order: CBC with PLT, INR, aPTT, fibrinogen level, d-dimer as a DIC screen
What is active management of PPH?
- oxytocin with or soon after delivery
- clamp cord
- controlled cord traction
- uterine massage after placenta delivers
What is shoulder dystocia?
impaction of the anterior shoulder against the symphysis after delivery of the fetal head. It varies by birth weight, usually increasing as weight increases.
What are the risk factors for should dystocia?
- prior shoulder dystocia
- gestational diabetes
- postdates pregnancy
- macrosomia
- short stature
- high pregnancy weight and weight gain
- abnormal pelvic anatomy
- 1st stage arrest disorders
- prolonged 2nd stage
- turtling
what are some of the complications of shoulder dystocia?
maternal:
- soft tissue injuries
- anal sphincter damage
- PPH
- uterine rupture
- symphyseal seperation
neonatal:
- brachial plexus palsy
- clavicle fracture
- humeral fracture
- fetal acidosis
- hypoxic brain injury
How do we prevent shoulder dystocia?
- elective cesarean delivery is NOT indicated
- glycemic control
- weight control
- deliver in alternative positions or McRoberts
- Deliver anterior shoulder with momentum of head delivery
what is a fetal sign that shoulder dystocia is taking place?
TURTLE SIGN –head bobs in and out
What is the HELPERR mnemonic and when should it be used
After recognition of shoulder dystocia, use the HELPERR mnemonic
H= help (call for assistance)
E = eval for episiotomy
L = legs (McRoberts Maneuver)
P = Pressure (suprapubic pressure to dislodge)
E= enter the vagina
R- remove the posterior arm
R = roll the patient (to hands and knees…which will help dislodge)
Is a shoulder dystocia a soft tissue injury?
NO
What is the McRobert’s maneuver?
flex maternal hips so that thighs are on abdomen
- straightens the lubsacral lordosis
- increases AP diameter
- flexes the fetal spine
How long should you attempt suprapubic pressure for
30-60 seconds
What do you attempt when you E (enter the vagina)
Rubin Manuever
- approach ANTERIOR fetal shoulder from BEHIND
- exert pressure on scapula to adduct most accessible shoulder and rotate to oblique position
- do McRoberts Manuever
OR
Woods Screw Manuever
- approach POSTERIOR fetal shoulder from the FRONT
- gently rotate toward symphysis
- combine with rubin maneuver
OR
Reverse Wood’s Manuever
- approach POSTERIOR fetal shoulder from BEHIND
- rotate fetus in opposite direction from Rubin or Woods screw
- attempt if other maneuvers have failed
How does rolling the patient onto all fours help?
increases pelvic diameter
What is the Zavanelli Maneuver?
Zavanelli maneuver is an obstetric maneuver that involves pushing back the delivered fetal head into the birth canal in anticipation of performing a cesarean section in case of shoulder dystocia
A symphsioomty is most often used where?
in 3rd world counties. break the pubic sympysis.
