Obs 1 Flashcards
What is an Amniotic Fluid Embolism?
Obstetric emergency in which amniotic fluid and foetal cells enter the maternal circulation causing cardiorespiratory collapse
- Rare complication of pregnancy
- High mortality rate
What is the aetiology of Amniotic Fluid Embolism?
Unclear…
- Embolism provokes an anaphylactic reaction, or
- Complement cascade > pulmonary artery spasm > increases pulmonary artery pressure and RVP > hypoxic myocardial and pulmonary capillary damage > LVF and death
What are the RFs for Amniotic Fluid Embolism?
(Often occurs in lack of RFs):
- Increasing maternal age
- Induction of labour (use of uterotonics)
- Placenta praevia/abruption
- C-section
What are the S/S of Amniotic Fluid Embolism?
Majority of cases occur in labour , but can also occur during CS and after delivery in the immediate postpartum.
- Sudden onset SoB ± cyanosis
- Chills, shivering, sweating, anxiety and coughing
- Bleeding / DIC
- Seizures
- Tachypnoea/tachycardia
- Pulmonary oedema
- Uterine atony
- Hypotension
- Bronchospasms
- Arrhythmia and MI
What are the investigations for Amniotic Fluid Embolism?
Clinical diagnosis of exclusion, as there are not definitive diagnostic tests.
- ABG – hypoxaemia, raised PACO2
- FBC– low Hb
- Clotting - low platelets, high PT/APTT, low fibrinogen,
- U&Es, X-match
- CXR – cardiomegaly, pulmonary oedema
- ECG – right heart strain, rhythm abnormalities
What is the management for Amniotic Fluid Embolism?
ABC approach and refer to ITU with MDT
Management is predominantly supportive (ventilatory/circulatory/haemodynamic support, ionotropics)
Immediate:
- Airway = maintain patency
- Breathing = high flow O2 ± intubation
- Circulation = 2 large bore cannulae, fluid resus
Pharmacological:
- Ionotropics as needed
- Correct coagulopathy - transfusion of RBCs, FFP, CFs
- Uterine atony > PPH management
Consider immediate operative delivery ± hysterectomy
What are the complications of an Amniotic Fluid Embolism?
- Cardiac arrest, death
- DIC
- Seizures
- Uterine atony, haemorrhage
- Pulmonary oedema, ARDS
- Renal failure
Prognosis = poor
- 75% survive (many mothers and children have sequelae)
- 25% die within 12 hours
Define anaemia in pregnancy
Pregnant women with mean value of Hb:
- < 110 g/L in 1st trimester
- < 105 g/L in 2nd/3rd trimester
- < 100 g/L postpartum
- < 70 g/L – URGENT REFERRAL
What are the different causes of anaemia in pregnancy?
Iron deficiency:
- Blood loss, decreased absorption/intake, haemolysis
- > Hypochromic microcytic anaemia, pencil cells
Folate deficiency:
(leafy green veg)
- Diet, demand, malabsorption, drugs
- Megaloblastic anaemia (hypersegmented neutrophils, macrocytosis, thrombocytopaenia, leucopaenia)
B12 deficiency:
(Vegans, poultry, dairy, eggs)
- Diet, malabsorption
- Megaloblastic anaemia
Also:
- Chronic illnesses: IBD, UTI
What are the RFs for anaemia in pregnancy?
- Multiple pregnancy
- 2 pregnancies close together
- Lots of vomit due to morning sickness
- Pregnant teenager
- Anaemia before becoming pregnant
- DIET (esp. iron deficiency)
What are the S/S of anaemia in pregnancy?
- Tired or weak
- Dizziness
- SOB
- Trouble concentrating
- Tachycardia/Tachypnoea
- Pale skin, lips, nails, conjunctiva
B12-specific:
- Glossitis, depression, psychosis/dementia, paraesthesia, peripheral neuropathy
What are the investigations for anaemia in pregnancy?
Screened for anaemia at booking and at 28 weeks…
- FBC - hb, hct
- Haematinics / Iron Studies
- Blood film
What is the management of anaemia in pregnancy?
Supplements: Iron, B12 and folate (recheck in 2-3 weeks)
- Oral ferrous sulphate (note SEs: black stools, constipation, abdominal pain)
- Oral folic acid (if cause not known, don’t give this as can exacerbate B12 symptoms)
- IM hydroxocobalamin
Advice:
- Iron/folate – green leafy vegetables, nuts
- B12 – meat and dairy
- Lifestyle: Avoid alcohol, stop smoking
Intra-partum:
- Deliver in consultant-led unit
- IV access and group and screen on admission
- Active management of 3rd stage
- Active management of PPH
- Consider prophylactic syntocinon infusion
What are the complications of anaemia in pregnancy?
- Preterm
- LBW
- Postpartum depression
- Child with developmental delays
- Spina bifida (folate)
Prognosis = good!
Define asthma in pregnancy
A diagnosis of asthma BEFORE pregnancy
- Most common chronic disease in pregnancy (3-12%)
- Most occur between 24-36 weeks
What are the S/S of asthma in pregnancy?
- Wheeze, breathlessness, cough – worse in morning and at night
- Precipitating factors – e.g. cold, drugs (beta blocker, NSAIDs), exercise
- Atopic history
- Tachypnoea, use of accessory muscles, prolonged expiratory phase, polyphonic wheeze, hyperinflated chest
Describe the different severities of asthma
Moderate:
- PEFR 50-75%
Severe:
- PEFR 33-50%
- Pulse >110, RR > 25, inability to complete sentences
Life-threatening:
- PEFR <33%
- Silent chest, cyanosis, bradycardia, hypotension, confusion, coma
Near fatal:
- pCO2 raised
What are the investigations for asthma in pregnancy?
- Peak flow, pulse oximetry
- Bloods: ABG, FBC (WCC infection?), CRP, U&Es, blood/sputum cultures
- PEFR monitoring (diary)
What is the management of asthma in pregnancy?
Regular medications continued throughout labour > bronchoconstrictors should be avoided
General:
- Encourage smoking cessation
- Ensure patient is educated regarding condition, ensure optimal control and response to therapy
- Manage exacerbations aggressively
- Flu vaccine
- Monitor foetal movements daily after 28 weeks
Acute management:
MANAGE ACUTE ATTACKS AS IN NON-PREGNANT INDIVIDUAL, offer MDT approach.
- High flow oxygen, neb salbutamol, ipratropium
- Steroid therapy (IV hydrocortisone, PO pred)
- IV magnesium sulphate and senior help (PCO2 up)
- Discharge when - PEFR >75% of pts best, diurnal variation <25%, stable on discharge meds for 24h
Chronic management:
- SABA
- SABA + ICS
- SABA + ICS + LRTA
- LABA + ICS + LRTA
- LABA + higher-dose ICS + LRTA
- +Trial drugs e.g. theophylline
- +Oral CS
What are the complications of asthma in pregnancy?
- Prolonged hypoxia > FGR, and ultimately, foetal brain injury
- Oral CS use in first trimester increases cleft lip risk
- Preterm birth, perinatal mortality
Prognosis = severity of asthma remains stable in 1/3, worsens in another 1/3 and improves in the 1/3
What is the aetiology of cardiac disease in pregnancy?
40% rise in blood volume during pregnancy causing strain and women with cardiac disease cannot increase CO leading to uterine hypoperfusion and increased pulmonary oedema
Describe the epidemiology of cardiac disease in pregnancy
Increasing due to increased maternal age, increased life expectancy and increased immigrant populations
What are normal cardiac responses expected in pregnancy?
Most women will remain well throughout pregnancy; normal cardiac responses:
- ESM in 96% (more CO)
- Forceful apex (more CO)
- 3rd heart sound in 84% (more cardiac volume)
- Peripheral oedema (more volume)