Obs Emergencies Flashcards
What are some obstetric emergencies?
Emergencies:
- Shoulder dystocia
- Cord prolapse
- PPH
- Amniotic fluid embolism
- Placental abruption/APH
- Eclampsia
- Placenta praevia/vasa praevia
- Uterine rupture, uterine inversion
- Puerperal pyrexia, sepsis
What are 3 major causes of cardiac arrest in pregnancy?
How would you manage a pregnant lady in cardiac arrest?
- Obstetric haemorrhage
- Pulmonary embolism
- Sepsis –> metabolic acidosis + shock
A to E approach
- > Oxygen, intubate
- > Aggressive fluid resus
- > Start CPR, but elevate by 15 degrees to the left side to relieve aortocaval compression
- > Delivery of baby within 4 minutes, and within 5 mins of CPR at site of arrest –> improves maternal survival and improves return to heart + CO, as well as baby survival but this is secondary to mother
What are the 4Ts and 4Hs for reversible causes of cardiac arrest in adults? What does RCOG add to the list for pregnant women?
4 Ts = Thrombosis (PE/MI) = Tension pneumothorax = Toxins = Tamponade (cardiac)
4 Hs = Hypoxia = Hypovolaemia = Hypothermia = Hyperkalaemia, hypoglycaemia + other metabolic disturbances
RCOG adds:
- > Eclampsia
- > Intracranial haemorrhage
What is uterine inversion? How may these women present and how are they managed?
Inversion of the uterus where the funds comes down through the cervix and vagina (incomplete) or until the vaginal introitus (complete)
Presents typically with a large PPH +/- maternal shock and collapse
- > Johnson’s manouvere - manually place fundus back
- > Hydrostatic methods i.e. filling the vagina with fluid to inflate the uterus back to its original position
- > Surgery (laparotomy)
What might suggest uterine rupture in a patient, and when may it occur? What are some other RFs?
Obstetric emergency!
Presents with
- Acutely unwell mother (shock, pain, bleeding)
- Abnormal CTG
- Ceasing of uterine contractions in labour –> rupture of myometrium +/- uterine serosa –> significant bleeding and morbidity/mortality
Main RF = previous CS (e.g. VBAC: uterus may get even weaker with excessive pressure such as oxytocin)
Other RFs: uterine surgery, increased BMI, use of oxytocin to stimulate contractions and IOL, high parity
What is an amniotic fluid embolism and how does it occur? What are some RFs for it?
Obstetric emergency where amniotic fluid and foetal cells enter the maternal circulation causing cardiorespiratory collapse
- Rare (2/100,000 births)
- 5th leading cause of maternal death; PE is leading cause)
- Cause is unclear but embolism provokes an anaphylactic reaction or complement cascade -> pulmonary artery spasm -> inc PA pressure and RVP -> hypoxic heart damage and death
RFs (although often occurs without these)
- Increasing maternal age
- Placenta praaevia/abruption
- IOL - use of uterotonics
- CS
How may women present with an amniotic fluid embolism ?
Sx:
- Sudden onset SOB +/- cyanosis
- Bleeding/DIC
- Seizures
- O/E - high RR, high HR, hypotension, pulmonary oedema, uterine atony
How would you Ix a woman with a suspected amniotic fluid embolism?
Ix:
- A to E approach
- Bloods - FBC, clotting (low plt, high PT/APTT, U&Es, X-match
- ABG
- CXR - cardiomegaly, pulmonary oedema
- ECG - right heart strain, rhythm abnormalities
How would you manage an amniotic fluid embolism? What are the complications + prognosis?
Mx:
- A to E approach (ABC) + refer to ITU
- Maintain patent airway and high flow O2 (+/- intubate)
- 2 large bore cannulas and fluid resus
- Inotropes
- Correct coagulopathy (FFP, cryoprecipitate, plts, transfuse if needed)
- Consider delivery +/- hysterectomy
Complications:
- Death, cardiac arrest, DIC, haemorrhage, ARDS, renal failure
- Poor prognosis - 25% die within 12h, 75% survive but many mothers and children have sequelae
What is the management of a cord prolapse? What are some RFs?
Mx:
- Summon senior help and consider CTG monitoring of baby
- Prevent further cord compression and perform a digital vaginal exam
- Elevate presenting part or fill the bladder to reduce pressure on the prolapsed cord
- Tocolytics (nifedipine, atosiban, terbutaline)
- Avoid handling the cord as causes cord spasm; if the cord passes the introitus, do NOT push back in but keep warm/moist - Place mother in either ALL FOURS or left lateral position or knee-to-chest (baby will fall back into the uterus)
- Delivery ASAP by emergency CS or expedited vaginal delivery (whichever is quicker)
RFs:
- ARM is a big RF!!
- Malpresentation
- Multiple pregnancy
- Polyhydramnios
- Macrosomina
- Placenta praevia
What is placental abruption (APH)? What are some RFs for it? How is an APH defined?
Separation of the placenta from the uterine wall before delivery (AFTER 24w)
- > Bleeding before 24w = miscarriage
- > 1-2% pregnancies
May be idiopathic or occur secondary to raised pressure on maternal side/mechanical factors –> RFs:
- > HTN !!
- > Polyhydramnios
- > Abdominal trauma
- > Previous APH
- > Smoking, cocaine
- > PPROM
Classifications:
Minor haemorrhage – blood loss less than 50 ml that has settled
Major haemorrhage – blood loss of 50–1000 ml, with no signs of clinical shock
Massive haemorrhage – blood loss greater than 1000 ml and/or signs of clinical shock.
How may women present with placental abruption?
Sx:
- Constant abdominal pain +/- PV bleeding*
- SUSTAINED contractions
- Woman may be in shock
- Abdomen will be hypertonic, ‘woody’ and tender uterus
- Vaginal exam will show cervical dilation (do NOT do in praevia)
- Speculum to assess bleeding
*If revealed haemorrhage (80%) however 20% are concealed
What Ix would you consider in suspected placental abruption?
Ix:
- Abdominal exam
- Vaginal and speculum examination (not bimanual if PP)
- Bloods - FBC, clotting studies, U&Es, crossmatch, G&S, Kleihauer
- USS
How would you manage placental abruption (mild vs severe)? What are some complications and prognosis of placental abruption?
Mx:
General A-E approach, 2x IV access - bloods, blood products/antifibrinolytics, anti-D
Mild
- > If preterm and stable, then consider conservative management with close monitoring, steroids and IOL at term
- > Admit for at least 48h or until bleeding stops - if stable and no foetal distress, consider discharge and f/u for serial growth scans weekly until term
- > Give Anti-D Ig followed by Kleihauer test (how much foetal Hb is in the mothers blood)
Severe/Unstable:
-> Expedite delivery
Complications:
- > Maternal = haemorrhage (APH, PPH), DIC, renal failure, “couvelaire uterus”
- > Foetal = birth asphyxia, death
- > Mortality in severe abruption = 0.5% maternal and 3.3% foetal
What is the definition of a postpartum haemorrhage (PPH)? Categorisation?
Blood loss >500ml in SVD or >1000ml at CS
- Primary PPH is within 24 of birth
- Secondary PPH is from 24h to 12w post-birth
What are the causes of PPH? RFs associated with these causes?
4 Ts:
- Tone (70%) = uterine atony is the most common cause; avoid it by giving oxytocin for delivery of placenta. Occurs in 1st 24h due to:
- -> Overdistended uterus - polyhydramnios, multiple pregnancy, macrosomia
- -> Uterine muscle exhaustion - prolonged or rapid labour, grand multiparty, oxytocin use, GA
- -> Uterine anatomy is abnormal - fibroids, placenta praevia, placental abruption
- -> Intra-amniotic infection - fever, prolonged ROM
- Trauma (20%) = laceration to vagina, cervix, uterus e.g. episiotomy, haematomas, uterine rupture or inversion
- Tissue (10%) = retained placental products e.g. blood clots in atonic uterus, GTD, abnormal placentation such as placenta accreta/increta/percreta
- Thrombin (1%) = existing or acquired coagulopathies e.g. haemophilia, DIC, aspirin use, vWD (commonest)
Secondary PPH causes include endometritis, retained productions, trophoblastic disease and abnormal involution of placental site
How may women present with PPH and what Ix would you do?
Sx:
[Primary]
- Shock - high HR, low BP
- Signs of anaemia - breathlessness, pallor
- Abdomen exam shows atonic uterus (above umbilicus)
- Speculum (to exclude trauma)
- Vaginal exam to evacuate clots from the cervix as this inhibits contraction
[Secondary]
- Abdo exam - tender uterus
- Speculum to assess bleeding and if the cervical os is open
- Vaginal exam - uterine tenderness
