Obs - Obstetric emergencies

Question 1

A G2P1 is in active 1st stage of labour. She was earlier diagnosed with delayed 1st stage and an oxytocin infusion was started.
The midwife notices CTG abnormality but whilst she calls a senior for r/v, the patient complains of sudden severe abdominal pain that persists between contractions. She then collapses.

What is the likely diagnosis and how should you manage this patient.

Answer 1

Uterine rupture

1. call for help
2. protect airway + 15L 100% O2 through non-rebreath mask
3. insert 2 large bore cannulas + take blood samples
4. give up to 2L warmed crystalloids + 1-2L warmed colloids then transfuse Oneg or uncrossed matched specific blood until cross-matched blood is available
5. emergency CS + repair or removal of uterus

Question 2

Suggest risk factors for uterine rupture.

Answer 2

1. previous CS (esp. classical incision)
2. previous uterine surgery e.g. myomectomy
3. IOL esp. with PGs or augmentation
4. obstructed labour
5. multiple pregnancy
6. multiparity

Question 3

A 42yo G5P4 is in active labour when she suddenly complains of breathlessness before collapsing. During your A-E assessment, you note that the pt is cyanosed with SpO2 70%, BP is 60/40 and she has developed a widespread petechial rash on her chest.

What is the likely diagnosis and how should she be managed?

Answer 3

Amniotic fluid embolism

1. ALS +/- CPR
2. activate MOH protocol (ensure to correct DIC)
3. emergency CS +/- hysterectomy

Question 4

A 37yo G1P0 who is 38/40 presents to MAU with unilateral leg pain + swelling of left leg. O/E the entire leg is swollen and there is pitting oedema.

What is the likely diagnosis, how would you confirm and manage?

Answer 4

DVT

Ix (Well’s score not performed in preg. pop.)

• bloods: FBC, U+Es/creatinine, LFTs, coagulation screen
• duplex USS leg: lack of compressibility

Mx

• immediate LMWH e.g. DALTEPARIN (titrate dose against booking weight)
• early ambulation

Question 5

How long should pregnant women with VTE continue LMWH?

Answer 5

3/12 (at least 6/52 post-partum)

advise women to omit their dose 24hrs before any planned IOL or CS, or if they think they are going into labour

Question 6

A 37yo G1P0 who is 38/40 presents to MAU with sudden onset SOB, pleuritic chest pain + SOB. O/E: tachycardia + tachypnoea.

What is the likely diagnosis, how would you confirm and manage?

Answer 6

PE

Ix:

• FBC, U+Es/creatinine, LFTs, coag. screen
• ABG: ?hypocapnia, hypoxaemia
• ECG
• CXR
• V/Q scan if CXR normal or CTPA if CXR abnormal

Mx
- immediate LMWH e.g. DALTEPARIN (titrate dose against booking weight)

Question 7

Name 1 complication of V/Q scan and of CTPA in pregnant women.

Answer 7

• V/Q scan: higher risk of childhood cancer

- CTPA: higher risk of breast cancer