Obstetric Complications + Emergencies Flashcards
Name some causes of maternal collapse.
Can be broadly divided into head, heart, lungs, and uterus.
Head: eclampsia, intracranial bleed, trauma
Heart: MI, aortic dissection, arrhythmia
Lungs: PE, amniotic fluid embolism
Uterus: abruption, sepsis, haemorrhage
+drugs, anaphylaxis, hypoglycaemia
How would you manage maternal collapse?
- Call for help, 2222 call
- A to E approach, with CPR as needed. Ensure left lateral tilt (eg. with Cardiff Wedge) to prevent aortocaval compression in >20 weeks
- Insert 2 wide bore cannulae, take bloods (FBC, clotting, CM 6 units, U+Es, cardiac enzymes)
- CTG to assess fetal wellbeing, USS
- Ix and manage the cause
Name some risk factors for maternal sepsis.
ROM, immunocompromise, obesity, DM, UTI, GBS +ve, procedures (amniocentesis, cervical cerclage)
Describe features that may be seen with maternal sepsis.
- Obs: increased Temp, HR and RR, decreased BP, reduced urine output
- Rigors, rashes, mottling/pallor, cold peripheries, reduced LOC, D+V, abdo pain
How would you manage maternal sepsis?
- A to E approach
- Initiate sepsis 6 protocol:
- Gain peripheral venous access, take bloods including blood cultures, lactate. Also FBC, U+Es, CRP, ABG
- Further Ix to identify source of infection eg. urine dip, urine MC+S, vaginal swab, etc.
- Monitor urine output +/- catheter
- Start high flow O2, give broad spectrum antibiotics and IV fluids
What are some common bacteria that can cause maternal sepsis? Which antibiotics can be effective?
Group A strep (Strep pyogenes)
E coli
-Good broad spectrum eg. Tazocin/Carbapenem + clindamycin
Define antepartum haemorrhage. Name some causes
Vaginal bleeding >20 weeks. Divided into minor (<50 ml), major (50-1000ml), massive (>1000mls).
Causes can be divided into maternal, fetal, and placental
Placental: abruption, praevia
Maternal: ectropion, carcinoma, infection
Fetal: vasa praevia
What features are important to ask about in a history of PV bleeding at 24 weeks?
Blood: quantity, colour, any material/clots
Pain: pain vs contractions
Triggers: sex, trauma
Other features: discharge/fluids, fetal movements, fever
Smear
-Obs history
What is placental abruption?
Premature separation of the placenta from the uterine wall
Name some risk factors for placental abruption.
- Hypertension
- Smoking, cocaine
- Trauma
- Polyhydramnios
- Multiples
- FGR
Describe how placental abruption presents.
Painful bleeding with a tense rigid abdomen (unless concealed). Sweating, hypotension, tachycardia, tachypnoea, decreased fetal movements
What is placenta praevia?
Placental covering/encroaching on the cervical os
Name some risk factors for placenta praevia?
- Multiples
- Previous C section
- Uterine structural anomaly
- ART
Describe how placenta praevia presents
Presents as painless PV bleeding (though can then cause contractions). Collapse, hypothermia, dizziness, distress.
How would you manage antepartum haemorrhage?
-A-E approach, triage patient
If severe:
-Gain peripheral venous access, take bloods (ABG, FBC, clotting, G+S, CM 4 units if significant loss, U+Es, LFTs)
-IV fluids/transfusion
-USS, CTG
-Consider need for immediate delivery, corticosteroids if likely and 24-35 weeks.
-If mum Rh-ve, send Kleihauer test
A woman comes in at 30 weeks with moderate PV bleeding. Will you admit? If yes, when can she go home?
- Yes. Women with more than minor spotting should be admitted at least until the bleeding stops.
- She should not be discharged until bleeding stops + if there is not a clinical need to monitor closely (eg. abruption)
What is vasa praevia? What can happen as a result?
A condition where fetal vessels traverse the membranes that lie over the internal os. When there is SROM/ARM, these vessels bleed and there can be catastrophic consequences eg. fetal death
What is postpartum haemorrhage? What are the causes?
Bleeding >+ 500 mls that occurs after delivery.
Minor: 500-1000ml
Major: >1000ml
Causes: 4 T’s (Trauma, Tone, Tissue, Thrombin)
Uterine atony is most common!
Name some risk factors for uterine atony
- Macrosomia
- Multiples
- Prolonged labour
- Oxytocin use
- IOL
How can we prevent postpartum haemorrhage?
- Manage any antenatal anaemia well
- Give oxytocin to high-risk women (10IU IM in 3rd stage)
How would you manage PPH?
-Based on the amount of blood loss.
Minor without shock: IV access, send bloods urgently, give fluids, monitor
Major: initiate protocol for major obs haemorrhage.
-A-E approach
-High flow O2. Insert 2 large bore cannulae, take bloods (FBC, CM 6 units, etc)
-Give fluid challenge, blood transfusion
-Uterine compression/massage. Catheterise.
-Uterotonic drugs: 5-10 IU IV oxytocin/0.5mg IM ergometrine/combined eg. Syntometrine (0.5 mg ergo, 5 IU oxytocin)
-If no success, try 2nd uterotonic. Consider rectal misoprostol/carbaprost IM
-Transfer to theatre for surgical management eg. balloon tamponade, hysterectomy
Define eclampsia
1+ generalised convulsions or coma in the presence of pre-eclampsia
How do you prevent against eclampsia?
- Manage pre-eclampsia effectively with antihypertensives
- Mg sulphate if already had a fit/severe pre-eclampsia.
Name several risk factors for eclampsia.
Poorly controlled BP, obesity, DM, age <20 years
Describe the warning signs and symptoms of eclampsia
Epigastric pain, headache, hypertension (though not always), distress, hyper-reflexia and clonus, facial oedema, oliguria, papilloedema
How would you manage eclampsia?
Call for senior help (obs, anaesthetics) A-E approach Mg sulphate (4g loading dose followed by 1g/hr) Consider the need for immediate delivery Refer to critical care as needed
Define umbilical cord prolapse
Descent of the umbilical cord through the cervix with/ahead of the presenting part
Name for risk factors for umbilical cord prolapse
Multiples, polyhydramnios, unstable/transverse/oblique lie, LBW
A woman is seen at antenatal clinic at 36+3. On examination, the fetus is in an oblique lie. What would you discuss with this woman?
- Discuss risk of cord prolapse during labour
- Discuss admission from 37+0
- Inform her to call immediately if there is ROM or signs of labour
- Need for fetal monitoring during labour
How would you manage cord prolapse?
- Call for senior help
- Prep for Cat 1/2
- DO NOT touch the cord/push back in
- Elevate the uterus (mothers position, fill bladder)
- Deliver baby
What is shoulder dystocia?
Difficulty delivering the shoulders after traction, following vaginal cephalic delivery
Name some complications of shoulder dystocia.
Maternal: perineal injury, PPH, psychological trauma
Fetal: brachial plexus injury, fractured clavicle/humerus, hypoxia/death
Name some risk factors for shoulder dystocia.
Macrosomia, GDM/DM, obesity, previous dystocia
How would you manage shoulder dystocia?
Call for senior help
- Drop bed flat, position mum (flex + adduct hips)
- Apply suprapubic pressure
- Rubin II/Woods screw manouvres (Rubin II: push ant shoulder towards chest, Woods screw: same + push post shoulder to turn)
- Episiotomy
- Consider further action such as symphysiotomy, Zavanelli
Name some risk factors for VTE during pregnancy
Pre-existing: obesity, older age, underlying medical conditions, smoking, thrombophilia, previous VTE
Maternal: pre-eclampsia, multiples, C section
New onset/transient: immobility/hospitalisation, hyperemesis, OHSS, infection, surgery
How is VTE managed in pregnancy?
LMWH is 1st line (safe in breastfeeding)
Describe the types of uterine inversion
Uterine inversion occurs when the uterus turns inside out. 4 degrees:
1: Inside cervix
2: Inside vagina
3: Outside vagina
4: Uterus and vagina are outside the introitus
What can cause uterine inversion?
Prolonged second stage, Syntocinon
How is uterine inversion managed?
- Manual replacement +/- GA
- Hydrostatic replacement
- Hysterectomy
What are some risk factors for uterine rupture?
- Previous C section! Myomectomy
- Multiple pregnancy, IOL/augmentation
What are the signs and symptoms of uterine rupture?
- Maternal shock (Low BP, high HR, cold + clammy + pale)
- Severe sudden onset abdo pain
- Absent contractions
- Unable to auscultate fetal heartbeat
