Obstetric Emergencies Flashcards
Miscarriage definition
loss of pregnancy before 24 weeks
How many recognised pregnancies end in miscarriage
20%
85% of miscarriages occur in first/second trimester
first
RF for miscarriage (7)
age >30, SLE -> antiphospholipid syndrome, diabetes, obesity, multiparty, smoking/alcohol, coagulopathies
Miscarriage presentation
mainly vaginal bleeding,
often cramps too
think sister in fleabag!!!
Incomplete miscarriage
Os open,
POC in canal/mostly passed
Inevitable miscarriage
Os open,
POC not passed
Threatened miscarriage
os closed,
viable pregnancy with heartbeat
Missed miscarriage
Os closed,
dead foetus,
no fresh bleeding
Complete miscarriage
Os closed,
empty uterus
Investigation for miscarriage
transvaginal USS for heartbeat and CRL,
beta hCG once and second 48hrs later
If CRL <7mm & no heartbeat on TVS when investigating miscarriage, what is management?
repeat a scan in 7+ days
If CRL >7mm & no heartbeat on TVS when investigating miscarriage, what is management?
get 2nd opinion
serum hCG results - if >63% increase after 48hrs, what is management?
likely viable pregnancy,
re-scan in 7-14 days
serum hCG results - if >50% decrease after 48hrs, what is management?
unlikely to continue, advise pregnancy test in 14 days
First line management of miscarriage
first line: expectant management & pregnancy test in 3 weeks
medical management of miscarriage
vaginal/oral misoprostol for missed or incomplete + test in 3 weeks
surgical management of miscarriage
manual vacuum under local anaesthetic or surgical under GA
When give anti-D prophylaxis if rhesus negative if miscarriage?
> 12 weeks,
or if managed surgically
What is leading cause of first trimester maternal death?
ectopic pregnancy
How long after LMP do ectopic pregnancies classicaly present?
5-8weeks
High risk factors for ectopic pregnancy (7)
previous ectopic, assisted conception, tubal surgery/sterilisation, known tubal scarring or pathology e.g. PID, chlamydia, endometriosis, IUD, smoking
Most common site of ectopic pregnancy
ampulla,
OR isthmus
Ectopic pregnancy symptoms (4)
amenorrhoea,
abdo pain,
vaginal bleeding (not in all!!) and discharge - usually brown,
shoulder tip pain
Ectopic pregnancy signs (6)
adnexal tenderness, abdo tenderness. adnexal mass, fluid in Pouch of Douglas, shock from ruptured, fever
Investigation for ectopic
TV USS,
serum bHCG
PUL: If TV USS is indeterminate i.e. can’t find anything and BHCG is >1500, what is management?
consider surgical exploration
If TV USS confirms ectopic and BHCG <1500 and patient is stable and will attend follow up?
expectant management, allow run its course
If TV USS confirms ectopic and BCHG is 1500-5000, stable, no foetal heartbeat visible and mass <35mm, what is management?
IM methotrexate
If TV USS confirms ectopic and BCHG is >5000, patient is in severe pain, mass >35mm, and foetal heartbeat visible, what is management?
laparoscopic salpingectomy & anti-D!!
Placenta praevia presentation
painless FRESH RED vaginal bleeding after 24 weeks,
Often after sex,
Uterus soft non tender,
Fetal heart & movements normal
what is happening in placenta praevia and what is classification of low-lying/praevia
baby’s placenta partially or totally covers cervix:
low lying: placental edge less than 20mm from internal os in >16 weeks,
praaevia: placenta lies directly over
If bleeding in placenta praaevia, who is more at risk - baby or mother?
Mother due to blood loss as can be large
If no symptoms when is placenta praaevia usually diagnosed?
At 20week anomaly scan
Placenta praaevia resolves for 9/10 cases. T/F
True!
What are 8 risk factors for placenta praveia, what’s main one?
previous c-section(main one!), grand-multiparty (>5), maternal age >40, Assisted conception, Previous TOP multiple pregnancy, previous praaevia, Deficient endometrium
It is very important to not do what in placenta praevia?
DONT DO digital vaginal exam!!
Management of placenta praevia if presenting with bleeding
ABCDE, cross match bloods,
anti-D within 72 hours of bleeding if rhesus neg,
Assess baby - CTG for pregnancies >28 weeks,
If stable expectant management, if actively bleeding expedite delivery,
If delivering early: Steroids if 24-34+6 (up to 35+6), + MgSO4 for neuro protection from 24-32 weeks,
If still have placenta praaevia at 32 weeks what is management?
Planned C-section at 36/37 weeks
What happens in placental abruption
major obstetric emergency where placenta separates from uterus,
- > vasospasm followed by arteriole rupture into decidua; blood escapes into amniotic sac/under placenta/into myometrium
- > uterine tonic contraction due to PGs,
- > placental perfusion is reduced,
- > Couvelaire uterus (purple uterus due to bleeding into myometrium)
- > mom and baby at risk of DEATH
What is difference between concealed or revealed placental abruption
concealed means blood remains in uterus,
revealed means blood trickles through cervix often dark
3 symptoms of placental abruption
PAIN that is CONTINUOUS,
Backache with posterior placenta,
severe shock with symptoms beyond vaginal blood loss,
vaginal bleeding is usually old blood
7 signs of placental abruption
shock,
May be in preterm labour,
uterus spasms - WOODY!,
tender uterus,
foetal parts hard to feel,
often no foetal heart heard/bradycardia,
CTG shows irritable uterus (1contraction/min/FH abnormality e.g. decelerations)
Management of unwell patient with placental abruption
shock: O2, IVF, X-match 6 units, if foetus dead give morphine, Kleihauer,
Catheterise,
deliver foetus: urgent by c/section, IOL by amniotomy sometimes
treat blood loss complication e.g. DIC: check platelets, give FFP, transfuse with fresh blood
placental abruption risk factors (11)
HTN, smoking, Alcohol, cocaine, multiparity, previous abruption, maternal age >40years, Trauma, Polyhydramnios, Perterm PROM, Medical thrombophilias/renal disease/diabetes
In vaginal bleeding after 20 weeks, what 2 things should you think of? What is main difference in presentation of these clinically?
think of placenta praaevia or placental abruption,
placenta praaevia will be PAINLESS BRIGHT RED,
placental abruption will be PAINFUL DARK/CLOTTED red
Pre-eclampsia defintion
New hypertension (>140/90) after 20 weeks gestation with 1 or more of:
- proteinuria,
- organ dysfunction
- uteroplacental dysfunction
List 4 different organ dysfunction presentations that can occur with pre-eclampsia
renal insufficiency: creatinine 90 or more,
elevated transaminases,
neuro complications e.g. visual disturbances/drowsiness/hyperreflexia,
haem complications e.g. DIC/thrombocytopaenia/haemolysis,
Pre-eclampsia pathophysiology
high resistance, low flow uteroplacental circulation due to abnormal placentation and incomplete remodelling of spiral arteries
List 5 HIGH risk factors for pre-eclampsia
hypertensive disease in previous pregnancy, CKD, autoimmune disease e.g. SLE/APS, T1 or T2 DM, chronic HTx
List 6 MODERATE risk factors for pre-eclampsia
first pregnancy, age 40 or more, pregnancy interval >10yrs, BMI 35 or more, FH, multiple pregnancy
Mild, moderate and severe pre-eclampsia parameters
mild: 140/90-149/99 mmHg,
moderate: 150/100 - 159/109mmHg,
severe: BP>160/110 + proteinuria >0.5g/day
OR,
BP >150/90 + proteinuria + other symptoms
Management of pre-eclampsia
antihypertensive, admit severe pre-eclampsia, prophylactic aspirin if 2nd pregnancy, delivery (only cure!) plan for 37/38th week for most, early if high risk group
What is first line hypertensive for pre-eclampsia? what others can be used
labetalol first line,
nifedipine can be used or methyldopa IF asthmatic!
Eclampsia diagnosis
one or more tonic-clonic seizures on background of pre-eclampsia with no other neuro or metabolic causes
Foetal mortality rate of eclampsia
30%
During which parts of pregnancy do most seizures occur in eclampsia?
intrapartum or postnatally
List 8 signs of end organ dysfunction in eclampsia that to make diagnosis of eclampsia you usually have at least 1 of
headache, papilloedema, visual changes, hyperreflexia, abdo pain, N&V, RUQ pain +/- jaundice, change in mental state
7 maternal complications of eclampsia
HELLP, DIC, AKI, ARDS, cerebrovascular haemorrhage, permanent CNS damage, death
5 foetal complications of eclampsia
prematurity, IUGR, RDS, death, placental abruption
Management of eclampsia
ABCDE + left lateral position with secure airway, magnesium sulphate for seizures, BP control with labetalol/hydralazine, continuous CTG, prompt delivery of baby and placenta, monitor fluid balance
Postnatal care of eclampsia (4)
bloods 72hrs including LFTs,
BP,
CT head,
follow up at 6 weeks
uterine rupture
rare but full thickness disruption of uterine muscle and overlying serosa,
typically happens in labour
Risk factors for uterine rupture (6)
previous c-section (main risk!!), previous uterine surgery, induction of labour, obstruction of labour, multiple pregnancy, multiparity
Uterine rupture presentation (6)
CTG abnormalities (lose trace), abdo PAIN, vaginal bleeding (may be minor), maternal SHOCK, foetal parts palpable abdominally, may be preceded by cessation of contractions, C-section scar tenderness or haematuria
What is VBAC and what is main risk of doing it
vaginal birth after c-section,
main risk is uterine rupture
Incomplete vs complete uterine rupture
incomplete: peritoneum intact and uterine contents are in-utero,
complete: peritoneum torn and uterine contents can escape - 75% MORTALITY OF BABY!
Management of uterine rupture
IMMEDIATE LAPAROTOMY (in less than 30mins), ABCDE, resus, uterine repair post-delivery first line but may need hysterectomy
VBAC can only happen after how many c-sections
if you’ve only had 1.
VBAC contraindications (3)
classical (vertical) c-section scar,
history of uterine rupture,
usual vaginal delivery CIs
Success rate of VBAC
60-80%
Continuous what should happen during VBAC
CTG
They both present similarly but which is way more common - amniotic fluid embolism or PE?
PE!
Amniotic fluid embolism most likely to occur when?
during or shortly after labour
Risk factors for amniotic fluid embolism (7)
multiple pregnancy, increasing maternal age, IOL, uterine rupture, C-section/instrumental delivery, eclampsia, polyhydramnios
Amniotic fluid embolism presentation
sudden onset of: hypoxia/resp arrest, hypotension, tachypnoea, cardiac arrest, DIC!!!
Amniotic fluid embolism management
steroids, oxygen, IV fluids, urgent delivery, coagulopathy treatment (FFP for prolonged PT, cryoprecipitate for low fibrinogen, platelet transfusion)
Diagnosis for amniotic fluid embolism only definitive when?
only post-mortem finding of foetal squamous cells with debris in pulmonary vasculature
Shoulder dystocia definition
anterior shoulder gets stuck on maternal pubic symphysis
Shoulder dystocia presentation (4)
difficulty delivering foetal head/chin,
can’t see anterior shoulder,
failure of restitution: foetus remains in OA position and fails to look to side,
turtle neck sign: foetal head retracts back in
Complications of shoulder dystocia Foetal (4) Maternal (2)
Foetal: Hypoxia, permanent brachial plexus injury, humerus or clavicle fractures, Intracranial haemorrhage, Maternal: 3rd/4th degree teas, PPH
RIsk factors fo shoulder dysotica (10)
marosomia, previous shoulder dystocia, DM, maternal BMI >30, IOL, prolonged 1st stage, prolonged 2nd stage, secondary arrest of progress, augmentation of labour with oxytocin, assisted vaginal delivery e.g. ventouse/forceps
Shoulder dysotica management (HELPERR)
H: Help, E: Episiotomy, L: Legs - McRoberts Maneuver, P: External Pressure - suprapubic, E: Enter - rotational maneuvers, R: Remove the posterior arm, R: Roll patient to her hands and knees
What manoeuvres can be done for shoulder dystocia?
McRoberts - highly successful!! knees to chest and tell to stop pushing as increases AP diameter,
suprapubic pressure,
second line: posterior arm manoeuvres and internal rotation manoeuvres (e.g. Wood’s screw manoeuvre, rubin manoeuvre)
Umbilical cord prolapse what happens
umbilical cord descends though cervix before presenting part
umbilical cord prolapse often occurs in presence of?
rupture membranes
Umbilical cord prolapse ay be occult or overt. What does this mean?
occult: descends alongside presenting part so hard to see,
overt: descends past the presenting part so is visible
Umbilical cord prolapse has high foetal mortality rate due to occlusion and arterial vasospasm,. What are risk factors? (5)
abnormal lie e.g. transverse or breech, multiple pregnancy, polyhydramnios, artificial rupture of membranes, prematurity,
Presentation of umbilical cord prolapse
non-reassuring CTG,
foetal bradycardia,
NO BLEEDING per vagina
Umbilical cord prolapse management
do NOT touch the cord cos might cause arterial vasospasm,
encourage left lateral position or knee to chest,
consider tocolysis (relaxes uterus) if dlelivery not imminent,
c-section unless baby just about out
PPH definition
blood loss >500ml in first 24hrs,
SVD > 500mls,
Operative vaginal >750mls,
CS >1000ml
Primary vs secondary PPH
primary within 24hrs,
secondary from 24hrs to 6weeks
Primary PPH most common causes
HINT: 4 Ts
TONE: uterine atony,
TRAUMA,
Tissue: retained tissue,
THROMBIN: coagulopathies
Secondary PPH most common causes (2)
endometritis (main!!),
retained products of conception
What is given to all women for prophylaxis of PPH
IM oxytocin
Initial Management of uterine atony (4)
catheter,
massage uterus through abdo wall first line,
Drugs: oxytocin then ergometrine then carboprost then misoprostol,
IF FAIL: bimanual contraction, theatre.
Secondary PPH management
antibiotics and evacuation of RPOC
antepartum haemorrhage complicates 3-5% of pregnancies. What is definition?
vaginal bleeding between 24wks of pregnancy and before end of second stage of labour
differentials for antepartum haemorrhage (10)
placental abruption (common), placenta praaevia (common), vasa praevia, uterine rupture, malignancy of genital tract, trauma of genital tract, infection of genital tract, cervical ectropion, gestation trophoblastic disease, inherited bleeding disorder
Management of antepartum haemorrhage
IV access for g&s, FBC, coagulation screen, U&Es, LFTs,
USS,
CTG,
if risk of preterm birth and woman is 24-34 weeks gestation - antenatal steroids should be given
HELLP syndrome
haemolysis,
elevated liver enzymes,
low platelets
HELLP syndrome often occurs when and is associated with what
third trimester,
associated with hypertension including pre-eclampsia
6 symptoms of HELLP
headache, N&V, epigastric pain/RUQ pain to due hepatomegaly, Hypertension, blurred vision, peripheral oedema
3 maternal and 3 foetal complications for HELLP
maternal: organ failure, placental abruption, DIC,
foetal: IUGR, preterm, neonatal hypoxia
Management of HELLP
delivery,
maybe blood transfusions or steroids
If mother has Hep B and is positive for both HbsAg and HbeAg at time of delivery, there is ~95% chance of vertical transmission. What is management for baby?
Hep B IgG and HBV vaccine within 24 hours of delivery
Definition of major PPH
> 1000ml blood loss
If woman weighs 50kg, what is approximate circulating volume?
5L
Primary PPH management?
ABCDE, X2 large bore cannulas, Rapid crystalloid fluid warmed, Uterine atony: oxytocin, ergometrine, carboprost IM, misoprostol PR Tranexamic acid! IV
CI to ergometrine
Hypertension
Surgical management of PPH
First line: intrauterine balloon,
Brace sutures AKA B lynch,
Interventional radiology to block uterine arteries, internal iliac artery ligation,
Hysterectomy
Pros & cons of physiological management of 3rd stage, how long
Up to 60mins,
Pros: no drugs,
Cons: increased length of 3rd stage, increased PPH risk, increased need for blood transfusion
How long is active management of 3rd stage, what is given and what are pros and cons?
30mins,
Syntocinon (oxytocin) IM or syntometrine (oxytocin & ergotmetrine), Cord clamped and controlled cord traction,
Pros: decreased risk of PPH and decreased length of 3rd stage,
Cons: N&V, risk of cord avulsion or uterine inversion
What must be given to women when having manual removal of retained placenta?
spinal/general anaesthetic
Uterine inversion presentation? (3)
Uterus coming out vagina,
Lots of bleeding,
Tend to be BRADYCHARDIC due to huge vagal stimulation because cervix stretching
First degree tear
Perineal skin only
Second degree tear
Perineal skin and muscle but NOT anal sphincters
Third degree tear (3A, 3B, 3C)
Third degree: involving anal sphincters,
3A: <50% external anal sphincters,
3B: >50% external anal sphincters,
3C: both external and internal anal sphincter
Fourth degree tear
Disruption of anal epithelium/mucosa
APH minor, major and massive
Minor: <50ml,
Major: 50-1000ml no shock,
Massive: >1000ml &/or shock
Placental abruption is a clinical diagnosis. T/F?
TRUE
List 6 maternal complications of placental abruption
PPH, Anaemia, Hypovolaemic shock, Renal failure from renal tubular necrosis, Coagulopathy, Infection
List 3 foetal complications of placental abruption
Fetal death (14%),
Hypoxia,
Prematurity,
SGA
Placental abruption recurrence rate, APS treatment
10%,
APS give LMWH and low dose aspirin
Anatomical and physiological defintions of lower segment of uterus
Anatomical: part of uterus below utero-vesical pouch that is thinner and contains less muscle,
Physiological: doesn’t contract in labour but passively dilates
How do you assess for risk of preterm labour at 34 weeks?
Assess cervical length
What scan is carried out if placenta accreta suspected?
MRI
What must you NOT DO in placenta praevia?
Vaginal exam
Placenta praevia not bleeding management
No sex,
Consider delivery at 34+0-36+6 weeks if history of vaginal bleeding,
If uncomplicated placenta praevia consider delivery between 36-37 weeks
When might c-section for placenta praevia be vertical uterine incision?
incisions vertical if <28 weeks and if transverse lie
Vasa praevia has 60% fetal mortality rate. What is definition & diagnosis, clinical picture?
Unprotected fetal vessels transverse the membranes below the presenting part over the internal cervical os,
Diagnosis is TA/TV USS with doppler,
Clinical: articificial rupture of membranes and then sudden dark red bleeding and fetal bradycardia
Type I and type II vasa praevia
Type I: vessel connected to velamentous umbilical cord
Type II: connects the placenta with a succenturiate/accessory lobe
Vasa praevia management
Steroids from 32 weeks,
Deliver by elective c/section by 34-36 weeks,
If APH from vasa praevia then emergency c-section
PPH post delivery
Thromboprophylaxis,
Debrief couple,
Manage anaemia IV/oral iron
