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Repro > Obstetric Emergencies > Flashcards

Obstetric Emergencies Flashcards

1
Q

Miscarriage definition

A

loss of pregnancy before 24 weeks

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2
Q

How many recognised pregnancies end in miscarriage

A

20%

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3
Q

85% of miscarriages occur in first/second trimester

A

first

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4
Q

RF for miscarriage (7)

A 
age >30, 
SLE -> antiphospholipid syndrome, 
diabetes, 
obesity, 
multiparty, 
smoking/alcohol, 
coagulopathies
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5
Q

Miscarriage presentation

A

mainly vaginal bleeding,
often cramps too
think sister in fleabag!!!

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6
Q

Incomplete miscarriage

A

Os open,

POC in canal/mostly passed

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7
Q

Inevitable miscarriage

A

Os open,

POC not passed

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8
Q

Threatened miscarriage

A

os closed,

viable pregnancy with heartbeat

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9
Q

Missed miscarriage

A

Os closed,
dead foetus,
no fresh bleeding

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10
Q

Complete miscarriage

A

Os closed,

empty uterus

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11
Q

Investigation for miscarriage

A

transvaginal USS for heartbeat and CRL,

beta hCG once and second 48hrs later

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12
Q

If CRL <7mm & no heartbeat on TVS when investigating miscarriage, what is management?

A

repeat a scan in 7+ days

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13
Q

If CRL >7mm & no heartbeat on TVS when investigating miscarriage, what is management?

A

get 2nd opinion

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14
Q

serum hCG results - if >63% increase after 48hrs, what is management?

A

likely viable pregnancy,

re-scan in 7-14 days

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15
Q

serum hCG results - if >50% decrease after 48hrs, what is management?

A

unlikely to continue, advise pregnancy test in 14 days

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16
Q

First line management of miscarriage

A

first line: expectant management & pregnancy test in 3 weeks

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17
Q

medical management of miscarriage

A

vaginal/oral misoprostol for missed or incomplete + test in 3 weeks

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18
Q

surgical management of miscarriage

A

manual vacuum under local anaesthetic or surgical under GA

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19
Q

When give anti-D prophylaxis if rhesus negative if miscarriage?

A

> 12 weeks,

or if managed surgically

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20
Q

What is leading cause of first trimester maternal death?

A

ectopic pregnancy

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21
Q

How long after LMP do ectopic pregnancies classicaly present?

A

5-8weeks

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22
Q

High risk factors for ectopic pregnancy (7)

A 
previous ectopic, 
assisted conception, 
tubal surgery/sterilisation, 
known tubal scarring or pathology e.g. PID, chlamydia, 
endometriosis, 
IUD, 
smoking
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23
Q

Most common site of ectopic pregnancy

A

ampulla,

OR isthmus

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24
Q

Ectopic pregnancy symptoms (4)

A

amenorrhoea,
abdo pain,
vaginal bleeding (not in all!!) and discharge - usually brown,
shoulder tip pain

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25
Q

Ectopic pregnancy signs (6)

A 
adnexal tenderness, 
abdo tenderness. 
adnexal mass,
 fluid in Pouch of Douglas, 
shock from ruptured, 
fever
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26
Q

Investigation for ectopic

A

TV USS,

serum bHCG

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27
Q

PUL: If TV USS is indeterminate i.e. can’t find anything and BHCG is >1500, what is management?

A

consider surgical exploration

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28
Q

If TV USS confirms ectopic and BHCG <1500 and patient is stable and will attend follow up?

A

expectant management, allow run its course

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29
Q

If TV USS confirms ectopic and BCHG is 1500-5000, stable, no foetal heartbeat visible and mass <35mm, what is management?

A

IM methotrexate

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30
Q

If TV USS confirms ectopic and BCHG is >5000, patient is in severe pain, mass >35mm, and foetal heartbeat visible, what is management?

A

laparoscopic salpingectomy & anti-D!!

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31
Q

Placenta praevia presentation

A

painless FRESH RED vaginal bleeding after 24 weeks,
Often after sex,
Uterus soft non tender,
Fetal heart & movements normal

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32
Q

what is happening in placenta praevia and what is classification of low-lying/praevia

A

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

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33
Q

If bleeding in placenta praaevia, who is more at risk - baby or mother?

A

Mother due to blood loss as can be large

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34
Q

If no symptoms when is placenta praaevia usually diagnosed?

A

At 20week anomaly scan

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35
Q

Placenta praaevia resolves for 9/10 cases. T/F

A

True!

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36
Q

What are 8 risk factors for placenta praveia, what’s main one?

A 
previous c-section(main one!), 
grand-multiparty (>5), 
maternal age >40, 
Assisted conception, 
Previous TOP 
multiple pregnancy, 
previous praaevia, 
Deficient endometrium
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37
Q

It is very important to not do what in placenta praevia?

A

DONT DO digital vaginal exam!!

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38
Q

Management of placenta praevia if presenting with bleeding

A

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,

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39
Q

If still have placenta praaevia at 32 weeks what is management?

A

Planned C-section at 36/37 weeks

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40
Q

What happens in placental abruption

A

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
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41
Q

What is difference between concealed or revealed placental abruption

A

concealed means blood remains in uterus,

revealed means blood trickles through cervix often dark

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42
Q

3 symptoms of placental abruption

A

PAIN that is CONTINUOUS,
Backache with posterior placenta,
severe shock with symptoms beyond vaginal blood loss,
vaginal bleeding is usually old blood

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43
Q

7 signs of placental abruption

A

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)

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44
Q

Management of unwell patient with placental abruption

A

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

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45
Q

placental abruption risk factors (11)

A 
HTN, 
smoking, 
Alcohol, 
cocaine, 
multiparity, 
previous abruption, 
maternal age >40years,
Trauma, 
Polyhydramnios, 
Perterm PROM, 
Medical thrombophilias/renal disease/diabetes
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46
Q

In vaginal bleeding after 20 weeks, what 2 things should you think of? What is main difference in presentation of these clinically?

A

think of placenta praaevia or placental abruption,
placenta praaevia will be PAINLESS BRIGHT RED,
placental abruption will be PAINFUL DARK/CLOTTED red

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47
Q

Pre-eclampsia defintion

A

New hypertension (>140/90) after 20 weeks gestation with 1 or more of:

  • proteinuria,
  • organ dysfunction
  • uteroplacental dysfunction
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48
Q

List 4 different organ dysfunction presentations that can occur with pre-eclampsia

A

renal insufficiency: creatinine 90 or more,
elevated transaminases,
neuro complications e.g. visual disturbances/drowsiness/hyperreflexia,
haem complications e.g. DIC/thrombocytopaenia/haemolysis,

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49
Q

Pre-eclampsia pathophysiology

A

high resistance, low flow uteroplacental circulation due to abnormal placentation and incomplete remodelling of spiral arteries

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50
Q

List 5 HIGH risk factors for pre-eclampsia

A 
hypertensive disease in previous pregnancy, 
CKD, 
autoimmune disease e.g. SLE/APS, 
T1 or T2 DM, 
chronic HTx
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51
Q

List 6 MODERATE risk factors for pre-eclampsia

A 
first pregnancy, 
age 40 or more, 
pregnancy interval >10yrs, 
BMI 35 or more, 
FH, 
multiple pregnancy
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52
Q

Mild, moderate and severe pre-eclampsia parameters

A

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

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53
Q

Management of pre-eclampsia

A 
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
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54
Q

What is first line hypertensive for pre-eclampsia? what others can be used

A

labetalol first line,

nifedipine can be used or methyldopa IF asthmatic!

55
Q

Eclampsia diagnosis

A

one or more tonic-clonic seizures on background of pre-eclampsia with no other neuro or metabolic causes

56
Q

Foetal mortality rate of eclampsia

A

30%

57
Q

During which parts of pregnancy do most seizures occur in eclampsia?

A

intrapartum or postnatally

58
Q

List 8 signs of end organ dysfunction in eclampsia that to make diagnosis of eclampsia you usually have at least 1 of

A 
headache, 
papilloedema, 
visual changes, 
hyperreflexia, 
abdo pain, 
N&V, 
RUQ pain +/- jaundice, 
change in mental state
59
Q

7 maternal complications of eclampsia

A 
HELLP, 
DIC, 
AKI, 
ARDS, 
cerebrovascular haemorrhage, 
permanent CNS damage, 
death
60
Q

5 foetal complications of eclampsia

A 
prematurity, 
IUGR, 
RDS, 
death, 
placental abruption
61
Q

Management of eclampsia

A 
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
62
Q

Postnatal care of eclampsia (4)

A

bloods 72hrs including LFTs,
BP,
CT head,
follow up at 6 weeks

63
Q

uterine rupture

A

rare but full thickness disruption of uterine muscle and overlying serosa,
typically happens in labour

64
Q

Risk factors for uterine rupture (6)

A 
previous c-section (main risk!!), 
previous uterine surgery, 
induction of labour, 
obstruction of labour, 
multiple pregnancy, 
multiparity
65
Q

Uterine rupture presentation (6)

A 
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
66
Q

What is VBAC and what is main risk of doing it

A

vaginal birth after c-section,

main risk is uterine rupture

67
Q

Incomplete vs complete uterine rupture

A

incomplete: peritoneum intact and uterine contents are in-utero,
complete: peritoneum torn and uterine contents can escape - 75% MORTALITY OF BABY!

68
Q

Management of uterine rupture

A 
IMMEDIATE LAPAROTOMY (in less than 30mins), 
ABCDE, resus, 
uterine repair post-delivery first line but may need hysterectomy
69
Q

VBAC can only happen after how many c-sections

A

if you’ve only had 1.

70
Q

VBAC contraindications (3)

A

classical (vertical) c-section scar,
history of uterine rupture,
usual vaginal delivery CIs

71
Q

Success rate of VBAC

A

60-80%

72
Q

Continuous what should happen during VBAC

A

CTG

73
Q

They both present similarly but which is way more common - amniotic fluid embolism or PE?

A

PE!

74
Q

Amniotic fluid embolism most likely to occur when?

A

during or shortly after labour

75
Q

Risk factors for amniotic fluid embolism (7)

A 
multiple pregnancy, 
increasing maternal age, 
IOL, 
uterine rupture, 
C-section/instrumental delivery, 
eclampsia, 
polyhydramnios
76
Q

Amniotic fluid embolism presentation

A 
sudden onset of: 
hypoxia/resp arrest, 
hypotension, 
tachypnoea,
cardiac arrest, 
DIC!!!
77
Q

Amniotic fluid embolism management

A 
steroids,
 oxygen, 
IV fluids, 
urgent delivery, 
coagulopathy treatment (FFP for prolonged PT, cryoprecipitate for low fibrinogen, platelet transfusion)
78
Q

Diagnosis for amniotic fluid embolism only definitive when?

A

only post-mortem finding of foetal squamous cells with debris in pulmonary vasculature

79
Q

Shoulder dystocia definition

A

anterior shoulder gets stuck on maternal pubic symphysis

80
Q

Shoulder dystocia presentation (4)

A

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

81
Q

Complications of shoulder dystocia Foetal (4) Maternal (2)

A 
Foetal: 
Hypoxia, 
permanent brachial plexus injury, 
humerus or clavicle fractures, 
Intracranial haemorrhage, 
Maternal:  
3rd/4th degree teas, 
PPH
82
Q

RIsk factors fo shoulder dysotica (10)

A 
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
83
Q

Shoulder dysotica management (HELPERR)

A 
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
84
Q

What manoeuvres can be done for shoulder dystocia?

A

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)

85
Q

Umbilical cord prolapse what happens

A

umbilical cord descends though cervix before presenting part

86
Q

umbilical cord prolapse often occurs in presence of?

A

rupture membranes

87
Q

Umbilical cord prolapse ay be occult or overt. What does this mean?

A

occult: descends alongside presenting part so hard to see,
overt: descends past the presenting part so is visible

88
Q

Umbilical cord prolapse has high foetal mortality rate due to occlusion and arterial vasospasm,. What are risk factors? (5)

A 
abnormal lie e.g. transverse or breech, 
multiple pregnancy, 
polyhydramnios, 
artificial rupture of membranes, 
prematurity,
89
Q

Presentation of umbilical cord prolapse

A

non-reassuring CTG,
foetal bradycardia,
NO BLEEDING per vagina

90
Q

Umbilical cord prolapse management

A

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

91
Q

PPH definition

A

blood loss >500ml in first 24hrs,
SVD > 500mls,
Operative vaginal >750mls,
CS >1000ml

92
Q

Primary vs secondary PPH

A

primary within 24hrs,

secondary from 24hrs to 6weeks

93
Q

Primary PPH most common causes

HINT: 4 Ts

A

TONE: uterine atony,
TRAUMA,
Tissue: retained tissue,
THROMBIN: coagulopathies

94
Q

Secondary PPH most common causes (2)

A

endometritis (main!!),

retained products of conception

95
Q

What is given to all women for prophylaxis of PPH

A

IM oxytocin

96
Q

Initial Management of uterine atony (4)

A

catheter,
massage uterus through abdo wall first line,
Drugs: oxytocin then ergometrine then carboprost then misoprostol,
IF FAIL: bimanual contraction, theatre.

97
Q

Secondary PPH management

A

antibiotics and evacuation of RPOC

98
Q

antepartum haemorrhage complicates 3-5% of pregnancies. What is definition?

A

vaginal bleeding between 24wks of pregnancy and before end of second stage of labour

99
Q

differentials for antepartum haemorrhage (10)

A 
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
100
Q

Management of antepartum haemorrhage

A

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

101
Q

HELLP syndrome

A

haemolysis,
elevated liver enzymes,
low platelets

102
Q

HELLP syndrome often occurs when and is associated with what

A

third trimester,

associated with hypertension including pre-eclampsia

103
Q

6 symptoms of HELLP

A 
headache, 
N&V, 
epigastric pain/RUQ pain to due hepatomegaly, 
Hypertension, 
blurred vision, 
peripheral oedema
104
Q

3 maternal and 3 foetal complications for HELLP

A

maternal: organ failure, placental abruption, DIC,
foetal: IUGR, preterm, neonatal hypoxia

105
Q

Management of HELLP

A

delivery,

maybe blood transfusions or steroids

106
Q

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?

A

Hep B IgG and HBV vaccine within 24 hours of delivery

107
Q

Definition of major PPH

A

> 1000ml blood loss

108
Q

If woman weighs 50kg, what is approximate circulating volume?

A

5L

109
Q

Primary PPH management?

A 
ABCDE, 
X2 large bore cannulas, 
Rapid crystalloid fluid warmed, 
Uterine atony: oxytocin, ergometrine, carboprost IM, misoprostol PR 
Tranexamic acid! IV
110
Q

CI to ergometrine

A

Hypertension

111
Q

Surgical management of PPH

A

First line: intrauterine balloon,
Brace sutures AKA B lynch,
Interventional radiology to block uterine arteries, internal iliac artery ligation,
Hysterectomy

112
Q

Pros & cons of physiological management of 3rd stage, how long

A

Up to 60mins,
Pros: no drugs,
Cons: increased length of 3rd stage, increased PPH risk, increased need for blood transfusion

113
Q

How long is active management of 3rd stage, what is given and what are pros and cons?

A

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

114
Q

What must be given to women when having manual removal of retained placenta?

A

spinal/general anaesthetic

115
Q

Uterine inversion presentation? (3)

A

Uterus coming out vagina,
Lots of bleeding,
Tend to be BRADYCHARDIC due to huge vagal stimulation because cervix stretching

116
Q

First degree tear

A

Perineal skin only

117
Q

Second degree tear

A

Perineal skin and muscle but NOT anal sphincters

118
Q

Third degree tear (3A, 3B, 3C)

A

Third degree: involving anal sphincters,
3A: <50% external anal sphincters,
3B: >50% external anal sphincters,
3C: both external and internal anal sphincter

119
Q

Fourth degree tear

A

Disruption of anal epithelium/mucosa

120
Q

APH minor, major and massive

A

Minor: <50ml,
Major: 50-1000ml no shock,
Massive: >1000ml &/or shock

121
Q

Placental abruption is a clinical diagnosis. T/F?

A

TRUE

122
Q

List 6 maternal complications of placental abruption

A 
PPH, 
Anaemia, 
Hypovolaemic shock, 
Renal failure from renal tubular necrosis,
Coagulopathy, 
Infection
123
Q

List 3 foetal complications of placental abruption

A

Fetal death (14%),
Hypoxia,
Prematurity,
SGA

124
Q

Placental abruption recurrence rate, APS treatment

A

10%,

APS give LMWH and low dose aspirin

125
Q

Anatomical and physiological defintions of lower segment of uterus

A

Anatomical: part of uterus below utero-vesical pouch that is thinner and contains less muscle,
Physiological: doesn’t contract in labour but passively dilates

126
Q

How do you assess for risk of preterm labour at 34 weeks?

A

Assess cervical length

127
Q

What scan is carried out if placenta accreta suspected?

A

MRI

128
Q

What must you NOT DO in placenta praevia?

A

Vaginal exam

129
Q

Placenta praevia not bleeding management

A

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

130
Q

When might c-section for placenta praevia be vertical uterine incision?

A

incisions vertical if <28 weeks and if transverse lie

131
Q

Vasa praevia has 60% fetal mortality rate. What is definition & diagnosis, clinical picture?

A

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

132
Q

Type I and type II vasa praevia

A

Type I: vessel connected to velamentous umbilical cord

Type II: connects the placenta with a succenturiate/accessory lobe

133
Q

Vasa praevia management

A

Steroids from 32 weeks,
Deliver by elective c/section by 34-36 weeks,
If APH from vasa praevia then emergency c-section

134
Q

PPH post delivery

A

Thromboprophylaxis,
Debrief couple,
Manage anaemia IV/oral iron

Repro (49 decks)

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