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Y4 - GOSH > Obstetric Emergencies > Flashcards

Obstetric Emergencies Flashcards

1
Q

What is an obstetric emergency?

A

a situation where there is sudden collapse of the patient either antenatally or in the 6 weeks postpartum

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2
Q

What are the 3 main rules of handling an obstetric emergency?

A
  • emergency care ALWAYS starts with ABC
  • resuscitate the woman before considering the baby
  • always call for help early
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3
Q

What are the common causes of an obstetric emergency?

A
  • eclampsia
  • antepartum / postpartum haemorrhage
  • uterine rupture
  • uterine inversion
  • pulmonary embolus
  • septic shock
  • amniotic fluid embolus

myocardial infarction can also cause collapse

this was uncommon but now increasing due to increased maternal age

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4
Q

What is an antepartum haemorrhage?

A

bleeding from the genital tract after 24 weeks gestation

if bleeding occurs prior to 24 weeks, this is a threatened miscarriage

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5
Q

How can postpartum haemorrhage (PPH) be divided into 2 categories?

A

primary PPH:

  • a loss of > 500mls of blood from the genital tract up to 24 hours after birth

secondary PPH:

  • bleeding from the genital tract from 24 hours and up to 6 weeks after birth
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6
Q

What are the steps in the immediate management of APH/PPH?

A
  • call for help
  • ABC
  • facial oxygen + tilt bed head down
  • insert 2 large-bore cannulas in the antecubital fossa (ACF) + give 500mls crystalloid
  • send bloods for FBC, clotting & G&S (for 4 units blood)
  • insert urinary catheter
  • check fetal condition
  • give O negative or group-specific blood if necessary

after all of these things are complete, then the cause of bleeding should be assessed

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7
Q

What are the causes of APH?

A
  • placenta praevia
  • placental abruption
  • causes in the genital tract such as cervical erosion, polyp or trauma

the cause can be unexplained

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8
Q

What are the causes of PPH and how can they be remembered?

A

Tone:

  • atonic uterus

Trauma:

  • genital tract trauma

Tissue:

  • retained products of conception

Thrombin:

  • this produces abnormal clotting

remember the causes of PPH as the 4 Ts

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9
Q

What is involved in the management of APH?

A
  • establish whether the bleeding is painful or painless
  • use of scan to identify placental site
  • decide if a delivery is necessary - this is likely to be C-section

!! DO NOT DO A VAGINAL EXAMINATION UNTIL AFTER SCAN !!

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10
Q

What is the management for PPH caused by a retained placenta?

A

manual removal of the placenta under GA or spinal (depending on condition)

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11
Q

What is the management of PPH caused by an atonic uterus?

A

a series of drugs that make the uterus contract

  • ergometrine
  • syntocinon infusion
  • prostaglandins if no response
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12
Q

How is ergometrine given in PPH?

When is it contraindicated?

A
  • it is given IV or IM
  • it stimulates smooth muscle contraction
  • it is contraindicated in hypertension
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13
Q

What prostaglandin analogues may be given in PPH?

A

carboprost IM:

  • stimulates uterine contractions
  • use with caution in asthma

misoprostol:

  • stimulates uterine contractions
  • given sublingually
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14
Q

What medication can be given to reduce bleeding in APH / PPH?

A

tranexamic acid

this is a antifibrinolytic

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15
Q

What dose of IV sytocinon infusion is given in PPH?

A

40 units in 500mls

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16
Q

What are the major causes of secondary PPH?

A
  • retained products of conception
  • endometritis (infection)
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17
Q

What is involved in the investigations for secondary PPH?

A
  • USS to check for retained products of conception
  • endocervical + HVS to check for infection
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18
Q

What is the management of secondary PPH?

A
  • 24 hours of antibiotics
  • surgical evacuation of RPOC
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19
Q

Why is catheterisation performed in PPH?

A

bladder distention prevents the uterus from contracting

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20
Q

Why is PE common in pregnancy?

A
  • pregnancy produces a pro-thrombotic state
  • coagulation factors alter to promote clotting
  • there is a large pelvic mass
  • mobility is reduced
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21
Q

What factors increase the risk of PE during delivery?

A
  • dehydration
  • prolonged labour
  • operative delivery (incl. forceps, Ventouse and CS)
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22
Q

Who is at risk from PE in pregnancy?

A

ALL women are at risk at ALL gestations and post-partum

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23
Q

What are the symptoms and signs associated with PE?

A
  • collapse
  • SOB
  • pleuritic chest pain
  • hypotension
  • tachycardia
  • reduced air entry
  • reduced o2 sats

they may also present with NO SYMPTOMS

24
Q

What happens in uterine inversion?

A
  • the fundus of the uterus drops down through the uterine cavity and cervix
  • this turns the uterus partially or completely “inside out”
  • it is a complication of birth

it is VERY RARE

25
Q

What is the difference between complete and incomplete uterine inversion?

A

incomplete:

  • the fundus descends inside the uterus or vagina, but not as far as the introitus

complete:

  • the uterus descends through the vagina to the introitus

introitus = opening of the vagina

26
Q

What are the 2 reasons why uterine inversion usually occurs?

A
  • grand multiparity (many previous pregnancies)
  • incorrect management of the third stage (i.e. pulling too hard on the umbilical cord)
27
Q

How does uterine inversion present?

A
  • large postpartum haemorrhage +/- maternal shock or collapse
  • the uterus will be seen at the introitus in a complete inversion
  • the uterus can be felt on vaginal examination in an incomplete inversion
28
Q

What are the 3 options for treating uterine inversion?

A
  1. Johnson manoeuvre
  2. hydrostatic methods
  3. surgery
29
Q

What is the Johnson manoeuvre?

A
  • a hand pushes the fundus back up into the abdomen
  • the whole hand and most of the forearm is inserted into the vagina
  • it is held in place for several minutes
  • oxytocin (syntocinon) is given to create a uterine contraction
  • this generates tension for it to stay in place
30
Q

What is used if the Johnson manoeuvre fails?

A

hydrostatic methods

  • the vagina is filled with fluid to “inflate” the uterus back into normal position
  • it is difficult to achieve as a tight seal at the vagina is needed

this is also called “O’Sullivan’s method”

31
Q

If both the Johnson manoeuvre and hydrostatic methods fail, what is done?

A

surgery

  • laparotomy is performed to return the uterus to the normal position

other maeasures to stabilise the mother such as resuscitation + blood transfusion may be required

32
Q

What are the causes of maternal sepsis antenatally?

A
  • it can result from any maternal viral or bacterial infection that progresses rapidly
  • severe sepsis can result from midtrimester ROM
33
Q

What is meant by severe sepsis?

A
  • when sepsis results in organ dysfunction
  • demonstrated by a raised lactate, oliguria + hypoxia
  • septic shock occurs when organs are hypoperfused due to a drop in BP
34
Q

What are the 2 major causes of sepsis in pregnancy?

A
  • chorioamnionitis
  • urinary tract infections
35
Q

What is chorioamnionitis?

When does it typically occur?

A
  • infection of the chorioamniotic membranes, placenta and amniotic fluid
  • typically occurs in later pregnancy and during labour

chorioamniotic membranes = the amnion and the chorion that make up the amniotic sac which surrounds the embryo

36
Q

What makes chorioamnionitis more likely?

A
  • it occurs more often in when ROM occurs a long time before birth
  • bacteria can spread from the vagina, anus or rectum to the uterus
37
Q

What is the alternative to a NEWS score in pregnant patients?

A

MEOWS

maternity early obstetric warning system

38
Q

What might the MEOWS score indicate in maternal sepsis?

A

it can detect non-specific signs of sepsis, such as:

  • fever
  • tachycardia
  • reduced RR
  • reduced O2 sats
  • low BP
  • altered consciousness
  • reduced urine output

it may also be detected through raised WCC on FBC or abnormalities on CTG

39
Q

What are the additional signs of sepsis related to chorioamnionitis?

A
  • abdominal pain
  • uterine tenderness
  • vaginal discharge
40
Q

What are the key clinical signs and symptoms associated with chorioamnionitis?

A
  • tachycardia > 100 bpm
  • fetal tachycardia > 160 bpm
  • purulent / foul vaginal discharge
  • fever
  • uterine fundal tenderness
41
Q

What additional symptoms / signs may be present in sepsis caused by a UTI?

A
  • dysuria
  • urinary frequency
  • suprapubic pain / discomfort
  • renal angle pain (if pyelonephritis)
  • vomiting (if pyelonephritis)

pyelonephritis = bacterial infection causing inflammation in the kidneys

42
Q

What blood tests are requested in maternal sepsis?

A

FBC:

  • to assess WCC + neutrophils

U&Es:

  • to look for potential AKI

LFTs:

  • acute cholecystitis could be a possible source of infection

CRP

Clotting:

  • assesses for DIC

blood cultures:

  • to assess bacteraemia

ABG:

  • for lactate, glucose and pH
43
Q

What other additional investigations may be performed depending on the source of maternal sepsis?

A
  • urine dipstick / culture
  • high vaginal swab
  • throat swab / sputum culture
  • wound swab after procedures
44
Q

How are women with maternal sepsis managed?

A

sepsis 6

B - blood cultures
U - monitor urine output
F - give IV fluids
A - empirical broad spectrum abx
L - blood lactate level
O - give oxygen to maintain sats 94-98%

45
Q

What antibiotics are typically given in maternal sepsis?

A

IV broad spectrum abx

  • cefotaxime, metronidazole +/- gentamicin
46
Q

What is amniotic fluid embolus?

A
  • occurs when the amniotic fluid passes into the mother’s blood
  • usually occurs during labour / delivery
  • the mother’s immune system reacts to the fetal tissue and causes a systemic illness

  • it is rare but serious with a 20% mortality rate
47
Q

What are the risk factors for amniotic fluid embolus?

A
  • increasing maternal age
  • induction of labour
  • caesarean section
  • multiple pregnancy
48
Q

What are the presenting features of amniotic fluid embolus?

A
  • SOB
  • hypoxia
  • hypotension
  • coagulopathy
  • haemorrhage
  • tachycardia
  • confusion
  • seizures
  • cardiac arrest

it can present similarly to anaphylaxis, sepsis or PE

49
Q

What is the management for amniotic fluid embolus?

A
  • management is supportive
  • it is a medical emergency that requires transfer to ITU
  • correction of clotting
  • A to E approach
50
Q

What is required if cardiac arrest occurs as a result of amniotic fluid embolus?

A
  • cardiopulmonary resuscitation
  • immediate C-section
51
Q

What occurs in a uterine rupture?

A
  • the myometrium (muscle layer of the uterus) ruptures
  • it occurs during labour
52
Q

What are the 2 types of uterine rupture?

A

incomplete rupture / uterine dehiscence:

  • the uterine serosa (perimetrium) surrounding the uterus remains intact

complete rupture:

  • the uterine serosa ruptures
  • the contents of the uterus are released into the peritoneal cavity
53
Q

What is the major risk factor for uterine rupture?

A

previous caesarean section

  • the scar on the uterus becomes a point of weakness
  • it may rupture with excessive pressure (e.g. excessive stimulation with oxytocin)

!! it is RARE for uterine rupture to occur in first-time births !!

54
Q

What are the other risk factors associated with uterine rupture?

A
  • VBAC
  • previous uterine surgery
  • increased BMI
  • high parity
  • increased age
  • induction of labour
  • use of oxytocin to stimulate contractions
55
Q

How does uterine rupture present?

A

presents with acutely unwell mother + abnormal CTG with:

  • constant, severe abdominal pain that breaks through the epidural
  • vaginal bleeding
  • ceasing of uterine contractions
  • hypotension
  • tachycardia
  • collapse
56
Q

What is involved in the management of uterine rupture?

A
  • emergency C-section to remove baby + remove / repair uterus
  • resuscitation + transfusion as required

Y4 - GOSH (62 decks)

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