Obstetric Emergencies Flashcards
What is an obstetric emergency?
a situation where there is sudden collapse of the patient either antenatally or in the 6 weeks postpartum
What are the 3 main rules of handling an obstetric emergency?
- emergency care ALWAYS starts with ABC
- resuscitate the woman before considering the baby
- always call for help early
What are the common causes of an obstetric emergency?
- 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
What is an antepartum haemorrhage?
bleeding from the genital tract after 24 weeks gestation
if bleeding occurs prior to 24 weeks, this is a threatened miscarriage
How can postpartum haemorrhage (PPH) be divided into 2 categories?
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
What are the steps in the immediate management of APH/PPH?
- 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
What are the causes of APH?
- placenta praevia
- placental abruption
- causes in the genital tract such as cervical erosion, polyp or trauma
the cause can be unexplained
What are the causes of PPH and how can they be remembered?
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
What is involved in the management of APH?
- 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 !!
What is the management for PPH caused by a retained placenta?
manual removal of the placenta under GA or spinal (depending on condition)
What is the management of PPH caused by an atonic uterus?
a series of drugs that make the uterus contract
- ergometrine
- syntocinon infusion
- prostaglandins if no response
How is ergometrine given in PPH?
When is it contraindicated?
- it is given IV or IM
- it stimulates smooth muscle contraction
- it is contraindicated in hypertension
What prostaglandin analogues may be given in PPH?
carboprost IM:
- stimulates uterine contractions
- use with caution in asthma
misoprostol:
- stimulates uterine contractions
- given sublingually
What medication can be given to reduce bleeding in APH / PPH?
tranexamic acid
this is a antifibrinolytic
What dose of IV sytocinon infusion is given in PPH?
40 units in 500mls
What are the major causes of secondary PPH?
- retained products of conception
- endometritis (infection)
What is involved in the investigations for secondary PPH?
- USS to check for retained products of conception
- endocervical + HVS to check for infection
What is the management of secondary PPH?
- 24 hours of antibiotics
- surgical evacuation of RPOC
Why is catheterisation performed in PPH?
bladder distention prevents the uterus from contracting
Why is PE common in pregnancy?
- pregnancy produces a pro-thrombotic state
- coagulation factors alter to promote clotting
- there is a large pelvic mass
- mobility is reduced
What factors increase the risk of PE during delivery?
- dehydration
- prolonged labour
- operative delivery (incl. forceps, Ventouse and CS)
Who is at risk from PE in pregnancy?
ALL women are at risk at ALL gestations and post-partum
What are the symptoms and signs associated with PE?
- collapse
- SOB
- pleuritic chest pain
- hypotension
- tachycardia
- reduced air entry
- reduced o2 sats
they may also present with NO SYMPTOMS
What happens in uterine inversion?
- 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
What is the difference between complete and incomplete uterine inversion?
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
What are the 2 reasons why uterine inversion usually occurs?
- grand multiparity (many previous pregnancies)
- incorrect management of the third stage (i.e. pulling too hard on the umbilical cord)
How does uterine inversion present?
- 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
What are the 3 options for treating uterine inversion?
- Johnson manoeuvre
- hydrostatic methods
- surgery
What is the Johnson manoeuvre?
- 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
What is used if the Johnson manoeuvre fails?
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”
If both the Johnson manoeuvre and hydrostatic methods fail, what is done?
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
What are the causes of maternal sepsis antenatally?
- it can result from any maternal viral or bacterial infection that progresses rapidly
- severe sepsis can result from midtrimester ROM
What is meant by severe sepsis?
- 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
What are the 2 major causes of sepsis in pregnancy?
- chorioamnionitis
- urinary tract infections
What is chorioamnionitis?
When does it typically occur?
- 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
What makes chorioamnionitis more likely?
- 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
What is the alternative to a NEWS score in pregnant patients?
MEOWS
maternity early obstetric warning system
What might the MEOWS score indicate in maternal sepsis?
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
What are the additional signs of sepsis related to chorioamnionitis?
- abdominal pain
- uterine tenderness
- vaginal discharge
What are the key clinical signs and symptoms associated with chorioamnionitis?
- tachycardia > 100 bpm
- fetal tachycardia > 160 bpm
- purulent / foul vaginal discharge
- fever
- uterine fundal tenderness
What additional symptoms / signs may be present in sepsis caused by a UTI?
- dysuria
- urinary frequency
- suprapubic pain / discomfort
- renal angle pain (if pyelonephritis)
- vomiting (if pyelonephritis)
pyelonephritis = bacterial infection causing inflammation in the kidneys
What blood tests are requested in maternal sepsis?
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
What other additional investigations may be performed depending on the source of maternal sepsis?
- urine dipstick / culture
- high vaginal swab
- throat swab / sputum culture
- wound swab after procedures
How are women with maternal sepsis managed?
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%
What antibiotics are typically given in maternal sepsis?
IV broad spectrum abx
- cefotaxime, metronidazole +/- gentamicin
What is amniotic fluid embolus?
- 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
What are the risk factors for amniotic fluid embolus?
- increasing maternal age
- induction of labour
- caesarean section
- multiple pregnancy
What are the presenting features of amniotic fluid embolus?
- SOB
- hypoxia
- hypotension
- coagulopathy
- haemorrhage
- tachycardia
- confusion
- seizures
- cardiac arrest
it can present similarly to anaphylaxis, sepsis or PE
What is the management for amniotic fluid embolus?
- management is supportive
- it is a medical emergency that requires transfer to ITU
- correction of clotting
- A to E approach
What is required if cardiac arrest occurs as a result of amniotic fluid embolus?
- cardiopulmonary resuscitation
- immediate C-section
What occurs in a uterine rupture?
- the myometrium (muscle layer of the uterus) ruptures
- it occurs during labour
What are the 2 types of uterine rupture?
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
What is the major risk factor for uterine rupture?
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 !!
What are the other risk factors associated with uterine rupture?
- VBAC
- previous uterine surgery
- increased BMI
- high parity
- increased age
- induction of labour
- use of oxytocin to stimulate contractions
How does uterine rupture present?
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
What is involved in the management of uterine rupture?
- emergency C-section to remove baby + remove / repair uterus
- resuscitation + transfusion as required
