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Obstetric emergencies Flashcards

1
Q

Pathophysiology eclampsia

A

2 theories
1:
W extreme HTN, there’s abN cerebral flow w dilated vessels, incr permeability and oedema –> ischaemia and encepalopaty
2:
HTN –> vasoconstriction –> hypoperfusion ischaemia and oedema

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2
Q

Diagnosis of pre-eclampsia

A

HTN > 20/40 and 1>/
- proteinuria: PCR >30mg/mol / protein >3g/day / 1+ on dip
- Maternal organ dysfunction:
— renal: creat >90
— haem: plt < 100, haemolysis or DIC
— lft: raised AST/ ALT
— neuro: hyperreflexia, headaches, visual disturbance
— pulmonary oedema
- uteroplacental dysfx - FGR

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3
Q

Monitoring in eclampsia

A

BP every 15 minutes
Urine output and fluid inputt
O2 > 95%
RR hourly
Temp 4 hourly

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4
Q

Fluid management in eclampsia

A

AN: fluid restrict to 80ml/hr
Art line: unstable/ very high BP/ obese women/ haem >1l
CVP: CS. / complicated delivery
PP: restrict fluid to 80ml/hr, hourly UO monitoring

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5
Q

Medications in eclampsia

A

MgSO4
Labetalol: first line
- 200mg po stat, recheck 30 min
- bolus: 50mg IV over 5 min, repeat every 10 min to a max of 200mg
- infusion: 20mg/hr to a max of 160mg/hr
- CI in severe asthma, caution in pre-existing cardiac conditions
Hydralazine:
- Bolus: 2.5mg in 10ml water over 5 min
- Check BP every 5 min, can repeat every 20min to a max dose of 20mg
- infusion: 40mg in 40ml NS at 1-5ml/hr
- CI: hypersensitivity, severe tachycardia, heart failure
Nifedipine:
- potent, never give SL
- PO- bd or OD, max dose 90mg/day
Methyldopa
- avoid PP, causes depression

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6
Q

Target BP in eclampsia

A

SBP <160mmHg
MAP < 125mmHg

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7
Q

Management eclamptic fit

A

Call for help
ABCs
Left lateral
O2 at 10l/min via non-rebreather
IV access and bloods
Loading dose MgSO4 + infusion
Diazepam if seizure continues
Delivery once stabilised

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8
Q

Management of recurrent fits in eclampsia

A

Anaesthetics present to give IV diazepam 5-10mg
Or repeat bolus of MgSO4 of 2g and increase infusion to 1.5g/hr
- can be done twice
- assess for other causes of seizure if 2x doses needed

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9
Q

MgSO4 - MOA/ dose/ SE/Obs

A

Vasodilatation and membrane stabilisation
Loading dose 4g in 50ml IV over 5-10 min
Maintenance 1g/hr (20g in 500ml at 25ml/hr)
SE:
- motor paralysis
- absent tendon reflexes
- resp depression
- cardiac arrhythmias
Obs:
- 4 hourly iMEWS w UO and reflexes
- reduce rate if absent reflexes or RR <12
A

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10
Q

Antidote for MgSO4

A

Calcium gluconate 10ml 10% IV

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11
Q

Target Mg levels in eclampsia

A

Aim for 1.97-3.28mmol/L

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12
Q

Plt transfusion in eclampsia

A

Consider if plt <50
Recommended prior to CS if <20

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13
Q

Postnatal management eclampsia

A

Monitor until D3
4 hourly BPs
AntiHTN: B-blockers, ACE-i, CCBs.
- safe in breastfeeding
Avoid methyldopa
Discharge:
- D3-4 if BP <150/100 and bloods normal
- BP check every 1-2 days for up to 2/52
- follow up within 2/52

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14
Q

Epidemiology PPH

A

1/4 of all maternal deaths
Second leading cause of direct maternal mortality

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15
Q

PPH definition

A

> /= 500ml

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16
Q

Antenatal risk factors for PPH

A

Prev PPH
Obesity
Ethnicity (asian/ hispanic)
PET
Overdistension of the uterus (multiples, poly, macrosomia)
Anaemia
Inherited bleeding disorder
High parity
Fetal death
Uterine anomalies
IOL
Placenta praevia
PAS

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17
Q

Intrapartum risk factors for PPH

A

Prolonged labour
Precipitous labour
OVD
Uterine rupture
Augmented labour
Episiotomy
Volatile anaesthetic agents
PROM
Infection/ chorio
Uterine inversion
Placental abruption
Retained placenta

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18
Q

Primary PPH vs secondary vs MOH

A

Primary: within 24 hours post delivery
Secondary: 24 hours - 6 weeks
MOH: >/= 2500ml +/ 5 RCC +/- coag treatment

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19
Q

Preparedness re PPH

A

Identify high risk and mx anaemia (Hb <11)
Identify any RCC Ab
Doc any inherited bleeding disorders - notify haem, FM, anaes
FBC at booking and 28/40
Placenta- document site, if ? PAS - MDT
Ensure O neg, Kell neg supply in unit
Local drills
National MOH poster in units

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20
Q

Preventing PPH at delivery

A

Immediate cord clamping if active bleeding
Prophylactic uterotonics
If women refusing prophylaxis - fully inform and advise if placenta not delivered in 30 min
MROP in 30-60 min or sooner if bleeding
TXA if high risk

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21
Q

Oxytocin prophylaxis in elective CS w no PPH risk factors

A

1iu bolus, infusion at 2.5-7.5 iu/hr

22
Q

Oxytocin prophylaxis in intrapartum CS/ any CS w PPH risk factors

A

3iu bolus over 30sec, infusion at 7.5-15iu/hr

23
Q

Uterotonics for PPH

A

Oxytocin
Syntometrine
Misoprostol
Carbebtocin

24
Q

MOA, dosing and SE oxytocin

A

MOA: stimulates oxytocin receptors in the uterus.
- Onset of action: immediate IV, 3-7min IM.
- Duration of action: 30-60min
Dose:
- SVD: 10iu IM or 5iu slow IV
- CS: 1-3 iu slow IV bolus, infusion 7.5-15iu/hr over 4hours
- PPH: 5-10 iu bolus
SE:
- rapid administration –> hypoTN, tachy and arrhythmias
- caution w SIADH, hypotN

25
MOA, dosing and SE - ergometrine
MOA: ergot alkaloid causing sustained uterine contraction - onset: IV 1 min, IM 2-3min - Duration: 45m - 3 hours Dose: - Oxytocin 5iu/ ergometrine 500ug IM - PPH: 250-500ug IM or slow IV, repeated after 5min SE: - N&V, elevated BP - caution w use w other vasoconstrictors CI: - severe HTN/ PET/ cardiac disease/ severe renal or hepatic impairment
26
MOA, dosing and SE- misoprostol
MOA: PGE1 analogue - onset 9-15min - More rapid onset w PO and SL/ longer duration w PR and PV Dose: 400-600ug po (prophylaxis) - PPH: 800-1000ug SE: shivering, diarrhoea, pyrexia
27
MOA, dosing and SE - carbetocin
MOA: synthetic oxytocin analogue - stimulates oxytocin receptors in the uterus - onset: 2 min IV - Duration: IV 60min, IM 3 hours Dose: 100mcg IM or slow IV (prophylaxis) - PPH: 2250ug IM or intramyometrial SE: - rapid administration --> hypoTN, tachy, arrhythmia
28
Non-medical mx PPH
Balloon tamponade B lynch (vicryl) B/L ligation uterine artery/ internal iliac Selective arterial embolization Hyst
29
FBC targets in PPH
Hb >8 PTT <1.5 Plt > 50 Fibrinogen >2g/L
30
Causes of maternal collapse
5 H's Head - eclampsia, epilepsy, CVA, ICH, vasovagal Heart - MI, arrhythmia, PPCMO, CHD, dissection thoracic aorta Hypoxia - asthma, PE, pulm oedema, anaphylaxis Haemorrhage - abruption, atony, genital tract trauma, rupture, inversion, ruptured AAA wHole body and Hazards - hypoglycaemia, amniotic fluid embolus, septicaemia, trauma, anaesthesia complications
31
Defn shoulder dystocia
vaginal cephalic delivery. that required additional manoeuvres to deliver fetus after head delivery and gentle traction has failed
32
Incidence shoulder dystocia
0.5-0.7%
33
Assoc risks. with shoulder dystocia
Inc risk PPH 11% OASIS 3.8% BPI at 2-16% deliveries - <10% w permanent damage
34
Prelabour predictive factors for shoulder dystocia
Maternal: - history of shoulder dystocia - DM (2-4x increase) - BMI >30 Fetal: - macrosomia >4.5kg (48% <4kg) - malposition
35
Intrapartum predictive factors for shoulder dystocia
IOL Prolonged 1st stage Secondary arrest Prolonged 2nd stage Oxytocin augmentation OVD
36
Prevention of SD
IOL - GDM after 38/40 ElCS >4.5kg and DM ElCS >5kg
37
COnsiderations for future pregnancies in SD
Joint decision making for delivery 10x higher risk than general population Recurrence rate of 1-25% Recommend CS if: - neonatal injury - maternal injury - predicted fetal size - maternal choice
38
Signs of SD
Difficult delivery face/ chin Turtle neck sign Failure of restitution Failure of shoulders to descend
39
Management of SD
Diagnosis Call for help Scribe Flatten bed McRoberts - 90% success Suprapubic pressure If no epidural - on all fours Episiotomy if needed Internal rotation - woodscrew, reverse wood Deliver post arm - assoc w 1-12% humerus # Zalvanelli Cleidotomy Symphysiotomy
40
Defn and incidence cord prolapse
Descent of the cord through the cx with ruptured membranes - occult: alongside presenting part - overt: past presenting part 1.7/1000 live births (0.17%)
41
Antenatal risk factors for cord prolapse
Non-vertex presentation (breech or transverse - backup) Unengaged presenting part Unstable lie Polyhydramnios ECV PPROM Multiparity LBW Congenital abnormalities Cord abnormalities Male gender
42
Intrapartum risk factors for cord prolapse
AROM Prematurity Second trin Manual rotation or other vaginal manipulation of te fetus - internal podalic version - disimpaction of fetal head during rotational assisted delivery - placement of FSE - insertion of intrauterine pressure catheter or amnioinfusion catheter
43
Prevention of cord prolapse
Unstable lie - admit from 37-38/40 ARM when head well applied
44
Management of cord prolapse
Help Assess maternal and fetal wellbeing Elevate presenting part - mother adopts knee to chest/ head down left lateral/ all fours Manual displacement of head Fill bladder Wrapping cord Tocolysis Delivery - quickest means possible
45
Incidence of impacted head
8000 deliveries per year
46
Indication of impacted head
Fetal compromise Prolonged second stage
47
Maternal morbidity assoc w impacted head
More than double intraop trauma than CS at first stage Bladder/ bowel damage, uterine extensions = 10-27% PPH= 4.7-10% Psych
48
Neonatal morbidity assoc w impacted head
Trauma higher in OVD than CS More SCBU admission w CS than OVD (prolonged delivery not procedure)
49
Techniques for fully dilated CS
Exposure: - high uterine incision - NICE advises Joel Cohen incision (straight, 3cm above PS) Disimpacting: - uterine relaxants: GTN - pressure from below - frog legs - reverse extraction - Patwardhan extraction: delivery of shoulders through incision, then trunk, breech and finally head Medical devices: - fetal pillow (silicone balloon), C-snorkel
50
RCOG guidelines for disimpacting fetal head
Deflex Non-dominant hand delivery to reduce extensions Hand below - push up technique Patwardhans
51

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