Obstetric emergencies Flashcards
Pathophysiology eclampsia
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
Diagnosis of pre-eclampsia
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
Monitoring in eclampsia
BP every 15 minutes
Urine output and fluid inputt
O2 > 95%
RR hourly
Temp 4 hourly
Fluid management in eclampsia
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
Medications in eclampsia
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
Target BP in eclampsia
SBP <160mmHg
MAP < 125mmHg
Management eclamptic fit
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
Management of recurrent fits in eclampsia
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
MgSO4 - MOA/ dose/ SE/Obs
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
Antidote for MgSO4
Calcium gluconate 10ml 10% IV
Target Mg levels in eclampsia
Aim for 1.97-3.28mmol/L
Plt transfusion in eclampsia
Consider if plt <50
Recommended prior to CS if <20
Postnatal management eclampsia
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
Epidemiology PPH
1/4 of all maternal deaths
Second leading cause of direct maternal mortality
PPH definition
> /= 500ml
Antenatal risk factors for PPH
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
Intrapartum risk factors for PPH
Prolonged labour
Precipitous labour
OVD
Uterine rupture
Augmented labour
Episiotomy
Volatile anaesthetic agents
PROM
Infection/ chorio
Uterine inversion
Placental abruption
Retained placenta
Primary PPH vs secondary vs MOH
Primary: within 24 hours post delivery
Secondary: 24 hours - 6 weeks
MOH: >/= 2500ml +/ 5 RCC +/- coag treatment
Preparedness re PPH
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
Preventing PPH at delivery
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
Oxytocin prophylaxis in elective CS w no PPH risk factors
1iu bolus, infusion at 2.5-7.5 iu/hr
Oxytocin prophylaxis in intrapartum CS/ any CS w PPH risk factors
3iu bolus over 30sec, infusion at 7.5-15iu/hr
Uterotonics for PPH
Oxytocin
Syntometrine
Misoprostol
Carbebtocin
MOA, dosing and SE oxytocin
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
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
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
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
Non-medical mx PPH
Balloon tamponade
B lynch (vicryl)
B/L ligation uterine artery/ internal iliac
Selective arterial embolization
Hyst
FBC targets in PPH
Hb >8
PTT <1.5
Plt > 50
Fibrinogen >2g/L
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
Defn shoulder dystocia
vaginal cephalic delivery. that required additional manoeuvres to deliver fetus after head delivery and gentle traction has failed
Incidence shoulder dystocia
0.5-0.7%
Assoc risks. with shoulder dystocia
Inc risk PPH 11%
OASIS 3.8%
BPI at 2-16% deliveries
- <10% w permanent damage
Prelabour predictive factors for shoulder dystocia
Maternal:
- history of shoulder dystocia
- DM (2-4x increase)
- BMI >30
Fetal:
- macrosomia >4.5kg (48% <4kg)
- malposition
Intrapartum predictive factors for shoulder dystocia
IOL
Prolonged 1st stage
Secondary arrest
Prolonged 2nd stage
Oxytocin augmentation
OVD
Prevention of SD
IOL - GDM after 38/40
ElCS >4.5kg and DM
ElCS >5kg
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
Signs of SD
Difficult delivery face/ chin
Turtle neck sign
Failure of restitution
Failure of shoulders to descend
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
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%)
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
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
Prevention of cord prolapse
Unstable lie - admit from 37-38/40
ARM when head well applied
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
Incidence of impacted head
8000 deliveries per year
Indication of impacted head
Fetal compromise
Prolonged second stage
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
Neonatal morbidity assoc w impacted head
Trauma higher in OVD than CS
More SCBU admission w CS than OVD (prolonged delivery not procedure)
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
RCOG guidelines for disimpacting fetal head
Deflex
Non-dominant hand delivery to reduce extensions
Hand below - push up technique
Patwardhans
