Obstetric Emergencies Flashcards by Siby Cherakathil Chacko

What are the Antepartum obstetric emergencies ?

PET/ Eclampsia
Placental Abruption
Placenta Praevia

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What are the intrapartum obstetric emergencies ?

Cord prolapse
Uterine rupture
Shoulder dystocia
Acute uterine inversion

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What are the post-partum obstetric emergencies ?

*Massive obstetric haemorrhage/PPH
*Amniotic fluid embolism

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what are the elements of mild to moderate pre-eclampsia ?

Hypertension ≥ 140/90mmHg
Proteinuria >0.3g/24hrs
No biochemical dysfunction
* The BP should be checked in at least two ocassion at a gap of at least 20 min. and the baseline BP has to be normal

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What are the elements of severe pre-eclampsia ?

BP ≥ 160/100mmHg
Proteinuria often >1g/24hrs
Biochemical dysfunction (low platelets, raised LFTs )

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What are the clinical signs of pre-eclampsia ?

oedema, headache, visual disturbances, epigastric pain, vomiting, hyperreflexia, clonus

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What are the other parameters required to diagnose sever Pre-eclampsia in the absence of proteinurea?

*Thrombocytopenia: Platelet count less than 100,000
* Renal insufficiency: Serum creatinine concentrations greater than 1.1 mg/dL or a doubling of the serum creatinine concentration in the absence of other renal disease.
* Impaired liver function
* Pulmonary oedema
New-onset headache unresponsive to medication

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What are the maternal complications of PET ?

*Cerebral haemorrhage
*Placental abruption and Renal failure
*Pulmonary oedema (ARDS)
*Disseminated Intravascular Coagulation (DIC)
*HELLP syndrome
*Liver haemorrhage or rupture
*Thromboembolism
*Cortical blindness
*Laryngeal oedema

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What are the fetal complications of PET?

*Intrauterine Growth restriction (IUGR)
*Fetal death in utero (FDIU)
*Iatrogenic preterm delivery

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What is the presentation of eclampsia ?

Tonic clonic seizure and Every seizure in pregnancy is an eclamptic seizure until proven otherwise.

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What are the factors to monitor in acute PET?

*BP monitoring 15minutely until stable
*Blood profile: FBC, LFT, U&E, crea, urate, (coag)
*Assess for symptoms: headache, visual disturbances, hyperreflexia, clonus, epigastric pain

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What is the management in acute PET?

*Antihypertensive Rx:Oral Labetolol or Nifedipine, IV Labetolol, Hydralazine.
* Fluid balance - monitor hourly urinary output
*Fluid restriction approx 80 mls/hr (1ml/kg/hr)
* MgSO4 to reduce incidence of seizures ( 4g loading dose IV over 15 mins, 1-2 g/hr maintenance).
* Corticosteroids for fetal lung maturation ≥ 24 - 37 weeks gestation.
* Thromboprophylaixs
*Assessment of fetus: CTG, Biometry, AFI, UA Doppler
*Delivery

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What are the causes of antepartum bleeding ?

Placental Abruption
Placenta praevia
Vasa praevia
Trauma
Local causes (cervical ectropion, tumors, show)
Infection
Unknown origin

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What is Placental Abruption?

Premature separation of placenta aAssociated with very poor fetal and maternal outcomes as 30% mothers have DIC.

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What are the risk factors for Placental Abruption?

*Previous abruption
*Polyhydramnios
*Trauma and Smoking
*Hypertensive disorders, i.e PET
*Underlying thrombophilia

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what is the clinical presentation of Placental Abruption?

It is primarily a clinical diagnosis. The presence of constant- tense tender uterus, Irritable uterus with tetany, Bleeding, fetal compromise, and maternal hypovolemic shock indicates placental abruption.

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What is the management of placental abruption?

*When the fetus is alive, If CTG reassuring and bleeding light, accelerate labour and aim for vaginal delivery.
* If bleeding is heavy and fetus is compromised, deliver by emergency Caesarean Section

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What is placenta previa ?

It is a condition in which is a problem during pregnancy when the placenta completely or partially covers the opening of the uterus (cervix). It is associated to previous uterine surgery, advanced maternal age and smoking.

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What are the grades of placenta previa

Grade 1 (minor): placenta does not cover internal cervical os but is low lying.
Grade 2 (marginal): lower edge reaching the internal os.
Grade 3 (partial): lower edge partially covering the internal cervical os.
Grade 4 (complete): lies over the internal cervical os.

What is placenta acreta ?

The abnormal invasion of placental trophoblasts into the uterine myometrium (<50%) is called placenta accreta

What is placenta Increta?

The abnormal invasion of placental trophoblasts into the uterine myometrium (>50%) is called placenta increta

What is placenta precreta?

The abnormal invasion of placental trophoblasts into the uterine myometrium and Penetrates through myometrium past serosa and invades adjacent structures, i.e. bladder.

What is cord prolapse ?

Prolapse of the umbilical cord through the birth canal which
Causes compression of the cord and is a true obstetric emergency
Baby requires immediate delivery and is associated with CTG abnormalities.

What is the management of cord prolapse ?

*Check if the baby is still alive.

*Deliver immediately by Caesarean Section (may need general anaesthesia) or if fully dilated by instrumental delivery

*Decompress the cord by pushing back the fetal head vaginally or adopt the knee-chest position.

*Consider filling the maternal bladder to elevate the head
If the baby is dead allow for vaginal delivery.

What are the signs of Life-threatening emergency uterine rupture ?

Fetal distress (70%) Vaginal bleeding (4%) Abdominal pain (8%) Presenting part not felt on vaginal examination and Cardio-vascular collapse

What are the risk factors for uterine rupture ?

myomectomy, Caesarean section and use of oxytocin

What is the management of uterine rupture ?

Resuscitation ABC Immediate emergency laparotomy High perinatal mortality rate

what is Shoulder Dystocia?

It is defined as failure to delivery the anterior shoulder at the first attempt at downward traction. Impaction of the anterior shoulder against the maternal symphysis pubis after the fetal head has been delivered.

What are the prenatal risk factors for shoulder dystocia ?

Fetal macrosomia Gestational diabetes Post dates pregnancy Maternal obesity Short statue Advanced maternal age Prior shoulder dystocia

What are the Intrapartum risk factors for shoulder dystocia ?

Protracted active phase of first stage of labour Prolonged second stage Instrumental delivery Vacuum/ Forceps

What are the complications of shoulder dystocia ?

*Brachial plexus injuries * Fractures of Clavicle/ Humerus. * Permanent hypxic neurological damage and Death of the foetus. *Third / fourth degree tear (9%) in mother. *Postpartum Haemorrhage

What is Turtle sign in shoulder dystocia ?

fetal head retraction against the perineum.

what are the Tx options in shoulder dystocia ?

*Episiotomy *McRoberts Maneuver *Suprapubic pressure *Internal maneuvers: Rubin I+II or Woods screw. * Delivery of the posterior arm *Roll patient on all fours (Gaskin maneuver)

what are the last resort manuares in shoulder dystocia ?

*Deliberte clavicular fracture *Zavanelli maneuver *Symphysiotomy

What is acute uterine inversion ?

Uterine inversion is one of the most serious complications of childbirth. It refers to the collapse of the fundus into the uterine cavity.

What are the clinical findings in acute uterine inversion ?

* The fundus is not palpable abdominally. * The sudden onset of brisk vaginal bleeding leads to hemodynamic instability in the mother. * shock disproportionate to blood loss, which is possibly mediated by parasympathetic stimulation caused by the stretching of tissues. * The other symptoms are mainly severe lower abdominal pain with a strong bearing down sensation.

What is the definition of Post Partum Haemorrhage ?

Blood loss >500ml at vaginal delivery and >1000ml at caesarean section

What is the difference between primary vs secondary PPH?

*Primary PPH: (within 24 hours of delivery) *Secondary PPH: (between 24 hours and 6 weeks postpartum) mainly caused by infection or retained placental tissue

What is the cause of 50% maternal mortality in the world ?

Massive Obstetric Haemorrhage: >2500ml loss or needing transfusion of ≥5 units of red cell concentrate or coagulopathy secondary to blood loss.

What are the Causes of Primary Postpartum Haemorrhage?

*Uterine atony (90%) * Retained placental tissue *Perineal Lacerations *Uterine rupture *Coagulopathy

What are the antepartum risk factors for PPH?

PET Nulliparity Multiple gestation Previous PPH Previous Caesarean section

What are the Intrapartum risk factors for PPH?

*Prolonged 3rd stage *Episiotomy *Arrest of descent *Lacerations *Assisted delivery *Augmented/ induced labour

What are the 4 T's of PPH?

TONE-Atonic uterus (70%). TRAUMA-Tears/ lacerations/ haematomas/ uterine inversion/ ruptured uterus (20%). TISSUE- Retained placenta/ placenta accreta (10%). THROMBIN- Coagulopathies (1%)

What are the preventive measures of PPH ?

*Active management of 3rd stage of labor. *Administration of syntocinon (10 units) or syntometrine (5 units syntocinon + 500mcg ergometrine) IM. * Controlled cord traction to deliver placenta and membranes reduces risk of PPH by 65%.

What are the Uterotonic Drugs used to treat uterine atonia ?

*Syntocinon: bolus and infusion iv *Ergometrine: avoid if hypertensive *Misprostol: effective per rectum *Carboprost: IM

What is the first line drug of choice for PPH?

Oxytocin (Syntocinon)