obstetric emergencies Flashcards
what is HELLP syndrome
complication of pregnancy with: haemolysis, elevated liver enzymes and low platelets
when does HELLP syndrome usually present
during the 3rd trimester
clinical presentation of HELLP syndrome
headache, N+V, epigastric pain, RUQ pain (due to liver distension), blurred vision and peripheral oedema
definitive management of HELLP syndrome
delivery !!
what can be used for seizure prophylaxis during pregnancy
magnesium sulphate
what is the most common cause of iatrogenic prematurity
pre-eclampsia
name some risk factors for developing pre-eclampsia
first pregnancy, age > 40, high BMI, FHx, hypertension, CKD, multiple pregnancy
what is pre-eclampsia
new onset hypertension after 20 weeks of pregnancy associated with organ damage (proteinuria)
classic presentation of pre-eclampsia
hypertension, proteinuria and oedema
name some symptoms associated with pre-eclampsia
headache, visual disturbance, N+V, abdo tenderness (epigastric/RUQ)
prophylaxis for pregnancies that are high risk of pre-eclampsia
aspirin 75mg daily from 12 weeks gestation until birth
how do we screen for pre-eclampsia
urinalysis and blood pressure monitoring at every antenatal visit
curative management of pre-eclampsia
delivery
what is eclampsia
severe complication of pre-eclampsia, characterised by generalised tonic-clonic seizures
who is eclampsia more common in
teenage pregnancies
antihypertensives used in pregnancy
labetalol, hydralazine
acute seizure control in eclampsia
IV magnesium sulphate first line
diazepam or lorazepam if persistence
name some risk factors for sepsis in pregnancy
pre-natal invasive diagnostic procedures e.g. amniocentesis
cervical suture
prolonged rupture of membranes
operative delivery
immunosuppression
name 3 antenatal/intrapartum sources of infection
chorioamnionitis
resp: influenza, pneumonia, covid
genitoutery infections incl. HSV
name some post-natal causes of sepsis
caesarean, episiotomy, mastitis, UTI, endometritis, retained products of conception
why are pregnant women at risk of sepsis
pregnancy causes immunosuppression due to shift from cell-mediated to humoral immunity
steps of the sepsis 6
Blood cultures
Urine output
Fluids
Antibiotics
Lactate
Oxygen
management of sepsis in pregnancy (+also in penicillin allergic patients)
IV co-amoxiclav +/- gentamicin + clindamycin if sore throat
penicillin allergic: clindamycin + gentamicin
management of septic shock in pregnancy
tazocin, clindamycin and gentamicin
what causes aortocaval compression in pregnancy
gravid uterus compresses the maternal abdominal aorta and inferior vena cava
what can aortocaval compression cause
supine hypotensive syndrome - sudden drop in BP when pregnant women lie down
how to manage aortocaval compression
left manual uterine displacement
OR 30 degree tilt if on theatre table
what is amniotic fluid embolism
when amniotic fluid enters the maternal circulation
clinical presentation of an amniotic fluid embolism
sudden onset: hypoxia, hypotension, profound foetal distress
when is a perimortem c-section indicated
no response to CPR in 4 minutes
what are the shockable causes of cardiac arrest
ventricular fibrillation and pulseless ventricular tachycardia
what are the non-shockable rhythms
asystole and pulseless electrical activity
how do we manage non-shockable rhythms in cardiac arrest
start CPR and adrenaline 1mg IV
adrenaline 1mg every 3-5 mins (every 2nd cycle)
what can be an alternate route of admission of drugs in emergency settings if IV access is unaccessable
interosseous
how do we manage shockable rhythms in cardiac arrest
start CPR, administer shocks as advised
3rd shock: adrenaline 1mg + amiodarone 300mg
give adrenaline every 3-5 mins there after
consider a second dose of amiodarone (150mg) after shock 5
what are the 4H’s and 4T’s of reversible causes of cardiac arrest
hypovolaemia, hypoxia, hypo/hypermetabolic, hypothermia
thrombosis, tamponade, toxins, tension pneumothorax
what are 2 other reversible causes of cardiac arrest in pregnant women
pre-eclampsia or amniotic fluid embolism
why are pregnant women more at risk of VTE
pregnancy is a hypercoagulable state
what is a dural venous sinus thrombosis
occlusion of a dural venous sinuses in the cranial cavity
classic presentation of a dural venous sinus thrombosis
headache
investigation for a dural venous sinus thrombosis
MR venogram
management of dural venous sinus thrombosis in pregnancy
anticoagulation with LMWH
investigation for suspected PE
CTPA or V/Q scanning
management of PE in pregnancy
fixed dose LMWH based on early pregnancy body weight
name some risk factors for VTE in pregnant women
parity > 3, prolonged labour, postpartum haemorrhage >100oml, stillbirth, preterm birth, immobility
prophylaxis for VTE in pregnancy and postpartum
low molecular weight heparin
name some things that cord prolapse are associated with
abnormal lie, multiple pregnancy, high foetal head at delivery, low birth weight/prematurity
how might we detect cord prolapse and what would be a positive result
vaginal exam !!
CTG - variable or prolonged decelerations
what can be administered in cord prolapse to prevent further cord prolapse
tocolytics: nifedipine, atosiban, terbutaline
to stop uterine contractions
what is shoulder dystocia
bony impaction of foetal anterior shoulder on the maternal symphysis
name some antenatal risk factors for shoulder dystocia
maternal gestational diabetes, macrosomia, advanced maternal age, small pelvis, post-dates
name some intrapartum risk factors for shoulder dystocia
prolonged 1st and 2nd stage
induction of labour
instrumental delivery
name 2 clinical signs that indicate shoulder dystocia
turtle neck sign
head bobbing
what is turtle neck sign
delivered head becomes tightly pulled back against the perineum and there is difficulty delivering the head
what is head bobbing
jerking movement of the head between contractions as it tries to move forward but gets stuck
management of shoulder dystocia
HELPERR
all for Help
Evaluate for episiotomy
Legs (McRoberts’ manoeuvre)
External Pressure (suprapubic)
Enter (rotational manoeuvre)
Remove the posterior arm
Roll the patient onto her hands and knees
name some foetal complications of shoulder dystocia
hypoxia
brachial plexus injury
fracture of clavicle/humerus if needed
name some maternal complications of shoulder dystocia
PPH, genital tract trauma, pelvic injury
what is antepartum haemorrhage
bleeding from the genital tract after 24 weeks of gestation and before the end of the second stage of labour
what are the 2 most common causes of antepartum haemorrhage
placental abruption and placenta praevia
how do we quantify APH
spotting: staining, streaking, wiping
minor < 50 ml
major 50-1000 ml with no signs of shock
massive > 1000 ml OR signs of shock
first line medical management of antepartum haemorrhage
tranexamic acid
what is placental abruption
premature separation of the placenta from the uterine wall during pregnancy
name some risk factors for placental abruption
pre-eclampsia, trauma, smoking/drugs, multiple pregnancies, increased maternal age
‘woody’ uterus
PLACENTAL ABRUPTION!!
clinical presentation of placental abruption
severe abdominal pain, bleeding, foetal distress
management of placental abruption
delivery is the only way to ‘fix’ the problem
prophylaxis given to women with antiphospholipid syndrome during pregnancy
LMWH and low dose aspirin
what is placenta previa
placenta is lying directly over the internal os
what is a low lying placenta
when the placental edge is less than 2 cm from the internal os on ultrasound
name some risk factors for placenta previa
previous caesarean or TOP, increased maternal age, multiparity, assisted conception
classic presentation of placenta previa
bright red vaginal bleeding which is painless
later than 24 weeks
name something that might trigger bleeding associated with placenta previa
sex
what should be avoided in patients with suspected placenta previa
digital vaginal exam
gold standard investigation for diagnosis of placenta previa
TVUS
what should be avoided in women with placenta previa
sex
what is placenta acreta
abnormally adherent placenta to the uterine wall (myometrium)
what is placenta increta
placenta invades the myometrium
what is placenta percreta
placenta invades through the uterine walls and attaches to the intra-abdominal organs (usually bladder)
name some risk factors for placenta accreta
previous TOP or caesarean, placenta previa, ashermans
what is ashermans syndrome
build-up of scar tissue in the uterus
how can placenta accreta be identified
often asymptomatic - found on ultrasound
definitive management of placenta accreta
elective caesarean hysterectomy
what is uterine rupture - and how does this differ to dehiscence
full thickness opening of the uterus - including serosa
if serosa is intact - uterine dehiscence
name some risk factors for uterine rupture
previous uterine surgery incl. caesarean, multiparity, use of prostaglandins, obstructed labour
what is vasa praevia
foetal vessels run over the cervix without protection
what is the risk associated with vasa praevia
vessels are prone to rupture during the rupture of the membranes - can result in foetal haemorrhage
name some risk factors for vasa praevia
assisted reproduction, abnormal placental conditions
classic presentation of vasa praevia
painless vaginal bleeding, rupture of membranes, foetal bradycardia
primary management for vasa praevia
elective caesarean prior to the rupture of membranes
what is chorioamnionitis
intra-amniotic infection that affects the membranes surrounding the foetus and the placenta
risk factors for chorioamnionitis
invasive pre-natal diagnostics, pre-term rupture of membranes, prolonged labour, meconium stained liquour
name some organisms commonly associated with chorioamnionitis
group B strep, e.coli, anaerobes
clinical presentation of chorioamnionitis
fever, abdo pain, cervical tenderness, smelly vaginal discharge
management of chorioamnionitis
hospital admission and delivery
what should be avoided in post partum for patients who had chorioamnionitis
post-partum intra-uterine contraception
