Obstetric Emergencies Flashcards
What are the 3 questions you should ask every pregnant mother who is bleeding?
- Pain?
- Leaking fluid?
- Feeling baby move?
How do we approach pregnant women who are bleeding w/o prenatal care?
- Age
- Ob Hx (Gs and Ps)
- FDLMP
- HPI
- dDx
From what could 2nd or 3rd trimester bleeding occur?
- bloody show= associated with cervical insufficiency or labor.
- PLACENTA PREVIA= blocking the cervix.
- ABRUPTIO PLACNTA= placenta pulls off wall of uterus.
- VASA PREVIA
- UTERINE RUPTURE
How do we evaluate a bleeding pregnant woman?
- extent of bleeding
- pain
- estimated gestational age
- FHTs
- US
- speculum exam
- remember nothing in the vagina if bleeding or leaking
What are risks for previa?
- multiparity
- previous previa
- increased age
- uterine cutterage
- cesarean section
- uterine surgery
- smoking
- cocaine use
- chronic HTN
*** What is PLACENTA PREVIA?
- placenta is located over or near the internal os of cervix
* must go to C-SECTION (can’t delivery a placenta previa vaginally).
What are the 4 types of placenta previa?
- complete= completely covers internal os.
- partial= partially covers internal os.
- marginal= placenta just reaches internal os, but does not cover it.
- low-lying= extends into lower uterine segment, but does not reach internal os.
** What are the consequences of previa?
- antepartum BLEEDING
- hysterectomy
- placenta ACCRETA
- intrapartum/postpartum hemorrhage
- blood TRANSFUSION
- PRETERM DELIVERY
** Does PLACENTA PREVIA cause painful or painless vaginal bleeding?
- painLESS. With dilation of internal os, placenta begins to separate and cause bleeding.
How do you treat PLACENTA PREVIA?
- pelvic rest (no sex and nothing in the vagina).
- consider monitoring as inpatient.
- consider delivery if unstable.
- NO VAGINAL EXAMS
** What are the 3 types of placental implantation abnormalities?
- placenta ACCRETA= placenta ATTACHES to the myometrium without penetrating it; MOST COMMON TYPE.
- placenta INCRETA= placenta penetrates INTO myometrium.
- placenta PERCRETA= placenta penetrates (PERFORATES) through myometrium and into uterine serosa and may attach to rectum or bladder.
What may a placenta implantation abnormality lead to?
- massive HEMORRHAGE (3-5 L) resulting in DIC.
* most likely requires hysterectomy at time of delivery.
*** What is placental ABRUPTION?
- premature separation of the placenta (can be partial or complete).
- bleeding my be CONCEALED or APPARENT.
Where does bleeding occur in placental ABRUPTION?
between membranes and decidua basalis
What are some risk factors for placental ABRUPTION?
- prior abruption
- smoking
- cocaine use
- multifetal gestation
- trauma (MVA)
- thrombophilias
** How does placental ABRUPTION present?
- PAINFUL vaginal bleeding
- Rigid uterus
- contractions
How do you evaluate for placental ABRUPTION?
- rule out previa first with US.
- Labs: CBC, blood type and screen, PT/INR, PTT, fibrinogen.
What is the treatment for placental ABRUPTION?
- depends on maternal/fetal condition. If mom or baby is in bad shape, go right to OR to stabilize and then deliver baby.
- IV fluids
- O2
- transfusion
What are the complications of placental ABRUPTION?
- maternal= anemia, hemorrhagic shock, DIC, death
- fetal= hypoxia, anemia, intrauterine growth restriction, death
*** What is VASA PREVIA?
- the vessels run over or in close proximity to the cervical os instead of the cotyledons.
What should you NEVER do with VASA PREVIA?
- AROM bc they will hemorrhage
By how much does plasma volume increase during pregnancy?
- 40-50%
*** What are the 5 T causes post partum hemorrhage (PPH)?
- Tone (UTERINE ATONY); MOST COMMON
- Tissue (RETAINED PRODUCTS)
- Trauma (LACRATIONS)
- Thrombin (coagulopathies; von willebrand’s disease)
- Traction (uterine inversion)
- PPH= at 500 mL of blood loss after vaginal delivery or 1000 mL after C-section.
** What is UTERINE ATONY?
- uterus does not contract properly after the baby comes out.
- MOST COMMON reason for PPH.
** What are the risk factors associated with the 4 T’s in PPH? (TEST QUESTION)
- Tone (uterine atony)= polyhydramnios, multiple gestation, macrosomia (big baby), placental previa, prolonged ROM.
- Tissue (retained products)= incomplete placenta at delivery, previous uterine scar, atonic uterus, high parity.
- Trauma (lacerations)= precipitous or operative delivery, deep engagement.
- Thrombin= coagulopathies, liver disease, DIC, hx of DVT or PE.
How do we manage PPH?
- ABCs
- Examine pt (fundal massage).
- IV access and fluid resuscitation.
** What is the first step for treatment of PPH?
- examine perineum, vagina, and cervix to look for lacerations (repair with absorbable suture).
- explore uterine cavity for retained products of conception.
** What is the 2nd step for treatment of PPH?
- check uterine fundus to examine for uterine atony. If present, administer oxytocin, methergine, or prostaglandins (hemabate or misoprostol).
** What is the 3rd step for treatment of PPH?
- labs: CBC, coags (PT/INR, PTT, fibrinogen), type and cross.
- administer uterotonics
** What is the contraindication for METHERGINE (Ergot)? (TEST QUESTION)
- HTN
** What is the contraindication for PGF2a (Hemabate)? (TEST QUESTION)
- ASTHMA
** What can you do if uterotonics don’t work to stop PPH?
- Bakri balloon
- B-lynch suture
- uterine artery ligation
- hypogastric artery ligation
- uterine artery embolization
- hysterectomy (LAST RESORT)
What is uterine dehiscence?
- disruption and separation of uterine scar, but visceral peritoneum remains intact.
What causes uterine rupture?
- develops as a result of preexisting injury, anomaly, or trauma.
What is the most common cause of uterine rupture?
- separation of previous cesarean scar
What are the consequences of uterine rupture?
- protrusion or expulsion of fetus or placenta into abdominal cavity causing fetal distress (may see variable decelerations on EFM).
- significant uterine bleeding
- fetal mortality is 7%
What is the treatment for uterine rupture?
- immediate C-section
What is an amniotic fluid embolism (AFE)?
- amniotic fluid enters the maternal circulation leading to anaphylactic reaction, DIC, and sudden cardiac collapse.
- RAPID progression and may begin with gasps, seizures, or hypotension.
- dismal prognosis :(
When is amniotic fluid embolism most often seen?
- late stages of labor or immediately post partum.
- also after D&E
How do we manage an amniotic fluid embolism?
- cardiopulmonary resuscitation= Airway support, Breathing (O2), and Circulatory support.
- blood products
What are the signs of preeclampsia?
- headache
- visual changes (scotomata)
- SOB
- RUG pain (stretch of liver capsule)
- swelling of upper extremities and face
- hyperreflexia/clonus (flapping of foot)= late sign
What are the criteria for preeclampsia?
- BP greater than 140/90
- protein greater than 300 mg in 24 hour urine or protein:creatinine ratio
What is the treatment for preeclampsia?
- antihypertensives, IV magnesium sulfate (to prevent seizure)
- definitive= DELIVERY
What is eclampsia?
preeclampsia + seizures
How do you treat eclampsia?
- IV magnesium sulfate, antihypertensives, and immediate DELIVERY.
What is HELLP syndrome?
- Hemolysis, Elevated Liver enzymes, Low Platelets= manifestation of severe preeclampsia.
What will a blood smear show in HELLP syndrome?
- schistocytes
*** What do we have to remember about shoulder dystocia?
- UNPREDICTABLE
- UNPREVENTABLE
What is shoulder dystocia?
- failure of fetal shoulders to deliver spontaneously
How do you diagnose shoulder dystocia?
- turtle sign
- head delivers, but remainder does not
What causes shoulder dystocia?
- macrosomia (big baby)
- large chest relative to BPD
- absence of truncal rotation
What are the maternal complications of shoulder dystocia?
- hemorrhage
- 4th degree laceration
What are the fetal complications of shoulder dystocia?
- fracture humerus or clavicle
- asphyxia/cord compression
- brachial plexus injury (Erb’s/Klumpke’s palsy)
** How long do you have to get the baby out before neonatal asphyxia sets in?
7 MINUTES!!!
*** What do you do for shoulder dystocia?
- notify nurses and call for HELP.
- McROBERTS maneuver= push mom’s legs to chest.
- suprapubic pressure
- consider episiotomy for you to get your hands in.
- WOOD’S SCREW
- ROBIN’S I or II MANEUVER
- GASKIN= pt on all fours
- fracture of clavical
- ZAVANELLI maneuver= push baby back in and do C-section. VERY BAD.
- symphysiotomy
** What 3 words must you remember when delivering a baby?
GENTLE DOWNWARD TRACTION
*never pull harder
A 25 y/o healthy woman has a normal labor and a spontaneous delivery of the fetal head. On expulsion of the head, a shoulder dystocia is recognized. Before instituting maneuvers, the next step is to…?
Tell the patient not to push
*NEVER apply fundal pressure.
