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RGU 2 > Obstetric Emergencies > Flashcards

Obstetric Emergencies Flashcards

1
Q

What are the 3 questions you should ask every pregnant mother who is bleeding?

A
  1. Pain?
  2. Leaking fluid?
  3. Feeling baby move?
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2
Q

How do we approach pregnant women who are bleeding w/o prenatal care?

A
  • Age
  • Ob Hx (Gs and Ps)
  • FDLMP
  • HPI
  • dDx
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3
Q

From what could 2nd or 3rd trimester bleeding occur?

A
  • 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
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4
Q

How do we evaluate a bleeding pregnant woman?

A
  • extent of bleeding
  • pain
  • estimated gestational age
  • FHTs
  • US
  • speculum exam
  • remember nothing in the vagina if bleeding or leaking
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5
Q

What are risks for previa?

A
  • multiparity
  • previous previa
  • increased age
  • uterine cutterage
  • cesarean section
  • uterine surgery
  • smoking
  • cocaine use
  • chronic HTN
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6
Q

*** What is PLACENTA PREVIA?

A
  • placenta is located over or near the internal os of cervix

* must go to C-SECTION (can’t delivery a placenta previa vaginally).

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7
Q

What are the 4 types of placenta previa?

A
  1. complete= completely covers internal os.
  2. partial= partially covers internal os.
  3. marginal= placenta just reaches internal os, but does not cover it.
  4. low-lying= extends into lower uterine segment, but does not reach internal os.
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8
Q

** What are the consequences of previa?

A
  • antepartum BLEEDING
  • hysterectomy
  • placenta ACCRETA
  • intrapartum/postpartum hemorrhage
  • blood TRANSFUSION
  • PRETERM DELIVERY
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9
Q

** Does PLACENTA PREVIA cause painful or painless vaginal bleeding?

A
  • painLESS. With dilation of internal os, placenta begins to separate and cause bleeding.
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10
Q

How do you treat PLACENTA PREVIA?

A
  • pelvic rest (no sex and nothing in the vagina).
  • consider monitoring as inpatient.
  • consider delivery if unstable.
  • NO VAGINAL EXAMS
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11
Q

** What are the 3 types of placental implantation abnormalities?

A
  1. placenta ACCRETA= placenta ATTACHES to the myometrium without penetrating it; MOST COMMON TYPE.
  2. placenta INCRETA= placenta penetrates INTO myometrium.
  3. placenta PERCRETA= placenta penetrates (PERFORATES) through myometrium and into uterine serosa and may attach to rectum or bladder.
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12
Q

What may a placenta implantation abnormality lead to?

A
  • massive HEMORRHAGE (3-5 L) resulting in DIC.

* most likely requires hysterectomy at time of delivery.

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13
Q

*** What is placental ABRUPTION?

A
  • premature separation of the placenta (can be partial or complete).
  • bleeding my be CONCEALED or APPARENT.
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14
Q

Where does bleeding occur in placental ABRUPTION?

A

between membranes and decidua basalis

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15
Q

What are some risk factors for placental ABRUPTION?

A
  • prior abruption
  • smoking
  • cocaine use
  • multifetal gestation
  • trauma (MVA)
  • thrombophilias
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16
Q

** How does placental ABRUPTION present?

A
  • PAINFUL vaginal bleeding
  • Rigid uterus
  • contractions
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17
Q

How do you evaluate for placental ABRUPTION?

A
  • rule out previa first with US.

- Labs: CBC, blood type and screen, PT/INR, PTT, fibrinogen.

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18
Q

What is the treatment for placental ABRUPTION?

A
  • 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
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19
Q

What are the complications of placental ABRUPTION?

A
  • maternal= anemia, hemorrhagic shock, DIC, death

- fetal= hypoxia, anemia, intrauterine growth restriction, death

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20
Q

*** What is VASA PREVIA?

A
  • the vessels run over or in close proximity to the cervical os instead of the cotyledons.
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21
Q

What should you NEVER do with VASA PREVIA?

A
  • AROM bc they will hemorrhage
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22
Q

By how much does plasma volume increase during pregnancy?

A
  • 40-50%
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23
Q

*** What are the 5 T causes post partum hemorrhage (PPH)?

A
  • 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.
24
Q

** What is UTERINE ATONY?

A
  • uterus does not contract properly after the baby comes out.
  • MOST COMMON reason for PPH.
25
Q

** What are the risk factors associated with the 4 T’s in PPH? (TEST QUESTION)

A
  1. Tone (uterine atony)= polyhydramnios, multiple gestation, macrosomia (big baby), placental previa, prolonged ROM.
  2. Tissue (retained products)= incomplete placenta at delivery, previous uterine scar, atonic uterus, high parity.
  3. Trauma (lacerations)= precipitous or operative delivery, deep engagement.
  4. Thrombin= coagulopathies, liver disease, DIC, hx of DVT or PE.
26
Q

How do we manage PPH?

A
  • ABCs
  • Examine pt (fundal massage).
  • IV access and fluid resuscitation.
27
Q

** What is the first step for treatment of PPH?

A
  • examine perineum, vagina, and cervix to look for lacerations (repair with absorbable suture).
  • explore uterine cavity for retained products of conception.
28
Q

** What is the 2nd step for treatment of PPH?

A
  • check uterine fundus to examine for uterine atony. If present, administer oxytocin, methergine, or prostaglandins (hemabate or misoprostol).
29
Q

** What is the 3rd step for treatment of PPH?

A
  • labs: CBC, coags (PT/INR, PTT, fibrinogen), type and cross.
  • administer uterotonics
30
Q

** What is the contraindication for METHERGINE (Ergot)? (TEST QUESTION)

A
  • HTN
31
Q

** What is the contraindication for PGF2a (Hemabate)? (TEST QUESTION)

A
  • ASTHMA
32
Q

** What can you do if uterotonics don’t work to stop PPH?

A
  • Bakri balloon
  • B-lynch suture
  • uterine artery ligation
  • hypogastric artery ligation
  • uterine artery embolization
  • hysterectomy (LAST RESORT)
33
Q

What is uterine dehiscence?

A
  • disruption and separation of uterine scar, but visceral peritoneum remains intact.
34
Q

What causes uterine rupture?

A
  • develops as a result of preexisting injury, anomaly, or trauma.
35
Q

What is the most common cause of uterine rupture?

A
  • separation of previous cesarean scar
36
Q

What are the consequences of uterine rupture?

A
  • 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%
37
Q

What is the treatment for uterine rupture?

A
  • immediate C-section
38
Q

What is an amniotic fluid embolism (AFE)?

A
  • 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 :(
39
Q

When is amniotic fluid embolism most often seen?

A
  • late stages of labor or immediately post partum.

- also after D&E

40
Q

How do we manage an amniotic fluid embolism?

A
  • cardiopulmonary resuscitation= Airway support, Breathing (O2), and Circulatory support.
  • blood products
41
Q

What are the signs of preeclampsia?

A
  • headache
  • visual changes (scotomata)
  • SOB
  • RUG pain (stretch of liver capsule)
  • swelling of upper extremities and face
  • hyperreflexia/clonus (flapping of foot)= late sign
42
Q

What are the criteria for preeclampsia?

A
  • BP greater than 140/90

- protein greater than 300 mg in 24 hour urine or protein:creatinine ratio

43
Q

What is the treatment for preeclampsia?

A
  • antihypertensives, IV magnesium sulfate (to prevent seizure)
  • definitive= DELIVERY
44
Q

What is eclampsia?

A

preeclampsia + seizures

45
Q

How do you treat eclampsia?

A
  • IV magnesium sulfate, antihypertensives, and immediate DELIVERY.
46
Q

What is HELLP syndrome?

A
  • Hemolysis, Elevated Liver enzymes, Low Platelets= manifestation of severe preeclampsia.
47
Q

What will a blood smear show in HELLP syndrome?

A
  • schistocytes
48
Q

*** What do we have to remember about shoulder dystocia?

A
  • UNPREDICTABLE

- UNPREVENTABLE

49
Q

What is shoulder dystocia?

A
  • failure of fetal shoulders to deliver spontaneously
50
Q

How do you diagnose shoulder dystocia?

A
  • turtle sign

- head delivers, but remainder does not

51
Q

What causes shoulder dystocia?

A
  • macrosomia (big baby)
  • large chest relative to BPD
  • absence of truncal rotation
52
Q

What are the maternal complications of shoulder dystocia?

A
  • hemorrhage

- 4th degree laceration

53
Q

What are the fetal complications of shoulder dystocia?

A
  • fracture humerus or clavicle
  • asphyxia/cord compression
  • brachial plexus injury (Erb’s/Klumpke’s palsy)
54
Q

** How long do you have to get the baby out before neonatal asphyxia sets in?

A

7 MINUTES!!!

55
Q

*** What do you do for shoulder dystocia?

A
  1. notify nurses and call for HELP.
  2. McROBERTS maneuver= push mom’s legs to chest.
  3. suprapubic pressure
  4. consider episiotomy for you to get your hands in.
  5. WOOD’S SCREW
  6. ROBIN’S I or II MANEUVER
  7. GASKIN= pt on all fours
  8. fracture of clavical
    - ZAVANELLI maneuver= push baby back in and do C-section. VERY BAD.
    - symphysiotomy
56
Q

** What 3 words must you remember when delivering a baby?

A

GENTLE DOWNWARD TRACTION

*never pull harder

57
Q

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…?

A

Tell the patient not to push

*NEVER apply fundal pressure.

RGU 2 (24 decks)

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