Obstetric emergencies Flashcards
What is the definition of Antepartum Haemorrhage?
bleeding from the genital tract after 24 weeks gestation
Before 24 weeks it is termed a threatened miscarriage.
What is the definition of PRIMARY Postpartum haemorrhage?
bleeding of more than 500mls from the genital tract within the first 24 hours after delivery
What is the definition of SECONDARY Postpartum haemorrhage?
excessive bleeding from the genital tract between 24 hours and 6 weeks post-partum
What’s the best way to maintain and optimise patient’s airway in obstetric emergencies?
LL position
What is the immediate management of a patient presenting with obstetric haemorrhage?
call for help – senior staff plus pairs of hands
ABC
facial oxygen; tilt bed
head down
site 2 large bore cannulae; give 500 mls crystalloid
send bloods for FBC, clotting screen, GXM 4 units blood
assign dedicated scribe
urinary catheter
check fetal condition
if necessary give O negative or group specific blood
assess cause of bleeding
What are some causes of antepartum haemorrhage?
placenta praaevia
placental abruption
local causes in the genital tract
cervical erosion
cervical polyp
trauma
unexplained
What are some causes of post-partum haemorrhage?
4 Ts
Tone - atonic uterus
Trauma - genital tract trauma
Tissue - retained products of conception
Thrombin - Abnormal clotting
If a patient has stopped fitting, do you still give them anti-convulsants?
Yes - want to prevent further fits or status epilepticus
How would you manage someone with antepartum haemorrhage?
DO NOT DO A VAGINAL EXAMINATION UNTIL AFTER A SCAN
Stabilise patient first
• Assess for painful v painless bleeding
- Establish placental site (USS)
- Decide if delivery is necessary - likely to be by Caesarean section by experienced obstetrician with experienced anaesthetist
What is the one real contraindication to giving fluids in obstetric emergencies?
hypertensive problem eg. eclampsia/pre-eclampsia
What drug do you NOT given EVER in pregnancy, even in emergencies? What do you give instead?
warfarin
Heparin
How would you manage a postpartum haemorrhage caused by retained placenta?
Resuscitate patient (A-E)
manual removal under GA or spinal (depending on condition)
How would you manage a postpartum haemorrhage caused by atonic uterus?
give series of drugs to make uterus contract:
Ergometrine IV bolus
Syntocinon infusion
Still no response = prostaglandins
May need examination under anaesthesia +/- laparotomy
Repair genital tract trauma - repair
How would you manage a secondary PPH?
Causes include retained products +/- endometritis
Check for evidence of infection
Require 24 hours ABX
USS
Evacuation
Why is PE more likely in pregnancy/labour?
Pregnancy = pro-thrombotic state
Large pelvic mass (foetus)
Reduce mobility
Prolonged labour
Dehydration
Operative delivery
What are some signs of PE to be mindful of?
Asymptomatic
Chest pain - pleuritic SOB Hypotension Tachycardia Reduced air entry Reduced O2 sats Collapse
How would you manage a PE in a pregnant woman?
ABC
Investigations: ABG
CXR
ECG
VQ scan
Anti-coagulate while waiting for results (if highly likely)
Anti-coagulate (heparin) during remainder of pregnancy and postpartum
DO NOT USE WARFARIN
When is uterine inversion more likely?
grand multips
incorrect management of third stage of pregnancy
How might uterine inversion present?
Vaso-vagal shock (pale, clammy, hypotensive, bradycardia)
Mass at introitus
What are some complications of uterine inversion?
Haemorrhage
Clotting abnormalities
Renal dysfunction
How would you manage uterine inversion?
Uterine is replaced = shock correction
O’Sullivan’s method - hydrostatic technique of inversion
What is eclampsia?
Grand mal convulsion
Usually follows from pre-eclampsia
Repeated fits common
What is pre-eclampsia?
Proteinuria pregnancy-induced hypertension
Why is eclampsia an obstetric emergency?
High maternal and perinatal mortality
How would you manage eclampsia?
ABC
Diazepam or magnesium sulphate to stop fits
Magnesium sulphate infusion - prevent further fits
Stabilise BP and maternal condition. Labetalol, followed by nifedipine
Deliver baby
What is the first line treatment for managing BP in eclampsia/pre-eclampsia?
Labetalol
Followed by nifedipine
What aren’t anti-convulsants given prophylactically in pre-eclampsia?
No proven value
What can be a cause of septic shock antenatally?
Maternal bacterial or viral illness
Midtrimester rupture of membranes
How is mid trimester rupture of membranes managed?
Conservatively
What is the most common organism causing post-natal septic shock?
Strep A
What is the management for a pregnant/post-partum woman with septic shock?
A-E
IV broad spectrum ABX: cafotaxime, metronidazole +/- gentamicin
Uterine evacuation later if retained products of conception is present/cause
How might amniotic fluid embolus present? How is diagnosed?
Collapse
DIC
unaccountable bleeding
Diagnosis: exclusion or post-mortem
How would you manage someone with amniotic fluid embolus?
Supportive treatment (A-E)
GET EXPERT HELP
Early transfer to ITU (likely to need renal and inotropic support)
Correct clotting
What are some risk factors for uterine rupture?
multigravida patients
One previous CS
Multiparous women on uterine stimulants
What are symptoms of uterine rupture?
Fresh vaginal bleeding
Haematuria
Fetal distress
Constant, severe abdo pain which breaks through epidural
Shock
How would you manage someone with uterine rupture?
ABC
IV access and basic resuscitation
Immediate laparotomy to salvage baby - repair damage or hysterectomy
What is an obstetric emergency?
A situation where there is sudden collapse of the patient either antenatally or in the first 6 weeks post-partum.
What are common causes of emergency?
Antepartum or post-partum haemorrhage
pulmonary embolus
eclampsia
myocardial infarction - uncommon but increasing due to increased maternal age
uterine rupture
uterine inversion
septic shock – rare but increasing
amniotic fluid embolus - exceedingly rare
What are key things to remember in obstetric emergencies?
CALL FOR HELP EARLY
A-E FOR WOMAN BEFORE CONSIDERING BABY
If a pregnant or postpartum woman collapses and you are unsure of cause, who should you call?
anaesthetist
obstetrician
