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GOSH > Obstetric emergencies > Flashcards

Obstetric emergencies Flashcards

1
Q

What is the definition of Antepartum Haemorrhage?

A

bleeding from the genital tract after 24 weeks gestation

Before 24 weeks it is termed a threatened miscarriage.

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2
Q

What is the definition of PRIMARY Postpartum haemorrhage?

A

bleeding of more than 500mls from the genital tract within the first 24 hours after delivery

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3
Q

What is the definition of SECONDARY Postpartum haemorrhage?

A

excessive bleeding from the genital tract between 24 hours and 6 weeks post-partum

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4
Q

What’s the best way to maintain and optimise patient’s airway in obstetric emergencies?

A

LL position

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5
Q

What is the immediate management of a patient presenting with obstetric haemorrhage?

A

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

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6
Q

What are some causes of antepartum haemorrhage?

A

placenta praaevia

placental abruption

local causes in the genital tract
cervical erosion
cervical polyp
trauma

unexplained

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7
Q

What are some causes of post-partum haemorrhage?

A

4 Ts

Tone - atonic uterus

Trauma - genital tract trauma

Tissue - retained products of conception

Thrombin - Abnormal clotting

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8
Q

If a patient has stopped fitting, do you still give them anti-convulsants?

A

Yes - want to prevent further fits or status epilepticus

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9
Q

How would you manage someone with antepartum haemorrhage?

A

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
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10
Q

What is the one real contraindication to giving fluids in obstetric emergencies?

A

hypertensive problem eg. eclampsia/pre-eclampsia

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11
Q

What drug do you NOT given EVER in pregnancy, even in emergencies? What do you give instead?

A

warfarin

Heparin

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12
Q

How would you manage a postpartum haemorrhage caused by retained placenta?

A

Resuscitate patient (A-E)

manual removal under GA or spinal (depending on condition)

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13
Q

How would you manage a postpartum haemorrhage caused by atonic uterus?

A

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

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14
Q

How would you manage a secondary PPH?

A

Causes include retained products +/- endometritis

Check for evidence of infection

Require 24 hours ABX

USS

Evacuation

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15
Q

Why is PE more likely in pregnancy/labour?

A

Pregnancy = pro-thrombotic state

Large pelvic mass (foetus)

Reduce mobility

Prolonged labour

Dehydration

Operative delivery

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16
Q

What are some signs of PE to be mindful of?

A

Asymptomatic

Chest pain - pleuritic
SOB
Hypotension
Tachycardia
Reduced air entry
Reduced O2 sats
Collapse
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17
Q

How would you manage a PE in a pregnant woman?

A

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

18
Q

When is uterine inversion more likely?

A

grand multips

incorrect management of third stage of pregnancy

19
Q

How might uterine inversion present?

A

Vaso-vagal shock (pale, clammy, hypotensive, bradycardia)

Mass at introitus

20
Q

What are some complications of uterine inversion?

A

Haemorrhage
Clotting abnormalities
Renal dysfunction

21
Q

How would you manage uterine inversion?

A

Uterine is replaced = shock correction

O’Sullivan’s method - hydrostatic technique of inversion

22
Q

What is eclampsia?

A

Grand mal convulsion
Usually follows from pre-eclampsia

Repeated fits common

23
Q

What is pre-eclampsia?

A

Proteinuria pregnancy-induced hypertension

24
Q

Why is eclampsia an obstetric emergency?

A

High maternal and perinatal mortality

25
Q

How would you manage eclampsia?

A

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

26
Q

What is the first line treatment for managing BP in eclampsia/pre-eclampsia?

A

Labetalol

Followed by nifedipine

27
Q

What aren’t anti-convulsants given prophylactically in pre-eclampsia?

A

No proven value

28
Q

What can be a cause of septic shock antenatally?

A

Maternal bacterial or viral illness

Midtrimester rupture of membranes

29
Q

How is mid trimester rupture of membranes managed?

A

Conservatively

30
Q

What is the most common organism causing post-natal septic shock?

A

Strep A

31
Q

What is the management for a pregnant/post-partum woman with septic shock?

A

A-E

IV broad spectrum ABX: cafotaxime, metronidazole +/- gentamicin

Uterine evacuation later if retained products of conception is present/cause

32
Q

How might amniotic fluid embolus present? How is diagnosed?

A

Collapse
DIC
unaccountable bleeding

Diagnosis: exclusion or post-mortem

33
Q

How would you manage someone with amniotic fluid embolus?

A

Supportive treatment (A-E)

GET EXPERT HELP

Early transfer to ITU (likely to need renal and inotropic support)

Correct clotting

34
Q

What are some risk factors for uterine rupture?

A

multigravida patients

One previous CS

Multiparous women on uterine stimulants

35
Q

What are symptoms of uterine rupture?

A

Fresh vaginal bleeding

Haematuria

Fetal distress

Constant, severe abdo pain which breaks through epidural

Shock

36
Q

How would you manage someone with uterine rupture?

A

ABC

IV access and basic resuscitation

Immediate laparotomy to salvage baby - repair damage or hysterectomy

37
Q

What is an obstetric emergency?

A

A situation where there is sudden collapse of the patient either antenatally or in the first 6 weeks post-partum.

38
Q

What are common causes of emergency?

A

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

39
Q

What are key things to remember in obstetric emergencies?

A

CALL FOR HELP EARLY

A-E FOR WOMAN BEFORE CONSIDERING BABY

40
Q

If a pregnant or postpartum woman collapses and you are unsure of cause, who should you call?

A

anaesthetist

obstetrician

GOSH (33 decks)

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