Obstetric emergencies Flashcards by Lauren O'Loughlin

shoulder dystocia complicatons

fetal
asphyxia, bracial plexus palsey, fracture of the clavicle, intracranial hemorrhage cervical spine injury, fetal death
maternal PPH 3rd and fourth degree tears

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risk factors for shoulder dystocia

previous hx, fetal malformation, BMI greater than 30
DM, post-term preg
intrapartum
lack of progress in the fist or second stage of labour, and instrumental delivery.

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normal mechanism of shoulder dystocia

the anterior shoulder is impacted against the pubic symphysis often due to failure of he internal rotation of he shoulders.

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management of shoulder dystocia acronym

HELPERR

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management for shoulder dystocia

H- call for help
E- episiotomy- more room for internal procedures
L- legs to Mcroberts postion (hyperflexed at hips and thighs and thighs abducted and externally rotated).
P-suprapubic pressure applied to the posterior aspect of the anterior shoulder
try rocking motion.
E- enter the pelvis for internal maneuvers rubin (pressure on the post. aspect of anterior shoulder to try and rote to oblique angle)
woodscrew (pressure on the anterior aspect of the posterior shoulder)
reverse woodscrew (ant ant shoulder and post post shoulder)
R- relsease the posterior arm by flexing the elbow and sweeping arm aginst ches and face
R-roll over on all four to aim deliery (gaskin manouver)

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Things to not do in shoulder dystocia

Don’t exert head traction, keep time, PPH anticipated give 40IU oxytocin
documentation!!!!!!!! educate

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cord prolapse risk factors

abnormal lie or presentation
multipregancy 
polyhydramnios 
prematurity 
high head
long umblical cord

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management of cord prolapse

fetus delivery ASAP via instrumenta or CS
knee to chest postion
fill the bladder with 500ml saline
hand in the vagina o push up presenting part
prevent cord spasm
CALL neonatal team

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management of cord prolapse pharmacologically.

tocolytics (terbutaline 250microg) stop uterine contractions may cause PPH due to uterine atony.

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definition of hemorrhage

loss of 30-49% of blood (2 L)

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causes of massive heamorrhage

acute hypovolemia
cardiovascular decompensation
DIC
iatoenic
pulmonary oedema
pre-eclampsia
trnasfusion rxn
retained dead fetus

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causes of antepartum hemorrhage

Placenta- abrupion, praevia
amniotic sac- severe chorioamnioitis or sepsis
general- pre-eclampsia
retained dead fetus

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cause of intrapartum heamorrhage

placenta- abruption, accreta/percreta
uterus- rupture
systemic- amnioic fluid embolus
obstetric- CS

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primary postpartum causes of heamorrhage

tone- atonic uterus
thrombus- coagulopathy
trauma- genital tract
tissue- retained products of conception

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secondary postpartum causes of hemorrhage

infection-

gestational trophoblastic disease

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consequences of losing a litre of blood

acute hypovolemia, shock, loss of clotting factors, DIC, hypoxia, multiorgan failure

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what is DIC?

due t depletion of coagulation factors and replacement fluids which dilate the ramaining factors. If suspected use fresh frozen plasma as it contains all the coagulation factors.

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what is the first sign of maternal heamorrhage?

tachycardia

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management of heamorrhage: resus

call for help- ABC
position: left lateral tilt 
insert two large bore Iv cannula 
FBC, crossmatch, UE, LFT, coag 
start crystalloids 
blood transfuse with O- blood until cross match 
catheterize
replace clotting factors

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management of heamorrhage: medical

main principles

empty the uterus
treat the atony
repair the genital tract trauma

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PPH empty the uterus

deliver the fetus

remove the placenta

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PPH- treat uterine atony

massage-
give drugs- oxytocin 40IU
ergometrine 500microg
misoprostol- 800-1000 micrg
caboprost 250 micg
apply bimanual compression

PPH- surgical

repair any obvious tears, laprotomy bleeding from the placenta bed, rusch balloon, uterus atonic b-lynch procedure
internal illiac artery ligation
uterine artery embolization
hysterectomy

venous thromboembolism risk factors

prior VTE
congenital thrombophillia
acquired trombo diseas: SLE antiphospholipid syndrome 
greater than 35
obese 
varicose veins
sickel cell
inflammaory disorders 
new onset RF
ovarian hyperstimulation syndrome
hyperemesis 
mid caval instrumental delivery 
blood loss

preg- related RF
venous stasis in the lower legs (hospitalization)
changes in the coagulation system increase in procoagulation factors

preventing thromboemboli non-pharm

non pharm- aviod immbolisation and dehydration

preventing thromboemboli pharm

low molecular weight heparin

mgx previous provoked VTE

postpartum prophylaxis 6 wk

mgx prev. unprovoked VTE or medical coagulopathy

antnatal and postnatal greater than 6 wks

signs of VTE

DVT- calf sweeling, leg pain, enderness, fever, eryhema increased skin temp and oedema, lower abdo pain, elevated WBC PE- dyspnoea, focal signs in the chest, raised JVP, heamoptysis, chest pain, collapse

investigations for VTE -bloods

thrombophillia screen FBC, UE, LFT coag

investigations VTE- imaging

``` US, contrast venography, MRI if suspect PE (s1q3t3) ECG, CXR, ABG V:P lung scan CT MRI bilat.duplex scan ```

mgx for VTE

anticoagulation- LMWH- enoxaparin 1mg/kg bd | measure after three hours to ensure aniXa level 0.35-.7 IU/ml

warfarin

safe in breastfeeding

complications of LWMH

epidural heamatoma therefore- aviod until 12 after last dose.

placenta accreta

placental villi are attached to the myometrium

placenta percreta

villi pass through the whole myometrium potentially involving bladder and bowel.

pre-eclampsia characterized by

hypertension and protienuria thought to arise from the placenta.

RF for pre-eclampsia

``` 7x more likely if had before age old (40) or young family history obsetity first baby multiple preg fetal hydrops and hydatifrom mole medical conditions- renal disease and antiphos. ```

blood tests in pre-eclampsia

low pregnancy plasma protien A raised uric acid low platelets and high HB VEGF and placental growth factor.

imaging pre eclampsia

US doppler uterine artery

prevention pre-eclampsia

75 mg aspirin before 16 weeks

features of pre-eclampsia

headache, visual distrubance, RUQ pain, nausea and vomiting rapid oedema ``` signs - HTN greater than 140/90 protienuria (greater than 300 in 24 hr) liver involvement confusion hyperreflexia or clonus uterine tenderness fetal growth restriction ```

lab investigation in pre-eclampsia

coag profile - prolonged PT and APTT biochem- increased urate,increased urea and creatinine and increased transaminase, increased LDH (heamolysis marker), increased protienuria.

management of pre-eclampsia outpatient

outpatient- BP less than 160/110 and no or only 1+ protienuria warn red flag symptoms 1-2 wk review blood and urine

mgx pre-eclampsia inpatient

bp over 160/110 and sig. protienuria and admit 4hrly bp, 24 urine collection, daily check urine, daily fetal assessment, regular blood test regular US scan 2wk growth and 2 times wk doppler.

severe pre-eclampsia

bp over 160/110 and protienuria 2+

indications for immediate delivery with pre-eclampsia

worsening trombocytopenia or cogulopathy liver or renal function epigastric pain with abnormal LFTs HELPP syndrome or eclampsia abnormal CTG or reversed end diastolic flow.

severe pre-eclampsia mgx

BP stabilized with anti hypertensives- nifedipine 10 mg 30 min apart if after 2-3 doses start and labetalol take bloods for FBC, U&E, LFTs, and clotting profile strict fluid balance US of fetus evidence of IUGR if less than 34 weeks give steroids.

HELLP syndrome

eclampsia and heamolysis, elevated liver enzymes and low platelets.

eclampsia definition

occurrence of tonic-clonic seizure in associated with a diagnosis of pre-eclampsia.

symptoms of eclampsia

epigastric or RUQ pain and nausea and vomiting, tea colored urine

mgx of eclampsia

ABC and call for senior help MgSo4 a loading dose of 4g should be given over 10 minutes. followed by 1g/24 hr coninued fits can give 2g bolus. repeated seizures use diazapam. check pulse, bp, respiration and ox sats. check reflxes every hour for Mg toxicity (knee reflexesbut use biceps if epidural insitu. STOP infusion if renal damage (olgiouria) or raised creatinine. anihypertensives- nifedipine or labetalol. fluid resitrict if risk of pulmonary oedema

Mg toxicity

confusion, loss of reflexes, resp depression. and hypotension if toxic give 1g calcium gluconate over 10 minutes

eclampsia mgx during delivery

3rd stage managed with oxytocin rather than syntometrine.