- OBSTETRIC EMERGENCIES - Flashcards
Discuss the mechanical and hormonal changes that occur during pregnancy
HORMONAL/ENDOCRINE (from placenta)
- increase in prgesterone, oestrrogen, HCG&HPL
- HPL increases insulin resistance
- prolactin for breastfeeding
- ocytocin for labour
- thyroxine demmand increases
- increased circulating blood glucose
MECHANICAL
- uterus increase in size
- expands from 60g-100g
- uterine blood flow increases to 600-1000ml per min at 35 to 40 weeks
- increases metabolic demmand
Discuss the assessment of a pregnant woman in the ED
- EDD‐? Matches uterine size
• Vital signs – particular focus on BP
• Pain‐ where, how long, what sort and severity
• Bleeding‐ how much, how long, where from?
• Other vaginal loss‐odour, colour, amount, when noted
• Oedema - drug and alcohol use
- domestic violence concerns
• Fetal heart rate and wellbeing‐ growth, movements +/‐
CTG (cardiotocograph)‐at appropriate gestation
Identify the components of an obstetric history
EDB (aka EDC, EDD) ‐If known • Current pregnancy issues / concerns • Previous pregnancies and birth mode - Gravida(no. pregnancies) & Para (no.of babies over 20 wks.) • Maternal co‐existing medical conditions • Pregnancy related disorders • Incidental pathologies • Mental illness in pregnancy • Domestic violence concerns • Drug and Alcohol issues
Outline the management of vaginal bleeding in the first trimester
- Hx, Gynae exam, Path, Psychosocial, Ultrasound
Outline the management of hypertension in pregnancy
. - Hypertension in pregnancy is defined as: >140/90
- escalate to the doctor/nurse in charge
- thorough assessment and monitor for signs of pre-eclampsia
- hypertension ‘becomes’ preeclampsia when:
- 20+ weeks
- hypertension +
- renal, haematological, liver, neurological involvement, pulmonary oedema, fetal growth restriction, placental abruption
OUtline the management of pre-eclampsia
Aims of management: •Control of hypertension •Seizure prophylaxis •Fluid balance management ‐ overload is a risk •Fetal surveillance •Birth‐ timing and mode
Severe hypertension >160/110
• Labetalol‐ push IV followed by infusion OR
• Hydralazine ‐ push IV followed by infusion
•? IV crystalloid bolus ‐ eg. 250‐500ml over 15‐20
mins
Prophylaxis with MAGNESIUM SULFATE (MgSO4) should
be considered when:
• There is neurological irritability
• For all women with severe preeclampsia during
labour, birth and immediate postpartum
Magnesium Sulphate 50% via peripheral IV‐ initial loading
dose followed by infusion
Observations: • Frequent maternal vital signs • hourly patellar reflexes • hourly urine output (IDC) • Consider cardiac monitoring & pulse oximetry • Continuous CTG to monitor baby
Define HELLP syndrome
Haemolysis Elevated Liver enzymes Low Platelets
A variant of severe pre‐eclampsia and eclampsia
Outline the management of an emergency vaginal delivery
- Assess Symptoms and if birth is imminent
– Mother may be shocked‐baby may have facial bruising
– Keep baby dry and warm
– Assess blood loss (normal is < 500ml)
– Assess perineal trauma
– Allow spontaneous birth of placenta and membranes unless
oxytocics available
• Syntocinon 10 units IM (commonly used) or 5 units IV
• Syntometrine ‐ 5 units Syntocinon & 0.5 mg Ergometrine
IM (contraindicated with hypertension)
• Ergometrine‐ 250 micrograms IM/IV (contraindicated with
hypertension)
Discuss the cardiovascular changes that occur during pregnancy
CARDIOVASCULAR
- blood volume increases 30-40%
- plasma increases 50%
- RBCs 18% haemodilutional effect
- Cardiac output - 30-50%
- clotting factors increase to prevent haemorrhage but increases risk of DVT and PE
- increase in resting HR
- supine hypotension later in pregnancy
- pregnant usterus partially occludes inferior vena cava
PLACENTAL CIRCULATION
- low pressure arteriovenous shunt.
Discuss the respiratory changes that occur during pregnancy
Increased
•Gaseous exchange
–Oxygen requirement by 20%
• Tidal volume ‐ 40%
• Alveolar expansion (reduced residual volume)
• Oedema / vascular congestion of airways
•Respiratory rate slightly ‐ still normal range
Decreased
• Lung expansion with late pregnancy
• Maternal PCO2 ‐ Aids elimination of fetal CO2
Discuss the GIT changes that occur during pregnancy
GIT‐ Hormonal influences • Smooth muscle effects (progesterone) – Slower gastric emptying – Constipation –Haemorrhoids – Relaxed cardiac sphincter‐ reflux –Nausea, vomiting – Sensitivities, cravings (Pica); Ptyalism;
Discuss the renal changes that occur during pregnancy
Renal • Stretched, dilated ureters • Bladder pressure • Increased glomerular filtration rate 50‐60% • Increased blood volume • Decreased renal threshold –slight glycosuria –slight proteinuria ‐ slight is normal • Increased risk UTI / Cystitis/ Pyelonephritis
Outline the causes and management of vaginal bleeding in the second and third trimester
- placenta praevia
- placental abruption
• Management‐according to severity
– Immediate resuscitation‐call for help
– Vital signs, history, gentle palpation
– Assess pain and uterine activity and tone
– CTG and scan to assess fetal condition
– Corticosteroids if <34 weeks gestation
– Consider MgSO4 for fetal neuroprotection if <30
weeks gestation
– Consider urgent delivery
– Analgesia, communication, documentation
Outline the management of vaginal bleeding post-partum
INITIALLY 88% of major PPH occur in first 4 hours • Some loss expected for up to 6 weeks • Rubra to Serosa to Alba SECONDARY PPH (24h‐12 weeks after birth) • Infection • Retained products of conception • Delayed involution • Return to bright red loss , clots • Can be sudden and catastrophic
• Management according to severity and cause
– Immediate and extensive resuscitation if required
– Vital signs, birth history
– Assess loss‐volume, colour, odour, clots
– Swabs for MC&S
– Assess for speculum exam
– Possible D&C required if retained products
– Antibiotic therapy
List the potential causes for bleeding in the first trimester
• ‘Normal’‐breakthrough bleeding • ‘Abortion’‐threatened,missed,inevitable, complete, incomplete • Ectopic pregnancy (Tx methotrexate) • Gestational trophoblastic disease • Cervical issues‐malignancy, friability, polyps • Vaginal trauma • Infections
