Obstetric emergencies: Flashcards
List the 4 types of Maternal Obstetric Emergencies:
- Antepartum Haemorrhage
- Postpartum Haemorrhage
- Pre-eclampsia
- Venous thromboembolism
List the 3 types of foetal Obstetric Emergencies:
- Foetal distress
- Cord prolapse
- Shoulder dystocia
What is the definition of Antepartum Haemorrhage?
Bleeding from anywhere in the genital tract after 24th week of pregnancy (uterus, cervix, vagina, vulva).
(3-5% of pregnancies)
List 4 causes of antepartum haemorrhage:
- Low lying placenta/placenta praevia (classically painless)
- Placenta accreta
- vasa praevia
- Minor/major abruption (classically painful)
What is placenta accreta?
When the placenta growth too deeply into the uterine wall. When the placenta detaches during childbirth, in placenta accreta, part of the placenta may remain attached which can lead to severe blood loss after delivery (postpartum Haemorrhage)
What is vasa praevia?
It is when blood vessels run across or near to the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.
Can occur when there is a secondary lobe to the placenta (i.e. one on either side of the cervix).
What is placental abruption?
When the placenta separates from the uterus before childbirth. This commonly occurs around the 25th week of pregnancy.
When is placenta praevia/low lying placenta picked up?
At 20 week scan
How far from the cervical OS must the placenta be? What occurs if it is not? What occurs if it is at least that distance away?
> 25mm.
Minor praevia = repeat scan at 36 weeks.
Major praevia = repeat scan at 32 weeks
If the placenta remains <25mm away from cervical OS then elective caesarean section should be performed.
Outline the management of a low lying placenta:
- Advise symptoms to watch for
- Outpatient management if asymptomatic, inpatient is recurrent bleeds
- Remember anti-D if Rhesus Negative
- Elective Caesarean at 38-39 weeks
What O/E should be performed in those with bleeding placenta praevia?
1) 15min Maternal obs:
- BP, Pulse, temp, O2 sats, urine output
2) Examination:
- General and abdo
- Vaginal (avoid digital examination)
3) Foetal monitoring - CTG +/- arrange delivery
4) Steroids <34 weeks gestation
When should steroids be given during pregnancy/what situation?
If the mother is to deliver before 34 weeks
Outline the protocols you would complete in those with a major bleed:
1) Resuscitate ABC
2) Two 14/16 G cannulas in antecubital fossa
3) Crystalloid (IV saline)
4) X-match 6 units
5) FBC, U&E, LFTs, Clotting
6) Consultant Obs + Anaesthetist
Outline the difference between placental accreta, increta and percreta:
Accreta - placental invasion deeper into the endometrium/little bit of myometrium
Increta - placental invasion in the myometrium
Percreta - placental invasion through the myometrium + serosa.
Who and when would you typically look out for low lying placenta (LLP)?
At 20 week scan in those with a previous section - look for anterior LLP.
What Ix would you perform and subsequent management in someone with placental accreta?
Ix: - USS - loss of definition between wall of uterus + abnormal vasculature - MRI Rx: - Elective C-section at 36-37 weeks
Identify 2 risks of placenta accreta:
- Haemorrhage
- Caesarean hysterectomy
In those undergoing C-sections for placenta accreta, what must you warn the patient about as a complication?
May have to undergo a hysterectomy within the same procedure.
Give 5 risk factors for placental abruption:
- Previous abruption
- Hypertension
- Multiple pregnancy
- Trauma - aminodrainage due to domestic violence
- Vasoconstrictor drugs e.g. cocaine and crack
Give 5 complications of antepartum haemorrhage:
- Premature labour/delivery
- Blood transfusion
- Acute tubular necrosis (due to hypo-perfusion of kidneys)
- DIC
- Foetal morbidity (hypoxia) and mortality
Define post partum haemorrhage:
Primary - within 24hours of delivery, blood loss >500mls
Secondary - After 24hours and up tp 12 weeks post delivery
Minor - 500-100mls
Major - >1000mls
(it is a major cause of maternal death worldwide)
List 4 causes of Postpartum haemorrhage:
The four T’s:
- Tissue - Ensure placenta is complete
- Tone - ensure uterus contracted
- Trauma - look for tears and repair
- Thrombin - check clotting
Give 4 drugs that aid with uterine contraction to Rx postpartum haemorrhage:
- Syntometrine (synthetic oxytocin)
- Syntocinon (Synthetic oxytocin)
- Ergometrine
- Haemobate (also used for abortions)
- Misoprostol (also used for abortions)
Give 5 risk factors for postpartum haemorrhage:
- Big baby
- Nulliparity + grand multiparity
- Precipitate/prolonged labour
- Maternal pyrexia
- Operative delivery
What is given to women postpartum fro prophylaxis against venous thromboembolism?
LMW heparin
What is the leading direct cause of maternal death?
Pulmonary embolism
highest risk is in the postpartum period
List 5 risk factors for thromboembolism:
- Previous VTE
- Inherited and acquired thrombophilia
- Age >35
- BMI >30
- Smoking
- Parity >4
What is the leading cause of maternal mortality in the UK? What can be done to help prevent this?
Sepsis.
Advise all women to be immunised against seasonal flu.
List 5 risk factors for maternal sepsis:
- Obesity
- Diabetes
- Imapired immunity/immunosuppression
- Anaemia
- Vaginal discharge
- History of pelvic infection
- History of group B streptococcal infection
- Amniocentesis and other invasive procedures
- Cervical cerclage
- Prolonged spontaneous rupture of membranes
- GAS (group A streptococcus) infection in close contacts/family members
Give 5 signs/symptoms of maternal sepsis:
(just normal sepsis S/S):
- Pyrexia
- Hypothermia
- Tachycardia
- Tachypnoea
- Hypoxia
- Hypotension
- Oliguria
- Impaired consciousness
- Failure to respond to treatment
What does MEOWS stand for?
Modified Early Obstetric Warning Score
What is Sepsis Six?
1) Take ABG and give high flow O2
2) Take blood cultures (and everything else)
3) Commence IV antibiotics
4) Commence IV fluid resuscitation
5) Take blood for Hb, lactate (+glucose)
6) Measure hourly urine output
In foetal compromise, what signs should prompt delivery?
Prolonged bradycardia or foetal acidosis on scalp sample
In foetal compromise what should typically be done prior to attempting delivery?
Stabilise the mother if maternal compromise has lead to foetal compromise
Wha is cord prolapse and what can it cause?
Occurs when cord is presenting out of cervix after membrane rupture.
Exposure of the cord leads to vasospasm = significant risk to foetal morbidity and mortality from hypoxia.
Give 3 risk factors for cord prolapse:
- Premature rupture of membranes
- Polyhydramnios
- Long umbilical cord
- Foetal malpresentation
Outline the management of a cord prolapse:
- Call 999 (if not in hospital)
- Infuse fluid into bladder via catheter if at home
- Trendelenburg (?lying flat) with knees and hips up
- Constant foetal monitoring
- Alleviate pressure on cord (push presenting part off cord)
- Transfer to theatre and prepare for delivery
Define shoulder dystocia:
Shoulder dystocia is failure for the anterior should to pass under the symphysis pubis after delivery of the foetal head that requires specific manoeuvres to facilitate delivery.
What is shoulder dystocia an example of?
A intrapartum emergency.
What risks can shoulder dystocia cause?
- High risk of foetal and maternal morbidity
- Can cause foetal mortality
List 4 risk factors for shoulder dystocia;
- Big baby (macrosomia)
- Maternal diabetes
- Disproportion between mother and foetus (small mum, big baby)
- Post maturity and induction of labour
- Maternal obesity
- Instrumental delivery
Outline the management of shoulder dystocia:
HELPERR(R): H - Call for Help E - Evaluate for episiotomy L - Legs in McRoberts P - SupraPubic Pressure E - Enter pelvis R - Rotational manoeuvres R - Remove posterior arm (R) - Replace head and deliver by LSCS (Lower Segment C-Section)
List 3 maternal complications of Shoulder Dystocia:
- PostPartum Haemorrhage (PPH)
- Extensive vaginal tear (3rd and 4th degree)
- Psychological
List 3 Neonatal complications:
- Hypoxia
- Fits
- Cerebral palsy
- Injury to brachial plexus
