Obstetric Emergencies Flashcards
What is the first thing you should do in an obstetric patient who is critically unwell?
ABCDE assessment
Beyond what gestation can it be considered an ‘obstetric’ emergency and up until when?
From as soon as woman is pregnant up to 6 weeks postpartum
What are some common causes of obstetric emergency?
Antepartum or postpartum haemorrhage Pulmonary embolism Uterine rupture Uterine inversion Cord prolapse MI Septic shock
What is an APH?
What are some common causes?
Ante-partum haemorrhage
Bleeding from the genital tract after 24w gestation
(before 24 weeks it is know as a threatened miscarriage)
CAUSES: placenta praevia, ectropion, placental abruption, cervical poly, fibroid, trauma
What are the two types of post-partum haemorrhage?
What are some common causes?
PRIMARY: >500mL of blood lost from the genital tract in the 24h post delivery
SECONDARY: Excessive bleeding from the genital tract at anytime between 24h and 6 weeks post delivery
CAUSES: (THE 4Ts) - TONE (uterine atony - not contracting down), TRAUMA (genital tract trauma), TISSUE (retained products of conception), THROMBIN (abnormal clotting)
How should a post-partum haemorrhage be managed?
ABCDE assessment
Call for help
Place the bed head down
Administer oxygen
Insert 2 wide bore cannulas into ACF (often done already) and give a 500mL bolus of crystalloid stat (NaCl)
Send for FBC, clotting screen and cross match 4U
Urinary catheter
Check fetal CTG and consider delivery
Give O- blood once available or group specific (ideal)
What other management steps can be considered for APH?
Is bleeding panful or painless (praevia or abruption)
Establish placenta site
CTG
Decide whether delivery is necessary
What other management steps can be considered for PPH caused by uterine atony?
SYNTOMETRINE (sytocinon and ergometrine) is a UTEROTONIC DRUG - encourages contraction (5iU/0.5mg)
Then consider PGs if no response
Then consider exploitive laparotomy
What are the most common causes of secondary PPH? What investigations should be done
Retained products of conception +/- endometritis - USS urgently
Infection (start abx)
How does placental abruption present and how should it be managed?
Continuous abdominal pain and antepartum haemorrhage
The shock may be disproportionate to the blood loss - up to 20% of cases of placental abruption are ‘retroplacental’ meaning the bleeding is concealed behind the placenta
Uterus might feel HARD and WOODY as it is in spasm - might be hard to palpate fetal structures and auscultate FHR
How much blood loss is classed as PPH in NVD and C/S and how is blood loss graded?
> 500mL in NVD
1000mL in C/S
500mL-1000mL is MODERATE PPH
>1000mL is SEVRE PPH
What is a complication of PPH?
Pituitary gland is very active after birth (release prolactin to stimulate lactation) and has high oxygen demand
If PPH pituitary oxygen demands not met - can become ischaemic and necrosed
Pit gland can start to die (prolactin levels drop AS WELL AS levels of adrenocorticotrophic hormones, gonadotrphic hormones and thyroid stimulating hormones)
DEFICIENCIES GIVE RISE TO SHEEHAN SYNDROME
What are the symptoms of Sheehan Syndrome?
Agalactorrhoea (due to lack of prolactin)
Amenorrhoea (d/t lack of FSH and LH)
Low BP, Cold intolerance and weight gain (d/t/ lack of TSH)
How can Sheehan syndrome be detected?
Levels of all the pit hormones in the blood
MRI - sella turcica sign around pit gland
How is Sheehan syndrome managed?
Lifelong replacement of these hormones
Why is a woman more at risk of PE when pregnant?
Pregnancy is PRO-THROMBOTIC STATE (increased amount of clotting factors and decreased fibrinolysis)
Increased pressure on pelvis blood vessels meaning stasis more likely and less mobility
At what points is a pregnant woman at increased risk of PE?
ALL gestations and up to 6 weeks postpartum
What are some symptoms of PE?
Pleuritic chest pain, sudden onset breathlessness, cough, haemoptysis, tachycardia, hypotension, collapse, reduced air entry, swollen calves
How would you initially manage a pregnant woman with suspected PE?
ABCDE Facial oxygen ABG FBC U&E Fluids Pain killers (not opioids) V/Q scan (shouldn't do CTPA during pregnancy D-DIMER WILL BE RAISED IN PREGNANCY ANYWAY SO FAIRLY POINTLESS
What are some common causes of uterine inversion?
Incorrectly managed third stage (excessive traction on placenta)
It is more common in grand multips
How does uterine inversion present?
Pain
Haemorrhage
Shock (vasovagal: pale, clammy, sweaty, bradycardia and hypotensive)
Mass in the introitus - seen on scan
How should uterine inversion be managed?
Shock will correct itself when uterus is re-verted so this should be priority
MANUAL ATTEMPT - push fund back up via vagina: should be brief
IF failed…INSERT CLENCHED FIST INTO INTROITUS INDER GA AND PUMP SEVERAL LITRES OF WARM WATER UP AT PRESSURE TO REVERT
How should an eclamptic fit be managed?
ABCDE
Diazepam or MgSO4 to stop seizure
Continue Mg SO4 to prevent further seizures
Stabilise blood pressure and maternal condition
Deliver baby
What is the most common causative organism of maternal sepsis in the post-natal period?
Group A strep
Retained products of conception is a common reason for developing sepsis in the postnatal period
How should sepsis in the obstetric patient be managed?
BUFALO
ABx = cefotaxime and metronidazole +/- gentamicin
When is am amniotic fluid embolus most likely to happen and how serious is it?
Just after ARM
70% mortality rate
SAME SIGNS AS PE
Who is most at risk from uterine rupture?
Women who have had a previous C/S
Mutlips who are on uterotonic drugs
What are some symptoms of uterine rupture?
Fresh vaginal bleeding Haematuria Fetal distress Constant, SEVERE, abdominal pain (may break through epidural) Shock
How should a uterine rupture be managed?
ABCDE
IV access and fluid boluses
Immediate laparotomy to save baby and then stop source of bleeding and consider hysterectomy
What is a cord prolapse?
When the cord is seen/delivers before the presenting part - can come down through the cervix into the vagina
What are some risk factors for cord prolapse?
ARM - Major RFx Breech presentation Malposition Pre-term gestation Polyhydramnios Fetal growth restriction Placenta praevia
What are some presenting features of cord prolapse?
reduction in fetal blood flow can lead to fetal death so the CTG will show signs of distress
blood flow can be reduced even more because as the cord is in a colder environment it will start to go into spasm and occlude the vessels even further
How do you manage cord prolapse?
If FHR is still present the baby should be delivered IMMEDIATELY - either via instrumental delivery or C/S
POSITIONING - position the woman on all fours with her head down resting on pillow and hand should be pushed up inside the vagina to push the cord back into the uterus
Give a TOCOLYTIC TO REDUCE CONTRACTIONS
(TERBUTALINE 0.25mg slow IV)
What is shoulder dystocia? In what circumstance is it more likely?
When the anterior shoulder becomes trapped behind the symphysis pubis
More likely in macrosomic babies (risk in mothers with DM)
How should shoulder dystocia be managed?
Call for help
McRobert’s manoeuvre (knees to chest)
Push down on pubic symphysis
Consider episiotomy
