Obstetric Emergencies Flashcards
What are some common causes of obstetric emergency?
How do you manage any of these?
Antepartum or postpartum haemorrhage Pulmonary embolism Uterine rupture Uterine inversion Cord prolapse MI Septic shock
ABCDE assessment!!!!!!!
What are the two types of post-partum haemorrhage?
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
What are some common causes?
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 warmed crystalloid stat (NaCl) (can give up to 2.5L)
- 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)
- FFP after 4th unit (or guided by coat studies)
- Fundal massage
What is uterine atony?
What are the classic risk factors?
Uterine atony
-where the uterus fails to contract down after delivery of baby>PPH (most common cause of PPH)
Maternal profile: Age >40, BMI > 35, Asian ethnicity.
Uterine over-distension – multiple pregnancy, polyhydramnios, fetal macrosomia.
Labour – induction, prolonged (>12 hours).
Placental problems – placenta praevia, placental abruption, previous PPH.
What other management steps can be considered for PPH caused by uterine atony? (4)
Medicine management
- Bimannual compression
- Uterotonics (syntocinon> then syntometrine)
- Prostaglandins (misoprostol-recal or carboprost)
- Surgical managment (exploitive laparotomy)
*Tranexamic acid 1g IV (if within 3hrs from birth)
What are some examples of uterotonics used in uterine atony?
Uterotonics used in uterine atony
SYNTOCINON (synthetic oxytocin)
-bolus or infusion
SYNTOMETRINE (sytocinon and ergometrine)-given usually in 3rd stage for placental birth (5iU/0.5mg IM bolus)
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?
How is it investigated
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 (labetolol)
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?
How will it present
Just after ARM
70% mortality rate
SAME SIGNS AS PE
Who is most at risk from uterine rupture?
How common is it?
-Women who have had a previous C/S
-Women who have had previous uterine surgery (e.g.myomectomy)
other risk factors
-induction of labour (IOL) or use of oxytocin
-High parity
-Hyperstimulation
-Malpresentation
-Macrosomia (obstruction, failure to recognise)
-Trauma; RTA
1 in 50,000 pregnancies
What are some symptoms/signs of uterine rupture? (6)
UTERINE RUPTURE
- Fresh vaginal bleeding
- Constant, SEVERE, abdominal pain that is present between contractions (may break through epidural)
- Shock (may compensate well)
- Haematuria and blood stained liquor
- Fetal distress (CTG abnormalities are associated with 55–87%> change in uterine activity or failure to hear HR)
- Tenderness over previous surgical scars
