Obstetric emergencies Flashcards
after any emergency
Datix
Debrief pt
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Sepsis what do?
3in 3out
If hypotensive and/or lactate >4 initial 20ml/g crystalloid
If no response vasopressors for hypotn., aim MAP >65
If persistent hypotn, aim CVP >8mm or CVO2s >70% or MVO2s >6%
Antepartum haemorrhage
Admit until bleeding stopped ABC (IV access and fluids) FBC, G+S, CM, ?kleihauer Anti-D if indicated CTG if >27wk (IOL if early compromise) NOT bimanual risk of placentia praevia TVUSS for praevia
Placenta praevia Definitions
Applies >16w
Praevia: directly over os
low lying placenta: edge <2cm from internal osP
Placenta praevia Ix
FBC, clotting, G+S, Rh status, Kleihauer TVUSS CTG NOT bimanual admit for obs for 48hr if bleed settles
Symptomatic Mx of placenta praevia
only if minimal bleed and clearly of local vaginal origin
as long as cervical ca. excluded
DO NOT HAVE SEX IF YOU HAVE PP
Placenta praevia del.
c-section delivery
Low lying placenta at 20w scan
- only 10% go on to have LLP late in preg
- Rescan at 32w (avoid sex, consider ass. cervical length to determine risk PTL
- If low at 36w recommend elective c-section
- AN CS 24-34w
- if high presenting part or abnormal lie at 37w -> csec
- If major placenta praevia completely covering os admit 34w
Placenta praevia w/bleeding
Admit until it stops ABC IV access and fluids FBC, G+S, crossmatch, kleihauer Steroids 24-34wks CTG if <27w Growth and UAD every 2wk Consultant lead care Final USS 36-37w to determine delivery (vaginal only if grade 1) IOL if fetal compromise if major praevia with bleed admit from 34wk
PACES counselling for praevia
RF: Hx, multiple preg, prev.c-sec, AMA
Low-lying placenta:
- increased risk bleed, 90% will move away from os, rescan at 32w, avoid sex
Praevia and bleed:
- admit 48hrs (or until bleed stops), admit until del. if >34w, importance of monitoring, discuss del.
risks of del: blood loss, transfusion, maybe hysterectomy
Placenta accreta
Specialist Mx
?MRI to supplement USS
Plan del 35-37w
Explain risk of needing emergency hysterectomy
Vasa praevia
immediate c-sec
PPH minimising risk
Proph. uterotonics to manage stage 3 of labour (IM oxytocin 10iU)
If delivering by c-sec use IM oxytocin 5iU
Syntometrine in absence of HTN and increased risk PPH
In women at risk of PPH consider TXA + oxytocin
Minor PPH
500-1000ml w/o shock IV access G+S, FBC, coag screen + fibrinogen PR, RR, BP every 15min Commence warmed crystalloid
Major PPH
>1000ml Call for help ABC patient flat and warm 10-15/min O2 2 large bore cannulae FBC, clotting, G+S, cross match Transfuse ASAP if req. foley cath for output
Who to call in major PPH
Emergency buzzer consultant
anaesthetic team
haematologist
blood transfusion lab
Major PPH Mx
- IV/M syntoncinon, IM ergometrine/syntometrine
- IM carboprost
- Bakri balloon tamponade
- other measures eg B-lynch suture, hysterectomy
EMERGENCY: bimanual compression
Prolonged third stage of labour
Placenta not emergef after 30min active or 2hr phys. Mx
Manual removal in theatre
Eclampsia
RF: Hx HTN, first preg, AMA, obesity call 2222 secure airway seizres self terminate 2-3min Discuss need for urgent del. ?steroids HDU
Eclapmsia first line anticonvulsant
MgSO4 ASAP
4g over 10min
1g/hr for 24 hrs after delivery
(narrow therapetic window)
Amniotic fluid embolism
ABCDE
poor prog. 10% survival
supportive Mx in ICU
no spec. Mx
Cord prolapse
Digital exam immediately
call for help
Prepare for emergency del (generally emergency c-sec)
Prevent compression by elevating presenting part or filling bladder
?tocolytics
maternal position
CTG
should I just grab the cord and put it back in during cord prolapse?
no it’ll spasm so just keep warm and moist
maternal position if cord prolapse
all fours
knees to chest
left lateral
ideally head slightly declined
Shoulder dystocia RF
Macrosomia
high maternal BMI
DM
Prolonged labour
What to do if dystocia
- stop pushing
- call for senior help
- McRoberts (hips flexed + abducted
- suprapubic pressure
- Consider episiotomy
- Deliver posterior arm and consider internal rotation manoeuvres
- all fours
- symphysiotomy, cleidotomy, Zananelli
Internal rotation manoeuvers
Rubin + Rubin II, Woods screw and reverse woods screw
Rubin II: insert hand behind ant. shoulder and push toward chest
DVT/PE in pregnancy
any woman w/Sx should have testing and LMWH until Dx excluded
therapetic dose calc on booking wt.
DVT in pregnancy what do?
Compression duplex USS#
- negative and low suspicion stop anticoag
- negative and high suspicion stop anticoag and repeat USS d3-7
PE in pregnancy what do
- ECG and CXR
if CXR abnormal and suspicion of PE order CTPA - If Sx of DVT compression duplex USS
NO Sx of DVT: VQ or CTPA
CTPA/VQ scan and malignancy
VQ inc. chilld, CTPA inc. risk for mother breast cancer bu absolute risks v small
IVC filter in PE/DVT in pregnancy
perpartum if iliac vein VTE or pts w/proven DVT
or recurrent PE despite anti-coag
Massive PE in pregnancy Mx
options: IV heparin, consdier urgent thrombolysis in confmirmed, surgical embolectomy
IV unfrac. hep first line if massive PE w/CV compromise
Urgent portable echo/CTPA
Maintenance Rx of VTE in pregnancy
Therapeutic dose of sc. LMWH continued for preg. and at least 6w PN for total of 3m Mx
Self injection taught
Offer alternative: oral anti-coag (req. INR)
NOACs if pt cant tolerate heparin
neither heparin nor warfarin are CI bf
beware in long term LMWH
heparin induced TCP
heparin allergy
Anti-coagulation during labour and del.
If VTE at term IV unf. heparin considered
If on LMWH and enter labour do not inj. more
If planned del. LMWH discontinued 24hrs before
Regional anaesthetic needs 24hr window since last LMWH
Do not give LMWH if within 4hrs of spinal anaesthesia/epidural catheter removed
Continuous heparin and high risk of haemorrhage should have IV unfrac. heparain
Prevention of post-thrombotic syndrome in pregnancy
Prolonged LMWH (>12w) a/w lower risk of PTS Graduated elastic compression stocings
Patients at risk of VTE in pregnancy
Age>35, BMI >30, parity >3, smoker, pre-eclampsia, Hx, varicose veins, low risk throbmbphilia
4+ = immediate LMWH and 6wks PN
3 = initiate LMWH at 28wks until 6wk PN
PACES counselling of VTE in pregnancy
RF: (F)Hx, AMA, obesity, Dx: blood clot Importance: breathing difficulties Mx: injections (until 6wkPN), no dose within 24hr planned del. compression stockings - CTPA/VQ/CXR: absolute risk v low CTPA maternal breast ca VQ childhood ca benefits outweigh risks
Uterine inversion
Clinical Fx: significant bleeding, Hb shock, bradycardia
ABCDE
call help
IV fluid resus, catheter, pain Mx
Attempt manual replacement
if unsuccessful try hydrostatic replacement: 3L warm saline via tubing into vagina using hands to create seal
surgically: hysterectomy
Uterine rupture
Urgent laparotomy
Vaginal exam
delivery ASAP however quickest`
peurperal pyrexia
> 38C, first 14d after del.
causes: endometritis (most common), UTI, SSI, mastitis
Refer to hosp.
IV clindamycin + gentamicin until afebile >24hr
