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Obestetrics > Obstetric emergencies > Flashcards

Obstetric emergencies Flashcards

1
Q

after any emergency

A

Datix
Debrief pt
Document

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2
Q

Sepsis what do?

A

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%

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3
Q

Antepartum haemorrhage

A 
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
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4
Q

Placenta praevia Definitions

A

Applies >16w
Praevia: directly over os
low lying placenta: edge <2cm from internal osP

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5
Q

Placenta praevia Ix

A 
FBC, clotting, G+S, Rh status, Kleihauer
TVUSS
CTG
NOT bimanual
admit for obs for 48hr if bleed settles
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6
Q

Symptomatic Mx of placenta praevia

A

only if minimal bleed and clearly of local vaginal origin
as long as cervical ca. excluded
DO NOT HAVE SEX IF YOU HAVE PP

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7
Q

Placenta praevia del.

A

c-section delivery

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8
Q

Low lying placenta at 20w scan

A
  • 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
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9
Q

Placenta praevia w/bleeding

A 
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
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10
Q

PACES counselling for praevia

A

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

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11
Q

Placenta accreta

A

Specialist Mx
?MRI to supplement USS
Plan del 35-37w
Explain risk of needing emergency hysterectomy

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12
Q

Vasa praevia

A

immediate c-sec

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13
Q

PPH minimising risk

A

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

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14
Q

Minor PPH

A 
500-1000ml w/o shock
IV access
G+S, FBC, coag screen + fibrinogen
PR, RR, BP every 15min
Commence warmed crystalloid
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15
Q

Major PPH

A 
>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
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16
Q

Who to call in major PPH

A

Emergency buzzer consultant
anaesthetic team
haematologist
blood transfusion lab

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17
Q

Major PPH Mx

A
  1. IV/M syntoncinon, IM ergometrine/syntometrine
  2. IM carboprost
  3. Bakri balloon tamponade
  4. other measures eg B-lynch suture, hysterectomy
    EMERGENCY: bimanual compression
18
Q

Prolonged third stage of labour

A

Placenta not emergef after 30min active or 2hr phys. Mx

Manual removal in theatre

19
Q

Eclampsia

A 
RF: Hx HTN, first preg, AMA, obesity
call 2222
secure airway
seizres self terminate 2-3min
Discuss need for urgent del.
?steroids
HDU
20
Q

Eclapmsia first line anticonvulsant

A

MgSO4 ASAP
4g over 10min
1g/hr for 24 hrs after delivery
(narrow therapetic window)

21
Q

Amniotic fluid embolism

A

ABCDE
poor prog. 10% survival
supportive Mx in ICU
no spec. Mx

22
Q

Cord prolapse

A

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

23
Q

should I just grab the cord and put it back in during cord prolapse?

A

no it’ll spasm so just keep warm and moist

24
Q

maternal position if cord prolapse

A

all fours
knees to chest
left lateral
ideally head slightly declined

25
Q

Shoulder dystocia RF

A

Macrosomia
high maternal BMI
DM
Prolonged labour

26
Q

What to do if dystocia

A
  1. stop pushing
  2. call for senior help
  3. McRoberts (hips flexed + abducted
  4. suprapubic pressure
  5. Consider episiotomy
  6. Deliver posterior arm and consider internal rotation manoeuvres
  7. all fours
  8. symphysiotomy, cleidotomy, Zananelli
27
Q

Internal rotation manoeuvers

A

Rubin + Rubin II, Woods screw and reverse woods screw

Rubin II: insert hand behind ant. shoulder and push toward chest

28
Q

DVT/PE in pregnancy

A

any woman w/Sx should have testing and LMWH until Dx excluded
therapetic dose calc on booking wt.

29
Q

DVT in pregnancy what do?

A

Compression duplex USS#

  • negative and low suspicion stop anticoag
  • negative and high suspicion stop anticoag and repeat USS d3-7
30
Q

PE in pregnancy what do

A
  • 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
31
Q

CTPA/VQ scan and malignancy

A

VQ inc. chilld, CTPA inc. risk for mother breast cancer bu absolute risks v small

32
Q

IVC filter in PE/DVT in pregnancy

A

perpartum if iliac vein VTE or pts w/proven DVT

or recurrent PE despite anti-coag

33
Q

Massive PE in pregnancy Mx

A

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

34
Q

Maintenance Rx of VTE in pregnancy

A

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

35
Q

beware in long term LMWH

A

heparin induced TCP

heparin allergy

36
Q

Anti-coagulation during labour and del.

A

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

37
Q

Prevention of post-thrombotic syndrome in pregnancy

A 
Prolonged LMWH (>12w) a/w lower risk of PTS
Graduated elastic compression stocings
38
Q

Patients at risk of VTE in pregnancy

A

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

39
Q

PACES counselling of VTE in pregnancy

A 
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
40
Q

Uterine inversion

A

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

41
Q

Uterine rupture

A

Urgent laparotomy
Vaginal exam
delivery ASAP however quickest`

42
Q

peurperal pyrexia

A

> 38C, first 14d after del.
causes: endometritis (most common), UTI, SSI, mastitis
Refer to hosp.
IV clindamycin + gentamicin until afebile >24hr

Obestetrics (21 decks)

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