Obstetric emergencies Flashcards
What are the risk factors for placental abruption?
Hypertension Smoking Trauma Twin pregnancy Polyhydramnios Foetal growth restriction
What are the clinical features of placental abruption?
Painful vaginal bleeding
Tense rigid abdomen (Woody uterus)
Abdominal pain
Shock
What are the risk factors for placenta praevia?
Multiple gestations
Previous c-section
Uterine abnormalities
What are the clinical features of placenta praevia?
Painless vaginal bleeding
Bleeding may trigger preterm labour
Diagnosed via ultrasound (Low placenta is typically seen during week 20 ultrasound)
What are the clinical features of vasa praevia?
Foetal blood vessels covering the cervical os
Spontaneous rupture of membranes accompanied by painless fresh vaginal bleeding
Associated with high perinatal mortality
Hence, immediate C-Section is required
What is the definition of post-partum haemorrhage?
> 500ml blood loss following delivery
>1000ml blood loss considered major haemorrhage
What are the risk factors for post-partum haemorrhage?
Previous PPH Nulliparity Praevia Distended uterus (Polyhydramnios, Twins) Obesity PET Prolonged labour Chorioamnionitis
What are the causes of post-partum haemorrhage?
Tone (70%) - Atonic uterus
Trauma (20%) - Lacerations, episiotomy, haematoma
Tissue (10%) - Retained placenta
Thrombin (1%) - Coagulopathies
What is the general management of PPH?
ABC approach Obs Correction of circulation: - x2 cannulas - Blood for diagnostic tests - 2L crystalloid blood - 500ml tranexamic acid
What is the management of PPH caused by atony?
Mechanical:
- Bimanual uterine compression to stimulate contraction
Pharmacological:
- Syntocinon 5/10 units IV
- Ergometrine 0.5mg IV (CI: HTN/CHD)
- Haemabate/Carboprost IM (Synthetic prostaglandin)
- Rectal Misoprostol
Advanced:
- Intrauterine tamponade
- Balloon into vagina, that forces uterus shut when inflated
- B-Lynch suture
Last-line:
- If nothing else works, hysterectomy
What is the management of PPH caused by trauma?
Examine vagina/cervix
Urgent repair of tissues with sutures
What is the management of PPH caused by tissue?
Typically presents with bleeding 12-24 hours after delivery
Mostly managed by expectant management, medical management to induce contraction/expulsion; or surgery
What is the management of PPH caused by thrombin?
If they are still bleeding, must consider DIC
Must replace clotting agents
What are the sequelae of PPH?
- Sheehan’s syndrome
- Postpartum depression
- Anaemia
- Acute stress reaction
What are the clinical features of amniotic fluid embolism?
Caused by amniotic fluid entering the maternal circulation
Resulting in acute cardiorespiratory compromise and severe DIC
Diagnosed post-mortem
Clinical signs/symptoms:
- Collapse
- Tachycardia
- Shivering
- Chest pain
- Cyanosis
- SOB
- Hypotension
- Bronchospams
There is no treatment, just supportive management (O2, fluids, FFP, ITU admission)
10% survival
What is cord prolapse and what are the risk factors?
During rupture of membranes, the umbilical cord may descend below the presenting head, potentially leading to cord compression and hence foetal hypoxia
Risk factors:
- Induction of labour amniotomy (Most common cause)
- Preterm labour
- Breech presentation
- Polyhydramnion
- Twins
Diagnosed on CTG abnormality and palpable cord on vaginal examination
What is the management of cord prolapse?
- Cord should be pushed upwards
- Tocolytics (Terbutaline) given to prevent compression
- Patient placed on all 4s
- Immediate C-section
What are the clinical features of uterine rupture?
Rupture of the uterus typically occurs de novo or due an old caesarean scar opening
Causes foetal hypoxia and massive maternal haemorrhage
Bleeds more if de novo and c-section scar is at lower abdomen and this is less vascular. Also foetus less likely to extrude out of the abdomen
Symptoms:
- Severe abdominal pain
- Vaginal bleeding
- Haematuria
- Cessation of contractions
- Maternal tachycardia
- Foetal compromise (bradycardia)
Women with a C-section scar need continuous monitoring and a low threshold for c-section if there are any CTG abnormalities. Induction of labour should not be conducted
What is the management of uterine rupture?
Resuscitation (IV fluids and blood transfusion)
Bloods for clotting, Hb, cross-match
Urgent laparotomy for foetal delivery and repair/removal of uterus
Early c-section delivery in future pregnancies
What is the management of shoulder dystocia?
Calling My Supervisor Ensures Successful Results (Rah)
Call supervisor
McRobert’s manoeuvre (Legs hyperextended onto abdomen)
Suprapubic pressure applied (Disimpact shoulder from pubic symphysis)
Episiotomy consideration if need better access to shoulder
Start manoeuvres (Rubins and Wood’s corkscrew)
Removal of posterior arm
Rotate onto all fours
Which investigations should be performed in a patient with a suspected PE?
ECG
CXR
Compression duplex ultrasound (if DVT)
V/Q or CTPA
How should a DVT/PE during pregnancy be managed?
Therapeutic dose LMWH given daily in two divided doses according to the patient’s weight until 6 weeks postpartum (and at least 3 months in total)
How should VTE in a collapsed patient be managed?
Unfractionated heparin
Thrombolysis
Thoracotomy and surgical embolectomy
What is the management of uterine inversion?
Attempt manual replacement
If unsuccessful attempt hydrostatic replacement (Tube 2-3L of warm saline into the vagina, using your hands to block the vulva)
If unsuccessful, hysterectomy
What are risk factors for uterine inversion?
Full dilatation C-section Unsuccessful instrumental delivery IV syntocinon prior to C-section delivery Malpresentation Prolonged second stage
