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Yr4 - O&G > Obstetric Emergencies > Flashcards

Obstetric Emergencies Flashcards

1
Q

Define Amniotic Fluid Embolism

A

Recognised yet rare cause of maternal collapse

Often fatal complication of pregnancy and the puerperium and is a direct cause of maternal death

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2
Q

Risk factors for amniotic fluid embolism

A

Abnormalities of the amniotic fluid, uterus or placenta

  • Multiple pregnancy
  • Increasing maternal age
  • Induction of labour
  • Uterine rupture
  • Placenta praevia
  • Placental abruption
  • Cervical laceration
  • Eclampsia
  • Polyhydramnios
  • Caesarean or instrumental delivery
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3
Q

Clinical features of amniotic fluid embolism

A

Acute condition with sudden onset of

  • hypoxia/respiratory arrest
  • hypotension
  • foetal distress
  • seizures
  • shock
  • confusion
  • cardiac arrest
  • DIC
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4
Q

Management for amniotic fluid embolism

A

Resuscitation - ABCDE
- FBC, U+Es, calcium, magnesium, clotting studies, ABG
- ECG - ischaemic changes
- CSR - pulmonary oedema
Anaesthetics involved with measuring pulmonary artery wedge pressure
DIC managed by haematologists

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5
Q

Define shoulder dystocia

A

After delivery of the head the anterior shoulder of the foetus becomes impacted on the maternal pubic symphysis or less commonly the posterior shoulder on the sacral promontory
Obstetric emergency

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6
Q

Pathophysiology of shoulder dystocia

A

In normal labour, foetal head delivered by extension out of pelvic outlet followed by restitution of foetal head - shoulders lie in anterior-posterior position
Impaction of shoulder -> delay in delivery -> hypoxia in foetus proportional to time delay to complete delivery
Applying traction on foetal head can result in brachial plexus injury

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7
Q

Risk factors for shoulder dystocia

A 
Pre-labour
- previous shoulder dystocia
- macrosomia
- diabetes
- maternal BMI > 30
- induction of labour
Intrapartum
- prolonged 1st stage of labour
- secondary arrest - initially good progress in labour then progress stops usually due to malposition of baby
- prolonged second stage of labour
- augmentation of labour with oxytocin
- assisted vaginal delivery
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8
Q

Clinical features of shoulder dystocia

A

Difficulty in delivery of foetal head or chin
Failure of restitution - foetal remains in occipital-anterior position after delivery by extension
Turtle neck sign - foetal head retracts slightly back into pelvis so that neck is no longer visible

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9
Q

Initial management of shoulder dystocia

A 
If managed appropriately the risk of permanent brachial plexus injury can almost be eliminated
Call for help
Advise mother to sop pushing
Avoid downwards traction on foetal head
Consider episiotomy
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10
Q

First line manoeuvres for shoulder dystocia

A

McRoberts - hyperflex maternal hips

Suprapubic pressure - applied in either sustained or rocking fashion to apply pressure behind anterior shoulder

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11
Q

Further manoeuvres for shoulder dystocia

A

Posterior arm - insert hand posteriorly into sacral hollow and grasp posterior arm to delivery
Internal rotation - apply pressure simultaneously in front of one shoulder and behind the other to move baby 180 degrees
Cleidotomy - fracturing foetal clavicle
Symphysiotomy - cutting pubic symphysis
Zavenelli - returning foetal head to pelvis for delivery of baby via C-section

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12
Q

Post-delivery management for shoulder dystocia

A

Active management of 3rd stage of labour - increased risk of PPH
PR exam to exclude 3rd degree tear
Debrief mother and birth partners and advise on risk of recurrence
Consider physio and paed review

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13
Q

Complications of shoulder dystocia

A 
Maternal
- 3rd/4th degree tears
- PPH
Foetal
- humerus or clavicle fracture
- brachial plexus injury
- hypoxic brain injury
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14
Q

Define umbilical cord prolapse

A

Umbilical cord descends through cervix with or before presenting part of foetus

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15
Q

Classification of umbilical cord prolapse

A

Occult (incomplete) cord prolapse - umbilical cord descends alongside presenting part but not beyond
Overt (complete) cord prolapse - umbilical cord descends past presenting part and is lower than presenting part in the pelvis
Cord presentation - presence of umbilical cord between the presenting part and the cervix - occur with or without intact membranes

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16
Q

Pathophysiology of umbilical cord prolapse

A

Foetal hypoxia occurs via

  • occlusion - presenting part of foetus presses onto umbilical cord
  • arterial vasospasm - exposure of umbilical cord to the cold atmosphere results in umbilical vasospasm - reducing blood flow to foetus
17
Q

Risk factors for umbilical cord prolapse

A

Breech presentation - in footling breech cord can easily slip between foetal feet
Unstable lie - presentation of foetus changes between transverse/oblique/breech and back
- if > 37 weeks gestation consider inpatient admission until delivery
Artificial rupture of membranes
Polyhydramnios
Prematurity

18
Q

Clinical features of umbilical cord prolapse

A

Should always be considered in presence of non-reassuring foetal heart rate pattern and absent membranes
Confirmed by external inspection or on digital vaginal examination
Decelerations of contractions, foetal distress such as foetal bradycardia

19
Q

Management of cord prolapse

A

Call for help
Avoid handling cord - reduce vasospasm
Manually elevate presenting part - by vaginal digital exam or fill maternal bladder
Encourage into left lateral position - head down and pillow placed under left hip or knee-chest position
Consider tocolyis (terbutaline) - if delivery not imminently available as will relax uterus and stop contractions
Delivery via emergency C-section
- if fully dilated and vaginal delivery appears imminent encourage pushing or instrumental delivery
- if at threshold for viability consider expectant management

20
Q

Define eclampsia

A

Occurrence of one or more convulsions in a pre-eclamptic woman in absence of any other neurological or metabolic causes
- majority occurs in post-natal period

21
Q

Risk factors for eclampsia

A 
Moderate 
- nulliparity
- maternal age > 40
- maternal BMI > 35
- FH of pre-eclampsia
- pregnancy interval > 10 years
- multiple pregnancy
High Risk
- chronic hypertension
- HTN, pre-eclampsia or eclampsia in previous pregnancy
- pre-existing chronic kidney disease
- DM
- autoimmune diseases - SLE, antiphospholipid
22
Q

Clinical features of eclampsia

A 
New onset tonic-clonic type seizures
- 60-75 seconds
- followed by post-ictal phase
May cause foetal distress and bradycardia
End organ dysfunction
- headache
- hyper-reflexia
- N+V
- generalise oedema
- RUQ pain +/- jaundice
- visual disturbance - flashing lights, blurred vision or double vision
- change in mental stage
23
Q

Complications of eclampsia

A 
Maternal
- HELLP syndrome
- Disseminated Intravascular Coagulopathy
- Acute Kidney Injury 
- Adult respiratory distress syndrome 
- Cerebrovascular haemorrhage 
- Permanent CNS damage
- Death
Foetal complications
- IUGR
- prematurity
- infant resp distress syndrome
- intrauterine foetal death
- placental abruption
24
Q

Differential diagnosis for eclampsia

A 
Hypoglycaemia
Medication-induced
Pre-existing epilepsy
Brain tumour
Head trauma
Cerebral aneurysm
Haemorrhagic stroke
Septic shock
Meningitis
Ischaemic stroke
25
Q

Investigations for eclampsia

A

Exclude other reversible causes

  • FBC: ↓ Hb, ↓ platelets
  • U&Es: ↑ urea, ↑ creatinine, ↑ urate, ↓ urine output
  • LFTs: ↑ ALT, ↑ AST, ↑ bilirubin
  • Clotting studies
  • Blood glucose
26
Q

Management of eclampsia

A 
Resuscitation
- ABCDE 
- left lateral position 
Cessation of seizures 
- magnesium sulphate
Blood pressure control
- IV labetalol and hydralazine
Prompt delivery of baby and placenta
- mother must be stable
- C-section ideal mode
Monitoring
- fluid balance - prevent pulmonary oedema and AKI
27
Q

Post-natal care for eclampsia

A

Inpatient care:
- Regular symptom review – e.g headaches, epigastric pain
- Bloods 72 hrs post-partum – FBC, LFTs, creatinine
- Pre-conceptual counselling – advice regarding minimising risk factors and prophylaxis for future pregnancies
- Step-down care to community – when reached target BP and asymptomatic
Outpatient care:
- Consider CT Head – if persistent neurological deficit
- Measure BP – in the UK, blood pressure is checked daily for 2 weeks post-partum
- Follow-up at 6 weeks – check BP, proteinuria and creatinine and repeat FBC, LFTs and creatinine if not previously returned to normal

28
Q

Define uterine rupture

A

Full thickness disruption of uterine muscle and overlying serosa

29
Q

Types of uterine rupture

A

Incomplete – where the peritoneum overlying the uterus is intact. In this case, the uterine contents remain within the uterus
Complete – the peritoneum is also torn, and the uterine contents can escape into the peritoneal cavity

30
Q

Risk factors for uterine rupture

A

Previous caesarean section – this is the greatest risk factor for uterine rupture
Classical (vertical) incisions carry the highest risk.
Previous uterine surgery – such as myomectomy.
Induction – (particularly with prostaglandins) or augmentation of labour
Obstruction of labour – this is an important risk factor to consider in developing countries
Multiple pregnancy
Multiparity

31
Q

Clinical features of uterine rupture

A 
Non-specific
Severe abdo pain which persists between contractions
- Shoulder tip pain
- Vaginal bleeding
-> hypovolaemic shock
32
Q

Differential diagnosis of uterine rupture

A

Placental abruption – presents with abdominal pain +/- vaginal bleeding, uterus is often described ‘woody’ and tense on palpation
Placenta praevia – typically causes a painless vaginal bleeding
Vasa praevia – characterised by a triad of ruptured membranes, painless vaginal bleeding, and foetal bradycardia

33
Q

Investigations for uterine rupture

A

CTG monitoring
Maternal haematuria
USS for diagnosis

34
Q

Management of uterine rupture

A

Resuscitation
- Protect airway
- 15L of 100% oxygen through a non-rebreathe mask
- Assess circulatory compromise (Cap refill, HR, BP, ECG)
- Insert two large bore (14G) cannulas and take blood samples
- Start circulatory resuscitation -> Give cross-matched blood as soon as it is available, until then give up to 2L of warmed crystalloid and 1-2L of warmed colloids, then transfuse O negative or uncross matched group specific blood.
Additional blood products may be required, such as fresh frozen plasma, platelets and/or fibrinogen.
- Monitor patient’s GCS
- Expose patient to identify any other bleeding sources
Delivery foetus via C-section

Yr4 - O&G (19 decks)

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