Obstetric Emergencies Flashcards
What are causes of acute maternal collapse?
Think top to bottom
- Eclampsia (seizure)
- Amniotic fluid embolism
- Major Obstetric Haemorrhage (4Ts)
- VTE, PE
- Shoulder dystocia
- Sepsis
OR HEPARINS: Hemorrhage Eclampsia Pulmonary embolism Amniotic fluid embolism Regional anaethetic complications Infarction (MI) Neurogenic shock Septic shock
What position myst you put a an unwell pregnant woman?
Left lateral tilt (at 15 degrees) to minimise aorto-caval compression
What are RF for sepsis?
Ruptured membranes
Infection - UTI, PID, STD, Group B strep, amniocentesis
What score do you use for onset of sepsis?
By looking at MEOWS
What are the sepsis 6?
3 in (fluids, high flow oxygen, antibiotics) 3 out (blood culture, lactate, urine output)
What do you give before, antibiotics or blood cultures?
BLOOD CULTIRES FIRST
What are common organisms involved in puerperal sepsis?
lance field group A beta haemolytic step
E coli
What is APH?
Bleeding from or into the genital tract from 24 weeks to delivery
What are causes of APH?
Placental:
- placenta abrupta
- placenta previa
Foetal:
- vasa previa.
Maternal:
- Vaginal trauma
- Cervical ectropion.
- Cervical carcinoma
- Vaginal infection
- Cervicitis
What is placental abruption?
Premature separation. of. the placenta from the uterine w all
What are. the two types of placenta abruption
Complete (need to deliver)
Marginal (resolves spontaneously, due to a partial abruption)
What are the other two types of placental abruption
Revealed
Concealed (bleeding remains in uterus, forming retroplacental clot)
How do you recognise a concealed abruption
You don’t
All you see is that there is foetal distress
So you deliver immediately
What are RF for placental abruption
- prior abruption
- HTN and PET
- smoking, maternal age, BMI, cocaine
- Trauma to maternal abdomen
- Polyhydramnios
- Multiple preg
- FGR
What is the pathophysiology of placental abruption
Rupture of the maternal vessels in the basal layer of the endometrium
Blood accumulates and splits the placental attachment
The detached portion of the placenta does not function, causing rapid foetal compromise
What is classical presentation of placental abruption
PAINFUL bleeding with WOODY abdomen
SUDDEN foetal distress
How do you diagnose placental abruption
Transabdominal USS
- can confirm if it is!
- but not always specific (may give false negatives > does not rule it out!
What investigations can you do for placental abruption
Abdo exam, speculum, Obs FBC Clotting (low platelets due to. intrauterine clotting) G&S, X match USS CTG. assess for foetal distress
What is management of marginal abruption
Conservative Give steroids (if 24-34 weeks) Discharge after 24 h of no more bleeding
What is managaemtn of severe placental abruption
IMMEDIATE DELIVERY
usually via C sec
+ give Anti D if lady is negative (+ Kleihauer test)
What is placenta previa?
A placenta covering / enriching the cervical os
What is a low lying placenta?
A placenta near the cervical os but not covering it
What are symptoms of. placenta previa?
Painless bleeding
May be spontaneous / triggered by trauma (e.g. sex, speculum)
What are RF for PP?
Prior PP Iatrogenic: CS, curettage to endometrium, uterine surgery Uterine structural abnormality Assisted conception smoking, advanced maternal age
How is PP diagnosed?
Via TVUSS
How do you manage PP with so symptoms?
C section at 38 weeks
What is vasa previa?
Foetal vessels transversing the foetal membrane over the cervical os, not covered. in Wharton Jelly
Why does vasa previa usually occur?
As the vessels from the umbilical cord go into the foetal membranes and THEN into the placenta, instead of directly to the placenta
This means the vessels are not protected by Wharton Jelly within the cord
This makes Vasa Previa more likely to rupture
What is the BIG danger of VP?
Foetal mortality (doe to foetal exsangiuation) Vasa previa are likely to rupture when foetal membranes rupture during labour
How do you manage VP/PP?
Deliver baby via C section
What is a PP haemorrhage?
Blood loss >500 ml following vaginal or >1000 ml following C sec
What are categories of PPH?
Primary: <24h post partum
Secondary: >24h post partum
What are the four causes of PPH?
Tone (uterine atony)
Tissue (retained placenta)
Trauma (episiotomy/damage during C sec)
Thrombin 8coag defect)
What are causes of uterine atony’
- Retained placental tissue
- Repeated uterine distension (multiple prig, overstitching from twins, grand multiparty)
- Muscle fatigue during delivery (induction of labour, prolonged labour)
_ Unable to empty bladder (pushes onto uterus, interferes with contractions) - Obstetric medications (e.g. anaesthetics)
What are causes of trauma=
From C section surgery
How do you ensure that there is no tissue left in vagina after
Ensure that placenta has come out intact
Sweep the uterus with your hand for any fragments
Which two very dangerous events is eclampsia associated with?=
Cerebral haemorrhage
Stroke
How do you treat eclampsia?
Magnesium sulphate
Start with 4mg IV loading dose
Maintainance infusion of 1g/h for 24h after delivery
What must you be aware of with magnesium sulphate?
Narrow therapeutic range
What does overdose from mg sulphate cause?
Overdose causes resp depression, cardiac arrest
What is the antidote to mg sulphate?
10ml 10% calcium clucoronarte
What are sx of amniotic fluid embolus?
same as PE
HOw do you treat amniotic fluid embolus?
You can’t
Supportive tx in ITU
High mortality rate
What is umbilical cord prolapse?
The descent of the umbilical cord through the cervix with / before the presenting part of the foetus
Why is umbilical cord prolapse dangerous?
It causes foetal hypoxia
How does umbilical cord prolapse cause foetal hypoxia
- Occuylusion: presenting part of foetus compresses umbilical cord, blocking blood flow
- arterial vasospasm: due to exposure to cold air
How do you prevent umbilical cord prolapse
Schedule elective C section for transverse/oblique lie
How do you manage umbilical cord prolapse
Speculum + vaginal exam
Sumon senior help
Prep operating theatre
deal with the cord (prevent further compression by elevating the presenting part of foetus, and try to not touch the cord as it causes spasm)
DELIVER VIA C SEC
How do you place the mother in umbilical cord prolapse
Knee to chest
Left lateral position
What is shoulder dystocia
vaginal delivery resulting in unsuccessful delivering of the shoulders with gentle traction
Requires additional obstetric maneuvres
What actually occurs in shoulder dystocia
Anterior shoulder is stuck on pubic symphisis
Posterior shoulder stuck on sacral promontory
What are two key dangers in shoulder dystocia
Foetal distress / hypoxia
Damage to foetus (brachial plexus) if you pull
What are two signs that you see with shoulder dystocia
Failure of restitution (head remains in OA, does not become transverse again)
Turtle neck sign( head retracts back into pelvis, neck no longer visible)
How do you manage shoulder dystocia ?
Tell mother to STOP pushing Use only axial traction, avoid downward traction on foetal head (increased risk of brachial plexus injury) Maneuvres: - McRoberts (hyperflex maternal hips) - Suprapubic pressure
Consider episiotomy to increase space for manoeuvres
What are maternal complications form shoulder dystocia
- increased perineal trauma (OASI)
- PPH
- psychological trauma
What are foetal complications from shoulder dystocia
- brachial plexus injury
- fractured clavicle
- hypoxic brain injury
How do you prevent VTE in pregnant patients?
TED stockings
LMWH (clean - enoxaparin)
How do you investigate suspected PE in pregnant patients
V/Q scan
What is uterine ruprute?
Full thickness rupture of uterus
What are RF for uterine rupture?
- VBAC
- Prior uterine surgery
- <12 months from last C sec
- IOL, oxytocin use
How does uterine rupture present during labour’
Maternal shock
Foetal distress /loss of foetal heart on CTG
Unable to palpate any presenting part
Sudden severe abdo pain
How do you manage uterine rupture=
Vaginal exam to confirm
Foetus delivered asap whichever way is fastest
Urgent laparotomy
