Obstetric Emergencies Flashcards by Laura Lazzari

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

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What position myst you put a an unwell pregnant woman?

Left lateral tilt (at 15 degrees) to minimise aorto-caval compression

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What are RF for sepsis?

Ruptured membranes

Infection - UTI, PID, STD, Group B strep, amniocentesis

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What score do you use for onset of sepsis?

By looking at MEOWS

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What are the sepsis 6?

3 in (fluids, high flow oxygen, antibiotics)
3 out (blood culture, lactate, urine output)

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What do you give before, antibiotics or blood cultures?

BLOOD CULTIRES FIRST

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What are common organisms involved in puerperal sepsis?

lance field group A beta haemolytic step

E coli

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What is APH?

Bleeding from or into the genital tract from 24 weeks to delivery

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What are causes of APH?

Placental:

placenta abrupta
placenta previa

Foetal:
- vasa previa.

Maternal:

Vaginal trauma
Cervical ectropion.
Cervical carcinoma
Vaginal infection
Cervicitis

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What is placental abruption?

Premature separation. of. the placenta from the uterine w all

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What are. the two types of placenta abruption

Complete (need to deliver)

Marginal (resolves spontaneously, due to a partial abruption)

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What are the other two types of placental abruption

Revealed

Concealed (bleeding remains in uterus, forming retroplacental clot)

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How do you recognise a concealed abruption

You don’t
All you see is that there is foetal distress
So you deliver immediately

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What are RF for placental abruption

prior abruption
HTN and PET
smoking, maternal age, BMI, cocaine
Trauma to maternal abdomen
Polyhydramnios
Multiple preg
FGR

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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

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What is classical presentation of placental abruption

PAINFUL bleeding with WOODY abdomen

SUDDEN foetal distress

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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!

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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

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What is management of marginal abruption

Conservative 
Give steroids (if 24-34 weeks)
Discharge after 24 h of no more bleeding

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What is managaemtn of severe placental abruption

IMMEDIATE DELIVERY
usually via C sec
+ give Anti D if lady is negative (+ Kleihauer test)

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What is placenta previa?

A placenta covering / enriching the cervical os

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What is a low lying placenta?

A placenta near the cervical os but not covering it

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What are symptoms of. placenta previa?

Painless bleeding

May be spontaneous / triggered by trauma (e.g. sex, speculum)

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What are RF for PP?

Prior PP 
Iatrogenic: CS, curettage to endometrium, uterine surgery
Uterine structural abnormality 
Assisted conception
smoking, advanced maternal age

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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