Obstetric Emergency and Complications Flashcards
What are included in the obstetric emergency
Eclampsia
PE
MI - rare but increasing due to inc maternal age
Amniotic fluid embolus - exceedingly rare
Ante/post-partum Haemorrhage
Uterine rupture
Uterine inversion
Septic shock
Definition of Antepartum Haemorrhage
Bleeding from the genital tract after 24 wks gestation
What is PV bleed termed if it is before 24 wks
Miscarriage
Definition of primary post-partum haemorrhage
Bleeding > 500ml in the first 24 hours post delivery
Definition of secondary post-partum haemorrhage
Excessive bleeding form the genital tract between 24 hours and 6 wks
Possible causes of Antepartum Haemorrhage
Unexplained - 97%, usually marginal placental abruption
Placenta praevia - 1%
Placental abruption - 1%
Cervical specific causes eg cervical erosion, cervical polyp
Trauma
Others - infection, a show (loss of mucus plug), genital tumour, varicosities, vasa preavia
Potential causes of post-partum haemorrhage
4 Ts
Tone - atomic uterus - 90%
Trauma - genital tract trauma - 7%
Tissue - retained produced of conception
Thrombin - abnormal clotting eg coagulopathy, severe pre-eclampsia, placental abruption
Also
Large placenta
Abnormal placental sites —> placental preavia, placental accretion
Uterine inversion
Immediate management of Ante-postpartum haemorrhage
A-F assessment A B C D E F - foetal status eg foetal BP
Assessment of Antepartum Haemorrhage
Maternal assessment
- BP
- pulse
- other signs of haemodynamic compromise eg peripheral vasoconstriction etc
- uterine palpitation - for size, tenderness, foetal lie, presenting parting (if engaged then not a placenta praevia)
Never to perform a VE examination without first exclude a placenta praevia via USS
- once placenta praevia exclude then speculum to assess degree of bleeding
- VE to assess dilatation for delivery
foetal assessment - check if you can hear the heart beat of the foetus
What must you not do in a suspected Antepartum Haemorrhage patient
Never to perform a VE examination without first exclude a placenta praevia via USS —> if you insert your fingers, you can cause the placenta preavia to pop and so haemorrhage
Mx of APH
A-E assessment
- G+S
- coag
- Anti D (if rehesus -ve)
- cannulate just in case
If foetal/maternal compromise —> treat as massive obstetric haemorrhage +/- emergency C/S by experienced obstetrician and anaesthetist
If foetal/maternal haemodynamically stable —> admit for 24 hours to ensure no big APH coming
Further foetal USS for foetal well-being and to confirm placental location
Umbilical artery Doppler - measure the function of placenta which can be affected by small placental abruption
Mx of PPH
Tone - physical, medical and surgical
- physical - uterine massage
- medical
- syntocinon 5 units slow infusion —> ergometrine 500mcg IV bolus —> syntocinon infusion 40 units fast infusion —> Carboprost 250 mcg IM (synthetic prostaglandin) —> misoprostol (prostaglandin analgoue) 800-1000 mcg PR
SESCM
- surgical - uterine tamponade with Rusch ballon, if placental accreta, laparotomy to suture over placental bed, hysterectomy
Tissue - retain product
- active 3rd stage management or manual evacuation
Trauma
- repair genital tract trauma
Thrombin
- correct with blood product
Antepartum risk factor for PPH
Previous PPH Previous retained placenta Maternal low HB Inc BMI Para 4 or more APH Anything that causes oversizing of uterus - Multiple pregnancy - polyhydrammios Maternal age > 35
Intrapartum risk factor for PPH
Induction of labour Prolonged 1st, 2nd or 3rd stage of labour Use of oxytocin Vaginal operative delivery C/S
Definition of placenta abruption
When the placenta separates from the uterus before the delivery of the foetus
blood can accoumlate behind the placenta
Types of placenta abruption
Concealed
- no external bleeding evident (<20%) but instead confined behind the placenta and within the uterine cavity
- more severe form as blood loss can easily be underestimated
Revealed
- vaginal bleeding (80%)
RF for placenta abruption
Previous abruption
Multiple pregnancies
Threaten miscarriage int he earlier part of the same pregnancy
Trauma - RTA, domestic violence
Iatrogenic - ECV
HTN/Pre-eclampsia
Previous C/S
Cocaine or a feta mine use during pregnancy
Thrombophilia
Polyhdramnios due to DM
Presentation of placenta abruption
PV bleed - often darkish blood
Abdo pain - usual presentation, sudden onset, constant and severe
some uterine contraction +/- going into labour
Backache - due to posterior placenta tearing
Woody uterus - hard uterus as blood is irritant
Maternal hypovolaemia - late stage
Shock
Foetal distress
Ix/diagnostic criteria for placenta abruption
Usually Clinical diagnosis
USS only to confirm fetal well-being and exclude placenta praevia
CTG abnormal
Dec Platelet count/coag - if dec = significant abruption
Maternal shock
○ FBC, U and E, LFT ○ G&S (x-match 4-6 unit) ○ Check for HELLP syndrome ○ Coag, prothrombin time/activated partial thromboplastin time ---> inc In the case of severe placental abruption indicating coagulopathy ○ Fibrinogen level § Pregnanct is associated with hyperfibrinogenemia --> modestly depressed fibrinogen level may represent significant coagulopathy § A level of < 200 suggest severe abruption ○ Kleihauer-Betke test § Detect foetal blood cells in maternal circulation --> help with correct dose of Anti-D being given ○ Imaging --> USS
Mx of placenta abruption
admit all women with PV bleed or unexplained abdo pain
Dependence on gestation, signs and symptoms ie severity, maternal CVS status and any evidence of foetal compromise
- At/near term + foetal condition stable –> conservative meangement –> induction of labour by aminotomy and syntocinon infusion for vaginal delivery
- If foetal compromise –> C/S
Definition of placental praevia
When the placenta is inserted, wholly or in part into the lower segment of the uterus
RF for placenta praevia
previous placenta praevia Previous C/S Inc maternal age Inc parity Smoking Cocaine use during pregnancy Previous abortion/TOP Deficient endometrium —> due to past Hx of for example endometriosis, manual removal of placenta Assisted conception
Pathophysiology of placenta praevia
○ Occurs in 5-28% of pregnancies during the 2nd trimester
○ As the uterues grows, the placental site often migrates upwards (usually occur in 2nd and 3rd trimester)
○ Placenta develops from discoid condensation of trophoblasts on th surface of chorion at approx. 8-10 wks of gestation
Position of the placenta is decided by the site of implantation of discoid trophoblasts
Presentation of placenta praevia
Usually incidental finding on routine USS
Painless PV bleed starting after the 28th week —> sudden and profuse bleed
high presenting part or abnormal lie
When is the finding of placenta praevia not worrying
Before 20 weeks since it can still migrate upwards after that
Ix of placenta praevia
§ Foetal anomaly USS –> placenta localisation done as routine
§ If low lying –> follow-up USS incl a TVS at 32 wks
Mx of placenta praevia
§ Advice to come in –> if any bleeding, contraction pain
§ Give steroids between 34 and end of 35th weeks of gestation for a low-lying gestation or placenta praevia
§ C/S = usual method of delivery Type III or more severe of placenta in 3rd trimester
§ For minor previa –> vaginal delivery can be attempted if foetal head below leading edge of placenta
§ Delivery < 37 weeks if
□ Onset of labour which can’t be suppressed
□ Foetal distress
□ Severe growth restriction
□ IUD
□ Severe bleed
Type of placenta previa
Major - grade 3 and grade 4 where the placenta overlaps the internal os
Minor - grade 1 and grade 2 where the placenta does not overlaps the internal os
symptoms of PE in pregnancy
pleuritic chest pain SOB tachycardia hypotension reduced air entry collapse reduced oxygen saturations
incidences of VTE in pregnancy
1-2 / 1000 in pregnancy
incidence of DVT compare to PE
DVT 3 times higher risks than of PE
out of emergency C/S, elective C/S and vaginal delivery, which has the highest risk of having DVT
Emergency C/S has the highest risk because should the baby need emergency C/S, one can imagine that the health status of the women being women ie more dehydrated etc
which period of pregnancy (antenatal, intra-partum and peerperium) has the highest DVT rate
antenatal
which period of pregnancy (antenatal, intra-partum and puerperium) has the highest PE rate
puerperium
what factor is considered to be high risk for VTE in antenatal periods
any previous VTE except a single event related to major surgery
drug of choice in VTE prophylaxis in pregnancy
LMWH
what are the regime of LMWH
twice-daily dosage regime –> tinzaparin, enoxaparin 1mg/kg BD, dalteparin 100 units/kg BD up to 18,000 units/24 hours
when can warfarin can be used
warfarin can only be used for women with prostatic heart valve
pathophysiology of uterine inversion
when placentas fails to detach from the uterus as it exits, pulls on the inside surface and turns the whole uterus inside out
how common is uterine inversion
rare
what are some of the risk factors of uterine inversion
grand multips
incorrect management of the 3rd stage
how does uterine inversion present
usually present as PPH + vaso-vagal shock –> pale, clammy, hypotensive & bradycardia and a mass at the introitus
can also present as significant haemorrhage, clotting abnor and renal dysfunction
how many different types of uterine inversion are there?
1st to 4th degree
1st degree - only slight detachment of the fundus of the uterus
2nd degree - detachment passes cervical neck
3rd degree - detachment at the end of vaginal
4th degree -detachment out majority of the vagina
management of uterine inversion
prepare a theatre for possible laparotomy
cautious administration of tocolytics to allow uterine relaxation (might cause aggressive haemorrhage)
Johnson’s method - try to reposition the uterus manually and quickly by slowly and steadily pushing upwards towards the umbilicus –> then bimanual uterine compression and massage until the uterus is well contracted and bleeding has stopped
if fails –> O’Sullivan’s method - reduce inversion by hydrostatic technique
hypotension and hypovolaemia require aggressive fluid and blood requirement
general anaesthesia or uterine relaxant is then stopped and replaced with oxytocin, ergometrine or prostaglandins to help to contract the uterus
ABx is then started for at least 24 hours
what are some of the tocolytics
nitroglycerin (0.25-0.5mg) IV over 2 mins
or
terbutaline 0.1 - 0.25mg slowly IV
or
magnesium sulfate 4-6g IV over 20 mins
complications of uterine inversion
significant haemorrhage, clotting abnormalities and renal dysfunction can occur if not corrected promptly
what can severe sepsis cause to the pregnancy
mid-trimester rupture of membranes –> managed conservatively
management of septic shock
A-F approach airway breathing cardiac disability exposure foetus
IV broad spectrum ABx eg cefotaxmine, metronidazole +/- gentamicin
inform SCBU, check foetal presentation with USS, betametasone IM 12 mg (2doses 24 hours apart) should the baby be pre-term and need delivery
consider tocolysis (nifedipine and atosiban IV to prevent labour and delivery)
definition of ecalmpsia
grand mal convulsions - occurence of a tonic clonic seizure in association with a diagnosis of pre-eclampsia
mx of eclampsia
A-F assessment
give diazepam or magnesium sulphate to stop fits
prevent further fits by commencing magnesium sulphate infusion
deliver baby as pre-eclampsia/eclampsia are both conditions of the placenta
complication of pre-eclampsia/eclampsia
HELLP syndrome –> haemolysis, elected liver enzymes and low platelet
what is preterm labour
delivery before 37 weeks
what are some clinical features of preterm labour
cervical weakness - inc vaginal discharge, mild lower abdo pain and bulging membranes on examinations
infection, inflammation or abruption = lower abdo pain, painful uterine contractions and vaginal loss
what are some investigations for pre-term labour?
FBC, CRP (raised WBC and CRP - infection)
swabs (HVS, LVS, perianal)
speculum - blood, dischare and liquor
MSU
USS for foetal positiion, presentation and EFW
- consider using fibronectin/transvaginall USS if available
management of preterm labour
if transvaginal cervical length > 15mm –> unlikely to labour
fibronectin assay - if -ve, then unlikely to labour
if both of the above are +ve –> admit
- inform SCBU
- IM betametasone or dexamethasone 24 hours apart
- consider tocolysisi - nifedipine and terbutaline IV to prevent labour and delivery
- IV ABX in labour
what is an amniotic fluid embolus
amniotic fluids, foetal cells, hair enter the maternal blood stream via placenta causing an allergic like reaction
what is the pathophysiology of amniotic fluid embolus
initially pulmonary symptoms maybe minor
but can progress to sudden cardiovascular collapse, acute left ventricle failure with pulmonary oedema, DIC and neurological impairment
clinical features of amniotic fluid embolus
collapse DIC (if the woman survives for 30 mins) unaccountable bleeding seizures right sided heart failure aRDS
mx for amniotic fluid embolus
A-E assessment blood transfusion fluid resus early transfer to ITU - likely to need renal and inotropic support correct clotting require expert help at early stage
when does uterine rupture occur
almost always occurs in labour
aetiology of uterine rupture
previous C-Section scar
risk in a multiparous women on uterine stimulants eg oxytocin
clinical features of uterine rupture
clinically significant uterine bleeding chest of shoulder tip pain sudden shortness of breath scar pain and tenderness cessation of previosuly efficient uterine contractions foetal distress protrusion or epulsion of foetus +/- placenta into the abdo cavity fresh vaginal bleeding haematuria pai nthat break through epidural
ix for uterine rupture
USS - might show the foetus to be in abnor position, haemoperitoneum or absent or thin uterine wall
mx of uterine rupture
A_E assessment
blood transfusion
immediate laparotomy to salvage babe - repair damage or hysterectomy
