OBSTETRICS 1: O&G Emergencies Flashcards
Summarise sepsis in pregnancy?
Common in pregnancy and post-partum - some sx masked.
SOURCES = UTI/pyelonephritis, chorioamnionitis/endometritis (GBS), mastitis
IX = FBC, U&Es, LFTs, CRP, HVS/MSU +/- CXR, USKUB, US pelvis, US breast, CTG
Rx = sepsis 6 (administer O2 take blood cultures, give IV abx, give IV fluids, check serial lactates, measure urine output)
Maintain a low threshold for admission and IV abx
What is the leading cause of maternal mortality in developed countries?
DVT/PE/central venous sinus thrombosis
What are RFs for VTE in pregnancy?
- prev. VTE
- 1st degree relative
- > 35yo
- parity
- operative delivery
- PPH
- malignancy
- smoking
- HTN / PET / GDM
- IVF
- infection
How is VTE investigated and managed in pregnancy?
Ix = ‘walking’ / exertional HR and sats, ECG, US doppler LL, CTPA (+/- CXR), MRV (magnetic resonance venography)
Rx = LMWH throughout pregnancy, at least 3mths post-partum. Haem follow up 3mths post-partum
What are extra questions to ask in a history of antepartum haemorrhage?
- smears/prev. cervical history
- provoked?
- RFs for abruption - smoking/drugs esp. cocaine, blood group and rhesus status
What is placenta praevia?
Low-lying placenta
50% of antepartum haemorrhages
Categorised as minor (Grade I/II) = close to os
Major (Grade III/IV) = covering os
If placenta low on 20w scan, follow up at 32w and again tt 36w if still low.
If <2cm from os at term, for ELCS.
If presenting w/acute bleeding, admit for min. 24hrs, consider delivery if any compromise or ongoing bleeding
Summarise placental abruption?
Can be concealed.
Sx = sudden onset constant abdo pain, w/PVB, tense woody uterus, tender to palpate, may have reduced movement/fetal distress, may be in labour
Ix = CTG, USS
Mx = admit, bloods and IV access, likely delivery via c-section cat 1
What is vasa praevia?
When the fetal vessels run in membranes below presenting part, rare but high risk of mortality.
RFs = low lying placenta, multiple pregnancy, IVF, bilobed / succenturiate lobed placentas
Mx = c-section cat 1
Outline shoulder dystocia?
DEFINITION = bony impaction of anterior shoulder against pubic arch
RFs = prev. shoulder dystocia, assisted delivery, nulliparity, diabetes, obesity
Mx = call for help/emergency buzzer
- flatten bed
- McRoberts
- Episiotomy
- Suprapubic pressure
- Woodscrew’s manouvere
- Reverse Woodscrew’s
- Delivery of posterior arm
- All fours + repeat
- Cleidotomy / symphysiotomy / Zavenelli
What is the definition and causes of post-partum haemorrhage?
Definition:
- >500 = minor
- >1000 = major
<24hrs = primary
>24hrs = secondary
Causes:
Tone
Trauma
Tissue
Thrombin (clotting)
What are RFs for PPH?
TONE = prev. uterine atony, age, BMI, ethnicity, IOL, macrosomia, multiples
TRAUMA = episiotomy, tears, c-section
TISSUE = retained POC, fragments
THROMBIN = abruption / PET / DIC, vWD, haemophilia
How is PPH managed initially?
- help
- A-E
- oxygen 15L non-rebreathe
- IV access x2 large bore cannulae
- IV fluids
- FBC, U&Es, coagulation, G&S + crossmatch, LFTs, VBG
- catheter accurate U/O
Examine and establish cause
How are TONE causes of PPH managed?
Conservative = bimanual compression
Medical = syntocinon 40U IV, ergometrine IM, carboprost/haemabate IM, misoprostol PR
(generally avoid ergometrine and carboprost if hypertensive disease in pregnancy)
Surgical = EUA, direct uterine massage, uterine packing, bakri balloon, compression sutures, B-lynch, pelvic devascularization/uterine artery catheterisation, hysterectomy
What is breech presentation and what RFs are there?
DEFINITION = presenting part buttocks or feet (undiagnosed = failed to be diagnosed earlier in pregnancy)
RFs = prev. breech, preterm labour, high parity, multiple pregnancy, poly/oligohydramnios, uterine abnormalities, maternal pelvic tumour or fibroids, placenta praevia, fetal abnormalities
What types of breech are there?
Extended/frank
Flexed/complete
Footling
How is breech presentation managed?
If still breech at 36w, offer ECV
- works 50% of time, 1/200 risk EMCS
Otherwise ELCS or possibly vaginal breech birth
What is umbilical cord prolapse and what are the RFs?
DEFINITION = descent of umbilical cord through cervix either alongside (occult) or past (overt) presenting part, in presence of ruptured membranes
RFs = breech, unstable lie, oblique/transverse lie, fetal congenital abnormalities, polyhydramnios, ECV, LBW, ARM, engaged/high presenting part, prematurity
How is umbilical cord prolapse managed?
- call for help
- relieve pressure on cord (elevate presenting part)
- position
- immediate birth
Summarise uterine rupture?
DEFINITION = spontaneous tearing of uterus (usually through prev. CS scar)
Risk of VBAC uterine rupture 1/200 and 2-3x w/induction.
Sx = fetal distress, constant pain, losing ability to monitor/feel contractions
Mx = caesarean/laparotomy
What is the definition of pre-eclampsia?
BP >160/100 and proteinuria (PCR >30)
OR
BP >140/90 and proteinuria w/any of following:
- severe headache
- visual disturbance
- severe RUQ pain/vomiting/liver tenderness
- papilloedema
- >3 beats of clonus
- HELLP
- PLTs <150, ALT >70
What are RFs for pre-eclampsia?
Increased risk if 1 high RF or >1 moderate RF
HIGH RFs =
- hypertensive disease in prev. pregnancy
- CKD
- autoimmune disease e.g. SLE, antiphospholipid syndrome
- T1DM, T2DM
- chronic hypertension
MODERATE RFs =
- first pregnancy
- >40yo
- pregnancy interval >10yrs
- BMI >35
- FHx of pre-eclampsia
- multiple pregnancy
How is pre-eclampsia managed antenatally?
High risk of pre-eclampsia = 75mg to 150mg of aspirin daily from 12w until birth of baby
Monitor
Plan for labour/birth
How is pre-eclampsia managed acutely?
- Stabilise = control BP (labetalol or nifedipine), prevent seizures
- Monitor = obs, U/O and PCR, strict fluid balance, FBC/coag/U&Es/LFTs, neurological status, sx, CTG
- plan for labour/birth
How is eclampsia managed?
- Call for help
- Airway - left lateral position
- Breathing - high flow O2
- Circulation - IV access and full set of bloods
- Disability - control seizures w/magnesium sulfate 4g IV over 5mins, then maintenance dose 1g/hr for 24hrs, if recurrent seizures further bolus 2g
NOTE: can ask for eclampsia box which contains all necessary drugs, antidotes and instructions
Magnesium toxicity - antidote = calcium gluconate or chloride
Summarise fetal bradycardia?
DEFINITION = Deceleration (drop in baseline >15 for >15secs) that goes on longer than 3mins
Mx = change position (usually left lateral), examine, if does not recover, immediate delivery by quickest/safest route
Summarise amniotic fluid embolus?
DEFINITION = abnormal and exaggerated reaction to amniotic fluid entering maternal circulation, causing maternal collapse and often cardiac arrest
Very rare
Sx = anxiety/agitation, sob, resp distress, cardiovascular collapse, DIC
Mx = supportive, early correction of clotting factors, liaising w/ITU and haematology
What investigations are done for hyperemesis gravidarum?
Urinalysis for ketones
MSU - exclude UTI
FBC/U&Es/LFTs
USS to exclude multiple and molar pregnancies
PUQE score = Pregnancy-Unique Quantification of Emesis and Nausea
What is the triad of hyperemesis gravidarum?
Protracted nausea and vomiting of pregnancy with triad of:
- >5% prepregnancy weight loss
- dehydration
- electrolyte imbalance
How is hyperemesis gravidarum managed?
?Admit
IV NaCl w/20mmol K+ or Hartmann’s
Daily U&Es
Anti-emetics - cyclizine, promethazine, proclorperazine, metoclopramide (ondansetron)
Steroids
What is the definition/timeframe for miscarriage?
Defined as <24 weeks but majority <12 weeks
What are the types of miscarriage?
Threatened = bleeding/abdo pain w/closed cervix w/gestation sac/fetal pole/FH activity
Complete = bleeding/pain cease, closed cervix + empty uterus
Incomplete = bleeding/pain, open cervix, gestation sac/some endometrial thickness
Inevitable = bleeding/pain, open cervix, gestation sac/fetal pole/ FH
What are the management options for miscarriage?
Expectant
Medical = mifepristone (anti-progestogenic steroid if cervix needs to be more open) and misoprostol (prostaglandin analogue)
Surgical = ERPC, MVA (manual vacuum aspiration)
What is an ectopic pregnancy and what are the RFs?
Implantation of conceptus outside the uterine cavity - mostly tubal. Most commonly in ampulla
RFs =
- history of infertility or assisted conception
- PID
- endometriosis
- pelvic/tubal surgery
- prev. ectopic
- IUCD
- smoking
How is an ectopic pregnancy investigated and managed?
IX = TVUSS, hCG and progesterone
Mx:
- Expectant = as long as hCG falling <3000, asx, stable
- Medical = methotrexate single dose IM
- Surgical = salpingectomy > salpingostomy (unless contralateral tube damaged)
How is ovarian torsion investigated and managed?
TVUSS w/whirlpool sign
Mx = transfer to theatre - cystectomy vs oophorectomy
What is a bartholin’s abscess?
Blocked and infected bartholin’s duct in lower third of labia majora.
Rx =
- antibiotics
- word catheter
- incision and marsupialisation (cutting abscess open and then suturing together)
