OBSTETRICS 1: O&G Emergencies

Question 1

Summarise sepsis in pregnancy?

Answer 1

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

Question 2

What is the leading cause of maternal mortality in developed countries?

Answer 2

DVT/PE/central venous sinus thrombosis

Question 3

What are RFs for VTE in pregnancy?

Answer 3

• prev. VTE
• 1st degree relative
• > 35yo
• parity
• operative delivery
• PPH
• malignancy
• smoking
• HTN / PET / GDM
• IVF
• infection

Question 4

How is VTE investigated and managed in pregnancy?

Answer 4

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

Question 5

What are extra questions to ask in a history of antepartum haemorrhage?

Answer 5

• smears/prev. cervical history
• provoked?
• RFs for abruption - smoking/drugs esp. cocaine, blood group and rhesus status

Question 6

What is placenta praevia?

Answer 6

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

Question 7

Summarise placental abruption?

Answer 7

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

Question 8

What is vasa praevia?

Answer 8

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

Question 9

Outline shoulder dystocia?

Answer 9

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

Question 10

What is the definition and causes of post-partum haemorrhage?

Answer 10

Definition:
- >500 = minor
- >1000 = major
<24hrs = primary
>24hrs = secondary

Causes:
Tone
Trauma
Tissue
Thrombin (clotting)

Question 11

What are RFs for PPH?

Answer 11

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

Question 12

How is PPH managed initially?

Answer 12

1. help
2. A-E
3. oxygen 15L non-rebreathe
4. IV access x2 large bore cannulae
5. IV fluids
6. FBC, U&Es, coagulation, G&S + crossmatch, LFTs, VBG
7. catheter accurate U/O

Examine and establish cause

Question 13

How are TONE causes of PPH managed?

Answer 13

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

Question 14

What is breech presentation and what RFs are there?

Answer 14

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

Question 15

What types of breech are there?

Answer 15

Extended/frank
Flexed/complete
Footling

Question 16

How is breech presentation managed?

Answer 16

If still breech at 36w, offer ECV
- works 50% of time, 1/200 risk EMCS

Otherwise ELCS or possibly vaginal breech birth

Question 17

What is umbilical cord prolapse and what are the RFs?

Answer 17

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

Question 18

How is umbilical cord prolapse managed?

Answer 18

1. call for help
2. relieve pressure on cord (elevate presenting part)
3. position
4. immediate birth

Question 19

Summarise uterine rupture?

Answer 19

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

Question 20

What is the definition of pre-eclampsia?

Answer 20

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

Question 21

What are RFs for pre-eclampsia?

Answer 21

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

Question 22

How is pre-eclampsia managed antenatally?

Answer 22

High risk of pre-eclampsia = 75mg to 150mg of aspirin daily from 12w until birth of baby

Monitor

Plan for labour/birth

Question 23

How is pre-eclampsia managed acutely?

Answer 23

1. Stabilise = control BP (labetalol or nifedipine), prevent seizures
2. Monitor = obs, U/O and PCR, strict fluid balance, FBC/coag/U&Es/LFTs, neurological status, sx, CTG
3. plan for labour/birth

Question 24

How is eclampsia managed?

Answer 24

1. Call for help
2. Airway - left lateral position
3. Breathing - high flow O2
4. Circulation - IV access and full set of bloods
5. 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

Question 25

Summarise fetal bradycardia?

Answer 25

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

Question 26

Summarise amniotic fluid embolus?

Answer 26

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

Question 27

What investigations are done for hyperemesis gravidarum?

Answer 27

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

Question 28

What is the triad of hyperemesis gravidarum?

Answer 28

Protracted nausea and vomiting of pregnancy with triad of:
- >5% prepregnancy weight loss
- dehydration
- electrolyte imbalance

Question 29

How is hyperemesis gravidarum managed?

Answer 29

?Admit

IV NaCl w/20mmol K+ or Hartmann’s
Daily U&Es
Anti-emetics - cyclizine, promethazine, proclorperazine, metoclopramide (ondansetron)
Steroids

Question 30

What is the definition/timeframe for miscarriage?

Answer 30

Defined as <24 weeks but majority <12 weeks

Question 31

What are the types of miscarriage?

Answer 31

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

Question 32

What are the management options for miscarriage?

Answer 32

Expectant

Medical = mifepristone (anti-progestogenic steroid if cervix needs to be more open) and misoprostol (prostaglandin analogue)

Surgical = ERPC, MVA (manual vacuum aspiration)

Question 33

What is an ectopic pregnancy and what are the RFs?

Answer 33

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

Question 34

How is an ectopic pregnancy investigated and managed?

Answer 34

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)

Question 35

How is ovarian torsion investigated and managed?

Answer 35

TVUSS w/whirlpool sign

Mx = transfer to theatre - cystectomy vs oophorectomy

Question 36

What is a bartholin’s abscess?

Answer 36

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)