Obstetrics

Question 1

What are the causes of postpartum collapse?

Answer 1

Obstetric and non-obstetric

Obstetric: Haemorrhage, VTE, AFE, Cardiac disease, sepsis

Non obstetric:
Hypovolaemia: Haemorrhage most common
Hypoxia: AFE, PE, aspiration
HypoK/Hyper K: Hypoglycaemia
Temp not relevant

Toxicity - local anaesthetic, magenisum, Pre-eclampsia
Thromboembolism as above - also MI, cardiomyopathy
Tamponade - Aortic dissection
Tension - not relevant

Question 2

What is PPH and what is severe PPH?

Answer 2

PPH = blood loss > 500ml
Severe PPH = blood loss > 1000ml

Question 3

What are antenatal risk factors for PPH?

Answer 3

• Previous PPH
• Grand multiparity
• Uterine overdistension eg macrosomia, twins
• Placenta praevia
• Existing uterine abnormalities eg fibroids

Question 4

What are peripartum risk factors for PPH?

Answer 4

• Tone eg prolonged labour, induced labour
• Trauma eg instrumental/surgical delivery
• Tissue eg retained placenta
• Thrombin eg pre-eclampsia, AFE, HELLP

Question 5

What are DDx of post partum peripheral neurological complications:

Answer 5

• Intrinsic obstetric palsy (most common) - due to foetal head pressure on nerves
• Traumatic - intraneural injection/direct needle trauma
• Chemical - adhesive arachonoiditis due to irritants
• Ischaemic - expanding haematoma
• Infective - spinal/epidural abscess

Question 6

What are risk factors for amniotic fluid embolism?

Answer 6

• Maternal: Age >35, multiparity, Diabetes
• feotal: foetal distress, macrosomia, polyhydramnios
• Obstetric: IOL, PROM, uterine rupture, placental pathology, pre-eclampsia, instrumental/LSCS

Question 7

What is the management of amniotic fluid embolism?

Answer 7

• ALS modified for pregnancy if arrested (left uterine displacement, early intubation, periomortem C-section if no rosc within 4 mins)
• ABCs otherwise
• A - early intubation
• B - ventilation with 100% O2, likely to get ARDS, APO so lung protective ventilation (low TV, high RR, high PEEP)
• C - aggressive CVS support, large access, art line, CVC
• MTP if haemorrhage, give platelets empircally as AFE causes thrombocytopaenia
• If refractory to treatment then ECMO

Question 8

What are considerations for non obstetric surgery in the obstetric patient?

Answer 8

Foetal considerations:
- Foetal monitoring pre and post
- First trimester: avoid hypoxia, hypercarbia and hypotension
- Second trimester: best time to do surgery, uterus not too big and organogenesis done
- Third trimester: consider corticosteroids for foetal lung development, avoid NSAIDs

Maternal considerations:
A - increased BMV and intubation difficulty, friable+ oedematous airways, avoid nasal intubations
B - increased O2 requirement, decreased FRC
C - increased cardiac output may decompensate HF
- >18 weeks use left uterine displacement
- increased asp risk
- laparoscopy is safe but increased risk of hypercarbia, and decreased pressures for pneumoperitoneum
- avoid suggamadex as it binds progesterone