Obstetrics emergencies Flashcards
What is antepartum haemorrhage
bleeding from anywhere within the genital tract after 24 weeks of pregnancy
Give 3 common causes of antepartum haemorrhage
- placenta praevia
- placental abruption
- vasa praevia
Give 3 extra placental causes of antepartum haemorrhage
- cervical polyp
- varicose vein
- local trauma
What is placenta praevia
when part of the placenta has implanted into the lower portion of the uterus
How is low-lying placenta different to placenta praevia
- low-lying - used when the placenta is within 20mm of the internal cervical os
- (major/partial) placenta praevia - used only when the placenta is over the internal cervical os
Give 3 RFs for placenta praevia
- previous C section
- older maternal age
- smoking
How may placenta praevia present
painless vaginal bleeding around 2nd/3rd trimester
How is placenta praevia diagnosed
- usually picked up on 20 week anomaly ultrasound scan
- rpt transvaginal USS at 32w to determine placenta position
How is placenta praevia managed
- safety netting - pain/bleeding
- avoid sex if bleeding
- if recurrent bleeding - admit till delivery
- elective lower segment C section around 37/40
What should be done if a woman with known placenta praevia goes into labour before her elective caesarean section?
An emergency caesarean section should be performed due to the risk of postpartum haemorrhage
What is vasa praevia
where the fetal vessels are coursing through the fetal membranes over the internal cervical os and below the fetal presenting part, unprotected by placental tissue or the umbilical cord
Give 3 RFs for vasa praevia
- placenta praevia
- IVF pregnancy
- multiple pregnancy
What is the risk of vasa praevia
if the membranes rupture, there is a risk of major fetal haemorrhage with a high mortality
How is vasa praevia managed
- steroids from 32w (mature fetal lungs)
- elective LSCS 34-37w
What is placental abruption
premature separation of the placenta from the uterine wall during pregnancy
Describe the 2 types of placental abruption
- concealed - bleeding remains within the uterine cavity (behind placenta)
- revealed - blood escapes through the vagina
Give 4 RFs for placental abruption
- pre-eclampsia/ chronic HTN
- smoking
- trauma
- cocaine
- increasing maternal age
Give 5 ways placental abruption may present
- Woody-hard abdo on palpation
- maternal shock disproportionate to blood loss
- fetal distress
- vaginal bleeding
- continuous abdo pain
How is placental abruption managed
- unstable fetus/ mum - emergency C section
- no fetal distress & <36w : admit and give steroids between 24-34 weeks gestation
- no fetal distress & >36w: deliver vaginally
3 fetal complications of placental abruption
- intrauterine growth retardation
- hypoxia
- death
Give 3 maternal complications of placental abruption
- shock
- renal failure
- disseminated intravascular coagulation
What is cord prolapse
when the umbilical cord descends below the presenting part of the fetus into the vagina, after rupture of the fetal membranes
What is the risk of cord prolapse
exposure of the cord leads to vasospasm and can cause increased risk of fetal morbidity and mortality from hypoxia
Give 4 RFs for cord prolapse
- polyhydramnios
- long umbilical cord
- fetal malpresentation - eg breech
- multiple pregnancy
How is cord prolapse managed
- emergency c section
- alleviate pressure on the cord - push presenting part back into uterus
- constant fetal monitoring
- Trendelenburg position (feet higher than head) or knee-to-chest
- tocolytics - reduce uterine contractions
When do approximately 50% of cord prolapses occur during labor?
after artificial rupture of the membranes.
What is pre-eclampsia
hypertension in pregnancy usually with proteinuria
When does pre-eclampsia typically occur
after 20 weeks gestation
Give 7 RFs of pre-eclampsia
- previous pre-eclampsia / FHx
- nulliparity
- diabetes
- chronic HTN/ CKD
- BMI >35
- maternal age >40
- FHx
- autoimmune disease (eg antiphospholipid Ab syndrome)
Give 5 ways pre-eclampsia may present
- severe headache
- visual disturbances
- epigastric pain
- oedema
- clonus
How is pre-eclampsia diagnosed
- new onset high BP: >140/90 mmHg
Plus any of: - Urinalysis - proteinuria
- Organ dysfunction - thrombocytopenia, elevated LFTs and creatinine
- Placental dysfunction - fetal growth restriction
How is pre-eclampsia managed
- arrange emergency secondary care assessments
- if bp >160/110mmHg consider admission and obs
- Stabilise bp:
- 1st labetalol
- 2nd nifedipine
- 3rd methyldopa
- magnesium sulphate if hyperreflexia
Give 4 complication of pre-eclampsia
- eclampsia
- intrauterine growth retardation and prematurity
- haemorrhage
- cardiac failure
What is used for prophylaxis against the development of pre-eclampsia. When is this given
- Aspirin 75-150mg if at mod/high risk
- given from 12w gestation until birth
What is eclampsia
onset of seizure in a woman with pre-eclampsia
How is eclampsia managed
- IV magnesium sulfate 4mg over 5 mins
- 1g/hr infusion of magnesium sulfate for 24h
- treat HTN
What are the key characteristic of HELLP syndrome
Haemolysis
Elevated Liver enzymes
Low Platelets
What is shoulder dystocia
failure of the anterior shoulder to pass under the pubic symphysis after delivery of the foetal head
Give 5 RFs for shoulder dystocia
- macrosomia (large baby > 8 pounds 13 ounces)
- maternal DM
- disproportion between mother and fetus
- maternal obesity
- previous shoulder dystocia
How is shoulder dystocia managed (8)
HELPERRR
* call for help
* elevate for episiotomy
* legs into McRoberts
* Suprapubic Pressure
* Enter pelvis
* rotational maneuvers (rubin & wood’s screw
* remove posterior arm
* roll patient to hands and knees
Give 3 complications of shoulder dystocia to the mother
- postpartum haemorrhage
- 3rd/4th degree perineal tears
- psychological distress
Give 3 complications of shoulder dystocia to the baby
- hypoxia and subsequent cerebral palsy
- injury to brachial plexus
- fits
What is postpartum haemorrhage
blood loss of >500mls after delivery (>1000ml if C-section)
Define primary and secondary postpartum haemorrhage
- primary - bleeding within 24h of delivery
- secondary - bleeding from 24h to 12 weeks after birth
Define minor and major postpartum haemorrhage
- minor: 500-1000mls blood loss
- major: >1000mls blood loss
Give 4 causes of postpartum haemorrhage
4 Ts
* Tone - lack of uterine contraction
* Trauma - perineal tears
* Tissue - retained placenta
* Thrombin - abnormal clotting
GIve 5 RFs for a postpartum haemorrhage
- previous PPH
- multiple pregnancy
- prolonged labour
- large baby (LGA)
- instrumental delivery
How is postpartum haemorrhage managed
- IV fluids
- uterine massage
- uterine atony: IV oxytocin, IM ergometrine, IM carboprost
- lay woman flat and catheterise
- tranexamic acid to reduce bleeding
- treat underlying cause
- surgery: intrauterine balloon tamponade
