Obstetrics emergencies Flashcards
What is antepartum haemorrhage
bleeding from anywhere within the genital tract after 24 weeks of pregnancy, prior to delivery of the fetus
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
- multiparity
- multiple pregnancy
- smoking
How may placenta praevia present
- painless vaginal bleeding around 2nd/3rd trimester
- small bleeds before large
How is placenta praevia diagnosed
- usually picked up on 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 unprotected fetal vessels travel across or near the internal cervical os and below the fetal presenting part
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
- polyhydramnios
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
- prematurity
- multiparity
- 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
- women should be on all fours, or in knee-chest position
- tocolytics (terbutaline) - reduce uterine contractions
When do approximately 50% of cord prolapses occur during labor?
after artificial rupture of the membranes.
Define pre-eclampsia
new onset blood pressure ≥ 140/90 mmHg after 20 weeks gestation and ≥ 1 of
* proteinuria
* organ dysfunction
When does pre-eclampsia typically occur
after 20 weeks gestation
High RFs of pre-eclampsia
- hypertensive disease in previous pregnancy
- T1 or T2 diabetes
- chronic HTN
- chronic kidney disease
- autoimmune disease (eg. SLE or antiphospholipid Ab syndrome)
Moderate RFs of pre-eclampsia
- first pregnancy
- maternal age ≥ 40 years
- BMI ≥ 35
- FHx of pre-eclampsia
- multiple pregnancy
Give 5 ways pre-eclampsia may present
- severe headache
- visual disturbances
- epigastric pain
- oedema
- hyperreflexia
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
- arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
How is pre-eclampsia managed
- arrange emergency secondary care assessments
- if bp >160/110mmHg consider admission and obs
- delivery within 24-48 hours after 37 weeks
- IV magnesium sulphate should also be considered if birth is planned within 24 hours or if there is concern that a woman may develop eclampsia
- Stabilise bp:
- 1st labetalol
- 2nd nifedipine
Give 4 complication of pre-eclampsia
- eclampsia
- fetal growth restriction
- haemorrhage
- cardiac failure
What is prescribed to reduce the risk of hypertensive disorders in pregnancy?
- Aspirin 75-150 mg daily 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
- monitor RR as magnesium sulphate can cause respiratory depression
- treatment should continue for 24 hours after last seizure or delivery, which ever is later
What parameters should be monitored during treatment with magnesium sulphate for eclampsia
urine output, reflexes, respiratory rate and oxygen saturations
Treatment for magnesium sulphate induced respiratory depression
calcium gluconate
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
- maternal DM
- prolonged labour
- 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 vaginal 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 - (uterine atony) mc
* Trauma - perineal tears
* Tissue - retained placenta
* Thrombin - abnormal clotting
GIve 5 RFs for a postpartum haemorrhage
- previous PPH
- multiple pregnancy
- prolonged labour
- macrosomia
- pre-eclampsia
- increased maternal age
How is postpartum haemorrhage managed
- IV fluids
- uterine fundus massage
- lay woman flat and catheterise
- uterine atony: IV oxytocin, IM ergometrine (CI HTN), IM carboprost (CI asthma), rectal misoprostol
- tranexamic acid to reduce bleeding
- treat underlying cause
- surgery: intrauterine balloon tamponade
