Obstetrics: Emergencies Flashcards
What are some risk factors for developing Sepsis in pregnancy?
- Obesity
- Diabetes
- Impaired immunity
- Anaemia
- Pelvic infection
- History of group B strep infection
- Invasive procedures (cervical cerclage, amniocentesis)
- PROM
What are the most common causative organisms of sepsis in pregnancy?
- Group A Strep
- E Coli
What are the features of sepsis in a pregnant woman?
- Fever
- Rigors
- Diarrhoea and Vomiting
- Rash
- Abdo or Pelvic pain
- Cough
- Vag discharge
- Urinary symptoms
What investigations are key to order in a suspected septic pregnant lady?
BEDSIDE:
- Obs
- Mental state exam
- Examine for oedema
- Measure plasma glucose (Hyperglycaemia is associated with sepsis)
BLOODS:
- Raised WCC
- Leucopenia
- Lactate
- Blood Cultures! Before giving antibiotics
MEASURES OF ORGAN DYSFUNCTION:
- Urine output
- Creatinine rise
- LFTs and Clotting
- ABG
What antibiotic is best for pregnant women with Sepsis?
Piperacillin-Tazobactam.
Co-Amox is narrower spec and is associated with nectrotising enterocolitis in neonates
What other interventions beyond antibiotics would you consider?
20 mL/kg of crystalloid initially, consider Vasopressors.
Oxygen.
What additional precautions should be taken during labour in a woman with a history of Sepsis in pregnancy?
- Continuous foetal monitoring.
- Spinal and epidural analgesia should be avoided, GA should be used for CS
- Note that foetal blood sampling is less reliable
What are the most common sources of Sepsis in the puerperium?
- Genital tract and uterus causing endometritis
- Mastitis and/or breast abscesses are less common but do happen.
How do you diagnose eclampsia?
A tonic-clonic seizure in a woman with known pre-eclampsia
When does eclampsia occur?
Anywhere around birth, 40% antenatally, 20% during labour and another 40% post-natally
What are the main causes of death from Eclampsia?
Big 3:
- Cerebral Haemorrhage
- HELLP
- Organ failure
How do you manage Eclampsia?
1) Call for help (Senior Obs, Senior Midwife, Anaesthetic Reg and Neonatologist)
2) Airways, Breathing, Circulation, IV access
3) MAGNESIUM SULFATE!
Initial bolus of 4g IV over 5-10 mins,
Infusion of 1g/hour for 24 hours.
4) Monitor
- Catheterise for hourly urine output
- HR, BP, RR, Sats every 15 mins
- FBCs, Us and Es, LFTs, Creatinine, Clotting studies every 12 hours
- Monitor foetal HR with CTG
5) Once stablilised –> Delivery
- CS is ideal but vaginal is not contra-indicated
How would you manage/investigate recurring seizures in an eclampsia patient?
First rule out cerebral haemorrhage.
If okay, treat with Diazepam.
What medication can be used to manage persisting hypertension?
Labetolol 10mg IV
When should you stop a MgS infusion and how do you reverse these effects?
Toxicity!
- Look for resp rate to fall below 12, OR urine output to fall below 20ml/h OR tendon reflex loss
- Reverse with Calcium Gluconate 1g over 10 mins
What is HELLP Syndrome?
- Severe variant of Eclampsia
- Haemolysis, Elevated Liver enzymes, Low Platelets
- Happen sequentially so good to know order to spot early (LEs rise first, then Ps drop, then H occurs)
- Symptoms: RUQ or Epigastric pain, Nausea, Vomiting, Dark urine
How do you manage HELLP syndrome?
As with pre-eclampsia, MgSulf + Delivery
What are the common OBSTETRIC causes for maternal collapse?
- APH, PPH
- Eclampsia
- ICH (from eclampsia)
- Amniotic fluid embolism
- Sepsis
- Uterine inversion
- Peripartum cardiomyopathy
What are the common NON-OBSTETRIC causes for maternal collapse?
- PE
- Anaphylaxis
- Stroke
- Meningitis
- OD
- DKA
- Pre-existing cardiac disease
What are the most common dangerous causes of APH?
- Abruption
- Placenta praevia
- Vasa praevia