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
What are some lower genital tract causes of APH?
- Cervical polyps
- Erosions
- Carcinomas
- Cervicitis
- Vaginitis
- Vulval varicosities
Distinguish between placental abruption and placenta praevia?
A:
- Shock is out of proportion with visible blood loss
- Pain is constant
- Tender, tense uterus
- Normal lie and presentation
- Foetal HR is absent or distressed
- Coagulation problems are common
PP:
- Shock is in proportion to visible loss
- No pain
- Uterus is not tender
- Lie and presentation may be abnormal
- Foetal heart is normal
- Coagulation problems are rare
- More likely to have had smaller bleeds in the run up to this one
What is placental abruption?
Placenta becomes detached from the uterus, causing bleeding into the space created between.
Can eventually cause foetal hypoxia and death
What are some RFs for PA?
- PET
- Smoking
- IUGR
- Multiple preg
- Polyhydramnios
- Raised maternal age
- Thrombophilia
- Abdo trauma
- Cocaine or amphetamine use
Broadly, how do you manage an APH?
- Admit
- 2 large bore cannula, put up IV
- Take bloods (FBC, Us and Es, G and S, Clotting screen, crossmatch 2-6 units)
- Tilt bed down
- Give oxygen
- Catheterise bladder
Summon expert help immediately: Senior Obs, Anaesthetist, Theatre team, Haematologist, Lab staff, Neonatal team
Definitive management of a severe APH is delivery. For milder bleeds continue to monitor (BP, bloods, pulse, CTG 3-4 times a day), US to diagnose.
- If PP is diagnosis, consider admission until deliver
- IF PA which has resolved woman can be discharged with Anti-D, treat as high risk pregnancy
What is a cord prolapse?
Descent of the cord through the cervix after rupture of the membranes. Cord compression and vasospasm are likely, which will cause foetal asphyxia.
What are some RFs for cord prolapse?
- 2nd twin
- Footling breech
- Prematurity
- Polyhydramnios
- Unengaged head
- Unstable or transverse lie
- CP is possible during any ARM procedure as the head is less likely to be presenting well.
How does CP present?
Normally notice cord in introitus but if not only presentation may be foetal bradycardia (in which case do a vaginal exam)
How do you manage a cord prolapse?
- Get senior help
- Activate alarms, tell labour ward
- Lower head of bed, place hand on presenting part and essentially push it back in to prevent compression, avoid handling the cord as this can cause vasospasm
- Ask woman to go into knee to chest position
- Infuse the bladder with 500ml of saline (empty if attempting delivery)
- Give Terbutaline 0.25mg SC to reduce contractions and help with foetal bradycardia
If cervix is fully dilated and presenting part is low in pelvis can delivery by ventouse.
What is shoulder dystocia?
Any delivery requiring additional obstetric measure to release shoulders after downward traction has failed.
High rates of foetal mortality and morbidity (notably brachial plexus injuries, causing permanent disability), increased risk of PPH and 4th degree tears
What are some RFs for shoulder dystocia?
- Large or postmature foetuses
- High maternal BMI (30+)
- Maternal DM
- Induced labour, Oxytocin use
- Prolonged labour
- DM
- Assisted delivery
How id shoulder dystocia managed?
Only way to reduce risk of foetal asphyxiation or injury is speedy delivery, steps to increase speed include:
- Asking for help from extra midwives, senior Obs, anaesthetist, neonatologist
- EPISIOTOMY to give space for internal manoeuvres
- Place legs in MCROBERTS position (successful in 90% of cases)
- Apply suprapubic pressure and see if that helps
- If not, consider internal manoeuvres e.g. rotating the foetus so foetal shoulders lie in oblique angle to birth canal.
- Delivery of posterior arm could be tried next, as could maternal symphysiotomy, bilateral foetal cleidotomy
In practice, McRoberts + suprapubic pressure first. If this fails move onto whichever internal manoeuvre the team feels most comfortable with
What is the main cause of uterine rupture in the UK?
Dehiscence of CS scars.
Other causes include obstructed labour in the multiparous (especially if oxytocin is used), high forceps delivery, internal version, previous cervical or uterine surgery
What are the signs and symptoms of uterine rupture?
- Normally occurs in labour
- Pain can be mild or severe
- Vaginal bleeding is variable and may be slight
- Sudden maternal shock or tachycardia
- Cessation of contractions
How do you manage uterine rupture?
- If in labour, perform category 1 CS
- Give oxygen, set up IV infusion, crossmatch 6 units of blood
- Refer to senior Obs who will decide form of surgery to perform
- May be repairable but may require hysterectomy (esp. if cervix or vagina are torn as less likely to heal)
- Give prophylactic antibiotics post-op e.g. Cefuroxime and Metronidazole
What is Mendelson Syndrome?
Inhalation of Gastric Acid during GA –> Cyanosis + Bronchospasm + Pulmonary Oedema + Tachycardia
Common during pregnancy, labour.
How is Mendelson Syndrome managed?
- Tilt the patient’s head down
- Turn her to one side
- Aspirate the pharynx
- Give 100% O2
- Give Aminophylline 5mg/kg by slow IV infusion + Hydrocortisone 200mg IV stat
Define primary PPH, secondary PPH and Massive Obstetric Haemorrhage?
PPPH = Blood loss greater than 500ml in first 24 hours after childbirth.
SPPH = 500mls loss in after 24 hours delivery, normally caused by retained PoC (+/- infection)
MOH = more than 1500mls
What are the 4 causes of PPH?
- Tone (uterine atony)
- Tissue (retained products of conception)
- Trauma (genital tract trauma)
- Thrombin (clotting disorders)
How do you manage secondary PPH caused by retained PoC?
- US to look for PoC
- Extraction
- Prophylactic antibiotics
Outline the emergency management of a PPH?
GENERAL:
1) Call for help (Obs, Midwife, Anaesthetist), Consider using 2222 to alert haematology of massive haemorrhage
2) High flow oxygen
3) Two large bore cannulas, take bloods including CM 6 units. Consider blood transfusion then and there, consider intubation if reduced LoC.
4) Start IV fluids with 1 litre Hartman’s
5) Catheterise and monitor urine output
NEXT, TREAT BASED ON CAUSE:
Tissue:
- Empty the uterus of any clots, placenta, retained tissue
- If still retained take to theatre
Tone:
- Massage uterus to generate contraction
- Consider bimanual compression
- Give drugs in sequence (starting with Syntometrine, then Oxytocin, then Ergometrine, then Misoprostol, then Carboprost)
- If still bleeding after final drug, take to theatre
- Insert Rusch balloon to compress uterus
- If still bleeding but responds to compressions, put in a B-lynch suture
- If still bleeding, consider Uterine Artery Ligation
- If still bleeding, Hysterectomy
Tears: Surgically repair
Thrombin: Correct any coagulation abnormalities through blood products
How do you manage an inverted uterus?
- Call for help: Obs, Midwife, Anaesthetist
- Attempt immediate replacement by pushing the fundus through the cervix with the palm of your hand
- If this fails: Two LBCs, Bloods, CM 6 units of blood
- IV fluid
- Transfer to theatre for anaesthesia
- Tocolytic drugs e.g. Terbutaline –> Uterine relaxation and makes replacement easier, reattempt manual replaement
- If this fails, consider replacement with hydrostatic pressure, normal saline
- If this still fails, laparotomy.
All the while manage the woman’s pain.
Why does DIC occur so commonly in pregnancy?
DIC is caused by cytokine release, which an occur in a number of obstetric scenarios e.g. delayed delivery of stillbirth, PET, haemorrhage, toxic shock syndrome, amniotic fluid embolism.
How might a woman with DIC present?
- Heavy Bleeding
- Shock
What blood tests suggest DIC?
- Reduced Platelet count from FBC
- Raised Prothrombin time
- Reduced Fibrinogen
D-Dimer is not reliable in pregnancy as often raised anyway
How is DIC in pregnancy managed?
Treat underlying cause, will resolve DIC (e.g. treat haemorrhage, deliver stillbirth, manage PET…)
Specific management:
- Give O2
- 2 wide bore cannulas
- Give blood support products (using expert help from haematologist)
- Frequently reassess clinical picture
What blood products are used in the treatment of DIC in pregnancy?
- Tranexamic acid
- Vit K (especially if prolonged PT)
- Single pool platelets if platelets below 50
- Fibrinogen if low
Again, give according to haematologist guidance
What is Idiopathic Thrombocytopenia Purpura?
Condition whereby autoantibodies destroy platelets causing megakaryocytes to produce larger immature platelets.
AAs can cross the placenta and affect 10% of foetuses.
How is ITP managed in pregnancy?
- Exclude SLE, consider maternal HIV as cause
- If platelets fall below 75, manage with Prednisolone 1mg/kg, reassess frequently.
- If platelet fall below 30, admit for management through haematology.
- Aim for non-traumatic delivery of both mother and baby. Avoid instrumental delivery.
- Take cord blood sample at birth, if platelets below 20 give baby IgG 1g/k at birth.
How does ITP present in a pregnant mother?
- Nose bleeds
- Bleeding gums
- Rashes
What are the clinical features of an amniotic fluid embolism?
- Dysponea
- Chest pain
- Hypoxia
- Respiatory arrest
- ARDS
- Hypotension
- Foetal distress
- Seizures
- Reduced LoC
- Cardiac arrest
- Almost all women subsequently develop DIC
How is an amniotic fluid embolism managed?
Prevent resp failure:
- High flow oxygen, 15L/min, non rebreathable reservoir
- Call an anaesthetist urgently
- Intubation/Ventilation may be necessary
- Most deaths occur as a result of resp failure within first hour, support through that, stabilise then look to manage foetal distress, DIC etc…
- Monitor for foetal distress
- If hypotensive give fluids and/or Dobutamine
- Treat any DIC with fresh whole blood or packed cells and FFP
