Obstretics Emergencies Flashcards
Risk factors for vasa previa
Prev c section, lateral placental cord insertion, IVF, smoking, multiple gestation
What is placenta previa?
Implantation of the placenta in the lower segment of the uterus at > 16 weeks gestation
RF for placenta previa
Multiparity, advanced maternal age, assisted conception, previous placenta previa, previous CS, previous TOP, smoking, multiple preg, structural anomalies
When to deliver placenta previa
If uncomplicated, elective C-sect before 38 weeks
What is the PET for preeclampsia
FBC, UEC, LFT, uric acid +/- clotting
How to manage preeclampsia antenatally
Weekly PET & clinic
U/S fortnightly, fetal surveillance weekly (BPP, Doppler)
Cord prolapse RF
General: multiparity, LBW, preterm, breech, mal presentation, polyhydramnios, unengaged
Procedure: ARM, vag manipulation of fetus, ECV, IPV, stabilization of IOL
History and investigations for vasa précis
History: asymptomatic/painless PV bleed/bleeding on ROM
Test:
U/S
CTG: sinusoidal HR
Tests for placenta abruptio
U/S
CTG
FBC, coag profile, group and hold
Kleihauer and anti-D
Placenta abruptio management
Resus: ABCDE. - 2 large bore cannulae - IV fluids - blood for tests - packed RBC/FFP/cryoppt If fetal heart present: - preterm and stable: CS/MGSO4 if needed + tocolytics - preterm and unstable: emergency CS - term and stable: ARM + oxytocin, anticipate PPH If FH absent: - induce labour + vag delivery - anticipate PPH
How to manage placenta accreta
Term C-sect if asymptomatic
Hysterectomy
Occlude uterine arteries with inflation of balloon catheter
Test for placenta accreta
U/S 20 weeks, increased AFP in 2nd trimester
Diagnosis of placenta previa
Mid-trimester scan at 20-22 weeks
If suspected PP, do TVS
Then follow up at 32 weeks with another scan
If asymptomatic, consider another scan at 34-36 weeks
Antenatal management of placenta previa
Counsel regarding complications such as risk of bleeding, preterm birth, PPH, C-section
Prevent anemia
Consider early admission
MUST admit if active bleeding, major PP, > 2 bleed episodes, need C-section
Emergency mx of placenta previa
ABCDE 2 large bore IV cannulae FBC, HCT, platelet, fibrinogen, Kleihauer, group and cross match, coag Once stable - continuous CTG - MGSO4 and CS if needed - ultrasound once bleeding stops - discuss possible hysterectomy - emergency c section if heavy bleed - if less than 37 weeks, continue monitoring for 48 hours then discharge - follow up with 2 weekly ultrasound
Features of placenta previa
Painless PV bleed > 20 weeks - sudden onset, bleeding stops spontaneously but may recur several times PCB Pelvic cramping High fetal presenting part
APH classifications
Minor is <50 ml
Major is 50-1000 ml
Massive is >1000 ml and signs of shock
Investigations for APH
Minor
- FBC, G&H, coag studies of platelets low and consumptive coagulopathy suspected
Major/Massive
- FBC, consider VBG for rapid hemoglobin if unstable
- coag studies if ongoing bleed or suspected coagulopathy/preeclampsia , consider monitoring every 30-60 mins
- cross match 4 units in all with clinically significant bleeding
- UEC and LFT
- Kleihauer
- once stable, ultrasound for placental location, abnormal vessels, fetal growth/biophysical status
Cord prolapse management
Call for help
If not fully dilated, c-section
If birth imminent; operative vaginal delivery
Fill bladder to elevate presenting part
Adopt knee-to-chest position
Manually keep presenting part out of pelvis
Consider tocolytics while prepping for c section
Diagnosis of cord prolapse
VE: soft pulsating mass
CTG: prolonged fetal bradycardia and prolonged or variable decelerations
USG
Risk factor for cord prolapse
General: multiparity, LBW, preterm, breech, malpresentation, polyhydramnios, unengaged
Procedural: ARM, vaginal manipulation of fetus, ECV, IPV, stabilizing IOL
Shoulder dystocia acronym
HELPERRDD
Complications of shoulder dystocia
Need to resus neonate Birth asphyxia Facial purpuric rash Clavicle fracture Brachial plexus injury Maternal perineal trauma Uterine rupture and PPH
Signs of shoulder dystocia
Turtle sign, infants shoulder does not deliver with gentle symmetric traction, head does not restitute or externally rotate, difficult delivering face and chin
PPH definition, primary and secondary
Blood loss >500ml from genital tract after normal vaginal delivery, >750mml if csection
primary: first 24h
secondary: >24h and up to 6 weeks postpartum
Minor and Major PPH definition
Minor: 500ml or more
Major: 1000ml or more
Etiology for PPH
Tone: Overdistended uterus (multiple preg, macrosomia, polyhydramnios), uterine exhaustion (prolonged second stage, oxytocin induced), intra-amniotic infection, drug-induced (anaesthetic)
Trauma: Episiotomy or perineal tears, C-section, uterine rupture, uterine inversion (high parity)
Tissue: Retained placental products, placenta accreta
Thrombin: Abnormalities of coagulation (thrombocytopenia, preeclampsia, ITP, factor disorders)
Management of PPH flow
- Identify severity
- measure all vaginal blood loss but consider s&s of hypovolemia, speed of blood flow, women’s prior Hb and blood vol
- total blood vol at term is 100ml/kg - Communication
- call for help, alert midwife and obstetric resident and registrar if minor PPh without shock
- if major PPH, alert multidisciplinary team
- senior members of staff must attend if PPH >1500 and ongoing bleeding or shock - Resuscitation
- Identify and treat the cause
Minor PPH initial measures without clinical shock
Palpate uterine fundus and if lax, rub it up to stimulate contraction if actively bleeding prior to placenta being delivered
Administer uterotonics
Obtain IV access
Perform gene puncture for group & screen, FBC, coag screen
Commence crystalloid (compound sodium lactate) infusion
If placenta in situ attempt delivering by CCT
Insert urinary catheter
If actively bleeding massage fund us
Once placenta delivered, check placenta and membranous for completeness
Check for vaginal trauma, apply pressure to any bleeding tissue and suture immediately if able
Maternal observations every 15 minutes
- PR, RR, BP, uterine tone
- measured blood loss on pads
- accumulated blood loss in ML
Major PPH with ongoing hemorrhage OR clinical shock
Simultaneously commence resus and identify and treat cause and stop bleeding
Assess airway and breathing; administer high flow oxygen via face mask 15L per minute
Assess circulation
- left lateral tilt position
- IV access
- venepuncture for cross match, FBC, cog screen, RFT, LFT
- give IV tranexamic acid (within 3 hours) repeat in 30 mins if bleeding still
-fluid resus initially with compound sodium lactate warmed, up to 2L UNTIL blood available. infuse as quickly as possible using rapid infusion set or pressure cuff
- insert urinary catheter w burette
- commence fluid balance chart
- blood and blood products. plan to provide early FFP, cryoppt and platelets. trigger massive transfusion procedure if require more than 4 units RBC and has ongoing bleeding
- intraop cell salvage for emergency use
Record maternal observations every 5-15 minutes
- conscious state, vitals including SaO2
- uterine tone
- measured blood loss
- accumulated blood loss
- temperatures
- hb, coag profile, ionized calcium and acid-base balance
Uterotonic medications first second and third line
Oxytocin IV/IM
Sytometrine IM
Ergometrine IM
Oxytocin infusion
Misoprostol
Carboprost tromethamine
Oxytocin indication, dose/route, SE
First line in women with placenta in situ, hypertension or preeclampsia
5 units by slow IV or 10 units IM if no IV access
Water intoxication, hypotension
Syntometrine indications, dose/route, CI and SE
First line alternative for atomic uterus
1ml IM injection
Avoid with HTN, cardiac dx, asthma, placenta in situ, severe PVD
Administer with antiemetic unless already received within 6 hours
Severe vomiting, HTN, headache, placental entrapment
Ergometrine indications, dose/route and SE, CI
First line alternative for atonic uterus
250 micrograms IM
Same SE and CI as synthometrine
Oxytocin infusion indication and dose
Second line to maintain uterine tone when achieved
40 units in 500ml compound sodium lactate, IV infusion at 125ml per hour
Managing tone PPH
Massage uterus to stimulate uterine contraction and expel clots
Administer uterotonics
Empty bladder to aid contraction and insert catheter
If heavy bleeding continues, perform bi manual compression till further management decisions are made
If intractable bleeding, may need examination under anesthesia, Bakri’s balloon, B-Lynch suture, uterine artery/iliac artery ligation, radiological embolisation, hysterectomy
Complications of PPH
IDA Hemorrhagic shock Operative interventions Infection Delayed lactation Significant morbidity Renal impairment Death
Prophylaxis for PPH
Prevent and treat anemia during pregnancy (Hb <90g/L)
Determine placental location at mid-trimester scan
Recommend prophylactic uterotonics in active management of third stage of labour
Consider IV access early in labor, FBC group and hold or cross match, transfusion plan
Consider use of IV tranexamic acid in addition to oxytocin to reduce blood loss in women at sig risk of PPH
Third stage management after C section
Oxytocin 5 units slow IV
Oxytocin infusion
In women with sig risk of PPH, IV tranexamic acid
Antenatal RF for PPH
History of PPH, high BMI, maternal anemia, APH, previous macrosomia baby, polyhydramnios, fibroids, IOL, known coagulopathy, abnormal placentation, hypertensive disorders, placenta previa, multiple pregnancy
Intrapartum RF for PPH
Augmentation of labour, prolonged latent phase, prolonged active first/second/physiological third/active third stage, surgical intervention, pyrexia, shoulder dystocia, fetal macrosomia, placenta abruptio, incomplete third stage
Risk Factors for placenta abruptio
Pre-eclampsia/HTN SMOKING Cocaine Chorioamnionitis Uterine trauma Twins/polyhydramnios Previous history of abruptio FGR
