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Obstretics > Obstretics Emergencies > Flashcards

Obstretics Emergencies Flashcards

1
Q

Risk factors for vasa previa

A

Prev c section, lateral placental cord insertion, IVF, smoking, multiple gestation

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2
Q

What is placenta previa?

A

Implantation of the placenta in the lower segment of the uterus at > 16 weeks gestation

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3
Q

RF for placenta previa

A

Multiparity, advanced maternal age, assisted conception, previous placenta previa, previous CS, previous TOP, smoking, multiple preg, structural anomalies

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4
Q

When to deliver placenta previa

A

If uncomplicated, elective C-sect before 38 weeks

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5
Q

What is the PET for preeclampsia

A

FBC, UEC, LFT, uric acid +/- clotting

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6
Q

How to manage preeclampsia antenatally

A

Weekly PET & clinic

U/S fortnightly, fetal surveillance weekly (BPP, Doppler)

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7
Q

Cord prolapse RF

A

General: multiparity, LBW, preterm, breech, mal presentation, polyhydramnios, unengaged
Procedure: ARM, vag manipulation of fetus, ECV, IPV, stabilization of IOL

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8
Q

History and investigations for vasa précis

A

History: asymptomatic/painless PV bleed/bleeding on ROM
Test:
U/S
CTG: sinusoidal HR

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9
Q

Tests for placenta abruptio

A

U/S
CTG
FBC, coag profile, group and hold
Kleihauer and anti-D

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10
Q

Placenta abruptio management

A 
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
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11
Q

How to manage placenta accreta

A

Term C-sect if asymptomatic
Hysterectomy
Occlude uterine arteries with inflation of balloon catheter

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12
Q

Test for placenta accreta

A

U/S 20 weeks, increased AFP in 2nd trimester

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13
Q

Diagnosis of placenta previa

A

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

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14
Q

Antenatal management of placenta previa

A

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

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15
Q

Emergency mx of placenta previa

A 
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
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16
Q

Features of placenta previa

A 
Painless PV bleed > 20 weeks 
- sudden onset, bleeding stops spontaneously but may recur several times 
PCB 
Pelvic cramping 
High fetal presenting part
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17
Q

APH classifications

A

Minor is <50 ml
Major is 50-1000 ml
Massive is >1000 ml and signs of shock

18
Q

Investigations for APH

A

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

19
Q

Cord prolapse management

A

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

20
Q

Diagnosis of cord prolapse

A

VE: soft pulsating mass
CTG: prolonged fetal bradycardia and prolonged or variable decelerations
USG

21
Q

Risk factor for cord prolapse

A

General: multiparity, LBW, preterm, breech, malpresentation, polyhydramnios, unengaged
Procedural: ARM, vaginal manipulation of fetus, ECV, IPV, stabilizing IOL

22
Q

Shoulder dystocia acronym

A

HELPERRDD

23
Q

Complications of shoulder dystocia

A 
Need to resus neonate 
Birth asphyxia 
Facial purpuric rash
Clavicle fracture
Brachial plexus injury 
Maternal perineal trauma 
Uterine rupture and PPH
24
Q

Signs of shoulder dystocia

A

Turtle sign, infants shoulder does not deliver with gentle symmetric traction, head does not restitute or externally rotate, difficult delivering face and chin

25
Q

PPH definition, primary and secondary

A

Blood loss >500ml from genital tract after normal vaginal delivery, >750mml if csection

primary: first 24h
secondary: >24h and up to 6 weeks postpartum

26
Q

Minor and Major PPH definition

A

Minor: 500ml or more
Major: 1000ml or more

27
Q

Etiology for PPH

A

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)

28
Q

Management of PPH flow

A
  1. 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
  2. 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
  3. Resuscitation
  4. Identify and treat the cause
29
Q

Minor PPH initial measures without clinical shock

A

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

30
Q

Major PPH with ongoing hemorrhage OR clinical shock

A

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

31
Q

Uterotonic medications first second and third line

A

Oxytocin IV/IM
Sytometrine IM
Ergometrine IM

Oxytocin infusion

Misoprostol
Carboprost tromethamine

32
Q

Oxytocin indication, dose/route, SE

A

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

33
Q

Syntometrine indications, dose/route, CI and SE

A

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

34
Q

Ergometrine indications, dose/route and SE, CI

A

First line alternative for atonic uterus

250 micrograms IM

Same SE and CI as synthometrine

35
Q

Oxytocin infusion indication and dose

A

Second line to maintain uterine tone when achieved

40 units in 500ml compound sodium lactate, IV infusion at 125ml per hour

36
Q

Managing tone PPH

A

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

37
Q

Complications of PPH

A 
IDA 
Hemorrhagic shock 
Operative interventions
Infection
Delayed lactation
Significant morbidity 
Renal impairment 
Death
38
Q

Prophylaxis for PPH

A

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

39
Q

Third stage management after C section

A

Oxytocin 5 units slow IV
Oxytocin infusion
In women with sig risk of PPH, IV tranexamic acid

40
Q

Antenatal RF for PPH

A

History of PPH, high BMI, maternal anemia, APH, previous macrosomia baby, polyhydramnios, fibroids, IOL, known coagulopathy, abnormal placentation, hypertensive disorders, placenta previa, multiple pregnancy

41
Q

Intrapartum RF for PPH

A

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

42
Q

Risk Factors for placenta abruptio

A 
Pre-eclampsia/HTN 
SMOKING 
Cocaine
Chorioamnionitis 
Uterine trauma 
Twins/polyhydramnios 
Previous history of abruptio 
FGR

Obstretics (8 decks)

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