OSCE emergencies (Obs and Gynae) Flashcards
key emergencies in Obs and Gynae
Obs
- Preterm labour
- Eclampsia
- Uterine rupture
- Amniotic fluid embolism
- PPH
- Placenta praevia
- Placental abruption
- Sepsis
- Post partum psychosis
Gynae
- Miscarriage
- Ectopic pregnancy
- Ovarian rupture/torsion
- PID
- Hyperemesis
- Testicular tortion
prelabour rupture of membranes
The amniotic sac has ruptured before the onset of labour.
Preterm prelabour rupture of membranes (P‑PROM):
The amniotic sac has ruptured before the onset of labour and before 37 weeks gestation (preterm).
prematurity definition
birth before 37 weeks gestation
Babies are considered non-viable below
23 weeks gestation
prophylaxis of preterm labour
Between weeks 16 to 24
- Vaginal progesterone: decreases activity of myometrium and cervix rmeodelling in prep for delivery
- Cervical cerclage: invovles putting a stich in cervix to keep it closed
“Rescue” cervical cerclage
may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.
diagnosing preterm prelabour rupture of membranes
Rupture of membranes can be diagnosed by:
- Speculum examination revealing pooling of amniotic fluid in the vagina.
- No tests are required.
Where there is doubt about the diagnosis, tests can be performed:
- Insulin-like growth factor-binding protein-1 (IGFBP-1) is a protein present in high concentrations in amniotic fluid, which can be tested on vaginal fluid if there is doubt about rupture of membranes
management of Preterm Prelabour Rupture of Membranes
- Prophylactic antibitoics to prevent chorioamnionitis (erythromycin)
- Induction of labour from 34 weeks
management of Preterm Labour with Intact Membranes
- Fetal monitoring (CTG or intermittent auscultation)
- Tocolysis with nifedipine: nifedipine is a calcium channel blocker that suppresses labour
- Maternal corticosteroids: can be offered before 35 weeks gestation to reduce neonatal morbidity and mortality
- IV magnesium sulphate: can be given before 34 weeks gestation and helps protect the baby’s brain
- Delayed cord clamping or cord milking: can increase the circulating blood volume and haemoglobin in the baby at birth
how are antental sterois given
two doses of intramuscular betamethasone, 24 hours apart.
role of magnesium sulfate in preterm labour
- protect fetal brain reducing risk of CP
- given within 24 hours od delivery of babies less than 34 weeks
- given as an IV bolus
Side effect: magnesium toxicity
magnesium toxicity
Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:
- Reduced respiratory rate
- Reduced blood pressure
- Absent reflexes
inducing labour indication
Induction of labour can be used where patients go over the due date. IOL is offered between 41 and 42 weeks gestation.
Induction of labour is also offered in situations where it is beneficial to start labour early, such as:
- Prelabour rupture of membranes
- Fetal growth restriction
- Pre-eclampsia
- Obstetric cholestasis
- Existing diabetes
- Intrauterine fetal death
options for induction of labour
- Membrane sweep
- Vaginal prostaglandinE2 (dinoprostone)
- Cervical ripening balloon
- Artifical rupture of membranes with oxytocin infusion
- Oral mifepristone (anti-progesterone)
There are two means for monitoring during the induction of labour.
- Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour
- Bishop score before and during induction of labour to monitor the progress
complication of induction of labour
uterine hyperstimulation
Uterine hyperstimulation
is the main complication of induction of labour with vaginal prostaglandins. This is where the contraction of the uterus is prolonged and frequent, causing fetal distress and compromise.
The two criteria often given are:
- Individual uterine contractions lasting more than 2 minutes in duration
- More than five uterine contractions every 10 minutes
Uterine hyperstimulation can lead to:
- Fetal compromise, with hypoxia and acidosis
- Emergency caesarean section
- Uterine rupture
Management of uterine hyperstimulation involves:
- Removing the vaginal prostaglandins, or stopping the oxytocin infusion
- Tocolysis with terbutaline
Management of Failure to Progress
Experienced midwives and obstetricians will manage failure to progress. The main options for managing failure to progress are:
- Artificial rupture of membranes (ARM) for women with intact membranes
- Oxytocin infusion
- Instrumental delivery
- Caesarean section
Pre-eclampsia
refers to new high blood pressure (hypertension) in pregnancy with end-organ dysfunction, notably with proteinuria (protein in the urine).
- It occurs after 20 weeks gestation, when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels
Pre-eclampsia features a triad of:
Hypertension
Proteinuria
Oedema
complications of pre-eclampsia
maternal organ damage
fetal growth restirction
seizures (eclampsia)
early labour
Pregnancy-induced hypertension or gestational hypertension is
hypertension occurring after 20 weeks gestation, without proteinuria.
eclampsia
when seizures occur as a result of pre-eclampsia.
risk factors for pre-eclampsia
Risk Factors
The NICE guidelines categorise the risk factors into high-risk and moderate-risk factors.
High-risk factors are:
- Pre-existing hypertension
- Previous hypertension in pregnancy
- Existing autoimmune conditions (e.g. systemic lupus erythematosus)
- Diabetes
- Chronic kidney disease
Moderate-risk factors are:
- Older than 40
- BMI > 35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- Family history of pre-eclampsia
prophylaxis against risk factors for pre-eclampsia
Women are offered aspirin from 12 weeks gestation until birth if they have:
- one high-risk factor or
- more than one moderate-risk factors.
Pre-eclampsia has symptoms of the complications:
- Headache
- Visual disturbance or blurriness
- Nausea and vomiting
- Upper abdominal or epigastric pain (this is due to liver swelling)
- Oedema
- Reduced urine output
- Brisk reflexes
diagnosis of pre-eclampsia
- Systolic blood pressure above 140 mmHg
- Diastolic blood pressure above 90 mmHg
PLUS any of:
- Proteinuria (1+ or more on urine dipstick)
- Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
- Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
When pre-eclampsia is diagnosed, the general management is similar to gestational hypertension, except:
- Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
- Blood pressure is monitored closely (at least every 48 hours)
- Urine dipstick testing is not routinely necessary (the diagnosis is already made)
- Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
Medical management of pre-eclampsia is with:
Antihypertensives
- Labetolol is first-line as an antihypertensive
- Nifedipine (modified-release) is commonly used second-line
During labour:
- IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures
- Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload
if high blood pressure cannot be controlled
Eartly delivery and give corticosteroids to women to help fetal lungs mature
clinical features of eclampsia
New osnet tonic clonic tupe seizure in prescence of pre-eclampsia (ew onset hypertensiona nd peroteinuria after 20 weeks gestation)
Others due to end organ damage
- headache
- hyper-refexlia
- N and V
- abdominal pain
- oedema
- visual disturbances
On fundoscopy: papilloedema
syndrome associated with pre-eclampsia and eclampsia
HELLP syndrome
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
Management of eclampsia
1) A- E
2) Put lady in left lateral position
3) Cessation of seizures with magnesium sulphate
4) Blood pressure contorl: IV labetaolol and hydralazine
5) Prompt delivery of baby (oyl definitive treatment) - via C section
6) Monitoring after delivery: fluid balance
uterine rupture risk factors
Main: Previous caesarean section due to scar being a point of weakness
- VBCAC
- Induction of labour
- Oxytocin to stimulate contractions
presentation of uterine rupture
- Abdominal pain
- Vaginal bleeding
- Ceasing of uterine contractions
- Hypotension
- Tachycardia
- Collapse
+ Abnormal CTG
management of uterine rupture
Uterine rupture is an obstetric emergency.
1) Resuscitation and transfusion may be required.
2) Emergency caesarean section is necessary to remove the baby, stop any bleeding and repair or remove the uterus (hysterectomy).
minor Postpartum haemorrhage
<1000ml blood loss
major postpartum haemorrhage
Major PPH – over 1000ml blood loss
To be classified as postpartum haemorrhage, there needs to be a loss of:
- 500ml after a vaginal delivery
- 1000ml after a caesarean section
primary vs secondary PPH
- Primary PPH: bleeding within 24 hours of birth
- Secondary PPH: from 24 hours to 12 weeks after birth
causes of PPH
- T – Tone (uterine atony – the most common cause)
- T – Trauma (e.g. perineal tear)
- T – Tissue (retained placenta)
- T – Thrombin (bleeding disorder)
prevention of PPH
- Treating anaemia during the antenatal period
- Giving birth with an empty bladder (a full bladder reduces uterine contraction)
- Active management of the third stage (with intramuscular oxytocin in the third stage)
- Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
management of postpartum haemorrhage
- Resuscitation with an ABCDE approach
- Lie the woman flat, keep her warm and communicate with her and the partner
- Insert two large-bore cannulas
- Bloods for FBC, U&E and clotting screen
- Group and cross match 4 units
- Warmed IV fluid and blood resuscitation as required
- Oxygen (regardless of saturations)
- Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
- Treatment to stop the bleeding
Treatment to Stop the Bleeding
Mechanical
Medical
Surgical
Mechanical treatment options involve:
- Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
- Catheterisation (bladder distention prevents uterus contractions)
Medical treatment options involve:
- Oxytocin (slow injection followed by continuous infusion)
- Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
- Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
- Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
- Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
