Pregnancy Emergencies Flashcards
How should PPROM be managed?
Probability of spontaneous labour is 80% in seven days
Treat with antibiotics (erythromycin) and monitor for infection until 34 weeks when you should induce labor
Steroids to stimulate lung development in baby
Tocolytics may be necessary to prolong labour until steroids can be given
What is preterm premature rupture of membranes?
When the membranes rupture before labour
Usually defined as rupture before 37 weeks
Usually demonstrated by pooling on sterile speculum- do not perform VE due to infection risk
What is the incidence of breech presentation?
3%
What are the different types of breech?
Extended - 65%
Footling - 25%
Flexed - 10%
How can breech be managed?
External cephalic version:
Offer from 36-37 weeks
Success from 35-50%
Risks - pain transient bradycardia, abruption, emergency lscs
Caesarean section
Vaginal breech delivery
What are the absolute and relative contraindications to ECV?
Absolute: Placenta previa Uterine malformations Ruptured membranes Multiple pregs Abnormal ctg
Relative: Previous CS Active labour Pre eclampsia Foetal abnormality Fetal hyper extension
What is cord prolapse?
In cord prolapse, the umbilical cord protrudes below the presenting part after the rupture of membranes
What are potential complications of cord prolapse?
Cord prolapse may cause compression of the umbilical vessels by the presenting part and vasospasm from exposure of the cord
These may compromise foetal circulation
How is cord prolapse managed?
Deliver foetus as soon as possible - this may mean either instrumental deliver or CS?
What is shoulder dystocia?
Any delivery which requires additional obstetric manouevres after the gently downward traction on the head has failed to deliver the shoulders
What are the complications of shoulder dystocia?
Foetal hypoxia and resulting cerebral palsy Brachial plexus palsy Cervical spine injury Fracture of clavicle Post partum haemorrhage Genital tract trauma
How can shoulder dystocia be managed?
Episiotomy
Mcroberts position
Supra public pressure
Internal manouevres- twist baby round
What is Antepartum haemorrhage?
Bleeding from the genital tract after 24 weeks gestation
Before 24 weeks, it is termed a threatened miscarriage
What is the immediate manage of APH?
Call for help ABCDE Facial oxygen and tilt bed head down Two cannulas and give fluid challenge FBC, clotting screen, crossmatch Utinary catheter Check foetal condition - CTG USS Obstetric exam
What are causes of Antepartum haemorrhage?
Placenta previa Placental abruption Cervical erosion Cervical polyp Trauma Severe chorioamnionitis Severe pre-eclampsia - hepatic rupture
How is Antepartum haemorrhage managed?
Do not do vaginal exam until after scan!
Assess for painful versus painless bleeding
Establish placental site
Decide if delivery necessary - likely to be CS
CTG?
Why is pregnancy a pro-thrombotic state?
Coagulation factors later to promote clotting
Large pelvic mass (the foetus) reduces motility
Long labour, dehydration, and operative delivery can aggravate the situation
How does PE present in pregnancy?
Asymptomatic Pleuritic chest pain SOB Collapse Hypotension Tachycardia Reduces air entry Reduces O2 sats
How is PE managed in pregnancy?
Anticoagulate with low molecular weight heparins
Why is uterine inversion and how does it present?
Rare
Associated with multips and incorrect management of third stage of labour
Presents with vasovagal shock, and a mass at the introitus
Results in significant haemorrhage, clotting abnormalities and renal dysfunction
Shock corrects when uterus is replaced
What is pre-eclampsia?
pregnancy induced hypertension in association with proteinuria (>0.3g in 24 hours) with or without oedema
What is eclampsia?
The occurrence of one or more convulsions superimposed upon pre-eclampsia
Manage: ABCDE High flow oxygen, two cannulas Loading dose mgSO4 IV 4g Maintenance dose over 5 hours Continuous obs Control hypertension - labetol Continuous CTG - consider delivery
What are risk factors for pre-eclampsia?
First pregnancy Previous pre-eclampsia Age over 40 Bmi of 35 or more Family history of pre-eclampsia Medical conditions- pre existing hypertension, renal disease, diabetes, anti phospholipid antibodies
How does pre eclampsia present?
BP >140/90 New proteinuria Severe headache Swelling of face, hands or feet Liver tenderness Visual disturbance Papilloedema Reduced fetal movements Small for gestational age infants
What is HELLP syndrome?
Haemolysis
Elevated liver enzymes
Low platelets - may require transfusion
How should pre-eclampsia be investigated?
Urinalysis- mc&s
Frequent monitoring of FBC UandEs and LFTs
Clotting studies if severe thrombocytopenia
MRI/ct if focal deficits
Ultrasound for foetal growth, amniotic fluid vol, umbilical arteries
Frequent assessment of BP and urine:
24-32 weeks - min every three weeks
32 weeks - min every two weeks
How should pre-eclampsia be managed?
Manage conservatively if less than 34 weeks, haemodynamically stable and without HELLP.
Severe pre-eclampsia (BP >160/110): Labetol, oral nifedipine, IV hydralazine Fluid restriction Manage third stage with Syntocinon Treat seizures with magnesium sulphate
If after 34 weeks, consider delivery
Continue hypertensives after delivery
24 to 32 weeks - minimum 3 week assessments
32 to deliver - minimum 2 week assessments
Aspirin if high risk?
What are complications of pre-eclampsia?
Haemolysis HELLP syndrome DIC Renal failure ARDS
How can placenta previa be classified?
1 - encroaches on lower segment
2 - reaches internal os
3 - covers part of os
4 - completely covers os
What is placental abruption?
Defined as retroplacental haemorrhage and usually involves a degree of placental separation
What are risk factors for placental abruption?
Low social economic class Hypertension Pre-eclampsia Previous abruption Smoking during pregnancy
How is placental abruption managed?
Light bleeding from edge of normally situated placenta can be treated with rest and close supervision of foetal growth and placental function until normal labour
Major haemorrhage - urgent delivery required
How does placental abruption present?
Painful bleeds
Hard and tender uterus
May be no discernible foetal heartbeat
May be concealed haemorrhage occurring between placenta and uterine wall
May lead to DIC
Degree of shock may be present?
How does hellp syndrome present?
Nausea and vomiting
Epigastric pain
Right upper quadrant pain - due to haemorrhage with stretching if the liver capsule
How does chorioamnionitis present?
Abdominal pain Uterine tenderness Maternal pyrexia Raised CRP and wcc Meconium stained or foul smelling liquor Foetal tachycardia
How does acute fatty liver of pregnancy present
Sudden onset epigastric pain Anorexia Malaise Nausea and vomiting Diarrhoea Jaundice Hypertension Proteinuria Fulminant liver failure
What would be the biochemical findings of acute fatty liver?
Raised bilirubin and abnormal LFTs Raised WCC Thrombocytopenia Hypoglycaemia Coagulation defects
Distinguished from hellp syndrome by hypoglycaemia and high uric acid
How is acute fatty liver treated?
Correct fluid balance, coagulation and electrolytes
Deliver may be necessary
When does obstetric cholestasis occur?
After 30 weeks gestation
How does obstetric cholestasis present?
Severe pruritis of limbs, trunk, feet
No abdominal pain!
Due to impaired bile secretion
How is obstetric cholestasis managed?
Deliver at 37-38 weeks
Chlorphenamine to relieve itching
Ursodeoxycholic acid to reduce bile acids
In preterm labour, how is ritodrine used?
Ritodrine is a beta agonist tocolytic - inhibits smooth muscle contraction to delay labour, to allow time for corticosteroids
In preterm labour, how is atosiban used?
Atosiban is an oxytocin inhibitor that can be used to reduce delivery within a 48 hour period
Nifedipine, magnesium sulphate and indometacin may also be used
What are contraindications to tocolysis?
Foetal distress
Intrauterine infection
What is uterine rupture?
Uterine wall tears- usually in patients who have had previous myomectomy or LSCS, can occur if high parity and oxytocin drip
Presents with pain and shock, termination of contractions and ctg abnormalities
Operative delivery is required immediately
What is vasa previa?
The umbilical cord traverses the membranes and overlies the internal os
There is a rush of the vessels tearing in cervical dilation and when the membranes rupture
Perform LSCS
