Flashcards in 3A: Obstetric Emergencies Deck (42):
AFE is also known as
anaphylactoid syndrome of pregnancy.
1. Amniotic fluid and fetal tissue gain access to the maternal circulation via a defect in the ____.
2. The ______ carry the material up to the mom's heart and out to lungs.The fetal material makes its way thru the lungs and return to the heart where its pumped out to the entire body.
2. IVC and uterine veins
Top 3 Most common S/Sx of AFE
hypotension, fetal distress, Pulmonary edema/ ARDS
No definite test to diagnose AFE in a clinically useful time period. It is SUDDEN.
1. What is the principal hemodynamic alteration?
3. Blood products likely required (4)
4. Drug to administer as you are treating AFE as an anaphylactoid syndrome (2)
5. This may explain why few women who survive AFE do so not neurologically intact
1. Right heart failure
2. Symptomatic/ supportive (focus reversing the triad!)
3. Cryo, FFP, Platelts, PRBC
4. Antihistamines, Steroids
5. Severe hypoxemia
AFE is an infrequent, unpreventable and catastrophic complication of pregnancy. It is virtually impossible to predict which patients are at risk for this condition.
1. Venous air embolism can occur during labor, spontaneous vaginal delivery and operative delivery. It is frequently associated with ____.
2. When is it usually detected?
3. VAE is also common in patients who are to undergo
1. placenta previa
2. Between delivery and uterine repair
Venous Air Embolism:
1. Air is entrained into _______ in the uterine wall when the placenta separates or at the site of surgical incision.
2. Air returning to the heart may pass through a _____ and form an embolism in any organ in the body.
3. More often it passes through the right atrium and ventricle and lodges in the pulmonary arteries, impending blood flow to through the lungs. Increase in _____ causes an increase in CVP.
4. A _____ may persist for 10 minutes even after a small venous air embolism.
5. ETCO2 ____ because CO2 cannot return to the lungs.
6. A ____ may be heard over the precordium.
1. open maternal venous sinuses
2. patent foramen ovale (20-30% of population with ASD)
3. Pulmonary vascular resistance
4. heavy non-radiating chest pain
6. Mill-wheel murmur
1. This occurs when the umbilical cord protrudes through the cervix ahead of the fetus.
2. Management for #1 (5)
1. Prolapsed Umbilical Cord
2. Pushing the presenting part back into the uterus; delivery baby abdominally; knee chest or trendelenburg positions; may need epidural for uterine relaxation
What is a non-reassuring FHR?
HR < 60 or > 160
1. This is the leading cause of maternal mortality. The greatest threat is not to the mother but to the fetus.
2. 2 major causes of #1?
3. What is the source of hemorrhage?
2. Placenta previa and abruptio placenta
Management for postpartum hemorrhage:
1. Abdominal pain and shock without vaginal bleeding
2. Massive bleed
1. Consult for possible retroperitoneal hematoma
2. Call for help, ABC. Is the placenta delivered? (Yes: Fundal massage, oxytocin 10-30 units in 1L IV; No: exploration)
1. This occurs when placenta is covering the cervix. Placenta implants in front of the fetal presenting part.
2. What is the classic symptom?
3. Diagnostic tool
4. What do you need to avoid in these patients?
1. Placenta previa
2. Painless, vaginal bleeding in 2nd or 3rd trimester with absent contractions.
3. UTZ (95% accurate)
4. Avoid vaginal exams
1. All patients who present with vaginal bleeding in the third trimester should be considered to have placenta prevue until disproved.
2. Direct visualization done in the delivery room AFTER all preparations have been made to perform a C/S. DOUBLE setup.
3. If the placenta is removed intact, the threat to the mother is much less. neonate may require intensive resuscitation at birth.
T, T, T
What needs to be available BEFORE vaginal exam? (3)
At least 1 large bore IV, H/H, 2 units of PRBC
Anesthetic Management of Placenta previa:
3. This is useful in evaluation and treating hypovolemia.
4. Fyi: treat hypotension; awake extubation.
1. Ketamine 1mg/kg + SCh 1.5 mg/kg
2. O2 OR 50% O2 and N2) until baby delivered. (No N20, sevo or iso during true emergency OB)
1. Anesthesia for Placenta previa who is actively bleeding.
2. For those not bleeding?
1. Emergency CS under GA
2. Regional Anesthesia. CS may be considered but more controlled pace. You have time to insert spinal or epidural. You still need to have 2 IVs, H/H, T&C, etc
1. This occurs when placental implantations directs onto or into the myometrium. Any implantations can produce a markedly adherent placenta which cannot be removed without tearing the myometrium.
2. Who are at risk?
3. Other sites of implantation aside from the myometrium?
4. #1 is not reliably diagnosed until the uterus is open. You need to be alert for ___.
1. Placenta accreta
2. Hx of placenta previan and CS
3. Bowel, bladder, or other pelvic organs, and vessels
4. massive blood loss
With one prior uterine incision, incidence of placenta accrete has been reported to be 24-31% and with 2 or more prior uterine incisions, the incidence rises to 50%. This is due to ____
thinning of the uterine wall
1. Massive intraoperative blood loss is common in accrete and previa ranging from _____ with some patients requiring more than ___ units of blood.
2. Approximately 20% of these patients develop ____. Between 30 - 72% require ____
1. 2 - 5L ......... 30 units
2. coagulopathies...... hysterectomy
1. CV collapse may occur secondary to ___
2. After delivery of baby, ___ can be performed
3. This drug is given to facilitate placental involution.
1. Amniotic fluid- like syndrome
2. controlled hysterectomy
1. This is the separation of normal implanted placenta after 20 weeks gestation and before the birth of the fetus.
2. Fetal distress occurs because of
3. T/F: Bleeding may appear through the vagina or remain concealed in the uteroplacental unit.
1. Abruptio placenta
2. Loss of area for maternal-fetal gas exchange
1. What is the classic presentation of abruptio placenta? (3)
2. Classification of abrupt placenta?
1. Painful vaginal bleeding, uterine tenderness, increase uterine activity
2. Mild to moderate: No maternal hypotension or coagulopaties; severe: maternal hypotension, uterine irritability, hypertonicity, pain, fetal distress or death, coagulopathies.
1. What are the clotting abnormalities in abrupt placenta?
2. How to estimate fibrinogen level?
1. hypofibrinogemia, Low CF 5, 8, High fibrin degeneration products
2. 5 cc maternal venous blood in glass tube. Shake it and leave it alone. Clot should form in 6 minutes. If clot fails to form in 30 mins, fibrinogen level < 100mg/dL
1. This is the most common cause of DIC in pregnancy.
2. Major fetal risk in abrupt placenta is
Management of Abruptio Placenta:
1. Definitive mgt
2. Diagnotic tool to exclude placenta previa
3. If no signs of maternal hypovolemia and if clotting studies are normal, proceed with ___.
4. Severe abrupt, proceed with ___.
5. Regional Anesthesia is contraindicated in (2)
6. After delivery, be aware of blood that may have extravasated into the myometrium causing ____.
1. Empty the uterus
3. regional anesthetic
4. CS with GA
5. Hypovolemic shock and coagulopathies.
6. inability to contract --> continued bleeding
1. FFP replaces
2. Cryo replaces
3. this may only aggravate the DIC and carries high risk of transmitting viral illnesses.
4. Why coagulopathies exist?
5. When does dilution coagulopathies occur?
1. CF 5, 8
2. CF 1, 8 in a small volume
4. CF are diluted from massive transfusion and IVF
5. When blood loss is > 30%
1. Abruption may occur before birth of the infant in vaginal delivery. Watch for (2)
2. Maternal resuscitation will be mainly ___ (2). Be prepared for GA
1. maternal hemorrhage and fetal asphyxia
2. Volume and pitocin.
Why is there an increased incidence of uterine rupture in the last few years?
Moms demand for Vbac.
This is the most reliable and most common sign of uterine rupture.
Fetal distress, non reassuring fetal heart tones with variable deceleration.
Refers to the fetal heart rate changes with contractions.
Types of Decelerations:
1. FHR drops after every contraction.
2. FHR drops before contraction. May be a sign that the baby is ready to get deliver.
3. FHR is unrelated to contraction. This is usually associated with umbilical cord prolapse.
4. Pattern of bradycardia considered an emergency.
1. Late decels
2. Early decals
3. Variable decels
4. Ominous pattern. (need emergency CS if LUD, other management fail)
This is the most common cause of postpartum hemorrhage.
Uterine atony (Boggy uterus)
Postpartum hemorrhage is defined as blood loss _____ after delivery, or as a _____ in Hct from admission to the postpartum period, or need to administer PRBCs.
> 500 ml.... decrease 10% Hct
1. This is more likely to result in maternal mobility or mortality. It occurs during the 1st 24 hours after delivery .
2. Hemorrhage occurs between 24H - 6 weeks postpartum.
1. Primary postpartum hemorrhage
2. Secondary postpartum hemorrhage
Management for retained placenta (2)
1. Manual exploration of the uterus
2. Uterus may be clamped down
What do you need to monitor in patients taking NTG?
hypotension and headache
What is the first -line drug for prophylaxis or treatment of uterine atony.
1. This occurs when the placenta removal is attempted by traction on the umbilical cord. Careful pressure should be applied to the uterus through the abdomen.
1. Uterine inversion
2. Hypotension, bradycardia, hemorrhage
Cervical and vaginal lacerations may result in ____. Many times GA is required to allow OB to explore the uterus, cervix, and vaginal vault.
1. This is a noncardiogenic pulmonary edema resulting from immune reactivity of leukocyte Ab a few hours after blood transfusion.
2. Common cause
3. Confirmatory tests
1. TRALI (Transfusion related acute lung injury).
2. ABP incompatibility
3. Urine and plasma Hgb Assay; Ab screening