O&G - Postpartum hemorrhage, Gynaecological emergencies, Obstetric emergencies Flashcards
Ovarian cyst
Dysmenorrhea
Abnormal uterine bleeding
Ectopic pregnancy
Risk factors
Sites
Risk factors:
○ Previous ectopic pregnancy (3-8×) - due to underlying tubal disorder and salpingostomy
○ Contraceptive use (incl IUCD, COC)
○ Previous tubal surgery (4.5×)
○ Previous PID (4×) - alter tubal function, causes tubal blockage and pelvic adhesions
○ Infertility, in-vitro fertilization and failed sterilization
○ Advanced age and smoking
Sites of ectopic pregnancy:
- Tubal (96%) - can occur in ampulla, isthmus, interstitial or even fimbrial
- Uterine ectopic: inside uterus but at a depth or location not consistent with normal pregnancy e.g. Caesarean scar, intramural
- Cervical: at endocervical cana
- Ovarian
- Abdominal pregnancy: implant of blastocyst on peritoneum or extrusion from tube
- Heterotopic pregnancy: when an ectopic pregnancy co-exists with intrauterine pregnancy
Ectopic pregnancy
Presentation
Subacute presentation: Classical triad of
- Amenorrhoea
- Abdominal pain - intermittent dull (cf cramping in miscarriage) pelvic/lower abdominal pain, may be localized to one side
- Vaginal bleeding - recurrent intermittent bleeding, may be scanty or substantial
Associating features on pelvic examination
- Uterus - enlarged but small for gestation (due to decidual changes from hormones), may be tender with excitation tenderness
- Adnexa - palpable mass, tenderness
Ruptured:
- Haemodynamic instability - syncope, hypotension, tachycardia, hypovolaemic shock
- Generalized peritoneal signs - abdominal distension, guarding, rebound tenderness
Ectopic pregnancy
First line investigations
Initial Workup
- CBC, T/S, Rh status - for all cases of suspected ectopic pregnancy
- FAST scan - to confirm haemoperitoneum if in doubt
- Baseline serum hCG
- Trans-vaginal US: Extrauterine gestational sac with fetal pole/yolk sac ± cardiac pulsation
Suggestive features of ectopic pregnancy:
- Non-cystic adnexal mass, free fluid in POD (hemoperitoneum)
Non-diagnostic of ectopic pregnancy
- passage of tissue mass: wait for histopathology
- Serial hCG in 48h: >50% drop in hCG = non-viable pregnancy; 50% drop to 63% rise = abnormal pregnancy, >63% rise = viable IUP likely and repeat TVUS
Ectopic pregnancy
Management
Indication and C/I
Medical management: Intralesional methotrexate or 50mg/m2 IM injection, monitor hCG
- Indication: Stable, not ruptured, hCG<5000IU/L, no cardiac pulsation
- C/I: Intrauterine/ heterotropic pregnancy, 2X ALT (poor liver function for MTX), Cr >120μmol/L (poor renal function for MTX), WBC <3×109/L, PLT <100×109/L (cytopenia risk)
Surgical management: Salpingectomy or Salingotomy
- Indications: unsuitable for medical treatment eg. high hCG, large ectopic pregnancy, significant pain, ruptured with unstable hemodynamics, heterotropic pregnancy
- Salpingectomy: remove entire fallopian tube ± uterine horn in interstitial pregnancy
- Salpingotomy: remove products of gestation with tubal reconstruction
Abdominal pregnancy: laparotomy
C-scar pregnancy: Intralesional MTX with laparoscopic removal
Cervical pregnancy: Intralesional MTX if stable, endocervical curettage ± UAE, hysterectomy if unstable
Ectopic pregnancy
Prevention of further recurrence
○ Avoid sexual intercourse and new conception - contraception required for ≥3mo after completion
○ Avoid pelvic examination and strenuous exercises - theoretical risk of tubal rupture
After methotrexate:
○ Avoid sun exposure - to limit risk of methotrexate dermatitis
○ Avoid heavy alcohol intake - risk of liver toxicity
○ Avoid NSAID use - risk of renal toxicity
○ Avoid folate-containing supplements - reduce effectiveness
Go to hospital once ↑abdominal pain or other evidence of internal bleeding
Post-partum hemorrhage
Definition
Causes
Definition and Terminology
* Definition - bleeding from genital tract ≥500mL
* Primary PPH - PPH ≤24h of delivery
* Secondary PPH - PPH between 24h and 6w post-delivery
Causes
- Tone (75-90%) - uterine atony → failure of myometrial contraction that compresses the blood vessels supplying placental bed
○ Dx - flaccid, soft uterus without any contractions felt on abdomen
- Tissue - retained products of gestation → inhibit effective contractions
○ Dx - checking integrity of placenta, or suspected if uterine atony refractory to medical treatment → EUA if suspicion - Trauma - bleeding from lower genital tract injuries
○ Dx - initial perineal/vaginal exam → EUA if suspicion - Thrombin - due to coagulopathy
○ Dx - clotting profile, platelet count
PPH
Diagnosis
Risk factors/ anticipating factors
Diagnosis: recognize blood loss in delivery
○ Collect blood in graduated measurement containers
○ Use visual aids
○ Weigh bloody materials
Anticipating risk factors: Blood grouping, T/S, 16G IV catheter
Pre- existing factors:
* Hx of manual removal of placenta (MROP), PPH, precipitate labour, repeated suction-evacuation
* Previous surgery on uterus (C-section, myomectomy)
* Grand multiparity (≥5 births)
Maternal:
* Anaemia (Hb <10) at onset of labour
* Induced or augmented labour
Placental:
* APH, placenta praevia, abruption
* Bleeding tendencies
Fetal factors:
* LGA baby (>3800g)
* Multiple pregnancy
* Polyhydramnios
PPH
Treatment options
Fluid: IV fluid for major PPH (>1000mL blood loss), Cross-matched blood or Rh-ve, Fresh frozen plasma, Platelet concentrate, cryoprecipitate
Uterine atony: uterotonic agents:
- Syntocinon/oxytocin
- Carboprost
- Misoprostol
- Other agents: carbetocin (oxytocin analogue), ergometrine (5HT2, DA, α-agonist)
- Bimanual compression
RPOG/ lower genital tract injury:
- Surgical exploration of lower genital tract and uterus under GA
Other treatments:
* IV tranexamic acid
* Balloon tamponade of uterus, eg. Bakri postpartum balloon, (Sengstaken-Blakemore tube)
* Angiographic radioembolization
* Laparotomy for
○ Repair of uterine rupture (if any)
○ Application of compression sutures, eg. B-LYNCH sutures
○ IIA ligation
○ Hysterectomy
Severity grading of PPH
Difference in uterotonic agents between normla vaginal delivery and C-section, normal vs high-risk
Vaginal delivery:
- Normal: IM syntometrine 1mL
- High risk: IV Syntocinon 5U + Oxytocin infusion 40U in 500mL NS over 4h. Repeat both if uterine contraction inadequate
- Heart disease: NO routine ergometrine or syntometrine
- Severe pre-eclampsia: IV syntocinon 5U + oxytocin infusion 40U in 500mL NS over 8h
- Substance abuse: Syntocinon instead of ergometrine
C-section:
- Normal: Oxytocin 5U slow IV bolus + 40U oxytocin in 500mL NS over 4h ± 5U oxytocin slow IV bolus
- High risk: 100µg (1L) carbetocin IV bolus
MoA of uterotonic agents
Miscarriage
Definition
Causes
Definition: expulsion or extraction of a fetus weighing <500g (WHO); pregnancy loss <24w gestation, or before viability
Causes:
- No definite cause (majority)
Fetal causes:
- Chromosomal abnormalities
- Congenital anomalies: genetic abnormalities, extrinsic factors (eg. amniotic bands), teratogenic exposure, Trauma or invasive intrauterine procedure
Maternal causes:
- Uterine structural anomaly: Congenital anomalies (eg. bicornuate uterus, subseptate uterus) or Acquired anomalies (eg. submucosal/intramural fibroids)
- Maternal illness and infections
- Maternal diseases: APLS, Thyroid dysfunction, PCOS, Cushing’s syndrome, Thrombophilia
- Cervical insufficiency: childbirth trauma, prior surgical dilatation, congenital
Lifestyle causes:
- Maternal smoking, alcohol, caffeine, cocaine, cannabis
- Drugs: Antidepressants, NSAIDs abuse
- Stress
- Alloimmune incompatibility
Types of miscarriage
different stages of miscarriage process:
Threatened (bleeding) → inevitable (+abd pain +dilated cervix) → incomplete (+partial expulsion of conceptus) → complete (complete expulsion + resolution of symptoms)
Other types:
- Silent/ Missed miscarriage
- Recurrent miscarriage
- Septic miscarriage
Differentiate different types of miscarriage by physical exam
Diagnosis of silent miscarriage
