Obstetric emergencies Flashcards
(41 cards)
Placental praevia
low lying placenta: placenta overlying or within 2cm of the OS -> repeat US at 34wk to confirm true placenta praevia
major: overlying the OS
minor: within 2cm of OS
if normal at 34wk -> low lying placents
between 20-34wk: no sex, no VE, present if bleeding, consent for blood transfusion, hysterectomy
Placenta Praevia RX factors and Symptoms
Previous C section or Uterine surgery
Painless PV bleeding after 20wk
Abnormal Lie (placenta in the way) + high presenting part
Placenta Praevia IX + MX
IX as per APH
Early term elective C section at 38wk
Placental abrutpion definition
premature separation of the placenta from the uterine wall -> visible or concealed bleeding
Placental abrutpion RX and SX
Cocaine, Trauma (MVA)
Painful PV bleeding + constantly tender uterine contraction (not intermittent like in labour)
decreased fetal movements
EX: extremely tender woody hard uterus
Placental abruption IX and MX
IX as per APH
- TVUS or ABUS for retroplacental clot (cannot R/O retroplacental clot)
MX
- as per APH
- next presentation -> aspirin and high dose folate supplementation
Placenta Accreta definition
Accreta: placental villi attached to myometrium and not decidua
Increta: penetrates into myometrium
percreta: penetrates through myometrium
Placenta Accreta RX and SX
history of uterine surgery (affecting the myometrium like FIBROIDS)
previous C/S
SX: painless APH
EX: abnormal lie and mobile presenting part
Placental accreta IX and MX
IX
- US at 20wk : venous lakes on the placenta and bulging of the placenta
- repeat at 34wk to confirm +/- MRI to determine level of invasion
- Elevated AFP
MX
- nothing in vagina, to hospital if bleeding, consent for blood transfusion, hysterectomy
- 36+ elective C/S to beat labor + manual removal of placenta +/- hysterectomy if too attached.
Vasa Praevia definition
fetal blood vessels are present in the membranes covering the internal OS
Vasa Praevia RX and SX
RX: not been to previous antenatal appointments -> not picked up on US
SX: painless APH with ROM, Fetal distress with sinusoidal pattern
IX: vasa praevia and velamentous cord insertion on US 20wk -> do color TVUS doppler
EX: VE -> palpation of vessels on fetal membrane
Vasa praevia MX
Elective C/S at 34wk prior to ROM
Uterine rupture
Separation of the entire thickness of uterine wall -> extrusion of fetal parts/ intra-amniotic contents into the peritoneal cavity
mainly in VBAC
previous myomectomy
SX: sudden peritonism during labour with constant abdominal pain, bleeding, shoulder tip pain, maternal shock
EX: bandl’s ring
emergency C/S
PPH definitions
loss of >500ml blood in vaginal
loss of >750ml in C/S
Severe PPH >1000ml or hemodynamically unstable
Primary PPH within 24h of delivery
secondary >24h but within 6wk
secondary PPH usually due to?
Endometritis or retained products
Uterine Atony for PPH
Prolonged Labour (uterine exhaustion)
Overdistension (twins, polyhydramniosis, macrosomia)
Oxytocin withdrawal (loss of stimulus to contact)
Instrumental birth
Uterus is soft, boggy and enlarged (filled with blood)
Uterine Atony for PPH
Prolonged Labour (uterine exhaustion)
Overdistension (twins, polyhydramniosis, macrosomia)
Oxytocin withdrawal (loss of stimulus to contact)
Instrumental birth
Uterus is soft, boggy and enlarged (filled with blood)
Trauma causes of PPH
Uterine rupture or inversion (pull out placenta prior to clinical signs of separation (gush of blood from vagina and lengthening of the cord) -> inversion
uterus cannot be palpated on abdominal exam
Uterus inverting and striking cervix -> can cause cervical shock (bradycardia and hypotension, vagus nerve)
RX: grand multiparity and accreta
Perineal, cervical, vaginal, uterine (C/S) tears
Tissue PPH
Retained POC, placenta, clots, membranes -> prevent contraction
Thrombin PPH
Coagulopathy, DIC (from amiotic fluid embolus), PET
PPH MX
- Call code, send for help, communicate with patient/partner, allocate roles so following steps can be done simultaneously
- DRSABCDE
- Stop bleeding
- Document and debrief
PPH DRSABCDE
estimate blood loss, fluid chart, IDC (deflate bladder for uterine contractions, FBE for coauglopathy, G+H, 2 IV access, warm crystaloid fluids
keep warm with blankets
Activate Massive transfusion protocol
PPH stop bleeding
- uterine fundal massage
- bimanual compression
- Give TXA
- Uterotonics
PPH Utero tonics first line
1 of
Oxytocin (AKA syntocinon)
- 10u IM if no IV access or 10u slowly via IV
- Hypotension, hyponatremia, ECG changes
Ergometrine IV or IM
- CI: HTN, cardiac disease, PVD, placenta in situ
- ADR: V, HTN, placental entrapment. give with anti-emetic
Sytometrin IM
- Oxy and Ergometrin
