Obstetric Emergencies Flashcards
(56 cards)
1
Q
What is an obstetric emergency?
A
a situation where there is sudden collapse of the patient either antenatally or in the 6 weeks postpartum
2
Q
What are the 3 main rules of handling an obstetric emergency?
A
- emergency care ALWAYS starts with ABC
- resuscitate the woman before considering the baby
- always call for help early
3
Q
What are the common causes of an obstetric emergency?
A
- eclampsia
- antepartum / postpartum haemorrhage
- uterine rupture
- uterine inversion
- pulmonary embolus
- septic shock
- amniotic fluid embolus
myocardial infarction can also cause collapse
this was uncommon but now increasing due to increased maternal age
4
Q
What is an antepartum haemorrhage?
A
bleeding from the genital tract after 24 weeks gestation
if bleeding occurs prior to 24 weeks, this is a threatened miscarriage
5
Q
How can postpartum haemorrhage (PPH) be divided into 2 categories?
A
primary PPH:
- a loss of > 500mls of blood from the genital tract up to 24 hours after birth
secondary PPH:
- bleeding from the genital tract from 24 hours and up to 6 weeks after birth
6
Q
What are the steps in the immediate management of APH/PPH?
A
- call for help
- ABC
- facial oxygen + tilt bed head down
- insert 2 large-bore cannulas in the antecubital fossa (ACF) + give 500mls crystalloid
- send bloods for FBC, clotting & G&S (for 4 units blood)
- insert urinary catheter
- check fetal condition
- give O negative or group-specific blood if necessary
after all of these things are complete, then the cause of bleeding should be assessed
7
Q
What are the causes of APH?
A
- placenta praevia
- placental abruption
- causes in the genital tract such as cervical erosion, polyp or trauma
the cause can be unexplained
8
Q
What are the causes of PPH and how can they be remembered?
A
Tone:
- atonic uterus
Trauma:
- genital tract trauma
Tissue:
- retained products of conception
Thrombin:
- this produces abnormal clotting
remember the causes of PPH as the 4 Ts
9
Q
What is involved in the management of APH?
A
- establish whether the bleeding is painful or painless
- use of scan to identify placental site
- decide if a delivery is necessary - this is likely to be C-section
!! DO NOT DO A VAGINAL EXAMINATION UNTIL AFTER SCAN !!
10
Q
What is the management for PPH caused by a retained placenta?
A
manual removal of the placenta under GA or spinal (depending on condition)
11
Q
What is the management of PPH caused by an atonic uterus?
A
a series of drugs that make the uterus contract
- ergometrine
- syntocinon infusion
- prostaglandins if no response
12
Q
How is ergometrine given in PPH?
When is it contraindicated?
A
- it is given IV or IM
- it stimulates smooth muscle contraction
- it is contraindicated in hypertension
13
Q
What prostaglandin analogues may be given in PPH?
A
carboprost IM:
- stimulates uterine contractions
- use with caution in asthma
misoprostol:
- stimulates uterine contractions
- given sublingually
14
Q
What medication can be given to reduce bleeding in APH / PPH?
A
tranexamic acid
this is a antifibrinolytic
15
Q
What dose of IV sytocinon infusion is given in PPH?
A
40 units in 500mls
16
Q
What are the major causes of secondary PPH?
A
- retained products of conception
- endometritis (infection)
17
Q
What is involved in the investigations for secondary PPH?
A
- USS to check for retained products of conception
- endocervical + HVS to check for infection
18
Q
What is the management of secondary PPH?
A
- 24 hours of antibiotics
- surgical evacuation of RPOC
19
Q
Why is catheterisation performed in PPH?
A
bladder distention prevents the uterus from contracting
20
Q
Why is PE common in pregnancy?
A
- pregnancy produces a pro-thrombotic state
- coagulation factors alter to promote clotting
- there is a large pelvic mass
- mobility is reduced
21
Q
What factors increase the risk of PE during delivery?
A
- dehydration
- prolonged labour
- operative delivery (incl. forceps, Ventouse and CS)
22
Q
Who is at risk from PE in pregnancy?
A
ALL women are at risk at ALL gestations and post-partum
23
Q
What are the symptoms and signs associated with PE?
A
- collapse
- SOB
- pleuritic chest pain
- hypotension
- tachycardia
- reduced air entry
- reduced o2 sats
they may also present with NO SYMPTOMS
24
Q
What happens in uterine inversion?
A
- the fundus of the uterus drops down through the uterine cavity and cervix
- this turns the uterus partially or completely “inside out”
- it is a complication of birth
it is VERY RARE
25
What is the difference between complete and incomplete uterine inversion?
**incomplete:**
* the fundus descends inside the uterus or vagina, but **not as far as the introitus**
**complete:**
* the uterus descends through the vagina **to the introitus**
## Footnote
introitus = opening of the vagina
26
What are the 2 reasons why uterine inversion usually occurs?
* **grand multiparity** (many previous pregnancies)
* **incorrect management of the third stage** (i.e. pulling too hard on the umbilical cord)
27
How does uterine inversion present?
* **large postpartum haemorrhage** +/- maternal **shock or collapse**
* the uterus will be ***seen at the introitus*** in a complete inversion
* the uterus can be ***felt on vaginal examination*** in an incomplete inversion
28
What are the 3 options for treating uterine inversion?
1. Johnson manoeuvre
2. hydrostatic methods
3. surgery
29
What is the Johnson manoeuvre?
* a hand **pushes the fundus back up** into the abdomen
* the whole hand and most of the forearm is inserted into the vagina
* it is **held in place for several minutes**
* **oxytocin (syntocinon)** is given to create a uterine contraction
* this generates tension for it to stay in place
30
What is used if the Johnson manoeuvre fails?
**hydrostatic methods**
* the **vagina is filled with fluid** to "inflate" the uterus back into normal position
* it is difficult to achieve as a **tight seal** at the vagina is needed
## Footnote
this is also called "O'Sullivan's method"
31
If both the Johnson manoeuvre and hydrostatic methods fail, what is done?
**surgery**
* **laparotomy** is performed to return the uterus to the normal position
## Footnote
other maeasures to stabilise the mother such as resuscitation + blood transfusion may be required
32
What are the causes of maternal sepsis antenatally?
* it can result from **any maternal viral or bacterial infection** that progresses rapidly
* severe sepsis can result from **midtrimester ROM**
33
What is meant by severe sepsis?
* when sepsis results in **organ dysfunction**
* demonstrated by a **raised lactate, oliguria + hypoxia**
* septic shock occurs when organs are **hypoperfused** due to a **drop in BP**
34
What are the 2 major causes of sepsis in pregnancy?
* chorioamnionitis
* urinary tract infections
35
What is chorioamnionitis?
| When does it typically occur?
* infection of the **chorioamniotic membranes**, **placenta** and **amniotic fluid**
* typically occurs in **later** pregnancy and during **labour**
## Footnote
chorioamniotic membranes = the amnion and the chorion that make up the amniotic sac which surrounds the embryo
36
What makes chorioamnionitis more likely?
* it occurs more often in when **ROM** occurs a **long time before birth**
* bacteria can spread from the vagina, anus or rectum to the uterus
37
What is the alternative to a NEWS score in pregnant patients?
MEOWS
| maternity early obstetric warning system
38
What might the MEOWS score indicate in maternal sepsis?
it can detect **non-specific signs** of sepsis, such as:
* fever
* tachycardia
* reduced RR
* reduced O2 sats
* low BP
* altered consciousness
* reduced urine output
## Footnote
it may also be detected through **raised WCC** on FBC or **abnormalities on CTG**
39
What are the additional signs of sepsis related to chorioamnionitis?
* abdominal pain
* uterine tenderness
* vaginal discharge
40
What are the key clinical signs and symptoms associated with chorioamnionitis?
* **tachycardia** > 100 bpm
* fetal tachycardia > 160 bpm
* purulent / foul vaginal discharge
* **fever**
* uterine fundal tenderness
41
What additional symptoms / signs may be present in sepsis caused by a UTI?
* **dysuria**
* **urinary frequency**
* **suprapubic pain / discomfort**
* renal angle pain (if pyelonephritis)
* vomiting (if pyelonephritis)
## Footnote
pyelonephritis = bacterial infection causing inflammation in the kidneys
42
What blood tests are requested in maternal sepsis?
**FBC:**
* to assess *WCC + neutrophils*
**U&Es:**
* to look for potential *AKI*
**LFTs:**
* *acute cholecystitis* could be a possible source of infection
**CRP**
**Clotting:**
* assesses for DIC
**blood cultures:**
* to assess bacteraemia
**ABG:**
* for *lactate, glucose* and *pH*
43
What other additional investigations may be performed depending on the source of maternal sepsis?
* urine dipstick / culture
* high vaginal swab
* throat swab / sputum culture
* wound swab after procedures
44
How are women with maternal sepsis managed?
**sepsis 6**
B - **blood cultures**
U - monitor **urine output**
F - give **IV fluids**
A - empirical **broad spectrum abx**
L - blood **lactate** level
O - give **oxygen** to maintain sats 94-98%
45
What antibiotics are typically given in maternal sepsis?
IV broad spectrum abx
* **cefotaxime, metronidazole** +/- **gentamicin**
46
What is amniotic fluid embolus?
* occurs when the **amniotic fluid passes into the mother's blood**
* usually occurs during **labour / delivery**
* the mother's **immune system reacts** to the fetal tissue and causes a **systemic illness**
## Footnote
* it is rare but serious with a 20% mortality rate
47
What are the risk factors for amniotic fluid embolus?
* increasing maternal age
* induction of labour
* caesarean section
* multiple pregnancy
48
What are the presenting features of amniotic fluid embolus?
* SOB
* hypoxia
* hypotension
* coagulopathy
* haemorrhage
* tachycardia
* confusion
* seizures
* cardiac arrest
## Footnote
it can present similarly to anaphylaxis, sepsis or PE
49
What is the management for amniotic fluid embolus?
* management is **supportive**
* it is a medical emergency that requires transfer to ITU
* correction of clotting
* A to E approach
50
What is required if cardiac arrest occurs as a result of amniotic fluid embolus?
* cardiopulmonary resuscitation
* immediate C-section
51
What occurs in a uterine rupture?
* the **myometrium** (muscle layer of the uterus) **ruptures**
* it occurs during **labour**
52
What are the 2 types of uterine rupture?
**incomplete rupture / uterine dehiscence:**
* the uterine serosa (perimetrium) surrounding the uterus remains intact
**complete rupture:**
* the ***uterine serosa ruptures***
* the contents of the uterus are released into the peritoneal cavity
53
What is the major risk factor for uterine rupture?
**previous caesarean section**
* the scar on the uterus becomes a point of weakness
* it may rupture with ***excessive pressure*** (e.g. excessive stimulation with oxytocin)
**!! it is RARE for uterine rupture to occur in first-time births !!**
54
What are the other risk factors associated with uterine rupture?
* VBAC
* previous uterine surgery
* increased BMI
* high parity
* increased age
* **induction of labour**
* use of **oxytocin** to stimulate contractions
55
How does uterine rupture present?
presents with **acutely unwell** mother + **abnormal CTG** with:
* **constant, severe abdominal pain** that breaks through the epidural
* vaginal bleeding
* **ceasing of uterine contractions**
* hypotension
* tachycardia
* collapse
56
What is involved in the management of uterine rupture?
* **emergency C-section** to remove baby + remove / repair uterus
* **resuscitation + transfusion** as required
