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P2 > Obstetric emergencies > Flashcards

Obstetric emergencies Flashcards

1
Q

Pathophysiology eclampsia

A

2 theories
1:
W extreme HTN, there’s abN cerebral flow w dilated vessels, incr permeability and oedema –> ischaemia and encepalopaty
2:
HTN –> vasoconstriction –> hypoperfusion ischaemia and oedema

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2
Q

Diagnosis of pre-eclampsia

A

HTN > 20/40 and 1>/
- proteinuria: PCR >30mg/mol / protein >3g/day / 1+ on dip
- Maternal organ dysfunction:
— renal: creat >90
— haem: plt < 100, haemolysis or DIC
— lft: raised AST/ ALT
— neuro: hyperreflexia, headaches, visual disturbance
— pulmonary oedema
- uteroplacental dysfx - FGR

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3
Q

Monitoring in eclampsia

A

BP every 15 minutes
Urine output and fluid inputt
O2 > 95%
RR hourly
Temp 4 hourly

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4
Q

Fluid management in eclampsia

A

AN: fluid restrict to 80ml/hr
Art line: unstable/ very high BP/ obese women/ haem >1l
CVP: CS. / complicated delivery
PP: restrict fluid to 80ml/hr, hourly UO monitoring

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5
Q

Medications in eclampsia

A

MgSO4
Labetalol: first line
- 200mg po stat, recheck 30 min
- bolus: 50mg IV over 5 min, repeat every 10 min to a max of 200mg
- infusion: 20mg/hr to a max of 160mg/hr
- CI in severe asthma, caution in pre-existing cardiac conditions
Hydralazine:
- Bolus: 2.5mg in 10ml water over 5 min
- Check BP every 5 min, can repeat every 20min to a max dose of 20mg
- infusion: 40mg in 40ml NS at 1-5ml/hr
- CI: hypersensitivity, severe tachycardia, heart failure
Nifedipine:
- potent, never give SL
- PO- bd or OD, max dose 90mg/day
Methyldopa
- avoid PP, causes depression

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6
Q

Target BP in eclampsia

A

SBP <160mmHg
MAP < 125mmHg

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7
Q

Management eclamptic fit

A

Call for help
ABCs
Left lateral
O2 at 10l/min via non-rebreather
IV access and bloods
Loading dose MgSO4 + infusion
Diazepam if seizure continues
Delivery once stabilised

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8
Q

Management of recurrent fits in eclampsia

A

Anaesthetics present to give IV diazepam 5-10mg
Or repeat bolus of MgSO4 of 2g and increase infusion to 1.5g/hr
- can be done twice
- assess for other causes of seizure if 2x doses needed

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9
Q

MgSO4 - MOA/ dose/ SE/Obs

A

Vasodilatation and membrane stabilisation
Loading dose 4g in 50ml IV over 5-10 min
Maintenance 1g/hr (20g in 500ml at 25ml/hr)
SE:
- motor paralysis
- absent tendon reflexes
- resp depression
- cardiac arrhythmias
Obs:
- 4 hourly iMEWS w UO and reflexes
- reduce rate if absent reflexes or RR <12
A

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10
Q

Antidote for MgSO4

A

Calcium gluconate 10ml 10% IV

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11
Q

Target Mg levels in eclampsia

A

Aim for 1.97-3.28mmol/L

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12
Q

Plt transfusion in eclampsia

A

Consider if plt <50
Recommended prior to CS if <20

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13
Q

Postnatal management eclampsia

A

Monitor until D3
4 hourly BPs
AntiHTN: B-blockers, ACE-i, CCBs.
- safe in breastfeeding
Avoid methyldopa
Discharge:
- D3-4 if BP <150/100 and bloods normal
- BP check every 1-2 days for up to 2/52
- follow up within 2/52

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14
Q

Epidemiology PPH

A

1/4 of all maternal deaths
Second leading cause of direct maternal mortality

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15
Q

PPH definition

A

> /= 500ml

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16
Q

Antenatal risk factors for PPH

A

Prev PPH
Obesity
Ethnicity (asian/ hispanic)
PET
Overdistension of the uterus (multiples, poly, macrosomia)
Anaemia
Inherited bleeding disorder
High parity
Fetal death
Uterine anomalies
IOL
Placenta praevia
PAS

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17
Q

Intrapartum risk factors for PPH

A

Prolonged labour
Precipitous labour
OVD
Uterine rupture
Augmented labour
Episiotomy
Volatile anaesthetic agents
PROM
Infection/ chorio
Uterine inversion
Placental abruption
Retained placenta

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18
Q

Primary PPH vs secondary vs MOH

A

Primary: within 24 hours post delivery
Secondary: 24 hours - 6 weeks
MOH: >/= 2500ml +/ 5 RCC +/- coag treatment

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19
Q

Preparedness re PPH

A

Identify high risk and mx anaemia (Hb <11)
Identify any RCC Ab
Doc any inherited bleeding disorders - notify haem, FM, anaes
FBC at booking and 28/40
Placenta- document site, if ? PAS - MDT
Ensure O neg, Kell neg supply in unit
Local drills
National MOH poster in units

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20
Q

Preventing PPH at delivery

A

Immediate cord clamping if active bleeding
Prophylactic uterotonics
If women refusing prophylaxis - fully inform and advise if placenta not delivered in 30 min
MROP in 30-60 min or sooner if bleeding
TXA if high risk

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21
Q

Oxytocin prophylaxis in elective CS w no PPH risk factors

A

1iu bolus, infusion at 2.5-7.5 iu/hr

22
Q

Oxytocin prophylaxis in intrapartum CS/ any CS w PPH risk factors

A

3iu bolus over 30sec, infusion at 7.5-15iu/hr

23
Q

Uterotonics for PPH

A

Oxytocin
Syntometrine
Misoprostol
Carbebtocin

24
Q

MOA, dosing and SE oxytocin

A

MOA: stimulates oxytocin receptors in the uterus.
- Onset of action: immediate IV, 3-7min IM.
- Duration of action: 30-60min
Dose:
- SVD: 10iu IM or 5iu slow IV
- CS: 1-3 iu slow IV bolus, infusion 7.5-15iu/hr over 4hours
- PPH: 5-10 iu bolus
SE:
- rapid administration –> hypoTN, tachy and arrhythmias
- caution w SIADH, hypotN

25
Q

MOA, dosing and SE - ergometrine

A

MOA: ergot alkaloid causing sustained uterine contraction
- onset: IV 1 min, IM 2-3min
- Duration: 45m - 3 hours
Dose:
- Oxytocin 5iu/ ergometrine 500ug IM
- PPH: 250-500ug IM or slow IV, repeated after 5min
SE:
- N&V, elevated BP
- caution w use w other vasoconstrictors
CI:
- severe HTN/ PET/ cardiac disease/ severe renal or hepatic impairment

26
Q

MOA, dosing and SE- misoprostol

A

MOA: PGE1 analogue
- onset 9-15min
- More rapid onset w PO and SL/ longer duration w PR and PV
Dose: 400-600ug po (prophylaxis)
- PPH: 800-1000ug
SE: shivering, diarrhoea, pyrexia

27
Q

MOA, dosing and SE - carbetocin

A

MOA: synthetic oxytocin analogue - stimulates oxytocin receptors in the uterus
- onset: 2 min IV
- Duration: IV 60min, IM 3 hours
Dose: 100mcg IM or slow IV (prophylaxis)
- PPH: 2250ug IM or intramyometrial
SE:
- rapid administration –> hypoTN, tachy, arrhythmia

28
Q

Non-medical mx PPH

A

Balloon tamponade
B lynch (vicryl)
B/L ligation uterine artery/ internal iliac
Selective arterial embolization
Hyst

29
Q

FBC targets in PPH

A

Hb >8
PTT <1.5
Plt > 50
Fibrinogen >2g/L

30
Q

Causes of maternal collapse

A

5 H’s
Head - eclampsia, epilepsy, CVA, ICH, vasovagal
Heart - MI, arrhythmia, PPCMO, CHD, dissection thoracic aorta
Hypoxia - asthma, PE, pulm oedema, anaphylaxis
Haemorrhage - abruption, atony, genital tract trauma, rupture, inversion, ruptured AAA
wHole body and Hazards - hypoglycaemia, amniotic fluid embolus, septicaemia, trauma, anaesthesia complications

31
Q

Defn shoulder dystocia

A

vaginal cephalic delivery. that required additional manoeuvres to deliver fetus after head delivery and gentle traction has failed

32
Q

Incidence shoulder dystocia

A

0.5-0.7%

33
Q

Assoc risks. with shoulder dystocia

A

Inc risk PPH 11%
OASIS 3.8%
BPI at 2-16% deliveries
- <10% w permanent damage

34
Q

Prelabour predictive factors for shoulder dystocia

A

Maternal:
- history of shoulder dystocia
- DM (2-4x increase)
- BMI >30
Fetal:
- macrosomia >4.5kg (48% <4kg)
- malposition

35
Q

Intrapartum predictive factors for shoulder dystocia

A

IOL
Prolonged 1st stage
Secondary arrest
Prolonged 2nd stage
Oxytocin augmentation
OVD

36
Q

Prevention of SD

A

IOL - GDM after 38/40
ElCS >4.5kg and DM
ElCS >5kg

37
Q

COnsiderations for future pregnancies in SD

A

Joint decision making for delivery
10x higher risk than general population
Recurrence rate of 1-25%
Recommend CS if:
- neonatal injury
- maternal injury
- predicted fetal size
- maternal choice

38
Q

Signs of SD

A

Difficult delivery face/ chin
Turtle neck sign
Failure of restitution
Failure of shoulders to descend

39
Q

Management of SD

A

Diagnosis
Call for help
Scribe
Flatten bed
McRoberts - 90% success
Suprapubic pressure
If no epidural - on all fours
Episiotomy if needed
Internal rotation - woodscrew, reverse wood
Deliver post arm - assoc w 1-12% humerus #
Zalvanelli
Cleidotomy
Symphysiotomy

40
Q

Defn and incidence cord prolapse

A

Descent of the cord through the cx with ruptured membranes
- occult: alongside presenting part
- overt: past presenting part

1.7/1000 live births (0.17%)

41
Q

Antenatal risk factors for cord prolapse

A

Non-vertex presentation (breech or transverse - backup)
Unengaged presenting part
Unstable lie
Polyhydramnios
ECV
PPROM
Multiparity
LBW
Congenital abnormalities
Cord abnormalities
Male gender

42
Q

Intrapartum risk factors for cord prolapse

A

AROM
Prematurity
Second trin
Manual rotation or other vaginal manipulation of te fetus
- internal podalic version
- disimpaction of fetal head during rotational assisted delivery
- placement of FSE
- insertion of intrauterine pressure catheter or amnioinfusion catheter

43
Q

Prevention of cord prolapse

A

Unstable lie - admit from 37-38/40
ARM when head well applied

44
Q

Management of cord prolapse

A

Help
Assess maternal and fetal wellbeing
Elevate presenting part
- mother adopts knee to chest/ head down left lateral/ all fours
Manual displacement of head
Fill bladder
Wrapping cord
Tocolysis
Delivery - quickest means possible

45
Q

Incidence of impacted head

A

8000 deliveries per year

46
Q

Indication of impacted head

A

Fetal compromise
Prolonged second stage

47
Q

Maternal morbidity assoc w impacted head

A

More than double intraop trauma than CS at first stage
Bladder/ bowel damage, uterine extensions = 10-27%
PPH= 4.7-10%
Psych

48
Q

Neonatal morbidity assoc w impacted head

A

Trauma higher in OVD than CS
More SCBU admission w CS than OVD (prolonged delivery not procedure)

49
Q

Techniques for fully dilated CS

A

Exposure:
- high uterine incision
- NICE advises Joel Cohen incision (straight, 3cm above PS)
Disimpacting:
- uterine relaxants: GTN
- pressure from below
- frog legs
- reverse extraction
- Patwardhan extraction: delivery of shoulders through incision, then trunk, breech and finally head
Medical devices:
- fetal pillow (silicone balloon), C-snorkel

50
Q

RCOG guidelines for disimpacting fetal head

A

Deflex
Non-dominant hand delivery to reduce extensions
Hand below - push up technique
Patwardhans

51
Q
A

P2 (11 decks)

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