obstetric emergencies Flashcards
1
Q
Can bleeding be normal in pregnancy?
A
No bleeding is normal, even small spotting could indicate a much larger concealed bleed.
2
Q
Which conditions are more likely to cause haemorrhage in early pregnancy?
A
- Miscarriage
- Ectopic pregnancy
- May be unaware they are pregnant– ask last menstrual period, possibility of pregnancy, previous pregnancies, miscarriages, presence of coil or pelvic infections
3
Q
What is miscarriage, and how does it present?
A
- Spontaneous pregnancy loss up to 24 weeks
- Commonest between 6 and 14 weeks, calculated from first day of last menstrual period.
- Natural event, occurs in up to 20% of clinical pregnancies
- Can be associated with significant haemorrhage
- Vaginal bleeding, often heavy with clots, jelly-like gestation sack, crampy severe lower abdominal pain.
- Cervical shock: hypotension out of proportion to blood loss. Caused by retained miscarriage tissue stuck in cervix.
4
Q
What is an ectopic pregnancy? When does it occur?
A
- Where the ovum implants outside the uterus, normally within the fallopian tube, but can be ovary, abdomen or c-section scar
- Leading cause of maternal death in first 12 weeks of pregnancy
- Usually occurs at about 6-8 weeks gestation
- Greater suspicion if woman has had previous ectopic pregnancy, coil or previous pelvic infections
5
Q
What are the signs/symptoms of an ectopic pregnancy?
A
- Common symptoms: acute lower abdo pain, slight vaginal bleeding or brown loss
- May be tachycardic and show signs of hypovolemia due to intra-abdominal blood loss
- May also complain of shoulder-tip pain (pain at the bottom of the scapula) and unusual bowel symptoms-diarrhoea, fainting episodes may indicate a rupture
6
Q
What is antepartum haemorrhage and what are the two main types?
A
- Bleeding that occurs in the later stages of pregnancy & before birth
- Two main types; placenta praevia and placental abruption
7
Q
What is placenta praevia?
A
- Placenta develops abnormally in the lower segment of the uterus
- Partially or completely covers cervical opening
- Woman unlikely to be able to have a normal birth
- Significant risk of major haemorrhage when the uterus contracts, but can occur at any point of the pregnancy
8
Q
What is placental abruption?
A
- Partial or complete separation of the placenta from uterine wall
- Obvious or significant fresh vaginal bleeding, or no bleeding at all
9
Q
What are revealed and concealed bleeding?
A
- Revealed bleeding – obvious vaginal bleeding, clinical signs of hypovolaemic shock, often painless. Normally associated with placenta praevia
- Concealed bleeding – occurs into abdomen or uterus, maybe with minimal vaginal bleeding, usually associated with significant pain, signs of hypovolaemic shock, hard, woody painful uterus.
10
Q
How do you manage prehospital antepartum haemorrhage?
A
- Estimate blood loss, bring any blood soaked materials or clots
- Consider fluid resuscitation even if mother has central or radial pulses, especially if there is a high indication of significant blood loss
- Evidence of blood loss >500ml or signs of hypovolaemic shock: IV access with large bore cannula, 250ml bolus of fluid, high flow 02 with non-rebreather mask, analgesia/Entonox.
- Encourage left lateral positioning, or manually displace uterus to reduce pressure on inferior vena cava
- Pre-alert to nearest consultant-led obstetric unit for conveyance and transfer without delay
- Compensation can occur for a very long time, have a low threshold for iv fluids.
11
Q
What are the associations of uterine rupture?
A
- associated with previous caesarean or uterine surgery
- most common during labour
- associated with severe bleeding and severe constant abdominal pain and foetal compromise.
- Similar signs to placental abruption.
12
Q
What is the key history for gynaecological bleeding?
A
- Potentially pregnant
- Older women have a higher risk of malignancies
- Previous gynaecological history
- Recent gynaecological interventions
- History of trauma
- Abdo pain
- Volume of blood loss
- Signs of infection
13
Q
What are the 3 types of eclampsia/hypertension?
A
- Essential (chronic) - Diagnosed before pregnancy or in first 20 weeks, continues during pregnancy, Absence of proteinuria – no protein in urine
- Pregnancy induced - New diagnosis in pregnancy, after 20 weeks, Absence of significant proteinuria
- Pre-eclampsia - - New diagnosis of hypertension after 20 weeks, with significant proteinuria
14
Q
What are the risks of severe pre-eclampsia?
A
- Hypertension can lead to intercranial haemorrhage and stroke
- Renal failure
- Liver failure
- Abnormal blood clotting, eg low platelets and disseminated intravascular coagulation
- Can elicit severe frontal headache, epigastric pain due to stretching of liver capsule, visual disturbances and light intolerance, extra brisk reflexes, muscle twitching or tremor, nausea, vomiting and confusion
- Intra-cerebral and subarachnoid haemorrhage most common cause of death. Present with sudden collapse or severe headache with rapid deterioration
15
Q
What are the risks of eclampsia?
A
- Eclamptic seizure – generalised tonic/clonic seizure, self-limiting, lasting 60-90 seconds
- Usually occurring after 24 weeks
- Many will have pre-existing pre-eclampsia
- One thirds of cases of eclamptic seizure occur after birth
- BP may be only mildly elevated
