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Y4 - GOSH > Obstetric Emergency and Complications > Flashcards

Obstetric Emergency and Complications Flashcards

1
Q

What are included in the obstetric emergency

A

Eclampsia

PE

MI - rare but increasing due to inc maternal age

Amniotic fluid embolus - exceedingly rare

Ante/post-partum Haemorrhage

Uterine rupture

Uterine inversion

Septic shock

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2
Q

Definition of Antepartum Haemorrhage

A

Bleeding from the genital tract after 24 wks gestation

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3
Q

What is PV bleed termed if it is before 24 wks

A

Miscarriage

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4
Q

Definition of primary post-partum haemorrhage

A

Bleeding > 500ml in the first 24 hours post delivery

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5
Q

Definition of secondary post-partum haemorrhage

A

Excessive bleeding form the genital tract between 24 hours and 6 wks

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6
Q

Possible causes of Antepartum Haemorrhage

A

Unexplained - 97%, usually marginal placental abruption

Placenta praevia - 1%

Placental abruption - 1%

Cervical specific causes eg cervical erosion, cervical polyp

Trauma

Others - infection, a show (loss of mucus plug), genital tumour, varicosities, vasa preavia

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7
Q

Potential causes of post-partum haemorrhage

A

4 Ts

Tone - atomic uterus - 90%

Trauma - genital tract trauma - 7%

Tissue - retained produced of conception

Thrombin - abnormal clotting eg coagulopathy, severe pre-eclampsia, placental abruption

Also

Large placenta
Abnormal placental sites —> placental preavia, placental accretion
Uterine inversion

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8
Q

Immediate management of Ante-postpartum haemorrhage

A 
A-F assessment 
A
B
C
D
E
F - foetal status eg foetal BP
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9
Q

Assessment of Antepartum Haemorrhage

A

Maternal assessment

  • BP
  • pulse
  • other signs of haemodynamic compromise eg peripheral vasoconstriction etc
  • uterine palpitation - for size, tenderness, foetal lie, presenting parting (if engaged then not a placenta praevia)

Never to perform a VE examination without first exclude a placenta praevia via USS

  • once placenta praevia exclude then speculum to assess degree of bleeding
  • VE to assess dilatation for delivery

foetal assessment - check if you can hear the heart beat of the foetus

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10
Q

What must you not do in a suspected Antepartum Haemorrhage patient

A

Never to perform a VE examination without first exclude a placenta praevia via USS —> if you insert your fingers, you can cause the placenta preavia to pop and so haemorrhage

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11
Q

Mx of APH

A

A-E assessment

  • G+S
  • coag
  • Anti D (if rehesus -ve)
  • cannulate just in case

If foetal/maternal compromise —> treat as massive obstetric haemorrhage +/- emergency C/S by experienced obstetrician and anaesthetist

If foetal/maternal haemodynamically stable —> admit for 24 hours to ensure no big APH coming

Further foetal USS for foetal well-being and to confirm placental location
Umbilical artery Doppler - measure the function of placenta which can be affected by small placental abruption

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12
Q

Mx of PPH

A

Tone - physical, medical and surgical

  • physical - uterine massage
  • medical
    • syntocinon 5 units slow infusion —> ergometrine 500mcg IV bolus —> syntocinon infusion 40 units fast infusion —> Carboprost 250 mcg IM (synthetic prostaglandin) —> misoprostol (prostaglandin analgoue) 800-1000 mcg PR

SESCM

  • surgical - uterine tamponade with Rusch ballon, if placental accreta, laparotomy to suture over placental bed, hysterectomy

Tissue - retain product
- active 3rd stage management or manual evacuation

Trauma
- repair genital tract trauma

Thrombin
- correct with blood product

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13
Q

Antepartum risk factor for PPH

A 
Previous PPH 
Previous retained placenta 
Maternal low HB 
Inc BMI 
Para 4 or more 
APH 
Anything that causes oversizing of uterus 
- Multiple pregnancy 
- polyhydrammios 
Maternal age > 35
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14
Q

Intrapartum risk factor for PPH

A 
Induction of labour 
Prolonged 1st, 2nd or 3rd stage of labour 
Use of oxytocin 
Vaginal operative delivery 
C/S
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15
Q

Definition of placenta abruption

A

When the placenta separates from the uterus before the delivery of the foetus

blood can accoumlate behind the placenta

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16
Q

Types of placenta abruption

A

Concealed

  • no external bleeding evident (<20%) but instead confined behind the placenta and within the uterine cavity
  • more severe form as blood loss can easily be underestimated

Revealed

  • vaginal bleeding (80%)
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17
Q

RF for placenta abruption

A

Previous abruption

Multiple pregnancies

Threaten miscarriage int he earlier part of the same pregnancy

Trauma - RTA, domestic violence

Iatrogenic - ECV

HTN/Pre-eclampsia

Previous C/S

Cocaine or a feta mine use during pregnancy

Thrombophilia

Polyhdramnios due to DM

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18
Q

Presentation of placenta abruption

A

PV bleed - often darkish blood

Abdo pain - usual presentation, sudden onset, constant and severe

some uterine contraction +/- going into labour

Backache - due to posterior placenta tearing

Woody uterus - hard uterus as blood is irritant

Maternal hypovolaemia - late stage

Shock

Foetal distress

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19
Q

Ix/diagnostic criteria for placenta abruption

A

Usually Clinical diagnosis

USS only to confirm fetal well-being and exclude placenta praevia

CTG abnormal

Dec Platelet count/coag - if dec = significant abruption

Maternal shock

	○ FBC, U and E, LFT
	○ G&S (x-match 4-6 unit) 
	○ Check for HELLP syndrome 
	○ Coag, prothrombin time/activated partial thromboplastin time ---> inc In the case of severe placental abruption indicating coagulopathy 
	○ Fibrinogen level 
		§ Pregnanct is associated with hyperfibrinogenemia --> modestly depressed fibrinogen level may represent significant coagulopathy 
		§ A level of < 200 suggest severe abruption 
	○ Kleihauer-Betke test 
		§ Detect foetal blood cells in maternal circulation --> help with correct dose of Anti-D being given 
	○ Imaging --> USS
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20
Q

Mx of placenta abruption

A

admit all women with PV bleed or unexplained abdo pain

Dependence on gestation, signs and symptoms ie severity, maternal CVS status and any evidence of foetal compromise

  • At/near term + foetal condition stable –> conservative meangement –> induction of labour by aminotomy and syntocinon infusion for vaginal delivery
  • If foetal compromise –> C/S
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21
Q

Definition of placental praevia

A

When the placenta is inserted, wholly or in part into the lower segment of the uterus

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22
Q

RF for placenta praevia

A 
previous placenta praevia 
Previous C/S 
Inc maternal age 
Inc parity 
Smoking 
Cocaine use during pregnancy 
Previous abortion/TOP 
Deficient endometrium —> due to past Hx of for example endometriosis, manual removal of placenta 
Assisted conception
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23
Q

Pathophysiology of placenta praevia

A

○ Occurs in 5-28% of pregnancies during the 2nd trimester
○ As the uterues grows, the placental site often migrates upwards (usually occur in 2nd and 3rd trimester)
○ Placenta develops from discoid condensation of trophoblasts on th surface of chorion at approx. 8-10 wks of gestation
Position of the placenta is decided by the site of implantation of discoid trophoblasts

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24
Q

Presentation of placenta praevia

A

Usually incidental finding on routine USS

Painless PV bleed starting after the 28th week —> sudden and profuse bleed

high presenting part or abnormal lie

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25
Q

When is the finding of placenta praevia not worrying

A

Before 20 weeks since it can still migrate upwards after that

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26
Q

Ix of placenta praevia

A

§ Foetal anomaly USS –> placenta localisation done as routine
§ If low lying –> follow-up USS incl a TVS at 32 wks

27
Q

Mx of placenta praevia

A

§ Advice to come in –> if any bleeding, contraction pain
§ Give steroids between 34 and end of 35th weeks of gestation for a low-lying gestation or placenta praevia
§ C/S = usual method of delivery Type III or more severe of placenta in 3rd trimester
§ For minor previa –> vaginal delivery can be attempted if foetal head below leading edge of placenta
§ Delivery < 37 weeks if
□ Onset of labour which can’t be suppressed
□ Foetal distress
□ Severe growth restriction
□ IUD
□ Severe bleed

28
Q

Type of placenta previa

A

Major - grade 3 and grade 4 where the placenta overlaps the internal os

Minor - grade 1 and grade 2 where the placenta does not overlaps the internal os

29
Q

symptoms of PE in pregnancy

A 
pleuritic chest pain 
SOB 
tachycardia 
hypotension
reduced air entry 
collapse
reduced oxygen saturations
30
Q

incidences of VTE in pregnancy

A

1-2 / 1000 in pregnancy

31
Q

incidence of DVT compare to PE

A

DVT 3 times higher risks than of PE

32
Q

out of emergency C/S, elective C/S and vaginal delivery, which has the highest risk of having DVT

A

Emergency C/S has the highest risk because should the baby need emergency C/S, one can imagine that the health status of the women being women ie more dehydrated etc

33
Q

which period of pregnancy (antenatal, intra-partum and peerperium) has the highest DVT rate

A

antenatal

34
Q

which period of pregnancy (antenatal, intra-partum and puerperium) has the highest PE rate

A

puerperium

35
Q

what factor is considered to be high risk for VTE in antenatal periods

A

any previous VTE except a single event related to major surgery

36
Q

drug of choice in VTE prophylaxis in pregnancy

A

LMWH

37
Q

what are the regime of LMWH

A

twice-daily dosage regime –> tinzaparin, enoxaparin 1mg/kg BD, dalteparin 100 units/kg BD up to 18,000 units/24 hours

38
Q

when can warfarin can be used

A

warfarin can only be used for women with prostatic heart valve

39
Q

pathophysiology of uterine inversion

A

when placentas fails to detach from the uterus as it exits, pulls on the inside surface and turns the whole uterus inside out

40
Q

how common is uterine inversion

A

rare

41
Q

what are some of the risk factors of uterine inversion

A

grand multips

incorrect management of the 3rd stage

42
Q

how does uterine inversion present

A

usually present as PPH + vaso-vagal shock –> pale, clammy, hypotensive & bradycardia and a mass at the introitus

can also present as significant haemorrhage, clotting abnor and renal dysfunction

43
Q

how many different types of uterine inversion are there?

A

1st to 4th degree

1st degree - only slight detachment of the fundus of the uterus

2nd degree - detachment passes cervical neck

3rd degree - detachment at the end of vaginal

4th degree -detachment out majority of the vagina

44
Q

management of uterine inversion

A

prepare a theatre for possible laparotomy

cautious administration of tocolytics to allow uterine relaxation (might cause aggressive haemorrhage)

Johnson’s method - try to reposition the uterus manually and quickly by slowly and steadily pushing upwards towards the umbilicus –> then bimanual uterine compression and massage until the uterus is well contracted and bleeding has stopped

if fails –> O’Sullivan’s method - reduce inversion by hydrostatic technique

hypotension and hypovolaemia require aggressive fluid and blood requirement

general anaesthesia or uterine relaxant is then stopped and replaced with oxytocin, ergometrine or prostaglandins to help to contract the uterus

ABx is then started for at least 24 hours

45
Q

what are some of the tocolytics

A

nitroglycerin (0.25-0.5mg) IV over 2 mins

or

terbutaline 0.1 - 0.25mg slowly IV

or

magnesium sulfate 4-6g IV over 20 mins

46
Q

complications of uterine inversion

A

significant haemorrhage, clotting abnormalities and renal dysfunction can occur if not corrected promptly

47
Q

what can severe sepsis cause to the pregnancy

A

mid-trimester rupture of membranes –> managed conservatively

48
Q

management of septic shock

A 
A-F approach
airway 
breathing 
cardiac 
disability 
exposure 
foetus

IV broad spectrum ABx eg cefotaxmine, metronidazole +/- gentamicin

inform SCBU, check foetal presentation with USS, betametasone IM 12 mg (2doses 24 hours apart) should the baby be pre-term and need delivery

consider tocolysis (nifedipine and atosiban IV to prevent labour and delivery)

49
Q

definition of ecalmpsia

A

grand mal convulsions - occurence of a tonic clonic seizure in association with a diagnosis of pre-eclampsia

50
Q

mx of eclampsia

A

A-F assessment

give diazepam or magnesium sulphate to stop fits

prevent further fits by commencing magnesium sulphate infusion

deliver baby as pre-eclampsia/eclampsia are both conditions of the placenta

51
Q

complication of pre-eclampsia/eclampsia

A

HELLP syndrome –> haemolysis, elected liver enzymes and low platelet

52
Q

what is preterm labour

A

delivery before 37 weeks

53
Q

what are some clinical features of preterm labour

A

cervical weakness - inc vaginal discharge, mild lower abdo pain and bulging membranes on examinations

infection, inflammation or abruption = lower abdo pain, painful uterine contractions and vaginal loss

54
Q

what are some investigations for pre-term labour?

A

FBC, CRP (raised WBC and CRP - infection)
swabs (HVS, LVS, perianal)
speculum - blood, dischare and liquor
MSU
USS for foetal positiion, presentation and EFW
- consider using fibronectin/transvaginall USS if available

55
Q

management of preterm labour

A

if transvaginal cervical length > 15mm –> unlikely to labour

fibronectin assay - if -ve, then unlikely to labour

if both of the above are +ve –> admit

  • inform SCBU
  • IM betametasone or dexamethasone 24 hours apart
  • consider tocolysisi - nifedipine and terbutaline IV to prevent labour and delivery
  • IV ABX in labour
56
Q

what is an amniotic fluid embolus

A

amniotic fluids, foetal cells, hair enter the maternal blood stream via placenta causing an allergic like reaction

57
Q

what is the pathophysiology of amniotic fluid embolus

A

initially pulmonary symptoms maybe minor

but can progress to sudden cardiovascular collapse, acute left ventricle failure with pulmonary oedema, DIC and neurological impairment

58
Q

clinical features of amniotic fluid embolus

A 
collapse
DIC (if the woman survives for 30 mins) 
unaccountable bleeding 
seizures 
right sided heart failure 
aRDS
59
Q

mx for amniotic fluid embolus

A 
A-E assessment 
blood transfusion 
fluid resus 
early transfer to ITU - likely to need renal and inotropic support 
correct clotting 
require expert help at early stage
60
Q

when does uterine rupture occur

A

almost always occurs in labour

61
Q

aetiology of uterine rupture

A

previous C-Section scar

risk in a multiparous women on uterine stimulants eg oxytocin

62
Q

clinical features of uterine rupture

A 
clinically significant uterine bleeding
chest of shoulder tip pain 
sudden shortness of breath 
scar pain and tenderness 
cessation of previosuly efficient uterine contractions 
foetal distress 
protrusion or epulsion of foetus +/- placenta into the abdo cavity 
fresh vaginal bleeding 
haematuria 
pai nthat break through epidural
63
Q

ix for uterine rupture

A

USS - might show the foetus to be in abnor position, haemoperitoneum or absent or thin uterine wall

64
Q

mx of uterine rupture

A

A_E assessment
blood transfusion
immediate laparotomy to salvage babe - repair damage or hysterectomy

Y4 - GOSH (12 decks)

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