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3A Womens health > Obstetrics emergencies > Flashcards

Obstetrics emergencies Flashcards

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1
Q

Examples of maternal obstetric emergencies

A

Related to pregnancy
Disorders of any system
Initiated by pregnancy
Exacerbated by pregnancy
Disorders if the uterus and genital tract
Unrelated to pregnancy

e.g.
APH - uterus/ genital tract
PPH - uterus/ genital tract
VTE
PET

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2
Q

What is antepartum haemorrhage? (APH)

A

Bleeding from anywhere within the genital tract after the 24th week of pregnancy (uterus, cervix, vagina, vulva)

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3
Q

What are some identifiable causes of APH?

A

Low Lying placenta / placenta praevia.
Placenta accreta
Vasa praevia
Minor/Major abruption
Infection

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4
Q

What is low lying placenta?

A

Any part of the placentathat has implanted intothe lower segment
Major– covering/reachingos
Minor– in lowersegment/encroaching

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5
Q

Diagnosis of low lying placenta

A

20 week anomaly scan
High presenting part, abnormal lie, painless bleed
Minor praevia repeat scan at 36 weeks (TV)
Major praevia repeat scan at 32 weeks (TV)
Placenta must be >20mms from cervical os
Placenta remains < 20 mms elective caesarean section

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6
Q

What is the management of low lying placenta?

A

Advise to present if pain / bleeding
Advise to avoid sexual intercourse
If recurrent bleeds may require admission until delivery and ensuring has cross-match in date
Remember to give anti-D if Rh negative
Elective caesarean section at 38 -39 weeks (sometimes before if bleeding does not settle)

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7
Q

What occurs in a bleeding placenta praevia/ management

A

ABCDE
If major bleed: two 14/16 G cannulas, IV fluids (crystalloid), Xmatch 6 units, inform senior team andPaedsASAP

Examination
- General and abdominal
- Vaginal (avoid digital examination)
- ? USS (check20 weekscan)
Fetalmonitoring(CTG)+/- delivery
Steroidsif < 34weeksgestation

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8
Q

features of placenta previa

A
  • no pain
  • soft tender uterus
  • bright fresh blood
  • shock consistent with blood loss
  • breach / abnormal lie
  • normal feral heartbeat
  • low lying placenta
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9
Q

What is the management of placenta accreta?

A

At 20w scan watch for anterior LLP if previous CS

MRI scan may be useful
Arrange elective CS at 36 to 37 weeks
Discussion and consent includes possible interventions (such as hysterectomy, leaving the placenta in place, cell salvage and intervention radiology)
Multidisciplinary involvement in pre-op and procedure: consultant obstetrician,

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10
Q

What happens in Vasa praevia?

A
  • Fetalvessels coursing through the membranes overthe internal cervicalosand below thefetalpresenting part, unprotected by placental tissue orthe umbilical cord
  • 1 in 2,000 to 6,000 pregnancies
  • No major maternal risk, but majorfetalrisk
  • Membrane rupture leads to majorfetalhaemorrhage
    CTG abnormalities
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10
Q

types of placental invasion and severity

A

accreta- though the myometrium
increta- myometrium and serosa
percreta- invade through all layers and invades other organs

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10
Q

A woman presents with fresh vaginal bleeding immediately following the rupture of her membranes. Fetal heart abnormalities including bradycardias and decelerations are present. Transvaginal ultrasonography confirms that there are ruptured blood vessels which are fetal in origin, which overlie the cervix. What is the most likely cause of her bleeding?

A

vasa previa

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11
Q

what are the features of placental abruption

A
  • PAIN
  • hard woody uterus
  • absent / dark bleeding
  • shock inconsistent with blood loss
  • normal lie
  • fetal distress
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12
Q

risk factors of placental invasion

A

older age
previous cx- most common
uterine surgery

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13
Q

What happens in placental abruption?

A

Premature separation of the placenta from the uterine wall

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14
Q

why does having a previous c section increase risk of placental invasion

A
  • scarring can cause defective endometrial- myometrial interface
  • causing failure of normal decidualisation which allows placenta villi to invade further
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15
Q

what are the features of placental abruption

A

PAIN
hard woody uterus
absent / dark bleeding
shock inconsistent w blood loss
normal lie
fetal distres

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16
Q

management of placenta invasion

A

c section 35-37 weeks
hysterectomy with placenta left in situ

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17
Q

What happens in morbidly adherent placenta?

A

Placenta penetrates through decidua basalis and through themyometrium

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18
Q

How do we manage AIP?

A

At 20w scan watch for anterior LLP if previous CS
Loss of definition between wall of uterus and Abnormal vasculature
MRI scan may be useful
Arrange elective CS at 36 to 37 weeks
Discussion and consent includes possible interventions (such ashysterectomy, leaving the placenta in place, cell salvage andintervention radiology)
Multidisciplinary involvement in pre-op and procedure: consultantobstetrician, consultant anaesthetist and blood bank/

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19
Q

What are some complications following APH?

A

Premature labour/delivery
Bloodtransfusion
Acute tubular necrosis (+/- renal failure)
DIC
PPH!
ITUadmission
ARDS (secondary to transfusion)
Fetalmorbidity (hypoxia) andmortality

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20
Q

What is severe pre- eclampsia?

A

Hypertension + proteinuria

+/- at least 1 of the following
Severeheadache
Visual disturbancese.g.blurring/flashing lights
Papilloedema
Clonus
Liver tenderness
Abnormal liver enzymes
Platelet count falls to < 100 x 109/litre

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21
Q

What is the management of severe Pre- Eclampsia?

A
  • Stabilise blood pressure(labetalol, nifedipine, methyldopa)
  • Check bloodsincludingplatelets, renal and liver function
  • Magnesium sulphateif applicablee.g.hyperreflexia
  • Monitor urine output(fluid restrict to 80mlsper hour)
  • Treat coagulation defects
  • Fetalwellbeing(CTGs, USS forfetalgrowth)
    Delivery
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22
Q

What is eclampsia?

A
  • Onset of seizures in a woman with pre-eclampsia
  • Seizures in a pregnant woman are always eclampsiauntil proven otherwise
  • IV MgSo4 4gms given over 5 minutes, followed by aninfusion of 1 g/hour maintained for 24 hours
  • Recurrent seizures may require further doses
  • Treat hypertension(labetalol , nifedipine , methyldopa,hydralazine)
    Stabilise mum first, then deliver baby
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23
What happens during sepsis?
Sepsis is the leading direct cause of maternal death in the UK in the UK Always think sepsis! Advise all pregnant women to be immunised for seasonal flu and also COVID
24
What are the risk factors for sepsis?
Obesity Diabetes Impaired immunity / immunosuppressant medication Anaemia Vaginal discharge History of pelvic infection History of group B Strep infection Amniocentesis and other invasive procedures Cervical cerclage Prolonged spontaneous rupture of membranes Group A Strep infection in close contacts / family members
25
Sepsis Red Flag symptoms
- Responds to only voice or pain/ unresponsive - Systolic BP <90 mmHg - HR > 130 per minute - Resp rate 25 per minute - Non blanching rash - Not passed urine in 18 hours - Lactate >2 mmol/l
26
S + S of sepsis
Pyrexia Hypothermia Tachycardia Tachypnoea Hypoxia Hypotension Oliguria Impaired consciousness Failure to respond to treatment
27
What is the management of Sepsis?
Timely recognition – be alert to signs/MEOWS First hour SEPSIS SIX BUNDLE 1) O2 as required to achieve SpO2 over 94% 2) Take blood cultures  3) Commence IV antibiotics 4) Commence IV fluid resuscitation 5) Take blood for Hb, lactate (+glucose) 6) Measure hourly urine output Ongoing multidisciplinary care: obstetrician, anaesthetist, critical care, microbiologist, etc
28
What happens in fetal compromise?
What affects mother, affects baby Stabilise mother BEFORE attempting delivery of the fetus If strong suspicion of fetal compromise i.e. prolonged bradycardia or fetal acidosis on scalp sample – DELIVER
29
What happens in cord prolapse?
- Rare: 0.2 – 0.6% - Occurs when cord is presenting (first cord, then baby) - After rupturing membrane - Exposure of the cord leads to vasospasm  - Can cause significant risk of fetal morbidity and mortality from hypoxia
30
How does a cord prolapse occur?
This is an obstetric emergency where the cord passes through the os in front of the presenting part of the baby.
31
What can pressure on the presenting part of the cord cause?
may restrict umbilical cord blood flow resulting in acute foetal hypoxia and foetal distress. It occurs in 1:200-300 births.
32
What are the RFs for cord prolapse?
- Premature rupture membranes - Breech or transverse - Polyhydramnios (i.e. a large volume of amniotic fluid) - Long umbilical cord  - Multiparity 
33
What is the immediate management of a cord prolapse?
determine if the cord is still pulsating if the cord is pulsating then push any exposed loop back into the vagina so to keep it warm and moist - use 2 fingers to remove pressure on cord, do not remove until OR - give o2 as baby may be hypoxic - knee to chest, trendelenburg position - if dilated push - prep for CS infusion of fluid, e.g. 500 ml saline, into the bladder, via a size 16 catheter
34
Cord prolapse - management
- Call 999 (if not in hospital) or emergency buzzer - Infuse fluid into bladder via catheter if at home  - Trendelenburg position (feet higher than head) - Constant fetal monitoring - Alleviate pressure on cord  - Transfer to theatre and prepare for delivery
35
What is a cord prolapse an indication for?
Immediate CS
36
What is the foetal mortality rate of a cord prolapse?
There is a foetal mortality of ten to seventeen percent.
37
How do we prevent cord prolapse from happening?
Mothers with a high risk of cord prolapse e.g. transverse lie, should be admitted after 37 weeks so that if membranes should rupture and cord prolapse occur caesarian section can be performed without delay.
38
When is labour deemed obstructed?
Labour is deemed obstructed when there is no progress despite strong uterine contractions.
39
What is dystocia defined by?
Dystocia is defined as the slow or painful birth of a child.
40
What is shoulder Dystocia?
- Failure for the anterior shoulder to pass under the symphysis pubis  after delivery of the foetal head  - Around 1% of pregnancies - Intrapartum emergency - High risk for maternal morbidity and f0etal mortality and morbidity
41
What is the definition of shoulder dystocia?
● (RCOG) Vaginal cephalic delivery that requires additional obstetric manoeuvres to deliver the foetus after the head has delivered and gentle traction has failed.
42
What is the pathophysiology of shoulder dystocia?
● Discrepancy between size of foetal shoulders and maternal pelvic inlet leads to impaction: ○ Anterior shoulder behind maternal pubic symphysis (commonest). ○ Posterior shoulder behind maternal sacral promontory (more rare). ● Delay in delivery can result in hypoxic ischaemic encephalopathy (HIE) due to compression of the umbilical cord against the maternal pelvis. ● Another notable complication is brachial plexus injury resulting in Erb’s palsy (C5-6) or less commonly Klumpke’s palsy (C8-T1).
43
RFs for shoulder dystocia
- Macrosomia (most cases occur in normally grown babies) - Maternal diabetes - Previous shoulder dystocia - Disproportion between mother and fetus - Postmaturity and induction of labour - Maternal obesity - Prolonged 1st or 2nd stage of labour - Instrumental delivery
44
Signs of shoulder dystocia
○ Difficulty delivering face / chin ○ Turtle-neck sign (head retracts into birth canal) ○ Failure of restitution ○ Failure of shoulder descent.
45
How do we have a definitive diagnosis for shoulder dystocia?
● Definitive diagnosis is made when normal axial traction cannot deliver the baby’s body after the head has been delivered
46
Shoulder dystocia management
H – Call for help (emergency buzzer) E – Evaluate for episiotomy L – Legs in McRoberts P – Suprapubic pressure E – Enter pelvis  R – Rotational manoeuvres R – Remove posterior arm (R – Replace head and deliver by LSCS -Zavanelli)
47
First, second and third line management of shoulder dystocia?
● First Line: 1. McRoberts’ manoeuvre (mother hyperflexes hips, bringing her thighs to her abdomen) plus 2. Suprabupic pressure (to disimpact anterior shoulder) plus 3. Discourage pushing (to prevent further impaction. ● Second Line: 1. Deliver posterior arm The Peer Teaching Society is not liable for any false or misleading information. 25 2. Attempt internal rotation manoeuvres. 3. If above fails - all fours position and repeat manoeuvres. ● Third Line options (rare): ○ Cleidotomy ○ Symphysiotomy ○ Zavanelli manoeuvre.
48
What are the complications of shoulder dystocia?
Maternal   PPH  Extensive vaginal tear (3rd and 4th degree)  Psychological 3rd and 4th-degree perineal tears Neonatal   Hypoxia  Fits  Cerebral palsy  Injury to brachial plexus - most important
49
RFs for predicting Shoulder dystocia?
Macrosomia (most cases occur in normally grown babies) Maternal diabetes Previous shoulder dystocia Disproportion between mother and fetus Postmaturity and induction of labour Maternal obesity Prolonged 1st or 2nd stage of labour Instrumental delivery
50
What is shoulder dystocia associated with?
- a large fetus - any cause of macrosomia increases the risk - in diabetics the fetal head may be of normal size but the body is disproportionately large and the shoulders fail to enter the pelvis as the head is delivered; - post-mature fetus; - short cord; - rotational forceps delivery - this may occur because there is some degree of disproportion and the fetal head has failed to pass the pelvic outlet
51
What is the definition of postpartum haemorrhage?
Postpartum haemorrhage (PPH) refers to bleeding after delivery of the baby and placenta. It is the most common cause of significant obstetric haemorrhage, and a potential cause of maternal death
52
What is post partum haemorrhage?
Primary - Within 24 hours of delivery, blood loss > 500mls - >1000ml after CS Secondary After 24 hours and up to 12 weeks post delivery Minor (500 -1000 mls) Major (> 1000 mls) Severe (>2000mls)
53
Definition of Postpartum haemorrhage (PPH)
● Loss of more than 500ml of blood from the genital tract within 24 hours of delivering a baby
54
What is primary and secondary PPH?
Primary PPH: bleeding within 24 hours of birth Secondary PPH: from 24 hours to 12 weeks after birth - Abnormal or excessive bleeding from birth canal between 24hrs and 12 weeks postnatally. Affects ~ 1% of all pregnancies
55
What are the causes of Postpartum haemorrhage? (4Ts)
The four ‘T’s - Tissue: ensure placenta complete (MROP) - Tone: ensure uterus contracted (uterotonics) - most common cause - Trauma: look for tears (repair) - Thrombin: check clotting (transfusion RPC/ CP/ FFP)
56
What are the causes of secondary PPH?
- Endometritis - Retained products of conception (RPOC) - Subinvolution of the placental implantation site - Pseudoaneurysms - Arteriovenous malformations
57
What investigations can be done for secondary PPH?
- Assess blood loss - Assess haemodynamic status - Bacteriological testing (HVS and endocervical swab) - Pelvic ultrasound??
58
What are the risk factors for post partum haemorrhage?
Big baby Nulliparity and grand multiparity Multiple pregnancy Precipitate or prolonged labour Maternal pyrexia Operative delivery Shoulder dystocia Previous PPH Obesity Pre-eclampsia Placenta accreta Large baby General anaesthesia
59
What are some preventative measurements for PPH?
- Treating anaemia during the antenatal period - Giving birth with an empty bladder (a full bladder reduces uterine contraction) - Active management of the third stage (with intramuscular oxytocin in the third stage) - Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
60
what is the CI for syntometrine
HTN as it causes an increase in blood pressure
61
Management postpartum haemorrhage
Treat the cause Medications: - Sytocinon - Activation of receptors by oxytocin triggers release of calcium from intracellular stores and thus leads to myometrial contraction - Ergometrine - directly stimulates the uterine muscle to increase force and frequency of contractions. - Haemobate - works on prostaglandin F receptor sites in uterine muscle to increase contraction - TXA - Surgery
62
Management for a minor PPH
○ IV access with 14-gauge cannula ○ G+S, FBC, coagulation screen ○ Frequent observations every 15 minutes ○ Warmed crystalloid infusion.
63
Management for Major PPH
○ As for minor PPH, plus: ○ Lie patient flat, give high flow oxygen ○ O-negative blood as soon as possible - warmed crystalloid until blood is available ○ Ongoing haemorrhage: blood component transfusion - FFP, platelets, cryoprecipitate - guided by blood counts and clotting profile.
64
Treatment for both Minor and Major PPH
○ Treatment of underlying cause; treated as for atony: ■ Fundal massage ■ Catheterisation ■ Oxytocin and ergometrine ■ Carboprost (uterotonic) ■ Misoprostol ○ Second line surgical measures, performed in a stepwise manner: ■ Intrauterine balloon tamponade ■ Haemostatic suturing (B-Lynch) ■ Uterine devascularization / arterial ligation ■ Hysterectomy
65
Maternal vs fetal obstetric emergencies
Maternal: Antepartum haemorrhage Postpartum haemorrhage Venous thromboembolism Pre-eclampsia Fetal: Fetal distress Cord prolapse Shoulder dystocia
66
What is HELPERR(R)
H – Call for help (emergency buzzer) E – Evaluate for episiotomy L – Legs in McRoberts P – Suprapubic pressure E – Enter pelvis R – Rotational manoeuvres R – Remove posterior arm (R – Replace head and deliver by LSCS -Zavanelli)
67
What are the treatment options to stop the bleeding in postpartum haemorrhage?
Mechanical Medical Surgical
68
What are the mechanical treatment options for postpartum haemorrhage?
Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”) Catheterisation (bladder distention prevents uterus contractions)
69
What are the medical treatment options for PPH?
Oxytocin (slow injection followed by continuous infusion) Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
70
What are the surgical treatment options for PPH?
Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding B-Lynch suture – putting a suture around the uterus to compress it Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
71
What is secondary PPH?
Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).
72
What are the investigations for secondary PPH?
Ultrasound for retained products of conception Endocervical and high vaginal swabs for infection

3A Womens health (33 decks)

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