Obstretics Emergencies

Question 1

Risk factors for vasa previa

Answer 1

Prev c section, lateral placental cord insertion, IVF, smoking, multiple gestation

Question 2

What is placenta previa?

Answer 2

Implantation of the placenta in the lower segment of the uterus at > 16 weeks gestation

Question 3

RF for placenta previa

Answer 3

Multiparity, advanced maternal age, assisted conception, previous placenta previa, previous CS, previous TOP, smoking, multiple preg, structural anomalies

Question 4

When to deliver placenta previa

Answer 4

If uncomplicated, elective C-sect before 38 weeks

Question 5

What is the PET for preeclampsia

Answer 5

FBC, UEC, LFT, uric acid +/- clotting

Question 6

How to manage preeclampsia antenatally

Answer 6

Weekly PET & clinic

U/S fortnightly, fetal surveillance weekly (BPP, Doppler)

Question 7

Cord prolapse RF

Answer 7

General: multiparity, LBW, preterm, breech, mal presentation, polyhydramnios, unengaged
Procedure: ARM, vag manipulation of fetus, ECV, IPV, stabilization of IOL

Question 8

History and investigations for vasa précis

Answer 8

History: asymptomatic/painless PV bleed/bleeding on ROM
Test:
U/S
CTG: sinusoidal HR

Question 9

Tests for placenta abruptio

Answer 9

U/S
CTG
FBC, coag profile, group and hold
Kleihauer and anti-D

Question 10

Placenta abruptio management

Answer 10

Resus: ABCDE. 
- 2 large bore cannulae 
- IV fluids 
- blood for tests 
- packed RBC/FFP/cryoppt 
If fetal heart present: 
- preterm and stable: CS/MGSO4 if needed + tocolytics 
- preterm and unstable: emergency CS 
- term and stable: ARM + oxytocin, anticipate PPH 
If FH absent: 
- induce labour + vag delivery
- anticipate PPH

Question 11

How to manage placenta accreta

Answer 11

Term C-sect if asymptomatic
Hysterectomy
Occlude uterine arteries with inflation of balloon catheter

Question 12

Test for placenta accreta

Answer 12

U/S 20 weeks, increased AFP in 2nd trimester

Question 13

Diagnosis of placenta previa

Answer 13

Mid-trimester scan at 20-22 weeks
If suspected PP, do TVS
Then follow up at 32 weeks with another scan
If asymptomatic, consider another scan at 34-36 weeks

Question 14

Antenatal management of placenta previa

Answer 14

Counsel regarding complications such as risk of bleeding, preterm birth, PPH, C-section
Prevent anemia
Consider early admission
MUST admit if active bleeding, major PP, > 2 bleed episodes, need C-section

Question 15

Emergency mx of placenta previa

Answer 15

ABCDE 
2 large bore IV cannulae 
FBC, HCT, platelet, fibrinogen, Kleihauer, group and cross match, coag 
Once stable 
-  continuous CTG 
- MGSO4 and CS if needed 
- ultrasound once bleeding stops 
- discuss possible hysterectomy
- emergency c section if heavy bleed 
- if less than 37 weeks, continue monitoring for 48 hours then discharge 
- follow up with 2 weekly ultrasound

Question 16

Features of placenta previa

Answer 16

Painless PV bleed > 20 weeks 
- sudden onset, bleeding stops spontaneously but may recur several times 
PCB 
Pelvic cramping 
High fetal presenting part

Question 17

APH classifications

Answer 17

Minor is <50 ml
Major is 50-1000 ml
Massive is >1000 ml and signs of shock

Question 18

Investigations for APH

Answer 18

Minor
- FBC, G&H, coag studies of platelets low and consumptive coagulopathy suspected
Major/Massive
- FBC, consider VBG for rapid hemoglobin if unstable
- coag studies if ongoing bleed or suspected coagulopathy/preeclampsia , consider monitoring every 30-60 mins
- cross match 4 units in all with clinically significant bleeding
- UEC and LFT
- Kleihauer
- once stable, ultrasound for placental location, abnormal vessels, fetal growth/biophysical status

Question 19

Cord prolapse management

Answer 19

Call for help
If not fully dilated, c-section
If birth imminent; operative vaginal delivery
Fill bladder to elevate presenting part
Adopt knee-to-chest position
Manually keep presenting part out of pelvis
Consider tocolytics while prepping for c section

Question 20

Diagnosis of cord prolapse

Answer 20

VE: soft pulsating mass
CTG: prolonged fetal bradycardia and prolonged or variable decelerations
USG

Question 21

Risk factor for cord prolapse

Answer 21

General: multiparity, LBW, preterm, breech, malpresentation, polyhydramnios, unengaged
Procedural: ARM, vaginal manipulation of fetus, ECV, IPV, stabilizing IOL

Question 22

Shoulder dystocia acronym

Answer 22

HELPERRDD

Question 23

Complications of shoulder dystocia

Answer 23

Need to resus neonate 
Birth asphyxia 
Facial purpuric rash
Clavicle fracture
Brachial plexus injury 
Maternal perineal trauma 
Uterine rupture and PPH

Question 24

Signs of shoulder dystocia

Answer 24

Turtle sign, infants shoulder does not deliver with gentle symmetric traction, head does not restitute or externally rotate, difficult delivering face and chin

Question 25

PPH definition, primary and secondary

Answer 25

Blood loss >500ml from genital tract after normal vaginal delivery, >750mml if csection primary: first 24h secondary: >24h and up to 6 weeks postpartum

Question 26

Minor and Major PPH definition

Answer 26

Minor: 500ml or more Major: 1000ml or more

Question 27

Etiology for PPH

Answer 27

Tone: Overdistended uterus (multiple preg, macrosomia, polyhydramnios), uterine exhaustion (prolonged second stage, oxytocin induced), intra-amniotic infection, drug-induced (anaesthetic) Trauma: Episiotomy or perineal tears, C-section, uterine rupture, uterine inversion (high parity) Tissue: Retained placental products, placenta accreta Thrombin: Abnormalities of coagulation (thrombocytopenia, preeclampsia, ITP, factor disorders)

Question 28

Management of PPH flow

Answer 28

1. Identify severity - measure all vaginal blood loss but consider s&s of hypovolemia, speed of blood flow, women’s prior Hb and blood vol - total blood vol at term is 100ml/kg 2. Communication - call for help, alert midwife and obstetric resident and registrar if minor PPh without shock - if major PPH, alert multidisciplinary team - senior members of staff must attend if PPH >1500 and ongoing bleeding or shock 3. Resuscitation 4. Identify and treat the cause

Question 29

Minor PPH initial measures without clinical shock

Answer 29

Palpate uterine fundus and if lax, rub it up to stimulate contraction if actively bleeding prior to placenta being delivered Administer uterotonics Obtain IV access Perform gene puncture for group & screen, FBC, coag screen Commence crystalloid (compound sodium lactate) infusion If placenta in situ attempt delivering by CCT Insert urinary catheter If actively bleeding massage fund us Once placenta delivered, check placenta and membranous for completeness Check for vaginal trauma, apply pressure to any bleeding tissue and suture immediately if able Maternal observations every 15 minutes - PR, RR, BP, uterine tone - measured blood loss on pads - accumulated blood loss in ML

Question 30

Major PPH with ongoing hemorrhage OR clinical shock

Answer 30

Simultaneously commence resus and identify and treat cause and stop bleeding Assess airway and breathing; administer high flow oxygen via face mask 15L per minute Assess circulation - left lateral tilt position - IV access - venepuncture for cross match, FBC, cog screen, RFT, LFT - give IV tranexamic acid (within 3 hours) repeat in 30 mins if bleeding still -fluid resus initially with compound sodium lactate warmed, up to 2L UNTIL blood available. infuse as quickly as possible using rapid infusion set or pressure cuff - insert urinary catheter w burette - commence fluid balance chart - blood and blood products. plan to provide early FFP, cryoppt and platelets. trigger massive transfusion procedure if require more than 4 units RBC and has ongoing bleeding - intraop cell salvage for emergency use Record maternal observations every 5-15 minutes - conscious state, vitals including SaO2 - uterine tone - measured blood loss - accumulated blood loss - temperatures - hb, coag profile, ionized calcium and acid-base balance

Question 31

Uterotonic medications first second and third line

Answer 31

Oxytocin IV/IM Sytometrine IM Ergometrine IM Oxytocin infusion Misoprostol Carboprost tromethamine

Question 32

Oxytocin indication, dose/route, SE

Answer 32

First line in women with placenta in situ, hypertension or preeclampsia 5 units by slow IV or 10 units IM if no IV access Water intoxication, hypotension

Question 33

Syntometrine indications, dose/route, CI and SE

Answer 33

First line alternative for atomic uterus 1ml IM injection Avoid with HTN, cardiac dx, asthma, placenta in situ, severe PVD Administer with antiemetic unless already received within 6 hours Severe vomiting, HTN, headache, placental entrapment

Question 34

Ergometrine indications, dose/route and SE, CI

Answer 34

First line alternative for atonic uterus 250 micrograms IM Same SE and CI as synthometrine

Question 35

Oxytocin infusion indication and dose

Answer 35

Second line to maintain uterine tone when achieved 40 units in 500ml compound sodium lactate, IV infusion at 125ml per hour

Question 36

Managing tone PPH

Answer 36

Massage uterus to stimulate uterine contraction and expel clots Administer uterotonics Empty bladder to aid contraction and insert catheter If heavy bleeding continues, perform bi manual compression till further management decisions are made If intractable bleeding, may need examination under anesthesia, Bakri’s balloon, B-Lynch suture, uterine artery/iliac artery ligation, radiological embolisation, hysterectomy

Question 37

Complications of PPH

Answer 37

``` IDA Hemorrhagic shock Operative interventions Infection Delayed lactation Significant morbidity Renal impairment Death ```

Question 38

Prophylaxis for PPH

Answer 38

Prevent and treat anemia during pregnancy (Hb <90g/L) Determine placental location at mid-trimester scan Recommend prophylactic uterotonics in active management of third stage of labour Consider IV access early in labor, FBC group and hold or cross match, transfusion plan Consider use of IV tranexamic acid in addition to oxytocin to reduce blood loss in women at sig risk of PPH

Question 39

Third stage management after C section

Answer 39

Oxytocin 5 units slow IV Oxytocin infusion In women with sig risk of PPH, IV tranexamic acid

Question 40

Antenatal RF for PPH

Answer 40

History of PPH, high BMI, maternal anemia, APH, previous macrosomia baby, polyhydramnios, fibroids, IOL, known coagulopathy, abnormal placentation, hypertensive disorders, placenta previa, multiple pregnancy

Question 41

Intrapartum RF for PPH

Answer 41

Augmentation of labour, prolonged latent phase, prolonged active first/second/physiological third/active third stage, surgical intervention, pyrexia, shoulder dystocia, fetal macrosomia, placenta abruptio, incomplete third stage

Question 42

Risk Factors for placenta abruptio

Answer 42

``` Pre-eclampsia/HTN SMOKING Cocaine Chorioamnionitis Uterine trauma Twins/polyhydramnios Previous history of abruptio FGR ```