Pregnancy Emergencies Flashcards by Theo Pelly

How should PPROM be managed?

Probability of spontaneous labour is 80% in seven days

Treat with antibiotics (erythromycin) and monitor for infection until 34 weeks when you should induce labor

Steroids to stimulate lung development in baby

Tocolytics may be necessary to prolong labour until steroids can be given

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What is preterm premature rupture of membranes?

When the membranes rupture before labour

Usually defined as rupture before 37 weeks

Usually demonstrated by pooling on sterile speculum- do not perform VE due to infection risk

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What is the incidence of breech presentation?

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What are the different types of breech?

Extended - 65%
Footling - 25%
Flexed - 10%

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How can breech be managed?

External cephalic version:
Offer from 36-37 weeks
Success from 35-50%
Risks - pain transient bradycardia, abruption, emergency lscs

Caesarean section
Vaginal breech delivery

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What are the absolute and relative contraindications to ECV?

Absolute:
Placenta previa
Uterine malformations
Ruptured membranes
Multiple pregs
Abnormal ctg

Relative:
Previous CS
Active labour
Pre eclampsia
Foetal abnormality
Fetal hyper extension

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What is cord prolapse?

In cord prolapse, the umbilical cord protrudes below the presenting part after the rupture of membranes

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What are potential complications of cord prolapse?

Cord prolapse may cause compression of the umbilical vessels by the presenting part and vasospasm from exposure of the cord

These may compromise foetal circulation

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How is cord prolapse managed?

Deliver foetus as soon as possible - this may mean either instrumental deliver or CS?

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What is shoulder dystocia?

Any delivery which requires additional obstetric manouevres after the gently downward traction on the head has failed to deliver the shoulders

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What are the complications of shoulder dystocia?

Foetal hypoxia and resulting cerebral palsy
Brachial plexus palsy
Cervical spine injury
Fracture of clavicle
Post partum haemorrhage
Genital tract trauma

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How can shoulder dystocia be managed?

Episiotomy
Mcroberts position
Supra public pressure
Internal manouevres- twist baby round

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What is Antepartum haemorrhage?

Bleeding from the genital tract after 24 weeks gestation

Before 24 weeks, it is termed a threatened miscarriage

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What is the immediate manage of APH?

Call for help
ABCDE
Facial oxygen and tilt bed head down
Two cannulas and give fluid challenge
FBC, clotting screen, crossmatch
Utinary catheter
Check foetal condition - CTG
USS
Obstetric exam

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What are causes of Antepartum haemorrhage?

Placenta previa
Placental abruption
Cervical erosion
Cervical polyp
Trauma 
Severe chorioamnionitis
Severe pre-eclampsia - hepatic rupture

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How is Antepartum haemorrhage managed?

Do not do vaginal exam until after scan!

Assess for painful versus painless bleeding
Establish placental site
Decide if delivery necessary - likely to be CS
CTG?

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Why is pregnancy a pro-thrombotic state?

Coagulation factors later to promote clotting

Large pelvic mass (the foetus) reduces motility

Long labour, dehydration, and operative delivery can aggravate the situation

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How does PE present in pregnancy?

Asymptomatic
Pleuritic chest pain
SOB
Collapse
Hypotension
Tachycardia
Reduces air entry
Reduces O2 sats

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How is PE managed in pregnancy?

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Anticoagulate with low molecular weight heparins

Why is uterine inversion and how does it present?

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Rare
Associated with multips and incorrect management of third stage of labour

Presents with vasovagal shock, and a mass at the introitus

Results in significant haemorrhage, clotting abnormalities and renal dysfunction

Shock corrects when uterus is replaced

What is pre-eclampsia?

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pregnancy induced hypertension in association with proteinuria (>0.3g in 24 hours) with or without oedema

What is eclampsia?

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The occurrence of one or more convulsions superimposed upon pre-eclampsia

Manage:
ABCDE
High flow oxygen, two cannulas
Loading dose mgSO4 IV 4g
Maintenance dose over 5 hours
Continuous obs
Control hypertension - labetol
Continuous CTG - consider delivery

What are risk factors for pre-eclampsia?

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First pregnancy 
Previous pre-eclampsia
Age over 40
Bmi of 35 or more
Family history of pre-eclampsia
Medical conditions- pre existing hypertension, renal disease, diabetes, anti phospholipid antibodies

How does pre eclampsia present?

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BP >140/90
New proteinuria
Severe headache
Swelling of face, hands or feet
Liver tenderness
Visual disturbance 
Papilloedema
Reduced fetal movements
Small for gestational age infants

What is HELLP syndrome?

Haemolysis Elevated liver enzymes Low platelets - may require transfusion

How should pre-eclampsia be investigated?

Urinalysis- mc&s Frequent monitoring of FBC UandEs and LFTs Clotting studies if severe thrombocytopenia MRI/ct if focal deficits Ultrasound for foetal growth, amniotic fluid vol, umbilical arteries Frequent assessment of BP and urine: 24-32 weeks - min every three weeks 32 weeks - min every two weeks

How should pre-eclampsia be managed?

Manage conservatively if less than 34 weeks, haemodynamically stable and without HELLP. ``` Severe pre-eclampsia (BP >160/110): Labetol, oral nifedipine, IV hydralazine Fluid restriction Manage third stage with Syntocinon Treat seizures with magnesium sulphate ``` If after 34 weeks, consider delivery Continue hypertensives after delivery 24 to 32 weeks - minimum 3 week assessments 32 to deliver - minimum 2 week assessments Aspirin if high risk?

What are complications of pre-eclampsia?

``` Haemolysis HELLP syndrome DIC Renal failure ARDS ```

How can placenta previa be classified?

1 - encroaches on lower segment 2 - reaches internal os 3 - covers part of os 4 - completely covers os

What is placental abruption?

Defined as retroplacental haemorrhage and usually involves a degree of placental separation

What are risk factors for placental abruption?

``` Low social economic class Hypertension Pre-eclampsia Previous abruption Smoking during pregnancy ```

How is placental abruption managed?

Light bleeding from edge of normally situated placenta can be treated with rest and close supervision of foetal growth and placental function until normal labour Major haemorrhage - urgent delivery required

How does placental abruption present?

Painful bleeds Hard and tender uterus May be no discernible foetal heartbeat May be concealed haemorrhage occurring between placenta and uterine wall May lead to DIC Degree of shock may be present?

How does hellp syndrome present?

Nausea and vomiting Epigastric pain Right upper quadrant pain - due to haemorrhage with stretching if the liver capsule

How does chorioamnionitis present?

``` Abdominal pain Uterine tenderness Maternal pyrexia Raised CRP and wcc Meconium stained or foul smelling liquor Foetal tachycardia ```

How does acute fatty liver of pregnancy present

``` Sudden onset epigastric pain Anorexia Malaise Nausea and vomiting Diarrhoea Jaundice Hypertension Proteinuria Fulminant liver failure ```

What would be the biochemical findings of acute fatty liver?

``` Raised bilirubin and abnormal LFTs Raised WCC Thrombocytopenia Hypoglycaemia Coagulation defects ``` Distinguished from hellp syndrome by hypoglycaemia and high uric acid

How is acute fatty liver treated?

Correct fluid balance, coagulation and electrolytes Deliver may be necessary

When does obstetric cholestasis occur?

After 30 weeks gestation

How does obstetric cholestasis present?

Severe pruritis of limbs, trunk, feet No abdominal pain! Due to impaired bile secretion

How is obstetric cholestasis managed?

Deliver at 37-38 weeks Chlorphenamine to relieve itching Ursodeoxycholic acid to reduce bile acids

In preterm labour, how is ritodrine used?

Ritodrine is a beta agonist tocolytic - inhibits smooth muscle contraction to delay labour, to allow time for corticosteroids

In preterm labour, how is atosiban used?

Atosiban is an oxytocin inhibitor that can be used to reduce delivery within a 48 hour period Nifedipine, magnesium sulphate and indometacin may also be used

What are contraindications to tocolysis?

Foetal distress | Intrauterine infection

What is uterine rupture?

Uterine wall tears- usually in patients who have had previous myomectomy or LSCS, can occur if high parity and oxytocin drip Presents with pain and shock, termination of contractions and ctg abnormalities Operative delivery is required immediately

What is vasa previa?

The umbilical cord traverses the membranes and overlies the internal os There is a rush of the vessels tearing in cervical dilation and when the membranes rupture Perform LSCS

Pregnancy Emergencies Flashcards

(46 cards)