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Obstetrics and Gynae – Fellowship teaching 2013

Obstetrics and Gynae – Fellowship teaching 2013. Rachel Rosler. Basic concepts. Two patients Foetal survival depends on maternal stabilisation and well-being Vital signs may appear normal even in the event of significant blood loss. Emergencies in first half pregnancy. Ectopic Abortion

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Obstetrics and Gynae – Fellowship teaching 2013

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  1. Obstetrics and Gynae – Fellowship teaching 2013 Rachel Rosler

  2. Basic concepts • Two patients • Foetal survival depends on maternal stabilisation and well-being • Vital signs may appear normal even in the event of significant blood loss

  3. Emergencies in first half pregnancy • Ectopic • Abortion • Don’t forget Rh-ve • Unstable – IVF, r/o ectopic, tissue os, oxytocin to D&C • Gestational trophoblastic disease • 1/1700 • UTI • Don’t use trimethoprim • Hyperemesis

  4. Emergencies 2nd half pregnancy • Hypertension • >140/90 / 20mmHg rise in systolic /10mmHg rise diastolic • Preeclampsia • Hypertension, pathological oedema, proteinuria • Eclampsia • Preeclampsia plus seizures >20/40 to 7/7 post partum • Headache, visual symptoms, oedema, abdo pain • Cx – splenic/liver haemorrhage, end organ failure, DIC, abruptio placenta, ICH, foetal death • HELLP • Haemolysis, Elevated LFTs, low platelets • Multigravid, BP variable, can be mistaken for gastro, hepatitis, pancreatits, pyelonephritis • Emergency Delivery

  5. PV bleeding in second half pregnancy • 4% of pregnant women have significant bleeding >20/40 • 1/3 of foetuses die with PV bleeding >20/40 • Abruptio placenta • Placenta praevia • Marginal bleed • Vasa praevia • Premature labour and PROM • Lesions of lower Cx / lower GU tract

  6. Post-partum emergencies • Haemorrhage and infection – most common • Amniotic fluid embolus • Rare but important • Eclampsia • Peri-partum cardiomyopathy

  7. Post partum haemorrhage • Uterine atony – most common, Rx oxytocin • Uterine rupture – prior CS • Retained placenta • Uterine inversion • Coagulopathy • Laceration lower genital tract • Physiologic

  8. Gynaecological Emergencies • PID • Pelvic pain • Bleeding in the non pregnant patient • Sexual assault and contraception • Ovarian hyperstimulation syndrome

  9. Question 1 • A 32 year old woman who is 33 weeks pregnant is referred to your emergency department because of a blood pressure of 140/95 and right upper quadrant pain for 24 hours. One hour after arriving in the emergency department, the patient begins to have a grand mal seizure. Describe your management. (100%) (2008/2)

  10. Likely eclampsia • 2 patients – viable foetus, maternal stabilisation is the priority • Stop seizure • Prevent maternal hypoxia, left lateral position • Prevent/ treat secondary trauma • Manage hypertension, if present • Prevent of recurrent seizures • Evaluate for prompt delivery • Seek and treat alternative underlying pathology if indicated • Seek and treat complications of eclampsia • The definitive treatment of eclampsia is delivery, irrespective of gestational age, to reduce the risk of maternal morbidity and mortality from complications of the disease.

  11. Question 2 • Describe how the normal anatomical and physiological changes of pregnancy influence the assessment of a 32 week pregnant woman presenting with multiple trauma. (100%) (2007/2)

  12. Anatomical and physiological differences?

  13. Anatomical and physiological differences • A • Difficult intubation • B • ↑TV, ↓FRC, ↑consumption of oxygen • Impaired ability to compensate for respiratory compromise • Adequate ventilation and supplemental oxygen a priority

  14. Changes in CVS • ↑HR, blood volume, cardiac output • ↓blood pressure, SVR • Restriction of venous return from 20/40 • So what does this mean for a patient presenting to the ED?

  15. Implication of CVS changes • left lateral position (wedge under right hip) • Mother may lose 30-35% blood volume before manifesting signs shock AT EXPENSE OF FOETUS • ↑Volume of fluid required • Pressors may ↓uterine perfusion

  16. GI • Gastric reflux • Gallstones • ↑ALP (placenta) • Early nasogastric • ↑Danger of aspiration

  17. GU • ↑Kidney size, renal blood flow and GFR • ↓Urea and creatinine • Dilatation ureters and renal pelvises R>L

  18. Haemopoietic / Endocrine • ↓Hb, platelets • ↑WCC, Fe consumption ESR • CHO metabolism

  19. Uterus • Weight, volume, intra-abdominal at 12/40, blood flow of 600mlmin by term • Subject to trauma, compression of IVC, engorgement of lower extremities and lower abdominal vessels, possible source of significant haemorrhage • Trauma can cause amniotic fluid embolism, DIC, Rh immunisation

  20. Question 3 • You have just reviewed an 18 year old female who believes she is in premature labour. She is Gravida 1 and Parity 0. She is approximately 26 weeks pregnant by dates. She has received minimal antenatal care. • (a) Describe your assessment of this patient. (50%) • (b) Describe your management of this patient. (50%) (2005/1)

  21. Viable pregnancy but premature and at high risk of complications • Aims of assessment • Confirm labour • Identify stage of labour • Assess foetus – gestation and distress • Identify complications • Assess for maternal risk factors • Look for cause of premature labour • Aims of management • Assure safe delivery, preferentially transfer in utero to tertiary facility • Prepare for delivery – mother and baby • Slow labour for above • Treat any underlying cause or complication

  22. Question 4 • A 32 year old multiparous woman presents via ambulance with marked per vaginal bleeding following the precipitous delivery at home of her term infant 15 minutes previously. The infant is well and is under the care of the neonatal service. The ambulance service has been unable to establish intravenous access and her blood pressure is now unrecordable. • Outline your management of this patient. (100%) (2004/2)

  23. Critically unwell patient requiring aggressive resuscitation and treatment of underlying cause • Tone - uterine atomy • Trauma - genital tract trauma • Tissue - retained placenta • Thrombin – coagulopathy • Early consultation with obstetrics • Disposition to OT or ICU

  24. Overall pass rate 51/64 (79.7%)

  25. Case 1 • 25 year old female • 32/40 gestation • Presents with minor fall landing bottom • Now has mild lower abdominal and back pain • Noticed small amount of bright red PV bleeding • HR 95, BP 95/50

  26. So what causes bleeding in the second half of pregnancy?

  27. PV bleeding in the 2nd half of pregnancy • Antepartum haemorrhage • After 20/40 • Up to 4% of pregnancies • Up to 1/3 of foetuses die

  28. Differential diagnosis • Incidental • Physiologic • Placenta praevia • Accidental haemorrhage • Vasa praevia

  29. Placenta praevia

  30. Abruption • Foetal death in up to 30% • 2-4 litres may be concealed • Deceleration injury • Minor fall • Spontaneous • Minor bleeding if any, usually associated with pain • ONLY 50% SEEN ON ULTRASOUND

  31. Vasa praevia • Foetal vessels in amniotic membranes across cervical os • Rupture • Bleeding is from the foetus • Foetal bradycardia • Abnormal CTG

  32. What to do • Careful history • Examination • Post 30/40 right hip elevated • DO NOT do a PV until site of placenta is determined by ultrasound • PV – look for local cause bleeding, assess stage labour • CTG • For four hours after minor trauma even in asymptomatic patients if over 24/40

  33. Investigations • FBC, coag screen, Kleihauer test, blood group, Rhesus factor, rhesus antibodies, cross match • Pre-eclampsia screen if hypertension • Ultrasound

  34. Kleihauer test • Identifies presence of fetal blood in the maternal circulation • Helps to determine the amount of Anti-D to give • Only obtain on Rh negative patients • Giving 300mcg of Anti-D protects the mother from 30 mL of fetomaternal hemorrhage • Sensitive in detecting small foetomaternal haemorrhage, but amount has no prognostic value

  35. Management • Incidental – none / specific • Placenta praevia – close observation • Small abruption – conservative • Large abruption – emergency caesarian section • Transfer to hospital with obstetric facilities for admission and observation if foetus viable gestational age

  36. Our lady • 25 year old female • 32/40 gestation • Presents with minor fall landing bottom • Now has mild lower abdominal and back pain • Noticed small amount of bright red PV bleeding • HR 100, BP 95/50

  37. Case 2 • 34 year old female • Approx 30/40 pregnant • Brought in by ambulance still fitting after 30minutes • No history available

  38. What causes seizures in pregnancy?

  39. Seizures in pregnancy • Seizures • Increased risk of injury to both mother and foetus • Status – life threatening to both mother and foetus at any stage of pregnancy • Epilepsy • New seizures • Primary or secondary (glucose, drugs) • Pregnancy related - eclampsia

  40. Eclampsia • Seizure in patient with pregnancy–induced toxaemia occuring after the 20th week of gestation to 7 weeks post partum • PET • Hypertension • Oedema • Proteinuria • Seizures are typically brief, self terminating, and usually preceded by a headache with visual symptoms

  41. Treatment of eclampsia • Control seizure • Control hypertension • Expedite delivery of the placenta

  42. Management eclampsia • Magnesium • 4-6g IV over 15 minutes • Infusion of 1-2g per hour • Monitor deep tendon reflexes and Mg levels • Control BP • Mg • Hydralazine • Labetolol

  43. Back to the case • 34 year old female • Approx 30/40 pregnant • Brought in by ambulance still fitting after 30minutes • No history available

  44. Management • Left lateral position • Consider eclampsia • Consider glucose or other causes of seizure • Urgent control of seizures • Benzodiazepine • Magnesium • Phenobarbital (consider in place of phenytoin) • Assess and monitor foetal wellbeing • Urgent early referral for O+G and paediatrics

  45. Case 3 • 28 year old female • 35/40 pregnant • 7th pregnancy, last one precipitous • Contractions 2 minutes apart • Feels that she wants to push • Peripheral centre, no O+G on site

  46. General principles • Safe transfer to delivery suite is always preferable to delivery in ED • Known foetal abnormality or prematurity – do better if transferred in utero • No time to transfer, or patient arrives fully dilated with foetal presenting part on perineal verge = need to deliver in ED • High risk – concealed, obese unknown pregnancy, intellectual impairment or mental illness

  47. Prem labour • Risk factors • PROM, Abruptio, drug abuse, Std, Infection, multiple gestation, Poyhydramnios, cervical incompetence • Is this really labour? • Tocolytics – post consultations, risk vs benefit, salbutamol, terbutaline, mg, nifedipine, glucocorticoids – dex 6mg

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