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Obstetric Emergencies. Catriona Kerr-Wilson 0604596k@student.gla.ac.uk. Top Emergencies. Severe pre-eclampsia Antepartum haemorrhage Postpartum haemorrhage. Pre- eclampsia. A pregnancy-induced hypertension ≥ 20 weeks gestation Previously normotensive

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obstetric emergencies

Obstetric Emergencies

Catriona Kerr-Wilson

0604596k@student.gla.ac.uk

top emergencies
Top Emergencies
  • Severe pre-eclampsia
  • Antepartum haemorrhage
  • Postpartum haemorrhage
pre eclampsia
Pre-eclampsia
  • A pregnancy-induced hypertension
  • ≥ 20 weeks gestation
  • Previously normotensive
  • ≥140/90 mmHg on at least two occasions
  • + proteinuria ≥ 0.3g in 24h
  • ± oedema
  • Multisystem disease

RCOG Green top guidelines The management of severe pre-eclampsia/eclampsia

http://www.rcog.org.uk/files/rcog-corp/GTG10a230611.pdf

severe pre eclampsia
Severe pre-eclampsia
  • Diastolic blood pressure ≥ 110 mmHg on two occasions
  • Or systolic blood pressure ≥ 170mmHg on two occasions
  • Significant proteinuria (at least 1g/litre)

RCOG Green top guidelines The management of severe pre-eclampsia/eclampsia

http://www.rcog.org.uk/files/rcog-corp/GTG10a230611.pdf

risk factors
Risk factors
  • First pregnancy (primigravida)
  • Age <20 or >35 yrs
  • Previous Hx or FHx
  • Multiple pregnancy
  • Certain underlying medical conditions
    • Pre-existing hypertension (superimposed pre-eclampsia)
    • Pre-existing renal disease
    • Pre-existing diabetes
    • Antiphospholipid antibodies
clinical features
Clinical features
  • History
    • Usu. asymptomatic
    • Headache
    • Drowsiness
    • Visual disturbance
    • Nausea/vomiting
    • Epigastric pain
  • Examination
    • Oedema (hands and face)
    • Proteinuria on dipstick
    • Epigastric tenderness (liver involvement)
complications multisystem
Complications (multisystem)
  • Head/brain
    • Eclampsia, Stroke/ cerebrovascular haemorrhage
  • Heart
    • Heart failure
  • Lung
    • Pulmonary oedema, Bronchial aspiration, ARDS
  • Liver
    • Hepatocellular injury, liver failure, liver rupture
  • Kidneys
    • Renal failure, oliguria
  • Vascular
    • Uncontrolled hypertension, DIC
    • HELLP
complications fetal
Complications (fetal)
  • IUGR
  • Oligohydramnios
  • Placental infarcts
  • Placental abruption
  • Uteroplacental insufficiency
  • Prematurity
  • PPH
investigations
Investigations
  • Maternal
    • FBC – platelets (HELLP)
    • Coag screen if platelets abnormal
    • U&Es (urate, renal failure)
    • LFTs (liver involvement)
  • Fetal
    • USS
      • Fetal size/growth, amniotic fluid volume, umbilical cord blood flow
    • CTG
management
Management
  • No cure except delivery; Aim to minimise risk to mother in order to permit continued fetal growth
  • Antihypertensives
    • Methyldopa
    • Labetalol
    • Nifedipine
  • Eclampsia
    • Magnesium sulphate
  • Induction of labour
    • Antenatal steroids
past paper
Past paper

A 24-year-old primigravida presents at 32 weeks in a previously uneventful pregnancy. She is symptom free apart from marked facial oedema, but her BP is sustained at 145/105mmHg and there is proteinuria (+) on testing. You arrange her admission for further investigation and management.

  • List 4 investigations that would help you assess the maternal condition
past paper1
Past paper

Abnormal examination shows a fundal height of 26cm with apparently reduced liquor volume

  • List 3 ways ultrasound can be used to help assess the fetal condition
  • What other investigations would help reassure you about fetal well-being?
  • Delivery of the baby by caesarean section is planned, in the fetal and maternal interest. How can the administration of steroids help the survival of the pre-term infant?
  • What is the most likely diagnosis in this mother’s instance?
antepartum haemorrhage
Antepartum haemorrhage

Bleeding at > 24weeks (<24 weeks is miscarriage)

Top 5 causes:

  • Uteroplacental causes
    • Placental abruption
    • Placenta praevia
    • Uterine rupture
  • Cervical lesions
  • Vaginal infections (?)
  • Vasa praevia
  • Unexplained
definitions
Definitions
  • Placental abruption: part of the placenta becomes detached from the uterus
  • Placenta Praevia: The placenta is inserted wholly or in part into the lower segment of the uterus and therefore lies in front of the presenting part.

** AVOID PV exam; placenta

praevia may bleed catastrophically **

stems
Stems
  • 30-year-old multiparous woman presents with scant vaginal bleeding, severe hypotension and a tender uterus at 36 weeks gestation. Fetal heart sounds are undetected.

Abruptio Placentae

  • A22-year-old primigravid woman is seen at clinic at 28 weeks. She is noted to have ankle oedema and a BP of 160/110mmHg. Her urine demonstrates presence of protein.

Pre-eclampsia

  • A 20-year-old primigravid woman is brought into casualty following a fit in her 36th week of pregnancy. She is noted to have a BP of 170/110mmHg and 2+ of protein

Eclampsia

postpartum haemorrhage
Postpartum haemorrhage
  • Estimated blood loss ≥ 500ml
  • Primary: within 24hrs of delivery
  • Secondary: 24hrs-6weeks post delivery
causes 4 ts
Causes (4 Ts)
  • Tone: uterine atony
  • Tissue: retained placenta or retained products,
  • Trauma: cervical or perineal, or ruptured uterus,
  • Thrombin: coagulation disorder
risk factors1
Risk factors

Top 5 (from a gynaecologist!)

  • APH
  • Multiple pregnancy
  • Retained placenta
  • Mediolateral episiotomy
  • Emergency LSCS
risk factors2
Risk factors

Most cases of PPH have no identifiable risk factors

pph signs
PPH – signs
  • Pale
  • Confused
  • Increased HR, reduced BP (late sign)
  • Reduced urine output
  • Obvious or hidden bleeding
pph management
PPH Management

Top 5

  • Call for help
  • ABC
    • O2
    • Large bore IV access x 2
    • FBC, coag, cross match
    • Urinary catheter
  • Identify cause(s) of PPH
  • Control bleeding
  • Replace the blood loss
top 5 stages in management
Top 5: stages in management
  • Ensure 3rd stage complete – if not MROP
  • Rub uterine fundus to stimulate contraction +/- bimanual compression if required to stop uterine bleeding
  • Assess for cervical/vaginal wall/perineal tears – if present, repair
top 5 stages in management1
Top 5: stages in management

4. Medical management of atony with oxytocic medicines

  • Syntocinon
  • Ergometrine
  • Carboprost
  • Misoprostol

5. Surgical management

  • Intra uterine balloon device
  • B lynch suture if at Caesarean section
  • Uterine artery embolisation/ligation
  • Hysterectomy