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Obstetric-Emergencies Powered By Docstoc
					Obstetric Emergencies

        Catriona Kerr-Wilson
Top Emergencies

  Severe pre-eclampsia

  Antepartum haemorrhage

  Postpartum haemorrhage
  A pregnancy-induced
  ≥ 20 weeks gestation
  Previously normotensive
  ≥140/90 mmHg on at least two
  + proteinuria ≥ 0.3g in 24h
  ± oedema
  Multisystem disease
         RCOG Green top guidelines The management of severe pre-eclampsia/eclampsia
Severe pre-eclampsia
  Diastolic blood pressure ≥ 110
   mmHg on two occasions

  Or systolic blood pressure ≥
   170mmHg on two occasions

  Significant proteinuria (at least
          RCOG Green top guidelines The management of severe pre-eclampsia/eclampsia

Risk factors
    First pregnancy (primigravida)
    Age <20 or >35 yrs
    Previous Hx or FHx
    Multiple pregnancy
    Certain underlying medical
     • Pre-existing hypertension (superimposed pre-
     • Pre-existing renal disease
     • Pre-existing diabetes
     • Antiphospholipid antibodies
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)
   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)
    IUGR
    Oligohydramnios
    Placental infarcts
    Placental abruption
    Uteroplacental insufficiency
    Prematurity
    PPH
  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
 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
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.

a)List 4 investigations that would help you assess the
maternal condition
    Past paper
Abnormal examination shows a fundal height of 26cm
with apparently reduced liquor volume

b)List 3 ways ultrasound can be used to help assess
the fetal condition
c)What other investigations would help reassure you
about fetal well-being?
d)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?
e)What is the most likely diagnosis in this mother’s
Antepartum haemorrhage
Bleeding at > 24weeks (<24 weeks is miscarriage)

    Top 5 causes:
    1.Uteroplacental causes
       a) Placental abruption
       b) Placenta praevia
       c) Uterine rupture
    2.Cervical lesions
    3.Vaginal infections (?)
    4.Vasa praevia
 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 **
  Signs and symptoms
Placental abruption                 Placenta praevia

Shock out of keeping with visible   Shock in proportion to visible loss

Pain constant                       No pain

Tender, tense uterus (hypertonic)   Uterus not tender (hypotonic)

Normal lie and presentation         Both may be abnormal

Fetal heart absent/distressed       Fetal heart usually normal

Coagulation problems                Coagulation problems rare

Beware pre-eclampsia, DIC, anuria   Small bleeds before large
 30-year-old multiparous woman presents with scant
  vaginal bleeding, severe hypotension and a tender
  uterus at 36 weeks gestation. Fetal heart sounds are
  Abruptio Placentae
 A 22-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
 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
Postpartum haemorrhage

  Estimated blood loss ≥ 500ml

  Primary: within 24hrs of delivery

  Secondary: 24hrs-6weeks post
Causes (4 Ts)

  Tone: uterine atony

  Tissue: retained placenta or
  retained products,

  Trauma: cervical or perineal, or
  ruptured uterus,

  Thrombin: coagulation disorder
Risk factors
Top 5 (from a gynaecologist!)
Multiple pregnancy
Retained placenta
Mediolateral episiotomy
Emergency LSCS
Risk factors
 Antenatal                  •   Proven abruption
                            •   Placenta praevia
                            •   Multiple pregnancy
                            •   Pre-eclampsia
                            •   Previous PPH
                            •   Obesity
                            •   Anaemia
 Apparent during labour     •   Caesarean section
                            •   Instrumental delivery
                            •   Long labour > 12 hours
                            •   Pyrexia in labour
                            •   Retained placenta
                            •   Mediolateral episiotomy
 Antenatal or intrapartum   • Morbidly adherent

      Most cases of PPH have no
        identifiable risk factors
PPH – signs
  Pale
  Confused
  Increased HR, reduced BP (late
  Reduced urine output
  Obvious or hidden bleeding
PPH Management
 Top 5
 1. Call for help
 2. ABC
   a)   O2
   b)   Large bore IV access x 2
   c)   FBC, coag, cross match
   d)   Urinary catheter

 3. Identify cause(s) of PPH
 4. Control bleeding
 5. Replace the blood loss
        Top 5:
stages in management
1. Ensure 3rd stage complete – if
   not MROP
2. Rub uterine fundus to stimulate
   contraction +/- bimanual
   compression if required to stop
   uterine bleeding
3. Assess for cervical/vaginal
   wall/perineal tears – if present,
        Top 5:
stages in management
4. Medical management of atony
with oxytocic medicines
  a)   Syntocinon
  b)   Ergometrine
  c)   Carboprost
  d)   Misoprostol

5. Surgical management
  a)   Intra uterine balloon device
  b)   B lynch suture if at Caesarean section
  c)   Uterine artery embolisation/ligation
  d)   Hysterectomy
Thank you

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