Obstetrical Emergencies

OBSTETRICAL EMERGENCIES F.TAKHTI M.D. SENIOR CONSULTANT LANDESKLINIKUUM NEUNKIRCHEN -AUSTRIA EMERGENCIES BLEEDING SHOCK UMBLICAL CORD PROLAPS SHOULDER DYSTOCIA AMNIOTIC FLUID EMBOLISM UTERUS INVERSION UTERUS RUPTURE SEPSIS Bleeding Prepartal        Placenta praevia Placental Abruption Polyp Erosio portionis Trauma Dehiscence of cesarean scar Carcinoma PLACENTA PRAEVIA    The placenta covers the internal cervical os completely or partially: Placenta praevia totalis Placenta praevia partialis Placenta praevia marginalis 0.5% -1% of all births. Risk factors : previous cesarean section (x 6)- Multiparity(x 2.6) – previous D&C-Smoking PLACENTA PRAEVIA Manifestations: painless bleeding of maternal origin  Diagnosis:1. Sonography 2.If cervical os dilated cautious inspection  Risks: placental abruption,Anomalies of fetal presentation,postpartal bleeding  Management: Bed rest, Anti-D and Thrombosis prophylaxis  PLACENTA PRAEVIA DELIVERY MODUS   Practically all women do need cesarean section. There are four different constellations: 1.The fetus is preterm and there is no indication for delivery.(observe) 2.The fetus is mature and the bleeding does not stop.(cesarean S) 3.The patient is in labor (cesarean S) 4.The bleeding severe,and the fetus immature (cesarean Section ) PLACENTA PREV.TOTALIS PLACENTA PRAEVIA PLACENTA PREV. PARTIALIS PLACENTA PREV.MARGINALIS PLACENTAL ABRUPTION  One of the leading causes of the perinatal mortality  Incidence: 0.5% - 1% of all deliveries  Pathophysiology: The villi are seperated from decidua basalis due to:  Abdominal trauma  Hypoxia & Ischemia  Infections CLINICAL STAGING     Grade 0: asymptomatic;diagnosis often postnatal or by sonography Grade 1 :scant external & internal bleeding.No maternal circulatory changes;No fetal distress. Grade 2 :heavy bleeding (external –internal) Fetal distress (CTG ) Grade 3 :severe external & internal bleeding.The uterus very painfull; fetal demise;maternal shock in 30% of cases associated with coagulation disorders. ABRUPTIO PLACENTAE  I. II. III. IV. V. VI. VII. RISKFACTORS: Previous abruption (x 10) Myoms Uterusseptum Maternal diseases: Hypertension, Thrombophilia , Hyperhomocysteinemia Abnormal Placentation :for example: Plac. Circumvallata Nicotine & Cocaine Abuse Blunt Abdominal Trauma ABRUPTIO PLACENTAE DIAGNOSIS     Painfull vaginal bleeding Tetanic contractions of uterus Pathological CTG Sonography: ( Sensitivity : 50%) ABRUPTIO PLACENTAE MANAGEMENT    No symptoms(no bleeding ) :observe the mother and the fetus . Severe bleeding +the fetus is alive: Cesarean section. Clinical symptoms (bleeding)+the fetus is dead : Amniotomy +packed red cells+coagulation factors +labor induction (vaginal birth),but if the bleeding too severe then cesarean section PLACENTA CIRCUMVALLATA Risk factor for pl.abruption PLACENTA CIRCUMVALLATA BLEEDING INTRAPARTAL  BLOODY SHOW VASA PRAEVIA   INSERTIO VELAMENTOSA ABRUPTIO PLACENTAE UTERINE RUPTURE   VASA PRAEVIA Think of it if bleeding occurs after Amniotomy!!! INSERTIO VELAMENTOSA May cause intrapartal bleeding INSERTIO VELAMENTOSA PLACENTA BILOBATA A RISK FACTOR POSTPARTAL BLEEDING      ACCORDING TO WHO: WORLDWIDE ONE WOMAN DIES PRO MINUTE DUE TO POSTPARTAL BLEEDING. BLEEDING MORE THAN 500 ml IN THE FIRST 24 HOURS AFTER LABOR. THINK OF 4 T,s :TONUS-TISSUETRAUMA-THROMBIN. LATE SYMPTOMS DUE TO PREGNANCY CHANGES OF BLOOD VOLUME. WHO:WORLD HEALTH ORGANISATION TONUS If the uterus not contracted,the blood vessels are not compressed TISSUE (PLACENTA REST) TRAUMA CERVIX TEAR POSTPARTAL BLEEDING MANEGEMENT          LARGE BORE VENOUS CATHETER UTEROTONICA(Methergin-Oxytocin) MASSAGE THE UTERUS BIMANUAL COMPRESSION VOLUME SUBSTITUTION SPECULUM: CERVIX OR VAGINAL TEAR ? PLACENTAL TISSUE ? CURETTAGE NO INJURY :LAPARATOMY-LIGATION OF THE UTERINE ARTERY-ILIACA INTERNA ULTIMA RATIO : HYSTRECTOMY BIMANUAL COMPRESSION SHOCK     Shock is the reversible phase of death. Circulatory failure characterized by disorder of microcirculation. Centralisation results in hypoxia. Hypoxia causes acute tubular necrosis and endothelium injury of pulmonary capillary vessels that in turn causes renal failure and adult respiratory distress syndrome(ARDS) . SHOCK FORMS  HYPOVOLUEMIC CARDIAL   ANAPHYLACTIC NEUROGENIC SEPTIC   SHOCK MANAGEMENT HYPOVOLUMIC  DO NOT FORGET :THE TIME IS GOLD IN THE EARLY STAGES THE SHOCK CAN BE MANAGED EFFECTIVELY WITH SIMPLE MEASURES:INFUSIONS BUT IN THE ADVANCED STAGES YOU MAY NEED CONSIDERABLY MORE;A LONG TIME IN INTENSIVE CARE UNIT AND VERY HIGH COSTS. AMNIOTIC FLUID EMBOLISM       Rare: 1:8,000 to 1:30,000 labors Very high Mortality Misnomer: false name, because it is an Anaphylactic reaction to the fetal antigens. Mainly subpartu : under delivery Risk factors : Multiparity, Abruptio placentae,Blunt Abdominal Trauma External version ,fetal death, Amniocentesis AMNIOTIC FLUID EMBOLISM     Manifestations: Rigors,Perspiration, Restlessness , Coughing , Cyanosis, Hypotension, Bronchospasm, Tachypnea , Tachycardia , Arrhythmia,Convultions, Myocardial infarkt, DIC Diagnosis: Clinical manifestations+chest XRay +ECG +Blood gas analysis Therapy: Intensive Care Unit. NOTICE: SUDDEN COUGHING ATTACK AFTER CESAREAN OR VAGINAL BIRTH. UMBLICAL CORD PROLAPS    Incidence: 0.2% -0.6%of births Risk factors : lang umblical cord,breech +transverse lie, small fetus ,multiparity ,twins ,amniotomy ATTENTION: CTG changes after amniotomy are suspect of umblical cord prolaps until the contrary is proven. UMBLICAL CORD PROLAPS   DIAGNOSIS: Inspection +Palpation MANAGEMENT : Determine if the fetus is alive: 1. YES : elevate the presenting part and cesaraen section labor induction 2. NO: UMBLICAL CORD PROLAPS UMBLICAL CORD PROLAPS SHOULDER DYSTOCIA  INCIDENCE :0.2 %of all births,increases however to 10% if the fetus weighs 4000 G and even to 22% if the fetus weighs more than 4500G.  RISK FACTORS: Makrosomia Previous dystocia Overweight mother Multyparity Diabetes mellitus SHOULDER DYSTOCIA THE FETAL HEAD IS BORN.  AFTER THE CONTRACTION CEASES ,THE FETAL HEAD SLIPS BACK INTO THE VAGINA. (TURTLE PHENOMENEN).  BLUE LIVID COLOR OF THE FACE.  THIS DISCOLORATION IS CAUSED BY VENOUS CONGESTION AND IS NOT DUE TO HYPOXIA,  THEREFORE: NO HASTINESS,DO NOT ENDANGER THE FETUS THROUGH UNWISE HASTY ACTIONS.  SHOULDER DYSTOCIA MANAGEMENT McRoberts maneuver: 1.flexing the thighs sharply up onto the abdomen. 2.suprapubic pressure.  SHOULDER DYSTOCIA MANAGEMENT  Woods Maneuver: the posterior shoulder is rotated 180 degrees in a corkscrew manner so that the anterior shoulder is released. SHOULDER DYSTOCIA MANAGEMENT  Delivery of the posterior shoulder. Jacqumiere Maneuver. SHOULDER DYSTOCIA MANAGEMENT RUBIN MANEUVER: THE IMPACTED ANTERIOR SHOULDER IS ROTATED IN ABDOMEN DIRECTION. SHOULDER DYSTOCIA MANAGEMENT  If no success after all of the mentioned maneuvers ,then : 1.Fracture of the clavicula (upward direction). 2.Zavanelli maneuver: put the fetal head into the vagina and cesarean section. 3.Abdominal Rescue after O,Leary & Cuva. Abdominal Rescue   If you are not able to put the fetal head into the vagina then: Lap+uterotomy :release the impacted anterior shoulder abdominally,and the posterior shoulder vaginal and deliver the fetus vaginally. UTERUS INVERSION  IF THE FUNDAL PLACENTA IS PULLED OUT INCAUTIOUS AND FORCEFULLY. UTERUS INVERSION UTERUS INVERSION      Rare: 1 /2000 -1/20,000 Can results in death due to vasovagal shock and massive bleeding. Can be complete or partial. If the blood loss does not correspond to the shock symptoms think of the partial form. REPOSITION OF INVERSION : IN GENERAL ANESTHESIA REPOSITION of INVERSION     IF THE PLACENTA IS STILL ATTACHED DO NOT REMOVE IT. MANUAL REPOSITION OF UTERUS; THE HAND REMAINS IN THE UTERUS UNTIL IT IS EFFECTIVLY CONTRACTED. IF THE REPOSITION IS NOT POSSIBLE, THEN REMOVE THE PLACENTA. (DANGER OF HEAVY BLEEDING) AND TRY TO REPOSE THE UTERUS. AS ULTIMA RATIO :HYSTRECTOMY REPOSITION OF UTERUS YOU WILL REMEMBER A LITTLE OF WHAT YOU HEAR,SOME OF WHAT YOU READ,CONSIDERABLY MORE OF WHAT YOU SEE,BUT ALMOST ALL OF WHAT YOU UNDERSTAND.