OBSTETRIC EMERGENCIES

1
OBSTETRIC EMERGENCIES

• Dr. Ahmed Al Harbi
• Obstetrics/Gynecology
• Consultant

2
Overview

• Obstetric emergencies - cause damage and death to
  mothers and babies. They require quick, decisive
  and effective action from the staff immediately
  available.
• In the UK, the maternal mortality rate is around
  11.4 per 100,000.
• Worldwide, the situation is much worse, with
  around 600,000 maternal deaths reported each
  year.
• The causes of maternal death
• Embolism (Thrombotic Amniotic Fluid)
• Hypertensive Disorders
• Haemorrhage
• Sepsis

3
Definition of Obstetric Emergencies

• An emergency is an occurrence of serious and
  dangerous nature, developing suddenly and
  unexpectedly, demanding immediate attention.

4

• Obstetric emergencies related directly to
  pregnancy include, for instance
• Pre-eclampsia
• Eclampsia
• Antepartum Haemorrhage
• Postpartum Haemorrhage
• Amniotic Fluid Embolism
• Congenital Heart Disease
• Epilepsy

5
Principles Of Managing Obstetric Emergencies
6
Management

• If breathing spontaneously
• She must be moved to the left lateral position
  aspiration of stomach.
• If there is no spontaneous respiration
• Check the circulation at the carotid or femural
  pulse prior to chest compression if necessary.
• Artificial respiration is required if managing a
  case alone.
• Obtain as much help as is possible immediately.
• Summon the cardiac arrest team immediately.

7
Obstetric Haemorrhage

• Any blood loss from the vagina greater than a
  show during pregnancy
• Or excessive blood loss after delivery.

8

• Managing severe haemorrhage
• Call For Help
• Senior Obstetrician
• Anaesthetist
• Notify blood bank and consult haematologist.

9
Pulmonary Embolism (PE)

• Occurs in association with approximately
  31000 pregnancies.
• Two thirds of cases of puerperium.

10

• Diagnosis of Pulmonary Embolism
• Symptoms
• Acute Breathlessness
• Pleuritic Chest Pain
• Haemoptysis

11

• Signs
• Tachycardia
• Cyanosis
• Hypotension
• May be Confusion (hypoxia)

12

• Investigations
• Reduced oxygen tension in arterial blood
• Electrocardiogram lead 3
• Large Q waves, inverted T waves
• Chest X-ray
• Ventilation perfusion scan

13
Clinical Presentation Of Amniotic Fluid Embolism
14

• Symptoms
• Sudden severe chest pain
• Dyspnea

15

• Signs
• Hypotension
• Tachycardia
• Pulmonary Oedema
• Peripheral Shutdown
• Haemorrhage due to coagolation failure
• May be seizure seccondary to hypoxia or cardiac
  arrest.

16

• Investigations
• Electrocardiogram right ventricular strain
• Abnormal coagolation screen
• Reduced oxygen tension in arterial blood

17

• Treatment
• Urgent resuscitation and circulatory support
• Intubation and 100 oxygen
• Treat the coagolupathy agressively
• Correct acidosis
• Dopamine and steroids may be useful
• Transfer to intensive care unit

18
Hypertensive Disorders

• Pre-eclampsia
• Is a disease of pregnancy characterized by a
  blood pressure of 140/90 mmHg or more on two
  separate occasions after the 20th weekof
  pregnancy in a previously normotensive woman.
• Accompanied by significant proteinuria (gt300mg
  in 24 hours)
• Eclampsia
• A same condition that has proceeded to the
  presence of convulsions.
• Imminent Eclampsia or Fulminating Pre-eclampsia
• The transitional condition characterized by
  increasing symptoms signs.

19
Incidence Epidemiology

• Eclampsia
• Relatively rare in the UK, occurring in
  approximately 12000 pregnancies.
• It may occur
• Antepartum 40
• Intrapartum 20
• Postpartum 40
• Severe Pre-eclampsia
• A blood pressure of 160/110 mmHg or more.

20
Symtoms Of Severe Pre-Eclampsia

• Frontal Headache
• Visual Disturbance
• Epigastric Pain
• General Malaise Nausea
• Restlessness

21
Signs Of Severe Pre-Eclampsia

• Agitation
• Hyper-Reflexia
• Facial Peripheral Oedema
• Right Upper Quadrant Tenderness
• Poor Urine Output

22
Treatment Of Eclampsia

• Turn the woman onto her side with her head down
• Ensure the airway is protected
• Give oxygen
• Give a 5g bolus of magnesium sulphate
  intravenously over a few minutes.
• Progress to stabilizing the womans condition
• The mothers condition needs to be stabilized
  urgently, before considering delivery in
  antenatal cases

23

• Senior obstetric and anaesthetic staff must be
  involved
• Antihypertensive
• Hydralazine
• Labetalol
• Anticonvulsants
• Magnesium Sulfate
• Fluid Balance
• ? To avoid pulmonary and cerebral oedema,
  Central Venous Pressure (CVP) INPUT OUTPUT

24
Indications For Urgent Delivery

• Blood pressure persistently at 160/100 mmHg or
  more with significant proteinuria
• Elevated liver enzymes
• Low platelet count
• Eclamptic Fit
• Anuria
• Significant foetal distress

25
HELLP Syndrome

• H - Haemolysis
• E - Elevated
• L - Liver Enzymes
• L - Low
• P - Platelets
• ? 5 to 10 of cases of severe pre-eclampsia
• ? May be associated with dissaminated
  intravascular coagulation, placental abruption
  foetal death.

26
Hypertensive Disorders

• Fulminating pre-eclampsia eclampsia are
  dangerous
• Recognize women at risk
• Manage minor hypertensive problems to prevent
  progression
• In the serious case
• Prevent or control convulsion
• Bring down the blood pressure
• Minimize or avoid organ damage
• Control coagulopathy
• Avoid fluid overload
• Deliver a healthy baby safely

27
The Collapse Obstetric Patient

• Complete or partial loss of consciousness is
  very uncommon in pregnancy

28
Causes Of Loss Of Consciousness

• Simple Faint
• Epileptic Fit
• Hypoglycaemia
• Profound Hypoxia
• Intracerebral Bleeding
• Cerebral Infarction
• Cardiac Arrhythmia Or Myocardial Infarction

29

• Pulmonary Embolism
• Anaphylaxis
• Septic Shock
• Anaesthetic Problems
• Major Haemorrhage
• Eclampsia
• Amniotic Fluid Embolus
• Uterine Inversion

30
Basic Life Support Skills

1. Shake Shout
2. Airway
3. Breathing
4. Circulation
5. Look for hypovolaemia (Tachycardia, Pallor)
6. Aggressive Fluid Replacement
7. Stop Haemorrhage
8. Stabilize and seek a cause
9. Senior multi-disciplinary assistance throughout