Obstetric Emergencies

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Obstetric Emergencies

• Catriona Kerr-Wilson
• 0604596k_at_student.gla.ac.uk

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Top Emergencies

• Severe pre-eclampsia
• Antepartum haemorrhage
• Postpartum haemorrhage

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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
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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
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Risk factors

• First pregnancy (primigravida)
• Age lt20 or gt35 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

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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)

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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

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Complications (fetal)

• IUGR
• Oligohydramnios
• Placental infarcts
• Placental abruption
• Uteroplacental insufficiency
• Prematurity
• PPH

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Investigations

• Maternal
• FBC platelets (HELLP)
• Coag screen if platelets abnormal
• UEs (urate, renal failure)
• LFTs (liver involvement)
• Fetal
• USS
• Fetal size/growth, amniotic fluid volume,
  umbilical cord blood flow
• CTG

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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

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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

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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
  mothers instance?

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Antepartum haemorrhage
Bleeding at gt 24weeks (lt24 weeks is miscarriage)

• Top 5 causes
• Uteroplacental causes
• Placental abruption
• Placenta praevia
• Uterine rupture
• Cervical lesions
• Vaginal infections (?)
• Vasa praevia
• Unexplained

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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

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Signs and symptoms
Placental abruption Placenta praevia
Shock out of keeping with visible loss 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
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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
• 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 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

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Postpartum haemorrhage

• Estimated blood loss 500ml
• Primary within 24hrs of delivery
• Secondary 24hrs-6weeks post delivery

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Causes (4 Ts)

• Tone uterine atony
• Tissue retained placenta or retained products,
• Trauma cervical or perineal, or ruptured uterus,
• Thrombin coagulation disorder

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Risk factors

• Top 5 (from a gynaecologist!)
• APH
• Multiple pregnancy
• Retained placenta
• Mediolateral episiotomy
• Emergency LSCS

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Risk factors
Antenatal Proven abruption Placenta praevia Multiple pregnancy Pre-eclampsia Previous PPH Obesity Anaemia
Apparent during labour Caesarean section Instrumental delivery Long labour gt 12 hours Pyrexia in labour Retained placenta Mediolateral episiotomy
Antenatal or intrapartum Morbidly adherent placenta
Most cases of PPH have no identifiable risk
factors
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PPH signs

• Pale
• Confused
• Increased HR, reduced BP (late sign)
• Reduced urine output
• Obvious or hidden bleeding

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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

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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, repair

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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

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Thank you