Transcript Obstetric Emergencies

OBSTETRIC
EMERGENCIES
PGY1 Education Program
Wednesday 26th September and 3rd October 2012
Dr Wendy Carseldine
Teaching Fellow, Maternity and Gynaecology
OVERVIEW
Hypertension in Pregnancy
 Post-partum haemorrhage
 Shoulder dystocia
 Maternal collapse
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HYPERTENSION IN PREGNANCY
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Pre-existing hypertension
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Pregnancy induced hypertension
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Hypertension prior to 20 weeks gestation
Must be investigated before labelled essential
After 20 weeks gestation
Pre-eclampsia
Multi-system disorder unique to pregnancy
 Hypertension + involvement
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Renal
 Haematological
 Liver
 Neurological
 Pulmonary oedema
 IUGR
 Placental abruption
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HYPERTENSION IN PREGNANCY
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Crises in pre-eclampsia
HELLP: Complicate up to 20% of pre-eclampsia
 Pulmonary oedema
 Placental abruption
 Cerebral haemorrhage
 Cortical blindness
 DIC
 Renal failure
 Hepatic rupture
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Unusual causes of HT in pregnancy
Phaeochromocytoma
 Renal artery stenosis
 Coarctation of the aorta
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HYPERTENSION IN PREGNANCY:
HISTORY
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Symptoms
Headache, visual disturbance
 RUQ/epigastric pain
 Nausea and vomiting
 Severe oedema
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Signs
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Hypertension
Proteinuria
RUQ tenderness
Hyper-reflexia, clonus
IUGR +/- FDIU
Placental abruption
HYPERTENSION IN PREGNANCY:
INVESTIGATIONS
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Bloods
FBC
 EUC
 LFT
 Uric acid
 Co-ags
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Urine
Protein creatinine ratio
 24 hour protein collection
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Ultrasound
Fetal growth
 AFI
 Fetal dopplers
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HYPERTENSION IN PREGNANCY:
TREATMENT
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Prevention
Aspirin
 Clexane
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Antihypertensive treatment
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Oral agents
Labetalol
 Methyldopa
 Clonidine
 Nifedipine
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IV agents
Hydralazine
 Labetalol
 Diazoxide
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HYPERTENSION IN PREGNANCY:
TREATMENT
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Seizure prevention
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MgSO4
Loading dose
 Infusion for 24 hours
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Delivery
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Risk of prematurity
Risk of disease development
POST-PARTUM HAEMORRHAGE
Every minute, at least one woman dies
from complications related to pregnancy
or childbirth, 529 000 women a year.
Five direct complications account for more
than 70% of maternal deaths:
haemorrhage (25%), infection (15%),
unsafe abortion (13%), eclampsia (12%),
and obstructed labour (8%).
PPH
Incidence: 5-15%
 Definitions
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>500 mL blood loss during or after childbirth or
enough to cause haemodynamic compromise
 Severe >1000 mL
 Primary: first 24 hours
 Secondary: from 24 hours to 6 weeks postpartum
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PPH: RISK FACTORS/CAUSES (THE 4
‘T’S)
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Tone (70%)
 Prolonged 3rd stage
 Over distended uterus (polyhydramnious, twins, macrosomia)
 Exhausted uterus (rapid labour, prolonged 1st or 2nd stage, high parity,
dystocia/augmentation with Syntocinon)
 Infection
 Drug induced
 Uterine anomalies (fibroids, structural)
Trauma (20%)
 Episiotomy, perineal tear
 Caesarean section
 Uterine rupture
 Uterine inversion
Tissue (10%)
 Retained placenta/cotyledon
 Abnormal placenta (accreta or increta)
Coagulopathy (1%)
 Pre-existing
 Pregnancy acquired (pre-eclampsia, infection, DIC secondary to FDIU)
PPH: PREVENTION
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Identification of risk factors
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Abnormal placentation
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Appropriate antenatal and intrapartum management
Delivery in a unit with rapid access to blood and
blood products
All women should have an antenatal ultrasound for
placental location
Recognition of placenta praevia or abnormally
adherent placentation
Active management of the 3rd stage of labour
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Prophylactic oxytocin (reduce risk by 50%)
Early cord clamping, controlled cord traction
Provide appropriate information to women
requesting physiological 3rd stage
PPH: MANAGEMENT
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Communication
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Team: midwives, obstetric staff, anaesthetist,
Haematology lab, blood bank, haematologist
Porters for patient transport and delivery of
blood/specimens
Nominate a team member to record events
Use of Massive Transfusion Protocol
JHH: x7700
PPH: MANAGEMENT
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ABC
Assess Airway
Assess breathing
 Oxygen by mask (10-15 l/min)
Evaluate circulation
 2 x large IV access (at least 16g cannula), consider
arterial line
 Rapid IVF initial resuscitation (Normal saline,
gelofusine)
 Keep patient warm (also warmed IVF)
 Transfuse blood ASAP (Packed RBC, FFP,
Platelets, Cryoprecipitate)
 Consider Recombinant fVIIa
PPH: MANAGEMENT
Monitoring and Investigation
 Venepuncture
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X-match, FBC, Coagulation profile, EUC, LFT
Observations
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BP, HR, RR, O2 Sat, Temp
Insert IDC to monitor urine output and contract
uterus
 Thromboembolic prophylaxis once bleeding
controlled
 Estimate blood loss
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Weigh if large volume
PPH: MANAGEMENT
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Transfer to theatre
Examination under anaesthetic (GA/regional)
Atony
 Mechanical (bimanual compression, empty bladder)
 Pharmacological (Syntocinon, Ergometrine, Misoprostol/Cervagem,
Prostin F2)
 Balloon tamponade (Bakri)
 Laparotomy: B-Lynch Suture, uterine artery/internal iliac artery
ligation, hysterectomy
 Artery embolisation (radiology)
Trauma
 Examine uterus (rupture), cervix, vagina, vulva, perineum
 Apply pressure and surgical repair
 Correct inversion
Tissue
 Examination of placenta
 Manual removal (digital or curettage) of retained products
Coagulopathy
 Correction directed by laboratory testing
PPH: MANAGEMENT
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Once bleeding is controlled
Consider ICU/HDU care
 Ongoing review and laboratory testing
 Debriefing and counselling to woman, family and
staff
 Remember next pregnancy prevention/active
management
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SHOULDER DYSTOCIA
Incidence: 2%
 Risk Factors
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Maternal obesity
Macrosomia
Post-dates pregnancy
Diabetes
Assisted delivery
SHOULDER DYSTOCIA:
MANAGEMENT
Get help
 Consider episiotomy
 McRoberts manoeuvre
 Suprapubic pressure
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Constant
 Rocking
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Delivery of the posterior arm
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Consider use of infant feeding tube
Internal manoeuvres
 Last resort
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Zavanelli
 Fracture the fetal clavicle
 Symphysiotomy
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MATERNAL COLLAPSE
PPH
 Cardiac arrest
 Amniotic fluid embolism
 Thromboembolic disease
 Puerperal sepsis
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