Obstetric Emergencies

1. Obstetric Emergencies Catriona Kerr-Wilson 0604596k@student.gla.ac.uk

2. Top Emergencies • Severe pre-eclampsia • Antepartum haemorrhage • Postpartum haemorrhage

3. 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

4. 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

5. Risk factors • First pregnancy (primigravida) • Age <20 or >35 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

6. 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)

7. 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

8. Complications (fetal) • IUGR • Oligohydramnios • Placental infarcts • Placental abruption • Uteroplacental insufficiency • Prematurity • PPH

9. Investigations • 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

10. 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

11. 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

12. 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 mother’s instance?

13. Antepartum haemorrhage Bleeding at > 24weeks (<24 weeks is miscarriage) Top 5 causes: • Uteroplacental causes • Placental abruption • Placenta praevia • Uterine rupture • Cervical lesions • Vaginal infections (?) • Vasa praevia • Unexplained

14. 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 **

15. Signs and symptoms

16. 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 • A22-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

17. Postpartum haemorrhage • Estimated blood loss ≥ 500ml • Primary: within 24hrs of delivery • Secondary: 24hrs-6weeks post delivery

18. Causes (4 Ts) • Tone: uterine atony • Tissue: retained placenta or retained products, • Trauma: cervical or perineal, or ruptured uterus, • Thrombin: coagulation disorder

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

20. Risk factors Most cases of PPH have no identifiable risk factors

21. PPH – signs • Pale • Confused • Increased HR, reduced BP (late sign) • Reduced urine output • Obvious or hidden bleeding

22. 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

23. Top 5: stages in management • Ensure 3rd stage complete – if not MROP • Rub uterine fundus to stimulate contraction +/- bimanual compression if required to stop uterine bleeding • Assess for cervical/vaginal wall/perineal tears – if present, repair

24. 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

25. Thank you