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Top Emergencies
Top Emergencies
 Antepartum haemorrhage
 Postpartum haemorrhage
 Severe pre-eclampsia
 Acute ectopic pregnancy
CASE 1
 26yrs primi 8months pregnancy with bleeding pv.
 WHAT IS THE DIAGNOSIS?
 WHAT R THE CAUSES ?
 HOW WILL U DIFFE...
 WHAT IS THE DIAGNOSIS ?
ANTEPARTUM HEMORRHAGE
 Antepartum haemorrhage (APH) is defined as
bleeding from or in to the genital tract, occurring fro...
WHAT ARE THE CAUSES ?
Antepartum haemorrhage
1.Uteroplacental causes
a) Placental abruption
b) Placenta praevia
c) Uterine rupture
2.Cervical le...
Definitions
 Placental abruption: part of the placenta becomes detached from the
uterus
 Placenta Praevia: The placenta ...
 HOW WILL U DIFFERENTIATE BETWEEN
ABRUPTION AND PLACENTA PREVIA?
ABRUPTION
Placental Abruption
 Painful third trimester bleeding.
 Associated with PIH
 1:120 pregnancies, approx. 1%.
 Recurrenc...
Placental Abruption
Placental Abruption
Placental Abruption
Risk factors
 Increased blood pressure
 Trauma
 Drug use - cocaine
 Smoking/poor nutrition
 Chori...
PLACENTA PREVIA
Placenta Previa
 Painless third trimester vaginal bleeding
 1:200 - 1:250 pregnancies average
 1:50 grand multiparas,1:...
Signs and symptoms
Placental abruption Placenta praevia
Shock out of keeping with visible
loss
Shock in proportion to visi...
USG plays major role
TAS(Trans abdominal)
TVS(Trans vaginal)
TPS(Trans perineal)
Placental Abruption
HOW WILL U MANAGE ?
 INITIAL RESUSITATION
 Secure 2 large IV cannula
 Arrange blood
 Call for help
 Send blood for investigations and cro...
SPECIFIC MANAGEMENT?
Abruption
 Delivery is generally indicted unless the fetus is very
premature and both the mother and fetus are stable
 D...
Placenta previa
MANAGEMENT
 Total - needs operative delivery.
 Partial and Marginal - may consider a vaginal delivery
as...
Case 2
 Called for a woman who has just given birth
 Delivery performed by new midwife
 Upon Arrival patient is pale an...
Case 2 Continued
 P 165, BP 80/p, R 32, SaO 98% on NRB
 Continuous hemorrhage noted as you move her to the
bed
 WHAT IS THE DIAGNOSIS ?
 WHAT R THE CAUSES ?
 HOW WILL U MANAGE ?
WHAT IS THE DIAGNOSIS ?
Postpartum haemorrhage
 Estimated blood loss ≥ 500ml
 Primary: within 24hrs of delivery
 Secondary: 24hrs-6weeks post d...
WHAT R THE CAUSES ?
Causes (4 Ts)
 Tone: uterine atony
 Tissue: retained placenta or retained products,
 Trauma: cervical or perineal, or r...
WHAT ARE THE RISK FACTORS
FOR PPH ?
Risk factors
Antenatal • Proven abruption
• Placenta praevia
• Multiple pregnancy
• Pre-eclampsia
• Previous PPH
• Obesity...
PPH MANAGEMENT ?
INITIAL RESUSITATION
1. Call for help
2. ABC
a) O2
b) Large bore IV access x 2
c) FBC, coag, cross match
d) Urinary cathet...
SPECIFIC MANAGEMENT ?
stages in management in vaginal
delivery
1. Ensure 3rd stage complete – if not
MROP
2. Rub uterine fundus to stimulate
con...
stages in management
4. Medical management of atony with
oxytocic medicines
a) Syntocinon
b) Ergometrine
c) Carboprost
d) ...
MEDICAL MANAGEMENT ?
Newer Therapies ?
 B-Lynch Brace Suture
 Angiography and selective embolization
 Recombinant activated Factor VII
B-Lynch brace sutures
UTERINE COMPRESSION SUTURES
 SQUARE VERTICAL
Cho JH, Jun HS, Lee CN: Haemostatic Suturing Technique For uterine Bleeding ...
Selective Artery Embolisation
Advantages
Preserves Fertility
Useful in Haemorrhage associated with Placenta
praevia
Disadv...
Recombinant Activated Factor VII
 Novoseven is FDA approved for bleeding episodes in
hemophilia patients
 It has been ef...
ROLE OF HYSTERECTOMY ?
HYSTERECTOMY LAST BUT
DEFINITIVE
Stepwise devascularization
Pelvic Hematoma DO NOT IGNORE
Thank you
obstetric emergencies panel discussion.
obstetric emergencies panel discussion.
obstetric emergencies panel discussion.
obstetric emergencies panel discussion.
obstetric emergencies panel discussion.
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Transcript of "obstetric emergencies panel discussion."

  1. 1. Top Emergencies
  2. 2. Top Emergencies  Antepartum haemorrhage  Postpartum haemorrhage  Severe pre-eclampsia  Acute ectopic pregnancy
  3. 3. CASE 1  26yrs primi 8months pregnancy with bleeding pv.  WHAT IS THE DIAGNOSIS?  WHAT R THE CAUSES ?  HOW WILL U DIFFERENTIATE?  HOW WILL U MANAGE?
  4. 4.  WHAT IS THE DIAGNOSIS ?
  5. 5. ANTEPARTUM HEMORRHAGE  Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.
  6. 6. WHAT ARE THE CAUSES ?
  7. 7. Antepartum haemorrhage 1.Uteroplacental causes a) Placental abruption b) Placenta praevia c) Uterine rupture 2.Cervical lesions 3.Vasa praevia 4.Unexplained 5.Excessive show Bleeding at > 24weeks (<24 weeks is miscarriage)
  8. 8. 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 **
  9. 9.  HOW WILL U DIFFERENTIATE BETWEEN ABRUPTION AND PLACENTA PREVIA?
  10. 10. ABRUPTION
  11. 11. Placental Abruption  Painful third trimester bleeding.  Associated with PIH  1:120 pregnancies, approx. 1%.  Recurrence rate of 10%.  Port wine stained amniotic fluid.  Mark line at top of fundus at presentation and follow fundal height serially.
  12. 12. Placental Abruption
  13. 13. Placental Abruption
  14. 14. Placental Abruption Risk factors  Increased blood pressure  Trauma  Drug use - cocaine  Smoking/poor nutrition  Chorioamnionitis  Twins/polyhydramnios
  15. 15. PLACENTA PREVIA
  16. 16. Placenta Previa  Painless third trimester vaginal bleeding  1:200 - 1:250 pregnancies average  1:50 grand multiparas,1:1500 nulliparas  Undiagnosed third trimester bleeding, consider a double set-up in the OR.  Biggest risk factor is prior C-section, which confers a 1% risk.
  17. 17. 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
  18. 18. USG plays major role TAS(Trans abdominal) TVS(Trans vaginal) TPS(Trans perineal)
  19. 19. Placental Abruption
  20. 20. HOW WILL U MANAGE ?
  21. 21.  INITIAL RESUSITATION  Secure 2 large IV cannula  Arrange blood  Call for help  Send blood for investigations and cross matching
  22. 22. SPECIFIC MANAGEMENT?
  23. 23. Abruption  Delivery is generally indicted unless the fetus is very premature and both the mother and fetus are stable  DIC occurs in 4-10% of cases and usually is apparent by 8 hours after onset if symptoms  Renal failure is the most common cause of maternal mortality
  24. 24. Placenta previa MANAGEMENT  Total - needs operative delivery.  Partial and Marginal - may consider a vaginal delivery as the baby’s head may tamponade the placenta during descent  Consider fetal hemorrhage in addition to maternal hemorrhage.
  25. 25. Case 2  Called for a woman who has just given birth  Delivery performed by new midwife  Upon Arrival patient is pale and the bed is soaked in blood
  26. 26. Case 2 Continued  P 165, BP 80/p, R 32, SaO 98% on NRB  Continuous hemorrhage noted as you move her to the bed
  27. 27.  WHAT IS THE DIAGNOSIS ?  WHAT R THE CAUSES ?  HOW WILL U MANAGE ?
  28. 28. WHAT IS THE DIAGNOSIS ?
  29. 29. Postpartum haemorrhage  Estimated blood loss ≥ 500ml  Primary: within 24hrs of delivery  Secondary: 24hrs-6weeks post delivery
  30. 30. WHAT R THE CAUSES ?
  31. 31. Causes (4 Ts)  Tone: uterine atony  Tissue: retained placenta or retained products,  Trauma: cervical or perineal, or ruptured uterus,  Thrombin: coagulation disorder
  32. 32. WHAT ARE THE RISK FACTORS FOR PPH ?
  33. 33. Risk factors Antenatal • Proven abruption • Placenta praevia • Multiple pregnancy • Pre-eclampsia • Previous PPH • Obesity • Anaemia Apparent during labour • Caesarean section • Instrumental delivery • Long labour > 12 hours • Pyrexia in labour • Retained placenta • Mediolateral episiotomy Antenatal or intrapartum • Morbidly adherent placenta Most cases of PPH have no identifiable risk factors
  34. 34. PPH MANAGEMENT ?
  35. 35. INITIAL RESUSITATION 1. Call for help 2. ABC a) O2 b) Large bore IV access x 2 c) FBC, coag, cross match d) Urinary catheter 3. Identify cause(s) of PPH 4. Control bleeding 5. Replace the blood loss
  36. 36. SPECIFIC MANAGEMENT ?
  37. 37. stages in management in vaginal delivery 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
  38. 38. stages in management 4. Medical management of atony with oxytocic medicines a) Syntocinon b) Ergometrine c) Carboprost d) Misoprostol 5. Surgical management a) Intra uterine balloon device b) B lynch suture if at Caesarean section c) Uterine artery embolisation/ligation d) Hysterectomy
  39. 39. MEDICAL MANAGEMENT ?
  40. 40. Newer Therapies ?  B-Lynch Brace Suture  Angiography and selective embolization  Recombinant activated Factor VII
  41. 41. B-Lynch brace sutures
  42. 42. UTERINE COMPRESSION SUTURES  SQUARE VERTICAL Cho JH, Jun HS, Lee CN: Haemostatic Suturing Technique For uterine Bleeding during Cesarean Section delivery. Obstet Gynecol 200 0 96:129-131 A Straight needle is passed anterior to posterior and passed over fundus and ligated anteriorly. Multiple square sutures are Passed intramurally and tied at Various points.
  43. 43. Selective Artery Embolisation Advantages Preserves Fertility Useful in Haemorrhage associated with Placenta praevia Disadvantages  Requires 24hr availability of radiological expertise.  Patients must be stable  Complications include: Necrosis of uterine wall, contrast adverse effects, local haematoma formation
  44. 44. Recombinant Activated Factor VII  Novoseven is FDA approved for bleeding episodes in hemophilia patients  It has been effective in nonhemophiliac patients with extensive organ damage, hemorrhage and coagulopathy that did not respond to transfusion
  45. 45. ROLE OF HYSTERECTOMY ? HYSTERECTOMY LAST BUT DEFINITIVE
  46. 46. Stepwise devascularization
  47. 47. Pelvic Hematoma DO NOT IGNORE
  48. 48. Thank you
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