obstetric emergency

1. OBSTETRIC EMERGENCY
RED ALERT RED ALERT RED ALERT

2. Cases of Obstetric Red Alert
Emergencies
 Eclampsia/fits
 Severe Haemorrhage/Hypovolaemic shock
 Obstetric collapse
 Amniotic fluid embolism
 Pulmonary oedema
 Inversion of uterus
 Uterine rupture
 Septicaemic shock
 DIVC
 Shoulder Dystocia
 Cord Prolapse

3. HYPERTENSIVE DISORDER IN PREGNANCY
 Hypertension in pregnancy is defined as a SBP of ≥ 140 mmHg and/or DBP ≥ 90
mmHg.
 An increase of 15 mmHg diastolic and 30 mmHg systolic BP levels above
baseline BP is no longer recognised as hypertension if absolute values are
below 140/90mmHg.

4.  Gestational Hypertension
 Hypertension alone, detected for the first time after
20th week. The definition is changed to “transient”
when pressure normalises postpartum.
 Chronic Hypertension
 Hypertension diagnosed prior to 20thweek; or the
presence of hypertension preconception, or de novo
hypertension in late gestation that fails to resolve
postpartum.

5. PRE-ECLAMPSIA - ECLAMPSIA
 Clinically diagnosed in the presence of de novo hypertension after 20th week, and
1 or more of the following:
 i. Significant proteinuria
 ii. Renal insufficiency – serum creatinine ≥ 90 μmol/L or oliguria
 iii. Liver disease – raised transaminases and/or severe right upper quadrant or
epigastric pain
 iv. Neurological problems – convulsions (eclampsia); hyperrefexia with clonus or
severe headaches, persistent visual disturbances (scotoma)
 v. Haematological disturbances – thrombocytopenia, coagulopathy, haemolysis
 vi. Fetal growth restriction
 This is followed by normalisation of the BP by 3 months postpartum.

6. SEVERE PRE ECLAMPSIA
 Systolic BP (SBP) of ≥ 170 and/or diastolic BP (DBP) of ≥ 110 mmHg on two occasions
along with significant proteinuria of ≥ 1g/day or
 DBP of ≥ 100 mmHg on 2 occasions with significant proteinuria (1+ on dipstick), with
two or more symptoms and signs of imminent eclampsia, which includes:
 Severe headache
 Visual disturbance
 Epigastric pain and/or vomiting
 Clonus
 Papilloedema
 Liver tenderness
 Abnormal liver enzymes (raised ALT or AST)
 Platelet count < 100,000/cm3
 HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)
 Intrauterine growth restriction (IUGR)
 Pulmonary oedema and/or congestive cardiac failure

7. ECLAMPSIA
 Defined as tonic-clonic (grand mal) seizure occurring in association with
features of PE.
 May occur antepartum (45%), intrapartum (18 – 19%) or postpartum (36%).

8. ECLAMPSIA
 All cases of eclampsia should have the baby delivered immediately regardless
of gestation after BP is controlled.
 Sign and symptoms of severe pre eclampsia and eclampsia
 Severe frontal headache
 Vomiting
 Blurring of vision
 Epigastric pain
 Hyper- reflexia
 Severe hypertension

9. Management
 Initiate Red Alert System
 Give IM MgSO4 5g each buttock or IV MgSO4 4g slow bolus
 Continue the MgSO4 infusion at 1g / hr
 Anti-hypertensive drugs
 Manage patient in lateral position
 Suck out secretions / saliva
 Ix: Hb, platelet, coagulation profile, LFT, BUSE, serum creatinine, serum uric
acid, GXM
 Refer out (district hospital)

10. MgSO4 Therapy
 IM regime loading dose
 MgSo4 im deep intra-muscular 5g in each buttock (total 10g).
 IM regime maintenance dose
 MgSo4 IM deep intra-muscular injection 2.5g in each buttock every 4 hours
 IV regime loading dose
 MgSO4 iv 4 gm (diluted to 20 ml with NS) slow intravenous over 10-15 minutes,
 MgSO4 iv infusion 1g / hour.
 IV regime maintenance dose
 MgSO4 5 gm (10mls) in 40mls DS, infuse at 10ml/hour (infusion rate 1g / hour).
 25 gm MgSO4 at 2ml/hour

11. ANTI-HYPERTENSIVES INTRAVENOUS /
INFUSION DOSAGE – DURING HYPERTENSIVE
CRISIS
 Labetalol
 BOLUS (acute hypertension)
 Give 5 mg IV bolus (over 2 min). If 5 mg not effective then double the dose every
10 min. (10 mg, 20 mg, 40 mg). Maximum bolus dose is 40 mg.
 BP measure immediately before, and 5 minutes and 10 minutes after initial
dose.
 Maximum effect within 5 minutes of each injection.
 MAXIMUM TOTAL CUMULATIVE DOSE OF 300MG

12. LABETALOL
 INFUSION
 Drop-mat Infusion pump.
 Labetalol hydrochloride 200 mg + 160 mL DS / NS / D5% (resultant 200 mL)
 Infusion rate is 0.5mg/min (30mls/hr) to 2 mg/min (120mls/hr).
 Adjusted by 0.5 mg/min every 15 minutes according to BP response.
 Maximum infusion dose at 30 drops/min. If BP still not well-controlled despite at
maximum dosage, to consult Specialist.
 Syringe pump
 iv Labetalol 200 mg in 50 mls N/Saline, start at 20 mg/h (or 4 mls/h) and increase
every 30 min, stop infusion if rate exceed 150 mg/h (or 30 mls/h)).

13. TREATMENT FOR HYPERTENSION
 Exact level BP at which to start treatment is controversial, but generally
treat if SBP > 140 – 160 mmHg and DBP > 90 – 110 mmHg.
 Treatment is mandatory if BP is ≥ 160/110.
 Oral α-methyldopa (longest safety data – preferable especially during 1st and
2nd trimester) and labetalol (late 2nd and 3rd trimester, if not
contraindicated) are the first line of treatment, followed by Nifedipine.
 Addition of another anti-hypertensive should only be done after the first
antihypertensive has been maximized.

15. ANTEPARTUM HEMORRHAGE
 Definition: Bleeding from the genital tract after 22 weeks of pregnancy to
delivery of foetus
 Common Causes :
 Placenta praevia
 Abruptio placenta
 Local causes
 Indeterminate APH
 DO NOT PERFORM VE / SPECULUM EXAMINATION UNTIL YOU HAVE EXCLUDE
PLACENTA PRAEVIA

16. MANAGEMENT
 RESUSCITATION
 -estimated amount of blood loss
 Mild : 2 pads soaked or 200ml or less
 Severe : > 2 pads soaked or > 200ml.
 Mild APH - 1 IV line and GXM 2 units of blood
 Massive APH - 3 IV lines and GXM 4 units of blood
 -use branula size 16 and below
 -transfuse immediately and accordingly
 Oxygen 7L/min via mask.
 CBD insertion – if indicated, monitor urine output.
Quantify bleeding objectively by
using these measurements:
1 pad = 125ml,
1 gallipot = 250ml,
1 kidney dish = 1Litre,
1 sarong = 500ml.

17. MANAGEMENT
 B. Blood investigation
 Hb, platelet, BT, CT, BUSE, PT, APTT, INR, GXM
 C. Perform Ultrasound Scan
 D. Monitoring -close observation of mother (BP, PR, Pad Charts) and foetus
(CTG).
 E. Definitive treatment - Decision on clinical diagnosis and proceed
accordingly
 DO NOT USE TOCOLYTIC IN THE PRESENCE OF PER-VAGINAL BLEEDING

18. PLACENTA PREVIA
 Features of bleeding: painless, recurrent, always revealed
 General condition: Proportional to blood loss
 Abdomen: soft, relaxed, malpresentation is common, presenting part high
 Foetal heart sound: usually present
 Admission and Referral
 All placenta praevia major should be managed as in patient from 32 weeks
onwards.
 All bleeding placenta praevia should be admitted at any gestational age.

19. Abruptio Placenta
 Features of bleeding: painful, revealed, concealed or mixed
 General condition: out of proportion in concealed type
 Abdomen: tense, tender and woody, head engaged
 Foetal heart sound: usually absent particularly in concealed type
 Common presentation: preterm 30-35 weeks with elevated BP

20. POST PARTUM HEMORRHAGE
 DEFINITION: Bleeding from or into the genital tract of > 500ml following
delivery
 1. Type Primary PPH - <24 hours after delivery
 2. Secondary PPH - >24 hours after delivery
 Causes of Primary PPH(4T‟s)
 i. Tone; Atonic Uterus
 ii. Trauma :Trauma to genital tract
 iii. Thrombin: Coagulation defects
 iv. Tissue: Retained products of conception

21.  Referred Cases From Home Delivery/ District Hospital
 1. Assess blood loss
 2. Check vital signs
 3. No exploration to be done until blood is transfused (at
least 2 units of blood). Proceed to OT for exploration under
GA after transfusion.
 4. MO in district hospital should transfuse 1-2 litres of blood
first in their hospital in all cases of home/ hospital delivery
before transferring the patient.
 5. If patient are still oozing after exploration, transfer
patient to hospital with Specialist and trigger Red Alert
System

22.  6. Prophylaxis against PPH
 Gravida 5 and above, twin pregnancies, polyhydramnios and prolonged 1st and 2nd
stage should have IV drip with 40U of pitocin/ pint DS at 20drops/min for 6 hours
after 3rd stage of labour.
 7. If local causes, catch bleeder and pack vagina with roller gauze/ pads (up
to 3 pads rolled up into vagina). – remember to inform referral hospital.
 8. All cases of PPH > 800mls or if BP low with systolic < 90, pulse rate >
120/min, please alert Specialist stat via Red Alert.

23. MATERNAL COLLAPSE IN PREGNANCY AND
THE PEURPERIUM
 Maternal collapse is defined as an acute
event involving the cardiorespiratory
systems and/or brain, resulting in a
reduced or absent conscious level (and
potentially death), at any stage in
pregnancy and up to six weeks after
delivery.