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Obstetric emergencies

Emergencies in obstetrics need immediate attention and comprehensive care

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Obstetric emergencies

  1. 1. 1Copyright © 2014 Well Woman Clinic. All rights reserved. 1 A holistic approach to Woman’s health Dr Nupur Gupta Dept of Obstetrics & Gynecology Paras Hospital, Gurgaon Obstetric Emergencies
  2. 2. 2Copyright © 2014 Well Woman Clinic. All rights reserved. 2 Our Team
  3. 3. 3Copyright © 2014 Well Woman Clinic. All rights reserved. 3 Emergency Obstetric Care To Avert Death and Disability… …We Need to Ensure that Women have Access To Emergency Obstetric Care (EmOC)
  4. 4. 4Copyright © 2014 Well Woman Clinic. All rights reserved. What is an Obstetric emergency?  A suddenly developing pathologic condition in a patient, due to accident or disease, which requires urgent medical or surgical therapeutic intervention There are 2 patients; fetus is very vulnerable to maternal hypoxia
  5. 5. 5Copyright © 2014 Well Woman Clinic. All rights reserved. But we do know that of any population of pregnant women at least 15% will experience an obstetric complication … How Do We Know Which Women Will Experience Complications? WE DON’T
  6. 6. 6Copyright © 2014 Well Woman Clinic. All rights reserved. 6
  7. 7. 7Copyright © 2014 Well Woman Clinic. All rights reserved. 7
  8. 8. 8Copyright © 2014 Well Woman Clinic. All rights reserved.  Hyperdynamic , hypervolumic , maternal circulation  Cardiac output increases by 50% , blood volume by 45% (peak at 32-34 wks)  30% loss of fluid may be tolerated without any tachycardia PREGNANCY CHANGES
  9. 9. 9Copyright © 2014 Well Woman Clinic. All rights reserved. Obstetric Emergencies  Maternal  Fetal  Both maternal & fetal High Mortality rate
  10. 10. 10Copyright © 2014 Well Woman Clinic. All rights reserved. Maternal Complications of Pregnancy First Trimester Second Trimester Third Trimester
  11. 11. 11Copyright © 2014 Well Woman Clinic. All rights reserved. First Trimester 1. Ectopic pregnancy 2. Abortion 3. Molar Pregnancy 4. Uterine rupture Second Trimester 1. Abortion Third Trimester 1. Placenta Praevia 2. Placenta Accreta 3. PPH 4. Uterine rupture 5. Inversion 6. Hypertensive crisis
  12. 12. 12Copyright © 2014 Well Woman Clinic. All rights reserved. Hypertensive Complications Haemorrhage Topics of Discussion
  13. 13. 13Copyright © 2014 Well Woman Clinic. All rights reserved. Pregnancy and hypertension/Toxaemia/PIH  Single largest cause of maternal death worldwide  Incidence- 7-12% ( 2nd most common cause after anaemia)  Pre-eclampsia - HTN + proteinuria with or without edema > 20 weeks  Eclampsia - preeclampsia with seizure
  14. 14. 14Copyright © 2014 Well Woman Clinic. All rights reserved. Pregnancy and hypertension  Chronic hypertension - diagnosed pre-pregnancy or before 20 weeks or persisting > 6 weeks post-partum  Gestational or late transient HTN - high BP in latter half of pregnancy or 24hrs after delivery without any signs of eclampsia & disappears within 10 days post-partum
  15. 15. 15Copyright © 2014 Well Woman Clinic. All rights reserved.
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  17. 17. 17Copyright © 2014 Well Woman Clinic. All rights reserved. SBP > 140 (or +20 from baseline or DBP >90 (or +10 from baseline) Proteinuria .3g/24h +/- Edema No Oliguria No Associated symptoms Normal lab No IUGR BP>160/90 Proteinuria >5g/24h Edema Present Oliguric Visual sym, abd pain, pulm. edema Lab (dec. plts, inc. LFT, inc. bili, inc. creatinine, increased uric acid) IUGR Mild Severe HYPERTENSION & PROTEINURIA IS THE HALLMARK Preeclampsia
  18. 18. 18Copyright © 2014 Well Woman Clinic. All rights reserved. Management Goals Safety of mother & newborn Prevent Eclampsia Guidelines Hospitalization Definitive treatment being delivery Expectant management depends on maternal & fetal status, labour & gestational age
  19. 19. 19Copyright © 2014 Well Woman Clinic. All rights reserved. Antihypertensive drugs in PIH Antihypertensive drugs ↙ ↓ ↓ ↘ Nifedipine Hydralazine Labetalol Captopril ↓ ↓ ↓ ↓ Acts in 3 min. Arterial vasodilator rapid action Sublingual 25mg Peak at 1 hr. I/V bolus 5 mg I/V 10 mins acts in 5 min Oral (Sublingual) Oral 25 mg oral- 1 hr only used in post Upto 120 mg/day partum cases Divided 6 hrly Nitroglycerine drip
  20. 20. 20Copyright © 2014 Well Woman Clinic. All rights reserved. General Measures for management of Eclampsia  Foley’s catheter, I/O chart  Urine Albumin 4 hrly  Vitals  Eye pads  Change of position 2hrly  Fetal assessment  Antibiotic cover  Deep tendon reflexes  Shift to ICU  Railing cot  Nasal O2  I/V 5% Dextrose or RL  Investigations  Mouth Gag  Suction  Slight head low position
  21. 21. 21Copyright © 2014 Well Woman Clinic. All rights reserved.
  22. 22. 22Copyright © 2014 Well Woman Clinic. All rights reserved. Eclampsia to treat convulsions: Magnesium Sulphate
  23. 23. 23Copyright © 2014 Well Woman Clinic. All rights reserved. Eclampsia to treat convulsions
  24. 24. 24Copyright © 2014 Well Woman Clinic. All rights reserved. Eclampsia to treat convulsions
  25. 25. 25Copyright © 2014 Well Woman Clinic. All rights reserved. Eclampsia to treat convulsions  Next dose should be repeated (after checking the parameters) every 4 hrs 5gm I/M & continue till 24 hrs after delivery or after the last convulsion  To prevent fit in severe pre-eclampsia give only I/M dose  Other drugs- Diazepam, Pethidine, Promethazine, Chlorpromazine
  26. 26. 26Copyright © 2014 Well Woman Clinic. All rights reserved. Delivery within 12 hours of onset of convulsions
  27. 27. 27Copyright © 2014 Well Woman Clinic. All rights reserved.
  28. 28. 28Copyright © 2014 Well Woman Clinic. All rights reserved.
  29. 29. 29Copyright © 2014 Well Woman Clinic. All rights reserved. HELLP SYNDROME
  30. 30. 30Copyright © 2014 Well Woman Clinic. All rights reserved. 30 HAEMORRHAGIC/HYPOVOLUMIC SHOCK IN OBSTETRICS Antenatal - Ruptured ectopic pregnancy, APH, Incomplete abortion, Uterine perforation during evacuation, Uterine rupture, Abdominal wall hematoma Intranatal - uterine rupture Postnatal - PPH (primary, secondary) - Atonic,Traumatic, Retained tissue, Thrombosis, Acute uterine inversion
  31. 31. 31Copyright © 2014 Well Woman Clinic. All rights reserved. Ruptured Ectopic Pregnancy: A Surgical Emergency of Pregnancy  One of the leading causes of first trimester maternal death  Usually 5-8 weeks after LMP  High Risk: History of ectopic, tubal surgery or sterilization procedure, Known tubal scarring or pathology
  32. 32. 32Copyright © 2014 Well Woman Clinic. All rights reserved.
  33. 33. 33Copyright © 2014 Well Woman Clinic. All rights reserved. INCOMPLETE/INEVITABLE ABORTION
  34. 34. 34Copyright © 2014 Well Woman Clinic. All rights reserved.
  35. 35. 35Copyright © 2014 Well Woman Clinic. All rights reserved.
  36. 36. 36Copyright © 2014 Well Woman Clinic. All rights reserved. CAUSES
  37. 37. 37Copyright © 2014 Well Woman Clinic. All rights reserved. PLACENTA PRAEVIA
  38. 38. 38Copyright © 2014 Well Woman Clinic. All rights reserved.
  39. 39. 39Copyright © 2014 Well Woman Clinic. All rights reserved.
  40. 40. 40Copyright © 2014 Well Woman Clinic. All rights reserved.  Vaginal bleeding – bright red, painless & recurrent  Soft pain free uterus  Easy to feel uterus (floating head, breech or transverse  No fetal distress  AVOID INTERNAL EXAMINATION PLACENTA PRAEVIA SYMPTOMS & SIGNS Management is conservative – transfuse blood & prolong pregnancy till 36 weeks Delivery vaginal – anterior placenta & ARM, LSCS for posterior placentation
  41. 41. 41Copyright © 2014 Well Woman Clinic. All rights reserved. Placenta Praevia  Ultrasound is highly accurate in making diagnosis (PPV 93%, NPV 98%)
  42. 42. 42Copyright © 2014 Well Woman Clinic. All rights reserved. 4 types according to distance from internal os - Partial - Low Lying - Marginal - Major or Complete
  43. 43. 43Copyright © 2014 Well Woman Clinic. All rights reserved.
  44. 44. 44Copyright © 2014 Well Woman Clinic. All rights reserved.
  45. 45. 45Copyright © 2014 Well Woman Clinic. All rights reserved.
  46. 46. 46Copyright © 2014 Well Woman Clinic. All rights reserved.
  47. 47. 47Copyright © 2014 Well Woman Clinic. All rights reserved.  Abdominal pain  Severe shock not proportionate to bleeding  Vaginal bleeding, usually old blood  Shock  Uterus tense & spasmodic  Tenderness  Fetal parts are hard to feel  Often fetal heart not heard SYMPTOMS SIGNS ABRUPTIO PLACENTAE ANTEPARTUM HAEMORRHAGE
  48. 48. 48Copyright © 2014 Well Woman Clinic. All rights reserved.  It is a death threat to the fetus & a hazard to the mother  Placental separation – blood clot – release of PGs – spasm – alters placental perfusion – blood tracks into the myometrium – serosa – pain & shock – uterine muscle spasm ABRUPTIO……..Mechanism & Pathology ABRUPTIO……..Emergency treatment  Treat the shock – large bore IV line, Haemaccel, cross match blood  Treat DIC – FFP, PRBCs  Deliver the fetus - Emergency Caesarean if fetus is alive & mature - Vaginal delivery if cervix is favourable & fetus dead
  49. 49. 49Copyright © 2014 Well Woman Clinic. All rights reserved. Abruptio Placentae
  50. 50. 50Copyright © 2014 Well Woman Clinic. All rights reserved.
  51. 51. 51Copyright © 2014 Well Woman Clinic. All rights reserved.
  52. 52. 52Copyright © 2014 Well Woman Clinic. All rights reserved.
  53. 53. 53Copyright © 2014 Well Woman Clinic. All rights reserved. Abruption  Delivery  DIC occurs in 4-10% of cases and usually is apparent by 8 hours after onset  Renal failure is the most common cause of maternal mortality
  54. 54. 54Copyright © 2014 Well Woman Clinic. All rights reserved.
  55. 55. 55Copyright © 2014 Well Woman Clinic. All rights reserved. Placenta Accreta  Absence of decidua basalis and imperfect formation of the fibrinoid layer (Nitabuch)  Increta in myometrial invasion  Percreta the placenta goes through to the serosa  Risk Factor - previous LSCS, D&C,
  56. 56. 56Copyright © 2014 Well Woman Clinic. All rights reserved.
  57. 57. 57Copyright © 2014 Well Woman Clinic. All rights reserved. Post-partum Haemorrhage: Primary  Estimated blood loss > 500ml in normal & > 1000ml in LSCS  Change in Haematocrit by 10%  Any amount of blood loss that threatens woman’s haemodynamic stability  In a woman with PIH, Anaemia, Dehydration, GDM, even small amount of blood loss can alter the situation
  58. 58. 58Copyright © 2014 Well Woman Clinic. All rights reserved. Primary PPH : Third Stage/True PPH
  59. 59. 59Copyright © 2014 Well Woman Clinic. All rights reserved. Post-partum Haemorrhage: Secondary
  60. 60. 60Copyright © 2014 Well Woman Clinic. All rights reserved. PPH: INCIDENCE  Complicates 3.9% of vaginal deliveries & 6.4% of C-section deliveries  1/1000 deliveries in developing countries versus 1/100000 in developed countries
  61. 61. 61Copyright © 2014 Well Woman Clinic. All rights reserved. PPH: Incidence Cause  Lacerations  Atony  Abruption  Retained placenta  Praevia  Accreta  Rupture  Inversion Incidence  1:8  1:20-1:50  1:80-1:150  1:100-1:160  1:200  1:2000  1:2500  1:6400
  62. 62. 62Copyright © 2014 Well Woman Clinic. All rights reserved. Etiology of PPH: The 4 Ts to remember  Tone - uterine atony  Tissue - Retained tissue/clots  Trauma - lacerations, rupture or inversion  Thrombin - Coagulopathy
  63. 63. 63Copyright © 2014 Well Woman Clinic. All rights reserved. Risk factors for Haemorrhage  H/O PPH in previous pregnancy  APH  Multiple pregnancies  PIH (Pre-eclampsia, eclampsia, HELLP)  Chorioamnionitis  Hydramnios  Fetal death  Anaemia, Multiparity  Uterine myoma  Operative or assisted delivery  Prolonged labour  Precipitate labour  Induction or augmentation  Chorioamnionitis  Shoulder dystocia  Internal podalic version  Acquired coagulopathy Antepartum Intrapartum
  64. 64. 64Copyright © 2014 Well Woman Clinic. All rights reserved. Risk factors for Haemorrhage  Lacerations or extended episiotomy  Retained placenta or placental abnormalities  Uterine rupture  Uterine inversion  Acquired coagulopathy Postpartum
  65. 65. 65Copyright © 2014 Well Woman Clinic. All rights reserved. Prevention of PPH  ACTIVE MANAGEMENT OF THIRD STAGE OF LABOUR  Identifying risk factors & managing them accordingly  Correct anaemia  Effective management of High risk patients at tertiary care centre  I/V access or blood transfusion  Restrictive use of episiotomy
  66. 66. 66Copyright © 2014 Well Woman Clinic. All rights reserved. Active management of third stage  Within one min. of birth give uterotonic (Inj. Oxytocin)  Early clamping & cutting of cord  Controlled traction on umbilical cord while applying counter traction on uterus  Massage the uterus after delivery of placenta
  67. 67. 67Copyright © 2014 Well Woman Clinic. All rights reserved. Prevention of PPH during Caesarean  Identify high risk patients  Arrange and cross match blood  Precautions during surgery to minimize blood loss  Wait for spontaneous expulsion of placenta rather than manual shearing  Rapid closure of uterine incision
  68. 68. 68Copyright © 2014 Well Woman Clinic. All rights reserved.
  69. 69. 69Copyright © 2014 Well Woman Clinic. All rights reserved.
  70. 70. 70Copyright © 2014 Well Woman Clinic. All rights reserved.
  71. 71. 71Copyright © 2014 Well Woman Clinic. All rights reserved. Uterine atony  It complicates 1 in 20 deliveries – most common cause  Etiology  Over distended uterus Uterine exhaustion Intra-amniotic infection Functional or anatomic distortion of uterus
  72. 72. 72Copyright © 2014 Well Woman Clinic. All rights reserved. Uterine atony  Clinical risk factors Polyhydramnios Multiple gestation Macrosomia Induced labour Prolonged or rapid labour High parity Fever/PROM Fibroid uterus Placenta praevia
  73. 73. 73Copyright © 2014 Well Woman Clinic. All rights reserved. Uterine atony- management  General management Obtain help Adequate venous access Foley’s catheter Monitor adequate renal perfusion Volume replacement- infuse crystalloid, FFP, platelets or cryoprecipitate Bimanual compression
  74. 74. 74Copyright © 2014 Well Woman Clinic. All rights reserved. Bimanual Compression
  75. 75. 75Copyright © 2014 Well Woman Clinic. All rights reserved.
  76. 76. 76Copyright © 2014 Well Woman Clinic. All rights reserved. Uterine atony- Oxytocin  Specific treatment Oxytocin infusion- first line treatment for PPH I/V bolus can cause severe hypotension & CVS side effects Dilute oxytocin prepared by adding 20-40 U to 1 lit. of crystalloid & infusion at rate 10 ml/min (200mu/min) up to 100-500 mu/min might be used
  77. 77. 77Copyright © 2014 Well Woman Clinic. All rights reserved. Uterine atony- oxytocin analogues  Carbetocin synthetic analog of oxytocin with a half life 4-10 times longer than that of Oxytocin used as a single dose injection can be given I/V or I/M  It appears to be more effective than continues infusion of oxytocin with similar safety profile  Buctocin, Des- amnio-oxytocin
  78. 78. 78Copyright © 2014 Well Woman Clinic. All rights reserved. Ergometrine (Methyl ergonovine maleate)  Ergot alkaloid  Oral/IM/IV 0.2 mg onset of action within 10 mins. I/M or I/V 1-3 min  SE- nausea, vomiting, weakness, paresthesias, chest pain  CI - sepsis, HTN, heart disease, peripheral vascular diseases, liver & kidney diseases  Can be repeated every 2-4 hrs up to maximum of 5 doses
  79. 79. 79Copyright © 2014 Well Woman Clinic. All rights reserved. Syntometrine  Combination of oxytocin 5U & ergometrine 0.5 mg I/M  No important clinical difference in effectiveness between syntometrine & I/V oxytocin in prevention of PPH  Associated with higher risk of HTN & vomiting
  80. 80. 80Copyright © 2014 Well Woman Clinic. All rights reserved. Prostaglandin: PROSTODIN  15 Methyl PGF2a- I/M or intramyometrial, 250mcg Controls refractory PPH C/I- Asthma due to broncho-constriction activity, cardiac, renal & hepatic diseases S/E- nausea, vomiting, diarrhoea & pyrexia
  81. 81. 81Copyright © 2014 Well Woman Clinic. All rights reserved. Prostaglandin: MISOPROSTOL Synthetic PGE1 analogue Oral, P/V,/P/R, Sublingual Adverse affect- nausea, vomiting, diarrhoea, abdominal pain, chills, shivering, fever Routine oral 600 - 800mcg as effective as 10 u oxytocin Sublingual is as effective as I/V infusion of oxytocin
  82. 82. 82Copyright © 2014 Well Woman Clinic. All rights reserved. Surgical procedures for PPH  Uterine packing  Aortic compression using the pressure between the fist and vertebral column  Stimulate uterine contraction - PGF2α injected locally in to the uterus or IM  Balloon tamponade  Suture techniques  Internal iliac artery ligation  Angiographic embolisation
  83. 83. 83Copyright © 2014 Well Woman Clinic. All rights reserved. 83 B Lynch Suture
  84. 84. 84Copyright © 2014 Well Woman Clinic. All rights reserved. Lacerations: Traumatic PPH  First thing to be ruled out in bleeding post partum woman with a firm uterus  Careful examination of the entire genital tract  Rarely results in massive blood loss  May be life threatening if extends to the retro peritoneum
  85. 85. 85Copyright © 2014 Well Woman Clinic. All rights reserved.
  86. 86. 86Copyright © 2014 Well Woman Clinic. All rights reserved. Rupture Uterus  A potential obstetric catastrophe  A major cause of maternal death  Incidence: 1 in 1148 to 1 in 2250  Complete (Spontaneous & Traumatic)  Incomplete
  87. 87. 87Copyright © 2014 Well Woman Clinic. All rights reserved.
  88. 88. 88Copyright © 2014 Well Woman Clinic. All rights reserved.
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  94. 94. 94Copyright © 2014 Well Woman Clinic. All rights reserved.
  95. 95. 95Copyright © 2014 Well Woman Clinic. All rights reserved. Inversion  Usually occurs when the placenta is fundally implanted  Prompt replacement is generally easier.  Halothane or nitroglycerine are effective agents  Uterotonics then needed to contract the uterus
  96. 96. 96Copyright © 2014 Well Woman Clinic. All rights reserved. AMNIOTIC FLUID EMBOLISM The initial response of the pulmonary vasculature to the presence of amniotic fluid is intense vasospasm resulting in severe pulmonary hypertension and hypoxaemia Amniotic fluid contains lipid-rich particulate material which stimulates a systemic inflammatory reaction. Leads to capillary leak & DIC
  97. 97. 97Copyright © 2014 Well Woman Clinic. All rights reserved. AMNIOTIC FLUID EMBOLISM Respiratory support – Oxygen (FiO2 0.6–1.0). CPAP or mechanical ventilation Cardiovascular support - controlled fluid loading and ionotropic support Haematological management - blood product therapy Treatment with cryoprecipitate
  98. 98. 98Copyright © 2014 Well Woman Clinic. All rights reserved. What can we do as Clinicians: THE WAY FORWARD?  Establish obstetric emergency response teams  5 situations – PPH, APH, Shoulder dystocia, Emergency Caesarean, Eclampsia  Conduct Obstetric Skills & Drills Training  Labour Ward Drills  IMPROVED TEAMWORK

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