By: Hayelom Michael
Obstetrical emergencies are life-threatening medical
conditions that occur in pregnancy or during or after labor
There are a number of illnesses and disorders of
pregnancy that can threaten the well-being of both mother
Obstetrical emergencies may also occur during active
labor, and after delivery (postpartum).
Abortion: is the process of termination or expulsion of
the pregnancy before the 28th completed weeks of
gestation or less than 1000gm weight (in Eth & UK).
When the abortion occurs spontaneously, the term "
miscarriage" is often used.
Abortion is one of the leading cause of maternal
15% of clinically evident pregnancies end in
spontaneous abortion and a further 10-60% are
terminated by an induced abortion.
More than 80 % of spontaneous abortions are in the first
Unsafe abortion is a leading cause of maternal mortality:
13% - worldwide
17% - east Africa
The causes of abortion can conveniently be divided in to
three groups :-fetal
- Chromosomal abnormality or disease of the fertilized
ovum may account for 60% of spontaneous, first trimester
- Malformation of the trophoblast and poor implantation of
the blastocyst may result in placental separation with
consequent hypoxia and impaired embryonic development.
Disease acquired during pregnancy such as rubella or
influenza, especially if they are accompanied by acute
fever, interfere with transplacental oxygenation and may
Chronic disorders, for example renal disease accompanied
by hypertension, may have a similar effect.
Drugs :- large doses of any drug are poisonous and should
- ABO incompatibility between mother and embryo may
result in abortion.
Local disorders of the genital tract
A retroverted uterus which is unable to rise out of the
pelvis may occasionally predispose to abortion.
Physical defects of the uterus, such as sub mucosal
leiomyomas, uterine polyps, or uterine malformations
may prevent implantation adequate to support fetal
Since the paternal spermatozoon gives to the ovum
half of its chromosomes, defects may result in
particularly if both partners share many common HLA
1. Threatened abortion
It is presumed that a pregnancy is threatening to abort
when vaginal bleeding occurs before the 24th week
vaginal bleeding (light).
cramping lower abdominal pain
Uterus softer than normal but correct size for date
cervix is closed
U/S essential & Shows the presence of fetal heart
There is chance of continuing the pregnancy to
This is the term to the fetus w/c is died is retained its
placenta in the uterus for at least 4 weeks.
Usually history of threatened abortion preceding it
Why the pregnancy is not expelled is not known.
Early ultrasonic scan may identify missed abortion
before the mother experiences any symptoms.
Pain and bleeding may cease but the mother may
experience a residual brown vaginal discharge as
having an odor of decaying matter and it can be
offensive and distressing.
All other physiological signs of pregnancy will
regress, uterine enlargement will cease and a
pregnancy test will prove negative
3. Inevitable abortion
When it is impossible for the pregnancy to continue it is
termed as inevitable abortion
Heavy vaginal bleeding.
Severe cramping lower abdominal pain which follows
Cervix is open/dilated, effaced, membrane ruptured
Uterus corresponds to dates
But No expulsion of products of conception
No chance of continuing the pregnancy to viability.
4. Incomplete Abortion
When the products of conception are only
partially evacuated during abortion.
Bleeding is profuse but the abdominal pain and
back ache may cease.
The cervix will be soft and purplish in color and
will be partly closed.
Prolonged retention of the tissues predisposes
the woman to infection and immediate medical
intervention is needed
16 Hayelom Michael 17/9/2014
5. Complete abortion
A complete abortion is more likely to occur prior to
the 8th week of pregnancy and constitutes the
expulsion of the embryo, placenta and intact
Uterus smaller than dates
Uterus softer than normal
History of expulsion of products of conception
Light cramping/lower abdominal pain
6. Recurrent abortion
Three or more consecutive pregnancy losses at 28
weeks or less or with fetal weights less than 1000
primary recurrent miscarriage—no successful
secondary recurrent miscarriage—one prior live birth
7. Septic abortion
Septic abortion is manifested by fever, malodorous
vaginal discharge, pelvic and abdominal pain, and
cervical motion tenderness.
Peritonitis and sepsis may be seen.
Trauma to the cervix or upper vagina may be
recognized if there has been a criminal abortion.
Ultrasound may be helpful in ruling out retained
products of conception.
Is implantation of fertilized ovum outside the
Is the leading cause of pregnancy related death in the 1st
>1 in 100 pregnancies
Recent evidence indicates that it is increasing in many
USA -5 fold
UK -2 fold
Recurrence rate 15% after 1st 25% after 2 ectopics
Risk Factors for Ectopic Pregnancy:
High risk Moderate risk Slight risk
Tubal surgery Infertility Previous pelvic/abdominal
Sterilization Previous genital infections Cigarette smoking
Previous ectopic pregnancy Multiple sexual partners Vaginal douching
In utero exposure to
Early age at first intercourse
(< 18 years)
Use of IUD
Documented tubal pathology
95% is tubal
A uterine pregnancy in conjunction with an extra uterine
1 in 30,000 pregnancies
Ectopic Pregnancy remains asymptomatic until it
when it ruptures present in two forms: Acute & Chronic
Abdominal Pain CMT
V. Bleeding Palpable mass
@ 4-5 wks
TVS can visualize a gestational sac at serum beta
HCG of 1500-2000 mIU/Lt
All viable IU pregnancies can be visualized by trans
abdominal US for serum HCG levels> 6500mlu/ML
Doubling time of serum HCG is 48 hours, if it takes
more than 7 days, ectopic pregnancy will be
Depends on the stage of the disease and the condition
of the patient at diagnosis
Preeclampsia refers to a systemic syndrome
characterized by widespread maternal endothelial
dysfunction presenting clinically with hypertension,
edema, and proteinuria during pregnancy.
Preeclampsia should be distinguished from gestational
hypertension that can develop in pregnancy without
BP ≥ 140/90 mm Hg after 20 weeks' gestation
Proteinuria ≥ 300 mg/24 hours or ≥ 1 + dipstick
Increased certainty of preeclampsia
BP ≥ 160/110 mg Hg
Proteinuria 5.0 g/24 hours or ≥ 2+ dipstick
Serum creatinine > 1.2 mg/dL unless known to be
Platelets < 100,000/mm3
Microangiopathic hemolysis (increased LDH)
Elevated ALT or AST
Persistent headache or other cerebral or visual
Persistent epigastric pain
Multipara with change of
Chronic renal disease
Previous history of
Family history of
Mild pre-eclampsia: blood pressure ≥ 140/90 mmHg ±
- blood pressure >140/90 mmHg + proteinuria ±
- diastolic blood pressure>110 mmHg or
- cerebral or visual disturbances.
N.B. Imminent eclampsia : It is a state in which the patient is
about to develop eclampsia. Usually there are :
- blood pressure much higher than 160 /110 mmHg ,
- heavy proteinuria (+++or ++++),
- severe continuous headache,
- blurring of vision,
- epigastric pain.
Fulminating pre-eclampsia: a rapidly deteriorating pre-eclampsia
to be imminent eclampsia.
Criteria Mild preeclampsia Severe preeclampsia
Blood pressure < 160/110 > 160/110
Symptoms Absent Present
Proteinuria < 5 g/dl 24 hours
> 5 g/dl; > 2+ on dipstick
Liver and Renal function Normal Abnormal
Platelet count Normal Thrombocytopenia
Pulmonary edema Absent Present
Convulsions Absent Present
HELLP syndrome Absent Present
Fetal growth restriction Absent Present
The presence of any 1 of the above findings is sufficient to lead to a classification
of the preeclampsia into the severe category
The onset is typically insidious, characterized by
hypertension and edema, with proteinuria following
within several days.
Headaches and visual disturbances are serious events and
are indicative of severe preeclampsia, often requiring
Eclampsia is heralded by central nervous system
involvement, including convulsions and eventual coma.
Visual disturbances: blurring of vision, flashes of light or
Epigastric or right upper quadrant pain: due to
enlargement and subcapsular haemorrhage of the liver.
Nausea and vomiting : due to congestion of gastric mucosa
and/ or cerebral oedema.
Oliguria or anuria: due to kidney pathology.
Complete urine examination: for proteinuria, pus
cells, RBCs, casts,specific gravity, culture and
Kidney function tests: serum uric acid > 6 mg % is
abnormal during pregnancy. It is more specific for
pre-eclampsia than creatinine.
Coagulation status :Platelet count, fibrinogen as DIC
Eye fundus examination.
Tests for foetal well being: as
- daily foetal movement count,
- non-stress test,
-Follow BP at out patient
-Deliver at term: induction
-C/S only if C/I for vaginal
-Anticonvulsant during delivery and 24 hrs after delivery
Mild Preeclampsia: conservatevely
-Follow BP more frequently
-Look for severity S/S or lab
-Deliver at term: Induction
-Rout: Vaginal unless C/I
Severe preeclampsia: aggressively
-Admit, prevent ECLAMPSIA
IV hydralazine if DBP >110, SBP >160
Oral: Methyldopa, nifidipine, labetolol,
: is the variant of preeclampsia i.e. characterized by:
Fragmented RBC, jaundice, LDH
-Elevated Liver Enzymes
mgt :Immediate termination
o is the occurrence of generalized tonic clonic convulsion
and/ or coma in a women with preeclampsia.
o It’s one of the most serious and often fatal
complications of preeclampsia.
o Eclampsia is a preventable complication of
preeclampsia & has almost disappeared in countries
with universal ante natal, intra partum ad post partum
Eclampsia still complicates preeclampsia in parts of the
world where maternal health service are not accessed by
The majority of Eclampsia occurs intra partum(50%)
with the remainder equally occurring in the ante partum
& post partum period( 25% each)
Air way and secretions
Broad spectrum antibiotic for aspiration pneumonia
Rout: vaginal if in labor or favorable bishop by
induction, if not C/S
Simple: Expectant, spontaneous
: Anti HTN
:Close follow up
Super imposed preeclampsia
: Consider as severe preeclampsia
: As eclampsia
Cord presentation and prolapse describe a situation in
which the umbilical cord is felt anterior to the fetal
presenting part on vaginal examination.
If the membranes are intact it is a cord presentation
while with ruptured membranes it is identified as a
As long as the membranes are not ruptured, the risk of
compression and asphyxia is low.
Cord prolapse can be:
Overt- being felt inside the
cervix, the vagina or even
hanging outside the
Occult- with the cord
anterior to the presenting
part in the lower segment
but not felt on digital
Cord prolapse can occur in:
vertex and frank breech presentations-0.5%
complete breech -5%
footling breech -15% and
shoulder presentation -20%.
Malpresentations in labor
Amniotomy with a high fetal station
Polyhydramnios with sudden membrane rupture
Second twin delivery
CPD in labor
Cord compression and constriction of umbilical
vessels due to cold exposure outside the introitus can
lead to fetal asphyxia and death.
Partial cord occlusion may give the fetus some time
but in complete cord occlusion the fetus can die of
asphyxia in 5-7 minutes if cord compression is not
There is increased maternal risk from cord prolapse
because of emergency operative vaginal or abdominal
delivery performed in order to salvage the fetus
In the vagina or inside the cervix anterior to the
Check for pulsation and its rate
Replace the cord immediately into the vaginal ( not
inside the uterus) canal if outside the introitus
If membrane is intact, cord presentation is diagnosed
In all malpresentations, a careful search for cord presentation or
prolapse should be made
Occult cord prolapse can only be diagnosed by detection of
abnormal FHR patterns
In cases of malpresentations, sonographic search can also be
made for cord anterior to the fetal presentation
If cord is pulsating:
Put mother in knee-chest position
Initiate oxygen administration by
face mask 5L/min
Insert bladder catheter and infuse
the bladder with 0.5L of saline
Replace the cord into the vaginal
Push fetal presenting part upwards
via the examining hand in the
vagina to relieve compression of
the cord by the presentation
Prepare for immediate delivery
Management is aimed toward relieving
pressure on the cord
There by relieving he compression and the
resulting fetal anoxia
Manage as any other labor as the cord prolapse will
not alter the course of labor (dead fetus)
Second stage of labor:
Expedite delivery by forceps delivery if other
conditions for forceps delivery are met.
Breech extraction if other conditions for breech
extraction are met (full cervical dilation)
First stage of labor:
Williams obstetrics 23rd edition
Current diagnosis and treatment in obstetrics and
Essential of obstetric and gynecology 4th edition
FMOH (2010): Management Protocol on Selected