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Obstatrics emergency


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This presentation mainly discuss about Abortion,Ectopic pregnancy, Preeclampsia/Eclampsia and Cord prolapse

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Obstatrics emergency

  1. 1. Obstetric Emergencies By: Hayelom Michael September,2014 By:Hayelom Michael 1 10/1/2014
  3. 3. INTRODUCTION  Obstetrical emergencies are life-threatening medical conditions that occur in pregnancy or during or after labor and delivery.  There are a number of illnesses and disorders of pregnancy that can threaten the well-being of both mother and child.  Obstetrical emergencies may also occur during active labor, and after delivery (postpartum). 3 10/1/2014
  4. 4. ABORTION  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 mortality  15% of clinically evident pregnancies end in spontaneous abortion and a further 10-60% are terminated by an induced abortion. 4 10/1/2014
  5. 5.  More than 80 % of spontaneous abortions are in the first 12 weeks  Unsafe abortion is a leading cause of maternal mortality: 13% - worldwide 17% - east Africa 5 10/1/2014
  6. 6. Causes Spontaneous abortion  The causes of abortion can conveniently be divided in to three groups :-fetal -maternal -paternal. 6 10/1/2014
  7. 7. Fetal causes - Chromosomal abnormality or disease of the fertilized ovum may account for 60% of spontaneous, first trimester abortions. - Malformation of the trophoblast and poor implantation of the blastocyst may result in placental separation with consequent hypoxia and impaired embryonic development. 7 10/1/2014
  8. 8. Maternal causes  Disease acquired during pregnancy such as rubella or influenza, especially if they are accompanied by acute fever, interfere with transplacental oxygenation and may precipitate abortion.  Chronic disorders, for example renal disease accompanied by hypertension, may have a similar effect.  Drugs :- large doses of any drug are poisonous and should be avoided  - ABO incompatibility between mother and embryo may  result in abortion. 8 10/1/2014  -
  9. 9. 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 development  Cervical incompetence 9 10/1/2014
  10. 10. Paternal causes Since the paternal spermatozoon gives to the ovum half of its chromosomes, defects may result in abortions, particularly if both partners share many common HLA antigen 10 10/1/2014
  11. 11. Clinically 1. Threatened abortion 2. Missed abortion 3. Inevitable abortion 4. Incomplete abortion 5. Complete abortion 6. Septic abortion 7. Recurrent abortion 11 3/23/2013
  12. 12. 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 activity  There is chance of continuing the pregnancy to viability. 12
  13. 13. 2.Missed Abortion  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. 13
  14. 14. 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 14 10/1/2014
  15. 15. . 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 the bleeding Cervix is open/dilated, effaced, membrane ruptured Uterus corresponds to dates Tender uterus But No expulsion of products of conception No chance of continuing the pregnancy to viability. 15 17/9/2014
  16. 16. 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
  17. 17. 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 membranes Light bleeding Closed cervix  Uterus smaller than dates Uterus softer than normal History of expulsion of products of conception Light cramping/lower abdominal pain
  18. 18. 6. Recurrent abortion Three or more consecutive pregnancy losses at 28 weeks or less or with fetal weights less than 1000 gram  primary recurrent miscarriage—no successful pregnancies secondary recurrent miscarriage—one prior live birth 18 3/23/2013
  19. 19. 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. 19 3/23/2013
  20. 20. ECTOPIC Pregnancy  Is implantation of fertilized ovum outside the endometrial cavity.  Is the leading cause of pregnancy related death in the 1st trimester.  >1 in 100 pregnancies  Recent evidence indicates that it is increasing in many countries  USA -5 fold  UK -2 fold  Recurrence rate 15% after 1st 25% after 2 ectopics
  21. 21. Etiology  Risk Factors for Ectopic Pregnancy: High risk Moderate risk Slight risk Tubal surgery Infertility Previous pelvic/abdominal surgery Sterilization Previous genital infections Cigarette smoking Previous ectopic pregnancy Multiple sexual partners Vaginal douching In utero exposure to diethylstilbestrol Early age at first intercourse (< 18 years) Use of IUD Documented tubal pathology
  22. 22. 22 10/1/2014
  23. 23.  95% is tubal Ampula>55% Isthmus-25% Fimbria-17 % Cornual-2 %  Cervix<2%  Abdomen<2%  Ovary<2%  Heterotopic Pregnancy A uterine pregnancy in conjunction with an extra uterine pregnancy  1 in 30,000 pregnancies 2 3 Sites
  24. 24.  Ectopic Pregnancy remains asymptomatic until it ruptures  when it ruptures present in two forms: Acute & Chronic Symptoms Signs  Amenorrhea Tenderness  Abdominal Pain CMT  V. Bleeding Palpable mass  Syncope Hypotension Pelvic mass 2 4 Clinical presentation
  25. 25. Dx 1.Ultrasound scanning – Abdominal/TVS 2.Serum Beta HCG level 3.Serum progesterone 4.D&C 5. Culdecentesis 6.Laparoscopy-gold standard 2 5
  26. 26. @ 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 confirmed. 2 6 Discriminatory zone
  27. 27. Management 2 7  Depends on the stage of the disease and the condition of the patient at diagnosis  Options Surgical Medical Expectant
  28. 28. Preeclampsia /Eclampsia  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 proteinuria. 28
  29. 29. Cont’d Minimum criteria 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 29
  30. 30. Cont’d  Serum creatinine > 1.2 mg/dL unless known to be previously elevated  Platelets < 100,000/mm3  Microangiopathic hemolysis (increased LDH)  Elevated ALT or AST  Persistent headache or other cerebral or visual disturbance  Persistent epigastric pain 30
  31. 31. Risk factors  Primigravida  Multipara with change of partner  Chronic hypertension  Chronic renal disease  Diabetes mellitus  Multifetal gestation  Polyhydramnios  RH Isoimmunized pregnancy  Hydatidiform mole  Previous history of preeclampsia  Family history of pregnancy induced hypertension 31
  32. 32. Classification Mild pre-eclampsia: blood pressure ≥ 140/90 mmHg ± oedema. Severe pre-eclampsia: - blood pressure >140/90 mmHg + proteinuria ± oedema or - diastolic blood pressure>110 mmHg or - cerebral or visual disturbances. 32
  33. 33. 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 ++++), - hyperreflexia, - severe continuous headache, - blurring of vision, - epigastric pain. Fulminating pre-eclampsia: a rapidly deteriorating pre-eclampsia to be imminent eclampsia. 33 10/1/2014
  34. 34. 34 Criteria Mild preeclampsia Severe preeclampsia Blood pressure < 160/110 > 160/110 Symptoms Absent Present Proteinuria < 5 g/dl 24 hours collection > 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
  35. 35. Clinical Feature  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 delivery.  Eclampsia is heralded by central nervous system involvement, including convulsions and eventual coma. 35
  36. 36. Symptoms  Visual disturbances: blurring of vision, flashes of light or blindness.  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. 36
  37. 37. Investigations  Complete urine examination: for proteinuria, pus cells, RBCs, casts,specific gravity, culture and sensitivity .  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 may develop. 37
  38. 38. cont’d  Eye fundus examination.  Tests for foetal well being: as - ultrasound, - daily foetal movement count, - non-stress test, 38
  39. 39. Complication Fetal  IUGR  Oligohydramnios  Placental infarcts  Placental abruption  Prematurity  Uteroplacental insufficiency  Perinatal death 39 Maternal  CNS seizures & stroke  DIC  Renal failure  Hepatic failure or rupture  Death
  40. 40. Management Gestational HTN: -Follow BP at out patient -Deliver at term: induction -Rout-vaginal, -C/S only if C/I for vaginal -Anticonvulsant during delivery and 24 hrs after delivery 40 10/1/2014
  41. 41. 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 -Anticonvulsants -Antihypertensive IV hydralazine if DBP >110, SBP >160 Oral: Methyldopa, nifidipine, labetolol, 41 10/1/2014
  42. 42. HELLP Syndrome : is the variant of preeclampsia i.e. characterized by: -Hemolysis: Fragmented RBC, jaundice, LDH -Elevated Liver Enzymes -Low Platelets mgt :Immediate termination 42 10/1/2014
  43. 43. Eclampsia 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 care provision 43 10/1/2014
  44. 44.  Eclampsia still complicates preeclampsia in parts of the world where maternal health service are not accessed by mothers.  The majority of Eclampsia occurs intra partum(50%) with the remainder equally occurring in the ante partum & post partum period( 25% each) 44 10/1/2014
  45. 45. Management Anti HTN Anti convulsants: Diazepam MgSO4 NG tube Air way and secretions Broad spectrum antibiotic for aspiration pneumonia Immediate termination Rout: vaginal if in labor or favorable bishop by induction, if not C/S 45 10/1/2014
  46. 46. Chronic HTN Simple: Expectant, spontaneous : Anti HTN :Close follow up Super imposed preeclampsia : Consider as severe preeclampsia Superimposed eclampsia : As eclampsia
  47. 47. Cord Prolapse 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 prolapsed cord.  As long as the membranes are not ruptured, the risk of compression and asphyxia is low. 47
  48. 48. Cont’d Cord prolapse can be: Overt- being felt inside the cervix, the vagina or even hanging outside the introitus. Occult- with the cord anterior to the presenting part in the lower segment but not felt on digital vaginal exam 48
  49. 49. Cont’d  Cord prolapse can occur in: vertex and frank breech presentations-0.5% complete breech -5% footling breech -15% and shoulder presentation -20%. 49
  50. 50. Etiology  Malpresentations in labor  PROM  Amniotomy with a high fetal station  Polyhydramnios with sudden membrane rupture  Second twin delivery  CPD in labor 50
  51. 51. Complications  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 immediately relieved.  There is increased maternal risk from cord prolapse because of emergency operative vaginal or abdominal delivery performed in order to salvage the fetus 51
  52. 52. Dx  In the vagina or inside the cervix anterior to the presenting part  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 52
  53. 53.  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 53 10/1/2014
  54. 54. Management Immediate management If cord is pulsating:  Put mother in knee-chest position  Initiate oxygen administration by 54 face mask 5L/min  Insert bladder catheter and infuse the bladder with 0.5L of saline  Replace the cord into the vaginal canal  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
  55. 55. Cont’d Delivery : Non-pulsatile cord:  Manage as any other labor as the cord prolapse will not alter the course of labor (dead fetus) Pulsatile cord: 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:  caesarean delivery. 55
  56. 56. Referances  Williams obstetrics 23rd edition  Current diagnosis and treatment in obstetrics and gynecology  Essential of obstetric and gynecology 4th edition  FMOH (2010): Management Protocol on Selected Obstetrics Topics 56 10/1/2014