Slide presentation of obstetric emergencies - common ones for the medical students as a quick reference and revision.

1. Obstetrics
emergency
Dr. Mini Sood

2. Obstetrics Emergency
Life threatening conditions
where mother can be in
shock or cardiac arrest
Causes Antepartum
•Ectopic Pregnancy
•Miscarriage
•APH
•PPH
•Eclampsia
•Uterine Rupture
Postpartum
•Uterine Inversion
•Amniotic Fluid Embolism
•Birth trauma

3. Obstetrics emergency- “Lots of people
confuse destiny with bad management.”
To avoid “bad
management”, we should
know, how to avoid a
Rapid deterioration
Rapid response of treating
team
Risk factors -Knowledge
and skills required
Diagnostic criteria-
knowledge and availability
Obstetric management-
Proper and aggressive
management ,Basis
resuscitation – ABC
Anaesthetics
management- Training and
drills

4. RISK FACTORS FOR
ABNORMAL PLACENTATION
Uterine fibroids
Prior caesarean section
History of postpartum haemorrhage
Multiparity

5. Obstetric
Management
• Placenta Previa
 Caesarean delivery: elective (if stable) or
 urgent (if haemorrhaging)
• Accreta/Percreta
 Recognition and (probably) hysterectomy
 May need surgeons with experience in
 bowel or urological surgery for per-creta

6. ANESTHETIC
MANAGEMENT
FOR PREVIA
 Examine the airway and provide aspiration prophylaxis.
 Ask OB about previous caesarean scar on ultrasound (risk of
accreta).
 Place two large-bore IV lines and have warmers
 available.
 BLOOD Should be typed and cross-matched.
 decide on the type of anaesthetic?
• A review of 514 women with placenta previa found:
• No differences between general or regional anaesthesia
• Am J Obstetric Gynecology 1999;180:1432

7. USE OF CELL SALVAGE-
Autotransfusion
A multicenter review of 139
patients who were
auto-transfused during
caesarean delivery compared
them to a control group
receiving banked blood.
There was no difference in:
Length of hospitalization
Need for ventilatory support /
A.R.D.S.
Coagulopathy or amniotic fluid
embolism
Infectious morbidity
Am J Obstetric Gyn
1998;179:715

8. USE OF
CELL
SALVAGE
• Cell salvage combined with blood filtration
• produced blood samples equivalent to
• maternal central venous blood.
• Editorial: Until a large prospective
• randomized study is done, cell salvage
• during C/S should only be used when
• necessary to preserve life – e.g., Jehovah’s
• Witness, difficult cross-match.
• Anaesthesiology 2000;92:1519 and 1531

9. INTERVENTIONAL RADIOLOGY
Prenatal diagnosis
of placenta accreta
/
percreta is now
becoming more
common
(vs diagnosis at
delivery) → develop
a
plan for potential
major haemorrhage.
Have a care
conference in
advance with
Anaesthesiology,
Obstetrician,
nursing and
Interventional
Radiologist present.
Am J Obstetric
Gynecology
2005;193:1756
Anaesthesia
2006;61:248

10. INTERVENTIONAL RADIOLOGY
Case report: A Jehovah’s Witness
patient
presented with placenta per-creta
invading the bladder. After uterine
and iliac catheters were placed in
IR, caesarean was performed.
Placenta was extensively adherent
to uterus and
penetrating the bladder wall.
Uterine artery embolization was
performed and the placenta left in
place. At 3 months the uterus was
empty
by ultrasound.
Methotrexate was considered, but
was unnecessary.
Obstetric Gynecology
2005;105:1247

11. Amniotic Fluid Embolism
Definition:
Amniotic fluid embolism is when
the amniotic fluid enters the
maternal circulation in cases of
tetanic uterine contractions
Especially in cases of IUD
Twin pregnancy Macrosomia Antepartum hemorrahge Multiparity
Hydramnios
Precipitate Labor
• Incidence
Rare 1 in 80000 Mortality rate 80%

12. Clinical features
Suspect when
Sudden onset of maternal
respiratory distress.
Cardiovascular collapse –
tachycardia, hypotension,
pulmonary hypertension,( right
heart failure and cardiac arrest).
Convulsions Hemorrhage DIVC.

13. differential diagnosis
• Pulmonary embolism
• Myocardial infarction
• Anaphylactic reaction
• Stroke
• Aspiration pneumonia

14. Management
Red Alert ABC resuscitation
Supportive therapy i.e.
• -ICU care
• -Ventilate and oxygenate
• -fluid management
• -CVP – monitoring
• -maintain cardiac output –inotropes
• -correct DIVC

15. Uterine inversion-Definition
Uterine inversion.
Fundus falls into the uterine cavity and the inside of the uterus is
turned outward with the placenta attached to the uterine wall.
Uterus is partly or completely turned inside out.

16. Uterine Inversion
Rare, 1 in 2000 deliveries
Types -Degree
• Inverted fundus extended to level of os
• Inverted fundus gone through os but not at introitus level
• Inverted fundus extended to introitus
• Uterus and cervix extended below introitus, associated with vaginal inversion
Completeness of inversion
• Complete – fundus has passed through the os
• Incomplete - inverted fundus still inside os

17. Uterine Inversion- Clinical features
Pain, haemorrhage or shock in
the presence of an inverted
(vaginally) or indented
(abdominally) uterus
Degree of shock more maybe
out of proportion of bleeding -
vasovagal shock!
90% will have PPH
40% will be in shock
96% occurs in first 24 hours
post partum
Chronic inversion can occur at
> 4weeks (very rare).

18. Complications
Neurogenic shock,
operation,
infection,
hemorrhage
maternal mortality.

19. Uterine Inversion -
Management
• ABC resuscitation, Red Alert
• IV fluids, blood transfusion
• Replace uterus soon, but do not
remove placenta until uterus is
contracted
• Manually replace it, 30% successful
without tocolytics
• If unsuccessful, do under tocolytics
• If unsuccessful do under GA

20. Uterine
Inversion-
management
• Once replaced, hand in uterus until
contracted.
• Give Oxytocin IV infusion or
Syntometrine IM
• Remove placenta only after uterus
contracted
• O’Sullivan Method – hydrostatic
pressure to replace uterus
• Check for trauma once replaced
• If all fail, Laparotomy, hysterectomy

21. ANESTHETIC MANAGEMENT
OF INVERSION
Uterine relaxation:
NTG (50-500 µg),
terbutaline, GETA
• Analgesia:
Pre-existing
epidural, ketamine,
GETA
Volume
resuscitation
Uterine contraction
with oxytocic's once
the
uterus is replaced

22. Uterine Rupture
Definition – complete separation of wall of pregnant uterus, before or during
labour
Risk Factors
• Previous one scar – risk of 0.5%
• Previous two scar – 2%
• Previous classical scar – 3-4%
• Previous ruptured lower segment – 4-10%
• Others – Myomectomy, Instrumental delivery, Trauma, High Parity, Prostin, oxytocin, obstructed
labour e.g.. Transverse lie

23. Uterine Rupture
• Maternal tachycardia
• Fetal distress –most common
• Abdominal pain – mild to severe (scar tenderness)
• Disappearance of presenting part from pelvis
• Shock, Per vaginal bleed
• Cessation of contractions
• haematuria
Suspect when
Can be asymptomatic

24. Weak
uterine scar
• Predisposing factors:
- Impaired healing of the uterine scar
- Over-distended uterus
- Obstructed labor
- Improper oxytocin use
- Uterine manipulation- MRP, Internal
podalic version, uterine inversion, previous
uterine surgery, after-coming head of fetus,
difficult forceps
- Multi-parity
- CPD

25. Types of rupture
Violent rupture
Usually associated with
causes such as obstructed
labor or the misuse of
oxytocic drugs.
The onset is dramatic and
occur during labor.
Silent rupture
Mild pain and collapse Impending rupture Signs of obstructed labor Tonic uterine contraction
Band's ring
Tenderness in the lower
abdomen

26. Laparotomy if uterine rupture is suspected.
Resuscitate mother, treat shock, transfuse blood
Antibiotic cover
Minor tear- repair and bilateral tubal ligation
Major tear- hysterectomy
Resuscitate baby

27. Uterine
Rupture
• Management
• ABC resuscitation, red alert if in shock
• IV line x2 large bore,
• Laparotomy
• Repair of rupture, CS in next
pregnancy
• Hysterectomy

28. DIAGNOSIS OF UTERINE
RUPTURE
Fatal distress (#1)
Cessation of uterine contractions (in labour)
Vaginal bleeding
Abdominal pain

29. MANAGEMENT OF
UTERINE RUPTURE
Uterine repair vs. Hysterectomy
Uterine rupture occurs in 1% of Lower segment uterine scars and 4-9% of classical incisions.
ACOG has practice guidelines for
management of VBAC.
Obstetric Gynecology 2004;104:203

30. RISK
FACTORS
FOR
UTERINE
ATONY
• Multiple gestation
• Precipitous labour
• Macrosomia
• Prolonged labour
• Polyhydramnios
• Augmented labor
• Grand multiparity (>5)
• Chorio-amnionitis
• Maternal age > 40
• Tocolytic agents
• Halogenated
• anaesthetics

31. MANAGEMENT OF
UTERINE ATONY
Bimanual uterine
compression and
Massage
Infusion of
oxytocin
Evaluation for
retained placenta
Use of other
oxytocic's

32. OXYTOCIC
DRUGS
• Drug/Dose Side Effects
• A. Oxytocin vasodilation with IV bolus,
hyponatremia
• diffuse vasoconstriction,
• 20-80 U/L
• B. Methergine® pulmonary and systemic
vasospasm, nausea
• bronchospasm, pulmonary
• (methylergonovine) hypertension, hypoxia,
• C. (prostaglandin F2α) nausea, diarrhoea,
hypertension, coronary
• 250 μg IM
• D. Hemabate®
• 0.2 mg IM

33. OXYTOCIN REGIMENS
The “Confidential
Enquiries into
Maternal
Deaths, 1997-1999”
describes two
deaths in
which the
anaesthesiologist
gave an IV bolus
of oxytocin after
delivery with
subsequent
maternal cardiac
arrest and death.
The
associated maternal
conditions were:
Postpartum
haemorrhage with
hypotension
Pulmonary
hypertension

34. OXYTOCIN
Two abstracts evaluated hemodynamic after 5 units
IV bolus oxytocin in healthy women with spinal
anaesthesia for caesarean.
MAP ↓ 27%, HR ↑ 17 beats per minute
Cardiac index ↑ 61% above baseline
Systemic vascular index ↓ 39%
No ↑ blood loss when given over 5 minutes
IJOA 2006;15:A-P01 and Anaesthesiology 2006;105:A11

35. ANESTHETIC
MANAGEMENT
OF ATONY
Volume Resuscitation
Large bore IVs, T&C, warmers, monitors
Analgesia
Pre-existing epidural, ketamine, GETA
Oxytocic's
Know side effects!
Move to O.R. sooner rather than later.
Consider notifying Interventional Radiology.

36. ANESTHETIC
MANAGEMENT
• The authors present a series of 12 cases using
• recombinant factor VIIa for life-threatening
• postpartum haemorrhage. They recommend its
• use before resorting to hysterectomy in cases of
• intractable PPH.
• At their hospital, the cost of one dose of Ravia =
• 50 units PRBC = an embolization procedure = 2
• days of ICU treatment. Cost effective??
• Br J Anaesth 2005;94:592

37. CAUSES OF
FETAL
DISTRESS
• During labor:
Umbilical cord prolapse
Umbilical cord compression→
variable decelerations
Uteroplacental insufficiency→
late decelerations
• At delivery:
Shoulder dystocia

38. UMBILICAL CORD GASES
The threshold for
pH and base deficit
that
predict adverse
neonatal sequelae
are:
pH < 7.0
Base deficit ≥ 12
mmol/L
The metabolic
component (base
deficit) is the
most important
variable associated
with
subsequent
neonatal morbidity.
Am J Obstetric
Gynecology
1999;181:867
Am J Obstetric
Gynecology
1997;177:1391

39. UMBILICAL CORD GASES
ACOG Committee
Opinion, November
2006:
“Moderate and severe
newborn
encephalopathy and
respiratory
complications…increase
with an umbilical
arterial base deficit of
12-16 mmol/L.
Moderate or
severe newborn
complications occur in
10% of
neonates who have this
level of acidemia and
the rate
increases to 40% in
neonates who have an
umbilical
arterial base deficit
greater than 16
mmol/L.”
Obstetric Gynecology
2006;108:1319

40. Thank you