Obstetric emergencies

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

Our Team

Emergency Obstetric Care
To Avert Death and Disability… …We Need to Ensure that Women have
Access To Emergency Obstetric Care (EmOC)

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

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

 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

Obstetric Emergencies
 Maternal
 Fetal
 Both maternal & fetal
High Mortality rate

Maternal Complications of Pregnancy
First Trimester
Second Trimester
Third Trimester

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

Hypertensive Complications
Haemorrhage
Topics of Discussion

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

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

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

Management
Goals
Safety of mother & newborn
Prevent Eclampsia
Guidelines
Hospitalization
Definitive treatment being delivery
Expectant management depends on
maternal & fetal status, labour &
gestational age

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

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

Eclampsia to treat convulsions: Magnesium Sulphate

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

Delivery within 12 hours of onset of convulsions

HELLP SYNDROME

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

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

INCOMPLETE/INEVITABLE ABORTION

CAUSES

PLACENTA PRAEVIA

 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

Placenta Praevia
 Ultrasound is highly accurate in making diagnosis
(PPV 93%, NPV 98%)

4 types according to
distance from internal os
- Partial
- Low Lying
- Marginal
- Major or Complete

 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

 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

Abruptio Placentae

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

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,

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

Primary PPH : Third Stage/True PPH

Post-partum Haemorrhage: Secondary

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

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

Etiology of PPH: The 4 Ts to remember
 Tone - uterine atony
 Tissue - Retained tissue/clots
 Trauma - lacerations, rupture or inversion
 Thrombin - Coagulopathy

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

Risk factors for Haemorrhage
 Lacerations or extended episiotomy
 Retained placenta or placental abnormalities
 Uterine rupture
 Uterine inversion
 Acquired coagulopathy
Postpartum

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

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

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

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

Uterine atony
 Clinical risk factors
Polyhydramnios
Multiple gestation
Macrosomia
Induced labour
Prolonged or rapid labour
High parity
Fever/PROM
Fibroid uterus
Placenta praevia

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

Bimanual Compression

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

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

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

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

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

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

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

B Lynch Suture

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

Rupture Uterus
 A potential obstetric catastrophe
 A major cause of maternal death
 Incidence: 1 in 1148 to 1 in 2250
 Complete (Spontaneous & Traumatic)
 Incomplete

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

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

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

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

Obstetric emergencies

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