Obstetrics emergency presentation - Ectopic pregnancy, miscarriages, Hypertension in pregnancy

1. Obstetric Emergencies
Dr Josphat Kosgei MBChB(Moi), M-ID(Lon),
DLSHTM
Lecturer, UoK

2. Ectopic Pregnancy
• An ectopic or extrauterine pregnancy is one in
which the blastocyst implants anywhere other than
the endometrial lining of the uterine cavity.
• 98% implant in the fallopian tube, with 80%
occurring in the ampullary segment. Other
locations include, but are not limited to, the ovary,
cervix, and abdomen.
• Ectopic pregnancies remain an important cause of
morbidity and mortality, a life threatening
condition.
• Tubal pregnancy outcome: tubal abortion, tubal
rupture, spontaneous resolution.

3. Tubal Pregnancy

4. Risk Factors
• Inflammation- Infection: Chlamydia, Neisseria
• Pregnancy after sterilization.
• History of infertility.
• Additional risk factors include:
▫ smoking,
▫ prior tubal surgery,
▫ diethylstilbestrol exposure, and
▫ advanced age.

5. Symptoms
• Classic symptoms: amenorrhea followed by vaginal
bleeding and abdominal pain on the affected side.
• Other pregnancy discomforts, such as breast
tenderness, nausea, and urinary frequency, may
accompany more ominous findings.
• Many women with a small un-ruptured ectopic
pregnancy may have unremarkable clinical findings.
• Vaginal bleeding varies from spotting to passing the
entire “decidual cast” simulating a spontaneous
abortion.

6. Clinical Findings
• Abdominal and pelvic findings scant before tubal
rupture; the diagnosis primarily based on history,
laboratory and ultrasound findings.
• With rupture; ¾ have marked tenderness on both
abdominal and pelvic examination, and pain is
aggravated with cervical manipulation.
• A pelvic mass, including fullness posterolateral to the
uterus, can be palpated in about 20% of women.
• Abdominal distension and tenderness, with or without
rebound, rigidity, or decreased bowel sounds, may be
seen in cases of intra-abdominal bleeding.
• Cervical motion tenderness caused by intraperitoneal
irritation and adnexal tenderness are commonly found.
• A slightly open cervix with blood or decidual tissue may
be found-!! Mistaken for a threatened and/or
spontaneous abortion.

7. Differential Diagnosis
• Early pregnancy complications (threatened,
incomplete, or missed abortion), placental polyp, or
hemorrhagic corpus luteal cyst are difficult to
diagnose.
• Any sexually active woman in the reproductive age
group who presents with pain, irregular bleeding,
and/or amenorrhea should have ectopic pregnancy as
a part of the initial differential diagnosis.

8. Diagnostic Evaluation
• Pregnancy Test.
• Ultrasound-transabdominal, transvaginal.
• Culdocentesis-?hemoperitoneum.
• Uterine curretage.
• Direct visualization, which is done most
commonly via laparoscopy.
• Supportive Evaluations-CBC, GXM.

9. Management
This is a medical emergency-urgent and immediate
consultation and referral.
Supportive care: IVF fluids, Lab evaluations, GXM,
etc.
Patient counselling and education.
• Medical-Methotrexate is a folic acid antagonist.
For the asymptomatic.
• Surgical-Salpingostomy/Salpingectomy

10. SPONTENOUS ABORTION
• Abortion is the expulsion of the fetus prior to 20
weeks of gestation. Spontaneous abortion
(miscarriage) occurs in the absence of intervention.
• An incidence of recognized spontaneous abortion of
15% to 25% is commonly cited, with approximately
80% occurring during the first 12 weeks.
• Approximately 50% of early spontaneous abortions
are attributed to chromosomal abnormalities.
• 2nd trimester abortions more likely to be caused by
maternal systemic disease, abnormal placentation,
or other anatomic considerations.

11. Etiology
• Infections: Chlamydia, Listeria, HIV, syphilis.
• Endocrine: Thyroid auto-antibodies, DM type 1.
• Environmental: Smoking, radiation.
• Immunological: Thrombophilias, coagulopathies
• Uterine: leiomyomas, Asherman’s syndrome,
DES exposure.

12. Types
• Threatened Abortion:
▫ bleeding in the first trimester without loss of fluid or tissue; often result in
spontaneous abortion.
▫ greater risk for preterm delivery and low birth weight.
▫ combination of bleeding and pain a poor prognosis for pregnancy
continuation.
• Inevitable Abortion:
▫ gross rupture of the membranes with cervical dilation.
• Incomplete Abortion:
▫ the internal cervical os opens with passage of blood.
▫ The products of conception may remain entirely in utero or may partially
protrude.
• Complete abortion:
▫ refers to a documented pregnancy that spontaneously passes all of the
products of conception.
▫ <10 weeks, the fetus and placenta are often expelled in toto.
• Missed abortion:
▫ is the retention of a failed intrauterine pregnancy for an extended period,
usually defined as more than two menstrual cycles.
▫ absence of uterine growth and early symptoms of pregnancy. Many women
have no symptoms during this period except persistent amenorrhea.

13. Hemorrhages
“She died during childbirth”
• PPH is the leading cause of maternal death,
more than any other cause.
• 150,000 mothers die annually due to PPH.
• 90% of deaths due to PPH is preventable.

14. Antepartum haemorrhage (APH)
Definition:
• Antepartum haemorrhage (APH) is defined as
bleeding from the genital tract during
pregnancy, before birth but after 24 weeks of
gestation. It occurs in about 5% of all
pregnancies.
• Worldwide, it is thought to account for about
50% of the 500,000 annual maternal deaths.

15. Causes:
• Bleeding can come from any of the anatomical
sites involved in pregnancy.
• Most commonly, bleeding comes from the
placenta.
• More rarely, it can come from the foetus or
• from the incidental causes relating to the
mother’s normal anatomical sites.

16. Causes of APH

17. Placental abruption (Abruptio Placentae)
Placental abruption refers to an abnormal premature
separation of an otherwise normally implanted placenta.
• An ‘abrupted’ placenta is one which is normally situated
and has separated from the uterine wall.
• This causes bleeding from the placental bed.
• Bleeding can be directly in to the genital tract (‘revealed’)
or it can be into the uterus with little or no loss into the
vagina (‘concealed’).
• This means that blood loss may be inconsistent with the
patient’s state- i.e. they may have severe shock even
though only a little blood loss has been observed.
• Retention of blood and possibly blood clots can cause
pain and tenderness, as well as a tense uterus.
• The blood supply to the foetus has been compromised.
This means that parts of the foetus may not be felt, or
that the foetus may be dead.

18. Types of Abruptio Placentae

19. Placenta Praevia
• This is a condition where the placenta is found lying in the lower segment of the
uterus.
• When the lower segment of the uterus starts to stretch, the placenta starts to stretch
and bleed and malpresentation of the foetus.
• Blood loss is not usually concealed, so the mother’s state should be consistent with
observed loss. Bleeding can be recurrent.
• Risk factors for praevia include: multiple gestation, a previous delivery by caesarean
section, a structural uterine abnormality or assisted conception.
• As the bleeding comes from the mother rather than the foetus, the situation is more
serious for the mother.
• Due to the position of the placenta and risk of further bleeding, it is considered good
practice not to carry out a vaginal examination on a women with placenta praevia.
• This also means that a VE should not be performed in a woman presenting with an
APH until placenta praevia has been excluded.
• Placenta praevia can be seen on ultrasound scanning.
• It is usually diagnosed early in pregnancy. Women with known placenta praevia will
have frequent scans to see if it ‘migrates’ away from the cervix, which many do.
• NB: there are different grades of placenta praevia depending on the extent that the
placenta covers the internal os. Delivery is usually by planned Caesarean section.

20. Types of Placenta Praevia

21. Differences Btw Abruption and Praevia

22. Other types of APH
• Foetal Vasa praevia is a rare condition in which the foetal
vessels run through the membranes, in front of the presenting
part of the foetus (i.e. over the cervical os).
▫ This causes problems when the membranes rupture, as the
vessels begin to bleed, causing massive foetal haemorrhage .
• Maternal/incidental In a non-pregnant state, various
pathological processes can cause bleeding from the genital
tract. Such ‘local’ causes can included those arising from the
cervix (e.g. cervicitis, ectropion or carcinoma) or from the
vagina (e.g. trauma or infection) .
• Maternal blood dyscrasias may also cause APH. These are
extremely rare however, and are usually known about before
pregnancy.
• Other: There are also a number of APHs which are
unexplained. There has been speculation that these may be
small and un-recognised placental abruption.

23. Management
Follows same principles as that for any haemorrhage
1) Ensure women is assessed in ABC fashion
2) Establish venous access and that a FBC and GXM have been taken
3) Take history of any precipitating factors e.g. sexual intercourse, abdominal
trauma
4) Establish obstetric history e.g. where placenta has been located on US
5) Regular observations and monitoring.
6) Vaginal examination with speculum to directly visualize ectropion/source of
bleeding/extent.
7) Urgent US to establish cause of bleed and establish fetal viability
8) Majority of women are advised to remain in hospital for period of
observation (usually 24 hours) and can be safely discharged if they remain
bleed free for 24 hours
9) Remember anti-D for women who are rhesus negative - this should be given
whenever ‘mixing’ of fetal and mothers blood may have occurred.
10) In cases of severe APH - a full ‘maternal haemorrhage’ may need to be
instigated, involving a an emergency caesarean section.

24. Postpartum Haemorrhage

25. Definitions
• Primary PPH – blood loss of 500ml or more
within 24hours of delivery.
• Secondary PPH – significant blood loss
between 24 hours and 6
weeks after birth.

26. Why do we care?
Major obstetric haemorrhage – more than 1000ml
Very rapidly lead to maternal death

27. Importance
• Leading cause of maternal morbidity/ mortality
• 58% of these cases care was “seriously
substandard”.
• Major cause of severe maternal morbidity in
“near-miss audits”.

28. Risk Factors
Most cases have no risk factors
• Previous PPH
• Antepartum haemorrhage
• Grand multiparity
• Multiple pregnancy
• Polyhydramnios
• Fibroids
• Placenta praevia
• Prolonged labour

29. Prevention
• Be aware of risk factors – may present
antenatally or intrapartum
• Treat anaemia antenatally
• Active management of the 3rd stage
• Prophylactic oxytocics reduce the risk of PPH by
60% (oxytocin or oxytocin & ergometrine)
• 5IU IM for vaginal delivery
• 5IU IV for LSCS
• Consider oxytocin infusions

30. Causes-4 T’s
Tone
Tissue
Thrombin
Trauma

31. Causes
Tone
Previous PPH
Prolonged labour
Age > 40 years
Big baby
Multiple pregnancy
Placenta praevia
Obesity
Asian ethnicity
Tissue
Retained placenta/
membrane/clot

32. Causes
Thrombin
Abruption
PET
Pyrexia
Intrauterine death
Amniotic fluid embolism
DIC
Trauma
Caesarean section
(emergency > elective)
Perineal trauma
Operative delivery
Vaginal and cervical tears
Uterine rupture

33. Caution!
• Blood loss is commonly underestimated
• Loss may be well-tolerated
• Beware the “trickle” and the “moderate
lochia”
• Minor PPH can easily progress to major PPH.

34. Management
• Has the placenta been delivered and is it
complete?
• Is the uterus well-contracted?
• Is the bleeding due to trauma?

35. Resuscitation
A & B
▫ 10 -15l/min O2 by facemask
C
▫ two 14 gauge cannula
▫ blood for Hb, U&E, LFTs, clotting
▫ crossmatch 4 units
▫ 2 litres of crystalloid rapidly
▫ transfuse as soon as possible: consider O –ve
blood if any delays.

36. Uterine Contraction-First Line Drugs
• Oxytocin 5IU
• Oxtocin infusion – 40IU in 500mls
• Ergometrine 0.5mg
• Carboprost (Haemabate©) 0.25mg IM every 15
minutes x 8 doses
• Misoprostol 600 mcg sublingually

37. Uterine Contraction – non-pharm
• Empty uterus
• Foley catheter
• Rub up a contraction
• Bimanual compression
• Balloon tamponade
• Brace suture
• Uterine artery ligation
• Internal iliac artery ligation
• Interventional radiology
• Hysterectomy – before it’s too late

39. B-Lynch Suture

40. Balloon Tamponade

41. Haematological Management
• Transfuse without delay
• Involve haematology service at an early stage
• Correct coagulopathy
• Liase with consultant haematologist re use of
recombinant Factor V11 (Novoseven©) and
Fibrinogen.

42. Others…
• Traumatic for patient, family and staff.
• Debriefing for patient and staff.
• Case analysed to ensure care was of good
standard and any substandard care can be
improved.

43. Secondary PPH
Main Causes
• Infection
• Retained placenta
• Trophoblastic disease
Treatment:
• Antibiotics
• Evacuation of retained products if bleeding
persistent or significant amount of tissue
retained.