Obstetric emergencies

1Copyright © 2014 Well Woman Clinic. All rights reserved. 1

A holistic approach to Woman’s health

Dr Nupur GuptaDept of Obstetrics & GynecologyParas 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 Trimester1. 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 SevereHYPERTENSION & PROTEINURIA IS THE HALLMARKPreeclampsia


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 25mgPeak at 1 hr. I/V bolus 5 mg I/V 10 mins acts in 5 minOral (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 PRAEVIASYMPTOMS & 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 PLACENTAEANTEPARTUM 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: MISOPROSTOLSynthetic 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

Healthcare