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Obstetric emergencies
- 1. 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
- 3. 3Copyright © 2014 Well Woman Clinic. All rights reserved. 3
Emergency Obstetric Care
To Avert Death and Disability… …We Need to Ensure that Women have
Access To Emergency Obstetric Care (EmOC)
- 4. 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
- 5. 5Copyright © 2014 Well Woman Clinic. All rights reserved.
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
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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
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Obstetric Emergencies
Maternal
Fetal
Both maternal & fetal
High Mortality rate
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Maternal Complications of Pregnancy
First Trimester
Second Trimester
Third Trimester
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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
- 12. 12Copyright © 2014 Well Woman Clinic. All rights reserved.
Hypertensive Complications
Haemorrhage
Topics of Discussion
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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
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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
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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
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Management
Goals
Safety of mother & newborn
Prevent Eclampsia
Guidelines
Hospitalization
Definitive treatment being delivery
Expectant management depends on
maternal & fetal status, labour &
gestational age
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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
- 20. 20Copyright © 2014 Well Woman Clinic. All rights reserved.
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
- 22. 22Copyright © 2014 Well Woman Clinic. All rights reserved.
Eclampsia to treat convulsions: Magnesium Sulphate
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Eclampsia to treat convulsions
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Eclampsia to treat convulsions
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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
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Delivery within 12 hours of onset of convulsions
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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
- 31. 31Copyright © 2014 Well Woman Clinic. All rights reserved.
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
- 33. 33Copyright © 2014 Well Woman Clinic. All rights reserved.
INCOMPLETE/INEVITABLE ABORTION
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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
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Placenta Praevia
Ultrasound is highly accurate in making diagnosis
(PPV 93%, NPV 98%)
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4 types according to
distance from internal os
- Partial
- Low Lying
- Marginal
- Major or Complete
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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
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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
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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
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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,
- 57. 57Copyright © 2014 Well Woman Clinic. All rights reserved.
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
- 58. 58Copyright © 2014 Well Woman Clinic. All rights reserved.
Primary PPH : Third Stage/True PPH
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Post-partum Haemorrhage: Secondary
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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
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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
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Etiology of PPH: The 4 Ts to remember
Tone - uterine atony
Tissue - Retained tissue/clots
Trauma - lacerations, rupture or inversion
Thrombin - Coagulopathy
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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
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Risk factors for Haemorrhage
Lacerations or extended episiotomy
Retained placenta or placental abnormalities
Uterine rupture
Uterine inversion
Acquired coagulopathy
Postpartum
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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
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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
- 67. 67Copyright © 2014 Well Woman Clinic. All rights reserved.
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
- 71. 71Copyright © 2014 Well Woman Clinic. All rights reserved.
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
- 72. 72Copyright © 2014 Well Woman Clinic. All rights reserved.
Uterine atony
Clinical risk factors
Polyhydramnios
Multiple gestation
Macrosomia
Induced labour
Prolonged or rapid labour
High parity
Fever/PROM
Fibroid uterus
Placenta praevia
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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
- 76. 76Copyright © 2014 Well Woman Clinic. All rights reserved.
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
- 77. 77Copyright © 2014 Well Woman Clinic. All rights reserved.
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
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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
- 79. 79Copyright © 2014 Well Woman Clinic. All rights reserved.
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
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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
- 81. 81Copyright © 2014 Well Woman Clinic. All rights reserved.
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
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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
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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
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Rupture Uterus
A potential obstetric catastrophe
A major cause of maternal death
Incidence: 1 in 1148 to 1 in 2250
Complete (Spontaneous & Traumatic)
Incomplete
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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
- 96. 96Copyright © 2014 Well Woman Clinic. All rights reserved.
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
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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
- 98. 98Copyright © 2014 Well Woman Clinic. All rights reserved.
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