Obstetric emergencies

Penelope Thomas
Maternity and Gynaecology Education Fellow
2015
Plan
 What are the important emergencies in Obstetrics and
Gynaecology?
 Case-based scenarios to illustrate
 Causes and risk factors
 Identification
 Management

 Enjoy the presentation!

Emergency
 ‘A serious, unexpected, and often dangerous situation
requiring immediate action’
 The Oxford English Dictionary

 In O&G:
 A situation that puts either mother or fetus in immediate danger
 Antenatal, intra-partum, post-natal – or Gynaecologic

 Hypertensive crises  Ectopic

 Cord prolapse
 Shoulder dystocia
 PPH
 Maternal collapse
Case 1
 Casey, a 36yr old G1P0, presents at 30 weeks to Day
Assessment feeling unwell.
 Her BP is 150/100

 What symptoms may she have?

 What might you find on examination?

 What tests should you do?

Hypertension in pregnancy
 Defined as
 Systolic blood pressure ≥ 140 mmHg and/or Diastolic blood
pressure ≥ 90 mmHg
 Agrees with non-pregnant values
 Perinatal mortality rises with DBP>90

 Usually BP falls in the first trimester, and will gradually rise to

pre-pregnancy levels at term
 Divided into
 Pre-existing (present before 20wks gestation)
 Gestational (Pregnancy induced_
 Pre-eclampsia/ Eclampsia
Pre-eclampsia
 5% of pregnancies

 Multisystem disorder

 Hypertension in pregnancy with involvement of one or more organ

system or fetus, in previously normotensive woman
 Kidneys (proteinuria, oliguria, raised creatinine)
 Brain (headache, floaters, cortical blindness, scotoma, ultimately cerebral
oedema, haemorrhage and death)
 Liver (epigastric pain, raised transaminases+- coags, capsule haematoma)
 Blood (Haemolysis, thrombocyopenia, DIC)
 Lung (pulmonary oedema)
 Peripheries (oedema)
 Fetus/placenta (FGR)
To return to Casey…
 Symptoms  Tests:
 Headache, Floaters, Epigastric  UE, LFT
pain, Nausea
 FBC (platelets)
 Signs  +- Coags
 Hypertension  Urine protein:creatinine ratio
 Hyper-reflexia, clonus
 Papilloedema
 Confusion  CTG
 Epigastric/RUQ tenderness  USS (growth, AFI, doppler)
 Small baby
 Proteinuria (>30mg/mmol or
>3g/24hours)
Management
 Anticipate and prevent  Treat symptoms

 Risk factors:  Lower BP (does NOT prevent

 Primigravid (x1.5-2) disease progression)
 Obese
 Anticipate delivery
 Hypertension
 Steroids if preterm
 Renal disease or DM
 Fetal neuroprotection if <30 weeks
 Previous pre-eclampsia (2% rec risk)
 Multiples  Deliver
 If risk factors:  Safest MOD and timing
 Aspirin +- Clexane  Favourability of cervix
 Calcium (high risk)  Prevent crises
Eclampsia
 New onset generalised TC seizure  Prevent
in women with pre-eclampsia  Magnesium sulphate loading and
infusion
 0.6-1% of pre-eclampsia  Deliver
 Anticipate  Continue Magnesium for 24hours
post delivery
 Symptoms and signs of
worsening pre-eclampsia or  Treat
cerebral irritability  ABC
 25% may be asymptomatic  CTG
 Magnesium sulphate
 Treat hypertension
 Once mum stable - deliver
Other crises
 Acute hypertension

 HELLP syndrome (20%)

 Abruption

 Fetal death

 Pulmonary oedema

 Cortical blindness
Case 2
 Sarah, a 23 yr old primigravid has presented at 40+ weeks
in labour. Her midwife tells you she is 4cm dilated on
examination but the head is high. Suddenly she has a gush
of fluid PV and the emergency bell goes off.
 What has happened?

 What needs to happen?

Cord prolapse
 Defined as loss of the cord into the vagina, with
compression of cord by fetal presenting part
 1:500

 Occurs at spontaneous or artificial ROM

 Risk factors:
 High head
 Unstable lie/ footling breech
 Polyhydramnios
Management
 Take pressure off cord  Deliver (emergent CS)

 Elevation of presenting part by

examining practitioner

 Position:
 All 4s
 Nipples to knees

 Fill bladder
Case 3
 Tracey, a 28 yr old obese diabetic woman, has been
pushing for an hour and has head crowning. Someone
shouts for help.
 Who do you need to call for?

 What steps should you follow?

Shoulder dystocia
 Emergency situation where after  Risk factors:
delivery of fetal head, anterior  Maternal obesity
shoulder wedged behind the pubic
 Maternal diabetes mellitus
symphysis
 Macrosomia
 Sequelae  Instrumental birth
 Fetal death  Previous shoulder dystocia (1-
 Neurologic compromise 25% rec risk)
 Brachial plexus palsy
 Birth trauma (humerus or
clavicle fracture)
Senior midwife(s)
Senior obstetrician
Paediatric team
Anaesthetist
Scribe
Manoevres
Last resort
 Zavanelli manoevre (and CS)

 Fracture clavicle

 Symphysiotomy
Case 4
 Jody, a 35yr old Para 5, has just had a normal birth after a 2
hour labour, and the placenta is awaited.
 You respond to the emergency bell- midwife tells you the
placenta is delivered but Jody is bleeding briskly
 What are her risk factors?

 How would you manage this?

Heavy menstrual bleeding
 QE 2 Hospital

 July 18th, 2014

PPH

25% of direct maternal deaths

worldwide
PPH
 5-15%

 Defined as
 >500 mL blood loss during or after childbirth or enough to
cause haemodynamic compromise
 Severe >1000 mL

 Primary (first 24hrs) or Secondary (24 hrs to 6wks)

Causes
- antenatal, intrapartum, postnatal RFs
 The 4 Ts  Trauma (20%)
 Episiotomy, perineal tear
 Tone (70%)
 Caesarean section
 Prolonged 3rd stage
 Uterine rupture
 Over distended uterus
 Uterine inversion
 polyhydramnious, multiples,
macrosomia  Tissue (10%)
 Exhausted uterus  Retained placenta/cotyledon
 rapid or prolonged labour  Abnormal placenta (accreta or
 high parity increta)
 Syntocinon
 Coagulopathy (1%)
 Infection
 Pre-existing
 Drug induced
 Pregnancy acquired (pre-
 Uterine anomalies eclampsia, infection, DIC
 fibroids, structural secondary to FDIU)
Preventing PPH
 Risk factor identification  Active management of the 3rd
 Includes antenatal USS for stage of labour
placental site and structure  Prophylactic oxytocin (reduces
 Appropriate antenatal and risk by 50%)
intrapartum management  Early cord clamping, controlled
cord traction
 IV access and bloods (FBC, G+S)
 Provide appropriate
in labour
information to women
 Planned CS and appropriate requesting physiological 3rd
counselling in abnormal stage
placentation

 Delivery in a unit with rapid

access to blood and blood products
Managing PPH
Recognise Keep patient warm (also
Call for help warmed IVF)
 Anaesthetist, senior staff, scribe

ABC Early recourse to theatre

 Oxygen by mask (10-15 l/min)
 P, BP Correct volume depletion,
 2 x large IV access (at least 16g cannula), anaemia, coagulopathy
consider arterial line
 Bloods (FBC, XM, UE, coags) Early transfusion
 Rapid IVF initial resuscitation (Normal (Packed RBC, FFP,
saline, gelofusine)
Platelets, Cryoprecipitate)
Stop bleeding
Bimanual compression, fundal
Consider Recombinant
massage, remove placenta fVIIa
Medication
Stop bleeding
 Depends on cause

 Time essential

 Physical compression (initial and maintained)

 IDC for maintenance and monitoring

 Medication to encourage uterine contraction

 Oxytocics (regular contractions)
 Ergometrine (sustained tonic contraction)
 Misoprostol
 PGF2-alpha, FVII, Tranexamic acid

 Surgical intervention
Surgical intervention
EUA, Manual removal of placenta
Repair of tears
Replace uterus if inverted
Bakri balloon

Life threatening bleeding:

Laparotomy, B-Lynch suture
Internal iliac artery ligation
Hysterectomy
B-Lynch suture
INTERNAL ILIAC ARTERY
LIGATION
 Shown to reduce pelvic blood flow by 49% and pulse pressure by 85%  low
pressure arterial system promoting haemostasis
 Successful in arresting haemorrhage in 40-100%

 Bilateral more effective

 Avoid hysterectomy in approx 50% of severe PPH

 Difficulties – operator experience, proximity to ureter and external iliac

vessels
 Risk of ureteric injury or ligation; venous injury; external iliac artery ligation
(hence loss of blood supply to lower limb)

 Post ligation fertility reported to be normal (multiple anastamoses,

recanalisation within 5 months)
TECHNIQUE
 +- Divide round ligament and open pelvic side wall
peritoneum
 Incise cephalad lateral to infundibulopelvic ligament

 Identify ureter and internal iliac vessels

 Locate bifurcation of internal iliac artery

 Place right angled clamp beneath the vessel and double

ligate (do not transect) 3cm below bifurcation
 http://www.youtube.com/watch?v=ty2Kqzep7Go
After the storm is over….
 Once bleeding is controlled
 Consider ICU/HDU care
 Ongoing review and laboratory testing
 Debriefing and counselling to woman, family and staff
 Remember next pregnancy prevention/active management
Maternal collapse
 PPH  Epileptic convulsions

 Cardiac arrest  CVA

 Amniotic fluid embolism  Eclampsia

 Thromboembolic disease  Cardiac arrhythmias

 Septic shock  Iatrogenic (local anaesthetic,

MgSO4)
 Vaso-vagal attacks
CVS changes in pregnancy
 Plasma volume Increased by up to 50%
 Dilutional anaemia
Reduced oxygen-carrying capacity

 Heart rate Increased by 15–20 bpm

 Cardiac output increased by 40%

 Systemic vascular resistance decreased

 Sequesters blood during CPR

 Uterine blood flow diverts10% of cardiac output at term

 Pressure of gravid uterus on IVC significantly reduces venous return

Increased CPR circulation demands, reduced reserve
Respiratory changes in pregnancy

 Respiratory rate increased, Residual capacity decreased by 25%

 Decreased buffering capacity acidosis more likely

 Oxygen consumption increased by 20%

 Hypoxia develops more quickly

 Arterial PCO2 decreased

 Decreased buffering capacity  acidosis more likely

 Laryngeal oedema increased

Difficult intubation
Other changes
 Gastric motility decreased

 Lower oesophageal sphincter relaxed

Increased risk of aspiration

 Uterus Enlarged, splinting diaphragm

Reduced residual capacity
Ventilation more difficult

 Aortocaval compression
Supine hypotension,
Reduced venous return significantly impairs CPR

 Weight Increases
 Large breasts may interfere with intubation

Makes ventilation more difficult

Amniotic Fluid Embolism
 1.3 per 100,000

 Mortality rate 24 percent

 Sudden collapse in labour or shortly after delivery with signs of central

cyanosis
 Diagnosis – post mortem lung tissue or fetal hair or squames in blood

 Anaphylactic reaction to particulate matter in lungs

 Pulmonary hypertension & hypoxia
 Central cyanosis and circulatory collapse
 Supsequent left ventricular failure
 DIC in 50%

 Treat with inotropic agents, ?high dose steroids, manage coagulopathies

Cardiac arrest
 Postnatal
 Associated hypovolaemia
 Obstructive heart disease
 Complex congenital heart disease
 Increasing ischemic heart disease

 Antenatal:

 Need to empty uterus if not successful with CPR in 4 minutes if >20

weeks
Remember lateral wedge
CPR 30 chest compressions:2 breaths
Maternal sepsis
 Maternal tachycardia

 The surviving sepsis campaign

 Multidisciplinary team
 Serum lactate
 Cultures prior to broad spectrum antibiotics per local protocol

 Hypotension or lactate >4

 20ml/kg of crystalloid or colloid
 After bolus a vasopressor (epinephrine or norepinephrine) to maintain
mean arterial pressure >65mmHg
 Place central line and maintain CVP >8 with fluids
 Oxygen by mask, transfuse HB <7
Ectopic
Defined as implantation and development of a pregnancy in any site other
than the endometrial cavity

 1-2:100 pregnancies

Risk factors
 PID, IUD, endometriosis, progesterone, previous ectopic

Presentation
 Pain, PV bleeding, collapse

Diagnosis:
 βHCG (inappropriate rise/fall)
 Ultrasound
Sites of implantation
Assesment
 Diagnosis
 BhCG level or inappropriate rise
 Empty uterus +- adnexal mass on USS
 Collapse with abdominal pain and pos BhCG

 Assessment
 Stable?
 Evidence of ongoing bleeding?
 Emergency or non-emergency management
 ABC, fluid and blood resuscitation, prompt transfer to theatre
 Expectant
 Stable, resolving βHCG or diagnosis unclear

 Medical: Methotrexate
 βHCG <5000
 < 3cm mass, unruptured (NO free fluid)
 Stable, otherwise well, reliable for follow-up, close by

 Surgical: salpingectomy/salpingostomy
 Laparoscopy/laparotomy
 Unstable
 Unsuitable for medical management
Summary
 Emergencies in O&G can be scary

 Call for help

 ABC

 Follow your algorithms

 Ensure maternal stability prior to considering fetus