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OBSTETRIC EMERGENCIES
IN PRIMARY CARE
Dr. Chew Kah Teik
Clinical Lecturer & Specialist
Department of Obstetrics & Gynaecology
Universiti Kebangsaan Malaysia Medical Centre
Definition
Obstetrics:
A branch
of medicine that
concerns management of
women during pregnancy,
chldbirth and puerperium
Emergency:
An
+
Obstetric Emergencies
Miscarriage
Ectopic pregnancy
Placenta praevia
Abruptio placenta
Pre-eclampsia
Eclampsia
Cord prolapse
Shoulder dystocia
Post partum haemorrhage
Case scenario
The
history:
the timing of onset of pain, the distribution
of pain, the occurrence of syncope and
shoulder tip pain
the timing of onset and type of bleeding
other areas including the use of
contraception, timing of last menses,
medical and surgical history, and
identification of other risk factors described
above including fertility treatments and
previous STD
The
examination:
the
diagnosis:
to pregnancy
related to non-pregnant gynaecological
disorders
related to non-gynaecological disorders
Investigation:
full
+
Early pregnancy
emergency
Presented
as acute
abdominal pain and/or
vaginal bleeding
Many
differential diagnosis
of acute abdominal pain
Require
Miscarriage
Ectopic
pregnancy
high index of
suspicious if:
Vaginal bleeding
Abdominal pain
Period of ammenorrhoea
Causes:
Miscarriage
Chromosomal
Spontaneous loss of
pregnancy before
24 weeks of
gestation
Fetal
Complete,
incomplete,
sepsis, missed,
inevitable
1st trimester or 2nd
trimester
abnormalities
abnormalities
Placenta
abnormalities
Infection
Medical
diseases
+
Miscarriage
Presentation:
Lower
abdominal pain
Vaginal
Is a leading cause
of early pregnancy
bleeding
bleeding
Fever
Purulent
vaginal discharge
Hypotension
Complications:
Haemorrhagic
shock
Sepsis
Tachycardia
Abdomen
guarding
tenderness,
+
Miscarriage
In
Definitive
diagnosis is
based on the confirmation
of passage of POC or
ultrasound findings
IUGS
Fetal echo
Endometrium thickness
Adnexal mass
+
Miscarriage
Therefore,
differential
diagnosis of early
pregnancy bleeding must
include:
Normal pregnancy
bleeding
Ectopic pregnancy
If
+
Management
If
If
Pain
management: analgesia
Transfer
to hospital
Ectopic
pregnancy
Is the
implantation
of a
pregnancy
outside the
endometrial
cavity
Ectopic pregnancy
The
incidence of ectopic
pregnancy in the UK is
approximately 1%
Globally,
the incidence
appears to be in increasing
trend.
More sensitive diagnostic
method
ART
Increased pelvic
inflammation disease
+
Ectopic pregnancy
Presentations:
Acute
abdomen
Lower
abdominal pain
Shock
Risk factors:
Previous ectopic
Previous tubal
surgery
IUCD
Subfertility
Smoking
Vaginal
bleeding --caution:
an ectopic pregnancy is
usually failing and so
falling progesterone levels
from the corpus luteum
can induce a withdrawal
bleed, mimicking
miscarriage
+
Ectopic pregnancy
Presentations:
Syncope
Shoulder
Vomiting
Gastrointestinal
symptoms,
particularly diarrhoea and
dizziness, in early gestation
are important indicators of
ectopic pregnancy
+
Ectopic pregnancy
Ultrasound
investigations
Is the single most
useful diagnostic
tool
To detect an IUGS
or identify
features of
ectopic
pregnancy
An
intrauterine gestation
sac is highly specific (99%)
for exclusion of an ectopic
pregnancy
Errors
may be due to a
pseudosac or heterotopic
pregnancy
Transvaginal
scanning can
identify most intrauterine
pregnancies from when
the hCG level reaches
1000 iu/l (the
discriminatory level)
+
Ectopic pregnancy
In
In
Beta hCG:
Level do not tell
us the location of
a pregnancy
Plateauing
+
Ectopic pregnancy
Levels
below 20 suggest a
failing pregnancy,
irrespective of location
Levels
Progesterone:
May improve
diagnostic
accuracy if used
in combination
with -hCG
from 20 to 60 are
associated with a high risk
of ectopic pregnancy in
the face of -hCG levels
above 25 iu/l
Levels
>60 suggest a
progressing pregnancy,
most of which will be
intrauterine
+
Management
Stable
History
Examination
Ultrasound
scan
Refer hospital
Unstable
Call
for help
Check airway
Oxygen
IV line
Fluid resuscitation
Blood
Refer hospital
+
Case scenario
+
Antepartum
haemorrhage
Complicates 2 -5% of
all pregnancy
It is defined as
bleeding of the
genital tract,
occurring from 24
weeks of gestation
until birth
Causes:
Placenta
praevia (20%)
Abruptio
placenta (#)%)
Vasa
paevia
Uterine
rupture
Cervical
Trauma
lesion
+
Placenta Praevia
Is a placenta that is
partially or wholly
implanted into the
lower uterine
segment
+
Placenta praevia
About 3% of
pregnancies are
praevia
Symptomatic
placenta praevia
occurs in between
0.4 and 0.8% of
pregnancies
Risk factors:
Increased
maternal age
Increase
parity
Previous
Caesarean
section
Previous
uterine surgery
Increased
placenta
Smoking
surface area of
+
Placenta praevia
Presentation:
Painless
vaginal bleeding
Vaginal
bleeding usually
bright red
Shock
Soft,
non-tender uterus
+
Management
If
If
+
Abruptio placenta
It
is often an unanticipated
emergency, although a small
bleed can suddenly evolve
into a major abruption
Therefore,
vigilance is
essential
It is defined as the
premature
separation of the
normally sited
placenta from the
uterus
Bleeding
begins in the
decidua basalis and leads to
separation of the placenta
from its attachment to the
uterine wall
This
+
Abruptio placenta
Blood
If
This
uterus becomes
weakened and can rupture
with increased intrauterine
pressure during
contractions
+
Abruptio placenta
The diagnosis
should be
considered in any
pregnant women
with abdominal
pain, even without
evidence of vaginal
bleeding
Presentation:
Painful
Dark
vaginal bleeding
blood
Abdominal
pain
commonly constant pain
Uterine
tenderness fetal
distress or IUD
Evidence
Shock
of DIVC
Abruptio placenta
Abruptio placenta
+
Abruptio placenta: classification
Class 0
Class 0 is asymptomatic
Class 1
Class 2
Fetal distress
Class 3
Hypovolaemic
Abruptio placenta
Coagulopathy
shock
secondary to haemorrhage
disseminated
intravascular coagulation
(DIC)
Acute
Maternal
complications
renal failure
Couvelaire
Postpartum
uterus
haemorrhage
Ischemic
necrosis of distal
organs (adrenal, pituitary)
Fetomaternal
haemorrhage
+
Abruptio placenta
Intrauterine
Hypoxi
death
Anaemia
Fetal
growth restriction
(FGR) if chronic
Risks
Fetal complications
of preterm birth
+
Management of an APH
+
Resuscitation
Resuscitation should follow the standard A
(airway), B (breathing), C (circulation) approach
high-flow
to 2 l crystalloid
Up to 12 l colloid until blood arrives
Consider
CVP
Indwelling bladder catheter
Pre-eclampsia
Gestational hypertension of at least
140/90 mmHg on two separate
occasions 4 hours apart
accompanied by significant proteinuria
of at least 300 mg in a 24-hour
collection of urine, arising de novo
after the 20th week of gestation in a
previously normotensive woman and
resolving completely by the 6th
postpartum week
result
from a combination
of impaired trophoblast
differentiation and
invasion during the first
trimester
Pre-eclampsia
complicating 28%
of pregnancies
Pre-eclampsia
Risk factors:
Primigravida
Advanced
maternal age
Previous
history of preeclampsia
Obesity
Diabetes
mellitus
Pre-existing
APS
hypertension
+
Pre-eclampsia:
prediction
There is still no
clinically useful
screening test to
predict preeclampsia
Angiogenic factors
vascular endothelial
growth factor (VEGF)
placental growth factor
(PlGF)
soluble endoglin (sEng)
and sFlt-1
have been shown to be
altered in pregnancy
the use as predictive
tests has been
disappointing
+
Pre-eclampsia:
prediction
+
Pre-eclampsia:
prevention
Aspirin
Anticoagulation
Calcium
Antioxidant
Low-dose
Advise
+
Pre-eclampsia:
prevention
Aspirin
Anticoagulation
Calcium
Antioxidant
Women
+
Pre-eclampsia:
prevention
Aspirin
Anticoagulation
Calcium
Antioxidant
The
use of anti-coagulants,
such as low-molecularweight heparin or
unfractionated heparin,
are not recommended for
reducing the risk of preeclampsia in either the
general population or in
those with a previous
history of pre-eclampsia
+
Pre-eclampsia:
prevention
Aspirin
Anticoagulation
Calcium
Antioxidant
Routine
calcium
supplementation for
healthy, nulliparous women
is not recommended in the
prevention of pre-eclampsia
There
+
Pre-eclampsia:
prevention
Aspirin
Anticoagulation
Calcium
Antioxidant
No
Pre-eclampsia
Occurrence
of one or more
convulsions, not
attributable to other
cerebral conditions in a
patient with pre-eclampsia
May
Eclampsia
Severe preeclampsia
Pre-eclampsia
Eclampsia
Severe
Moderate
Eclampsia
Severe preeclampsia
Any of:
severe headache and visual
disturbance
epigastric pain
clonus
papilloedema
liver tenderness
platelets <100 x 109/l
alanine amino transferase >50 iu/l
creatinine >100 mmol/l
+
Pre-eclampsia:
Management
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
+
Pre-eclampsia:
Management
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
BP
indwelling
O2
fluid
respiratory
fetal
+
Pre-eclampsia:
Management
Aim
to reduce blood
pressure to <160/105
(MAP <125 mmHg)
This
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
necessitates the
constant attendance of
medical staff
BP
Treatment
should be
titrated gradually
+
Pre-eclampsia:
Management
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
+
Pre-eclampsia:
Management
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
+
Pre-eclampsia:
Management
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
Magnesium
sulfate is THE
drug of choice
Loading
+
Pre-eclampsia:
Management
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
Clinical
Cessation
or reduction of
magnesium therapy if:
reflex absent
respiratory rate is
<12/minute
+
Pre-eclampsia:
Management
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
Adverse
effects of
magnesium sulfate toxicity
include:
motor paralysis
absent reflexes
respiratory depression
cardiac arrhythmia
Note
Antidote
10 ml 10%
calcium gluconate slowly
+
Pre-eclampsia:
Management
Careful
fluid balance is
aimed at avoiding fluid
overload
Total
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
If
Oliguria
should not
precipitate any specific
intervention, except to
encourage early delivery
+
Pre-eclampsia:
Management
Basic investigation
Monitoring
Anti-hypertensive
Anti-convulsant
Fluid management
Delivery
Delivery
should be well
planned, on the best day,
in the best place, by the
best route and with the
best support team
Once
Delivery
is not necessarily
by caesarean section
Case scenario
Cord Prolapse
It
Rare
obstetric emergency
Associated
with high
perinatal mortality
Cord Prolapse
Can
be overt or occult
Overt
Occult
Abnormal
Occult
Cord Prolapse
Risk factors:
Unengaged presenting
part
Malpresentation
Unstable lie
Polyhydramnios
Prematurity
Grand multiparity ( >5)
Breech presentation
PPROM
ARM
Cord Prolapse
Special considerations
Pressure
of the presenting
part on the cord may
restrict umbilical cord blood
flow resulting in acute fetal
heart rate changes, which,
if persistent hypoxia leads
to asphyxia
The
principle of pre-hospital
management is to monitor
the
cord for pulsations and use
maternal positioning to
prevent compression
+
Management
If
+
Management
If
+
Management
Do
If
Case scenario
+
Shoulder
dystocia
It is associated with
serious complications for
both the mother and baby
Perinatal morbidity
includes asphyxia, birth
trauma such as brachial
plexus injury and fractured
clavicles, and permanent
neurological damage
In
shoulder dystocia,
disproportion occurs
between the bisacromial
diameter of the fetus and
the antero-posterior
diameter of the pelvic
inlet, resulting in
impaction of the anterior
shoulder of the fetus
behind the symphysis
pubis
+
Shoulder
It
is usually becomes
obvious after the fetal
head emerges and retracts
up against the perineum,
failing to undergo external
rotation (turtle sign)
dystocia
+
Shoulder
dystocia
Risk factors:
Prolonges second stage
Assisted delivery
Maternal diabetes with or
without macrosomia
Previous shoulder
dystocia
A large fetus > 4.5 kg
(macrosomia)
History of a large foetus
Maternal obesity
Multiparity
Post-partum Haemorrhage
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Primary PPH
Causes:
Uterine
atony (79-90%)
Retained placenta /
cotyledons
Trauma :
Uterine rupture
Broad ligament
haematoma
Cervical tears
Vaginal tears / haematoma
Vulval tears / haematoma
Primary PPH
Active
management of the
third stage of labour lower
reduces the risk of PPH
Prophylaxis
oxytocin
should be offered routinely
the management of the
third stage of labour in all
women as they reduce the
risk of PPH by about 60%
+
Primary PPH: risk
factors
Tone
Tissue
Trauma
Thrombin
Etiology
Risk factors
Uterus over
distension
Multiple
pregnancy
Macrosomia
Polyhydramnios
Fetal
abnormalities
Uterine muscle
fatigue
Prolonged
labour esp
oxytocin use
High parity
Previous
history of PPH
Uterine
infection/
chorioamnionit
is
Prolonged
rupture of
membrane
Fever
Uterine
distortion /
abnormality
Fibroid uterus
Placenta
praevia
+
Primary PPH: risk
Etiology
Risk factors
Retained
placenta /
membranes
Tone
Tissue
Trauma
Thrombin
Incomplete
placenta at
delivery esp<
24 weeks
Previous
uterine
surgery
Abnormal
placenta
Abnormal
placenta on
ultrasoundaccessory /
succinturiate
lobe
factors
+
Primary PPH: risk
factors
Tone
Tissue
Trauma
Thrombin
Etiology
Risk factors
Cervical/vagina
l/perineal
tears
Precipitiousl
abour
Episiotomy
Operative
delivery
Extended tear
at caesarean
section
Malposition
Fetal
manipulation
Deep
engagement
Uterine rupture
Previous
uterine
surgery
Uterine
inversion
High parity
Fundal
placenta
Excessive
cord traction
+
Primary PPH: risk
factors
Tone
Tissue
Trauma
Thrombin
Etiology
Risk factors
Pre-existing
clotting
abnormality
eg.
Haemophilia/vonW
ille-brand
disease
History of
coagulopathy
/ liver
disease
Acquired in
pregnancy
Immune
thrombocytopaeni
cpurpura (ITP)
Preeclampsia
with
thrombocytopaeni
a (HELLP)
DIC from PET,
IUD, abruption,
sepsis
Bruising
Elevated BP
Proteinuria
Fetal demise
Antepartum
haemorrhage
+
Management
+
Conclusion
Primary
prevention
Identify
problems
Prompt
actions
Seek
Frequent,
Written
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