Obestetric emergencies-sassssssssss.pptx

Obestetric emergency in simple think

1. Obstetric emergencies By Dr Ruaa Abdul jabbar Al najmawi

2. Post partum hemorrhage Postpartum hemorrhage is defined as blood loss of >500 mL following vaginal delivery & >1000 mL following a cesarean section. It can also be defined as blood loss that results in hemodynamic instability. The incidence of PPH is about 5% of all pregnancies.

3. . PPH is divided into: • Primary PPH: Bleeding occurring within 24 hours of delivery. • Secondary PPH: Bleeding occurring after 24 hours but before 12 weeks of delivery.

4. . Minor PPH if the blood loss is 500 - 1000 mL In practice, blood losses between 500 & 1000 mL are relatively common, & can usually be tolerated well by the woman. Major obstetric haemorrhage is defined as blood loss ≥ 2,500 ml, or requiring a blood transfusion ≥5 units red cells or treatment for coagulopathy.

5. Causes of primary PPH (4 T)

6. Diagnosis Early recognition of blood loss & rapid action is vital in the management of PPH. Appreciation of risk factors. Accurate estimation of blood loss & recognition of the maternal signs of hypovolemia , These include Tachycardia, Low blood pressure, Symptoms of nausea, vomiting & feeling faint, pallor & slow capillary refill (>2 seconds).

7. How should PPH be managed? management involves four components, all of which must be undertaken SIMULTANEOUSLY : 1) Communication. 2) Resuscitation. 3) Arresting the bleeding. 4) Monitoring and investigation.

8. Communication Call for help: midwife, obstetrician, anesthetist, blood bank…

9. Resuscitation A : Assess airway. B : Oxygen by mask at 10–15 litres /minute. C : 2 I.V lines 20 ml blood sample for FBC, coagulation screen, urea, electrolytes & cross match (4 units). Position flat & Keep the woman warm Transfuse blood as soon as possible. Until blood is available, infuse warmed crystalloid /or colloid

10. . If cross matched blood is still unavailable, give O-NEGATIVE blood FFP 4 units for every 6 units of red cells or PT\APTT> 1.5 x normal Platelets concentrates if PLT count < 50 x 10 9 Cryoprecipitate If fibrinogen < 1 g/l.

11. Arresting bleeding Bimanual uterine compression to stimulate contractions. Ensure bladder is empty

12. Pharmacological measures Syntocinon 5 units slow i.v (may have repeat dose). Ergometrine 0.5 mg by slow i.v or i.m (C\I) Syntocinon infusion (40 units in 500ml fluid at 125ml/hour) Carboprost 0.25 mg by IM injection repeated doses may be needed Misoprostol 1000 micrograms rectally. If pharmacological measures fail to control the haemorrhage , initiate surgical haemostasis sooner rather than later.

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15. Monitoring & investigations temperature every 15 minutes. Continuous vital signs monitoring(using oximeter , electrocardiogram and automated blood pressure recording). Foley catheter to monitor urine output. Consider transfer to ICU once the bleeding is controlled. Documentation of fluid balance, blood, blood products and procedures performed.

16. Secondary PPH: etiology 1-subinvolution of uterus due to retained placental tissue &/or endometritis 2-Lower genital tract laceration/ hematoma 3-Surgical injury 4-Dehiscence of CS scar 5-Coagulopathy/ bleeding disorder 6-gestational trophobastic disease. Infection is the most common cause of post natal morbidity between day 2 & day 10.

17. Assessment History: History of offensive lochia, abdominal cramping & maternal pyrexia is often present Examination: general examination, fever, rigor, tachycardia abdominal palpation to assess uterine involution &/or tenderness vaginal exam : speculum examination to see if there’s any laceration.

18. Investigations FBC C-reactive protein high vaginal swab USG in case of retained product of conception. B- hcg duplex color Doppler

19. Management  Antibiotics.  uterotonics .  evacuation of retained products of conception  In continuing haemorrhage , insertion of balloon catheter may be effective  Secondary PPH is often associated with endometritis .

20. . When antibiotics are clinically indicated, a combination of ampicillin (clindamycin if penicillin allergic) and metronidazole is appropriate. In cases of endomyometritis (tender uterus) or overt sepsis, then the addition of gentamicin is recommended. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. A senior obstetrician should be involved in decisions and performance of any evacuation of retained products of conception as these women are carrying a high risk for uterine perforation.

21. Sudden maternal collapse Maternal collapse is defined as an acute event involving the cardiorespiratory systems and/or brain, resulting in a reduced or absent consciousness, in pregnancy & up to 6 weeks after delivery. vasovagal attacks & the postictal state are the most common causes of „maternal collapse‟.

22. Sudden maternal collapse

23. . A Airway : open airway with head tilt & chin lift; jaw thrust may be required (care must be taken if a cervical spine injury is suspected).

24. . B: Breathing : assess for chest movements & breath sounds; feel for breathing. If no breathing, put out cardiac arrest call & give 2 rescue breaths.

25. . C Circulation : check carotid pulse; optimize circulation by aggressive IV fluids & blood transfusion if indicated. (CPR) should be initiated as necessary.

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27. . D Drugs : to maintain circulation, combat infection, antidotes if drug overdose, anticoagulants in cases of massive embolism. E Environment : avoid injury ( eclampsia ), ensure safety of patient and staff. F Fetus : if CPR is required at >20wks, unless there is immediate reversal, immediate CS (at the location of the arrest) must be performed. If CPR is not required, assess fetal well-being and plan delivery as appropriate once maternal condition is stable.

28. Shoulder dystocia Defined as any delivery that requires additional obstetric manoeuvres after gentle downward traction on the head has failed to deliver shoulders Complicates 1:200 deliveries.

29. HELPERR H Call for help (including midwifes, senior obstetrician, neonatologist, anaesthetist ).

30. . E Episiotomy—remember shoulder dystocia is a bony problem, but an episiotomy may help with internal manoeuvres .

31. . L Legs into McRoberts ’ ( hyperflexed at hips with thighs abducted & externally rotated).

32. . P Suprapubic pressure: applied to posterior aspect of anterior shoulder (must know which side fetal back is on) to dislodge it from under symphysis pubis; if continuous pressure fails, a rocking movement may be tried.

33. . E Enter pelvis for internal manoeuvres , which include: pressure on the posterior aspect of anterior shoulder to adduct & rotate the shoulders to the larger oblique diameter (Rubin II)

34. . if this fails combine it with pressure on the anterior aspect of the posterior shoulder (Woods’ screw)

35. . If this fails, reversing manoeuvre may be tried with pressure on the anterior aspect of anterior shoulder and posterior aspect of posterior shoulder in opposite direction (reverse Woods’ screw).

36. . R Release of posterior arm by flexing elbow, getting hold of fetal hand, and sweeping fetal arm across chest and face to release posterior shoulder.

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38. . R Roll over to ‘all fours’ may help aid delivery by the changes brought about in the pelvic dimensions (Gaskin manoeuvre ). In practice, 80% of babies will deliver with suprapubic pressure & McRoberts ’ manoeuvre . If these fail, delivery of posterior arm is probably the best next manoeuvre .

39. Other manoeuvres Zanvanelli : Symphysiotomy :

40. Cord prolapse In cord prolapse the umbilical cord protrudes below the presenting part after rupture of membranes. This may cause compression of the umbilical vessels by the presenting part and vasospasm from exposure of the cord. These acutely compromise fetal circulation and if delivery is not immediate may lead to neurological sequelae or fetal death.

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42. MANAGEMENT

43. Management The fetus should be delivered as rapidly as possible; this may be by instrumental delivery or category 1 CS. Prevent further cord compression during transfer for CS by: 1. knee-to-chest position

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45. . 2. fill the bladder with about 500mL of warm normal saline to displace the presenting part upwards (remember to unclamp the catheter before entering the peritoneal cavity at CS).

46. . 3. A hand in the vagina to push up the presenting part (may not always be practical).

47. . Prevent spasm by avoiding exposure of cord. Reduce cord into vagina to maintain body temperature & insert a warm saline swab to prevent cord coming back out. It is important to avoid handling the cord as this provokes further spasms. Tocolytics may be administered to abolish uterine contractions & improve oxygenation to the fetus may cause PPH at CS due to uterine atony . Neonatal team must be present at delivery.

48. Uterine inversion Uterine inversion can cause serious maternal morbidity or death, incidence 1:2000–3000 deliveries, maternal mortality as high as 15%.

49. Signs and symptoms Haemorrhage (present in 94% of cases). Severe lower abdominal pain in the 3rd stage. Shock out of proportion to the blood loss (neurogenic, due to increased vagal tone). Uterine fundus not palpable abdominally (or inversion may be just felt as a dimple at the fundus). Mass in the vagina on VE.

50. Management of uterine inversion Call for help (including a senior obstetrician and anaesthetist ).

51. . Immediate replacement by pushing up the fundus through the cervix with the palm of the hand (Johnson manoeuvre ).

52. . Bloods for FBC, coagulation studies, & cross-match 4–6U. Immediate fluid replacement. Continuous monitoring of vital signs. Transfer to theatre & arrange appropriate analgesia. If the placenta is still attached to the uterus it is left in situ to minimize the bleeding, & removal attempted only after replacement. Tocolytic drugs, such as terbutaline , or volatile anaesthetic agents may be tried to make replacement easier.

53. . If manual reduction fails then hydrostatic repositioning (O’Sullivan’s technique) may be tried: warm saline is rapidly infused into the vagina with one hand, sealing the labia (a silicone ventouse cup may be used to improve seal) uterine rupture should be excluded first.

54. O’Sullivan’s technique

55. Surgical correction Sometimes both manual & hydrostatic methods fail & a laporotomy is needed for correction ( Haultain’s or Huntingdon’s procedure).

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57. Huntingdon’s procedure

58. . Thank you