OBS EMERGENCIES GROUP A.pptx obs lecture

A medical emergency can happen at any time during pregnancy, labour and birth. Some emergencies can be life threatening for pregnant women and their babies. These are called obstetric emergencies.

1. OBSTETRIC EMERGENCIES Hira Altaf (202001 Faiza Liaqat (202002) Zohra Nazir (202003) Abdul Muqeet (202004)

2. LEARNING OBJECTIVES To understand the incidence of common obstetric emergencies. To understand the risk factors for common obstetric emergencies. To be able to understand the early warning signs in obstetric emergencies. To be able to provide a stepwise approach in the management of common obstetric emergencies.

3. OBSTETRIC EMERGENCIES WHO defines obstetric emergencies as “life-threatening conditions that arise during pregnancy, child birth, or the post-partum period requiring immediate medical attention and intervention to prevent maternal and fetal morbidity and mortality”

4. Common emergencies It includes Placental abruption Sepsis Major obstetric haemorrhage(Antepartum and Postpartum) Pre-eclamsia and eclampsia Uterine Rupture Amniotic fluid emblolism Shoulder dystotia

5. Antepartum haemorrhage (aph) Antepartum haemorrhage is defined as bleeding from vagina after 20 weeks of gestation. It complicates about 2---5% of all pregnancies.

6. Causes of aph

7. Placental Abruption Premature separation of normally sited placenta from uterine wall. Poor fetal & maternal outcome Bleeding is maternal or/and fetal.

8. Risk Factors Hypertension Smoking Abdominal Trauma Cocaine use Polyhydramnios Multiple pregnancy IUGR

9. Warning Signs Vaginal bleeding associated with pain Painful tender abdomen Feeling cold Light headedness Restlessness Distress and panic Maternal collapse

10. Clinical presentation History How much bleeding? Triggering factors (e.g. postcoital bleed). Associated with pain or contractions? Is the baby moving? Last cervical smear (date/normal or abnormal)? Examination Pulse, blood pressure. Is the uterus soft or tender and firm? Fetal heart auscultation/CTG. Speculum vaginal examination, with particular importance placed on visualizing the cervix (having established that placenta is not a praevia, preferably using a portable ultrasound machine). Diagnosis May be diagnosed on ultrasound

11. Management Mild abruption: Mother & fetus well Give steroids CTG Doppler ultrasound Rest Correction of anemia Treat the cause like hypertension AIM IS TO TAKE PREGNANCY TO TERM Severe abruption: Immediate delivery

12. complications: DIC Hpovolumic shock fetal distress/ demise acute renal failure (Cortical necrosis) perinatal motality

13. Placenta praevia Definition: “A placenta covering or encroaching on the cervical os associated with bleeding.” in placenta previa,bleeding from maternal not from fetus and is more likely to compromise mother than the fetus, It can be : Minor placenta previa. Major placenta previa.

14. Risk factors Multiple gestation. Previous Caesarean Section. Uterine structural anomaly Assisted conception Patients with a placenta previa have a 4% -- 8% risk of having placenta previa in a subsequent pregnancy.

15. Warning Signs Low-lying placenta at 20 weeks anomaly scan Maternal collapse Feeling cold Light-headedness Restlessness Distress and panic Painless vaginal bleeding

16. Clinical presentation History: Painless vaginal bleeding. Heavy bleeding----Shock Irregular abdominal pain with uterine contractions Abdominal examination: Soft and non – tender uterus. High presenting part. Fetal malpresentation (breech/transverse/oblique). Normal fetal heart rate (unless there is severe bleeding or associated abruption). Vaginal examination: is contraindicated. Diagnosed by ultrasonography If diagnosed in 2 nd trimester, repeat scan at 30 - 32 weeks for follow-up evaluation.

17. Management Gestational age of fetus & Amount of vaginal bleeding Heavy bleeding (>1500 ml ): C/S regardless of gestational age. Bleeding in excess of 500 ml & pregnancy <35 weeks: Antenatal corticosteroids.

18. Management Minor bleeding: Admission. CBC, clotting profile & cross matching. Maternal & fetal monitoring. Correction of anemia. Anti-D if the mother is rhesus negative. Corticosteroids 48 hours before delivery. If bleeding continues: Emergency management. If bleeding settles: Hospital stay for further 48 hours. If patient reaches 36 weeks: C/S (fetal lungs maturity by steroids).

19. Complications of Placenta previa Preterm delivery IUGR (repeated bleeding). Malpresentation ↑ number of C/S. Morbid adherent placentae: Acreta , Increta and Percreta. PPH d/t failure of lower segment to contract Mortality

20. VASA PREVIA Fetal vessels traverse the fetal membranes over internal cervical os. Vessels may be from either a velamentous insertion of umbilical cord or may be joining an accessory placental lobe to main disc of placenta. Diagnosis is usually suspected when either spontaneous or artificial rupture of membranes is accompanied by fresh vaginal bleeding from rupture of fetal vessels. High perinatal mortality. If baby alive & diagnosis suspected---immediate delivery by C/S.

21. POST PARTUM HEMORRHAGE (PPH) Postpartum hemorrhage is defined as blood loss ≥500 ml. Major obstetric hemorrhage is defined as blood loss ≥2,500 ml, or requiring a blood transfusion ≥5 units red cells or treatment for coagulopathy PPH is one of the leading causes of maternal mortality worldwide

22. RISK FACTORS Uterine causes: atony , uterine inversion and rupture. Macrosomia Multiple pregnancy Prolonged labour , oxytocin use, induction of labor. Grand multiparity Polyhydramnios Antepartum hemorrhage, placental abruption Placenta previa and accreta, previous multiple caesarean sections Perineal trauma Full bladder Underlying hematological disorder (e.g. factor VIII deficiency) (DIC) hemorrhage occurs: uterus, placenta and cervix/vagina .

23. PREVENTION: Hemoglobin levels below the normal range for pregnancy should be investigated and iron supplementation considered. Prophylactic use of oxytocin agents for high risk patients. SYMPTOMS: Anxiety, thirst, nausea, cold, pain, dizziness WARNING SIGNS: failure of uterus to contract following delivery of the placenta, maternal collapse. SIGNS: Rising fundus, peritonism, reduced urine output, tachypnoea, tachycardia, hypotension, narrow pulse pressure.

24. MANAGEMENT Do not delay fluid resuscitation and blood Consider the administration of blood components before coagulation indices deteriorate Consider early recourse to hysterectomy if simpler medical and surgical interventions prove ineffective. In complicated cases (e.g. placenta accreata ), ideally obtain advanced consent

25. ECLAMPSIA Pre-eclampsia is HTN of at least 140/90 mmHg recorded on two separate occasions, 4 hours apart with proteinuria (300 mg protein in a 24 hour collection of urine) developed after 20th week of pregnancy & resolving completely by the 6 th postpartum week. Characterized by vascular dysfunction and systemic inflammation involving the brain, liver and kidneys of the mother. Eclampsia refers to the occurrence of one or more generalized tonic- clonic convulsions and/or coma in the setting of pre-eclampsia and in the absence of other neurological conditions Cerebral hemorrhage has been reported to be the most common cause of death in patients with eclampsia

26. Prevention: low threshold for administration of magnesium sulphate in woman with pre-eclampsia. Risk factors: Family history of preeclampsia, previous preeclampsia and eclampsia , difficult to predict, uncontrolled hypertension, two or fewer prenatal care visits, primigravida, obesity, black ethnicity, history of diabetes and age <20 or >35 years. Signs: epigastric pain, right upper quadrant tenderness, headache, uncontrolled hypertension, agitation, hyper reflexia and clonus, facial (especially periorbital) oedema, poor urine output, papilloedema .

27. MANAGEMENT Call senior help and emergency alert team. Initial approach is similar to the collapsed patient with a focus on airway, breathing and circulation Magnesium sulphate first-line anticonvulsant (at risk of eclampsia or when eclampsia occurs) . A loading dose of 4 g, maintenance infusion of 1 g/hour generally for 24 hours after delivery. Drawback: narrow therapeutic range and overdose can cause respiratory depression and ultimately cardiac arrest. Antidote is 10 ml 10% calcium gluconate given slowly intravenously.

28. AMNIOTIC FLUID EMBOLISM Amniotic fluid embolism is due to amniotic fluid entering the maternal circulation, sometimes there may be an abnormal maternal reaction to amniotic fluid as the primary event. causes acute cardiorespiratory compromise and severe disseminated intravascular coagulation. Typically diagnosed at postmortem, with the presence of fetal cells in the maternal pulmonary capillaries

29. Prevention: unknown. Risk factors: 35% for induction of labor 13% for women 35 years or older 7% for multiple pregnancy. Signs: maternal collapse, shortness of breath, chest pain, feeling cold, light-headedness, restlessness, distress and panic, pins and needles in the fingers, nausea and vomiting.

30. MANAGEMENT Sudden collapse structured ABC approach but poor prognosis (30% of patients dying in the first hour and only 10% surviving overall) Management is supportive, requiring intensive care, no specific therapies available. Perimortem caesarean section should be carried out within 5 minutes or as soon as possible after cardiac arrest as to improve the effect of resuscitation.

31. CORD PROLAPSE: The descent of the umbilical cord through the cervix alongside or past the presenting part in the presence of ruptured membranes It is estimated to occur in 0.1-0.6% of pregnancies with the perinatal mortality rate estimated at 91 per 1,000.

32. Risk factors: polyhydramnios, multiparity, multiple pregnancy/ second twin, unstable, transverse and oblique lie, fetal congenital abnormalities, low birthweight (<2.5 kg), internal podalic version, large balloon catheter induction of labour . Warning signs: signs of fetal distress on CTG following artificial or spontaneous rupture of membranes.

33. Prevention: with transverse, oblique or unstable lie, elective admission to hospital after 37+0 weeks' gestation allows for quick delivery should membranes rupture. Women with non-cephalic prelabour preterm rupture of membranes should be managed as inpatients. Avoid artificial induction of labour when the presenting part is non-stable and/or mobile. When performing vaginal examination avoid upward pressure on the presenting part.

34. Assessment: Visible umbilical cord Palpable umbilical cord FHS shows variable or prolonged deceleration on CTG Increases fetal movement followed by decrease fetal movement or cessation Management

35. SHOULDER DYSTOTIA: A vaginal cephalic delivery that requires additional obstetric maneuvers to deliver the fetus after the head has delivered and gentle traction has been unsuccessful in delivering the shoulders The anterior shoulder becomes trapped behind on the symphysis pubis, whilst the posterior shoulder may be in the hollow of the sacrum or high above the sacral promontory.

36. Risk factors : Macrosomia Poorly controlled gestational and insulin-dependent diabetes Maternal obesity previous shoulder dystocia instrumental Warning signs : Failure of restitution of head following delivery of the head Retraction of the fetal head against the perineum Prevention: diagnosis and optimal control of gestational and insulin-dependent diabetics, reduction of maternal obesity. Careful plan for mode of delivery in women with previous shoulder dystocia delivery (recurrence rate 10–15%).

37. Complications with Shoulder Dystocia Neonatal: Brachial plexus injury fracture (humerus, clavicle) Hypoxemia Stillbirth Maternal: Perineal laceration Uterine rupture Hemorrhage

38. Management Position and accessibility McRoberts maneuver Suprapubic pressure Episiotomy Internal rotation maneuver Wood’s screw Reverse Wood’s screw Repeat Symphysiotomy ,cleidotomy or zavaneli maneuver

39. Thrombosis and thromboembolism: Venous thromboembolism (VTE) is 10 times more common in pregnancy compared with non-pregnant women. Symptoms: Women with VTE may be asymptomatic or present with a range of symptoms (specific and non-specific) For example: calf or groin pain and/or swelling that is often unilateral, low-grade pyrexia to more extreme presentations including hemoptysis, shortness of breath, collapse and death.

40. Risk factors : Immobility Obesity Increased maternal age (≥35) Underlying medical conditions, Pre-eclampsia Dehydration Multiple pregnancy Raised body mass index (BMI) (≥30 kg/m2 ) Smoker Grand multiparity, Thrombophilia. Warning signs: immobility, dehydration, calf pain, shortness of breath.

41. Prevention: Thrombosis assessment should be performed on all patients early in pregnancy as per RCOG guideline To assess need for antenatal thromboprophylaxis and on each admission to hospital to assess for additional Risk factors. Managing patients where possible as outpatients and limiting bed rest. Thromboembolic stockings. Prophylactic low-molecular-weight heparin for at-risk patients

42. DIAGNOSIS: When DVT is suspected clinically, compression duplex ultrasound should be undertaken. If this is negative and there is a low level of clinical suspicion, anticoagulant treatment can be discontinued. If clinical suspicion remains high or symptoms fail to resolve, ultrasound may be repeated. Venography is invasive (injection & X-rays)—excellent visualization of veins both below & above the knee If pulmonary embolus is suspected, investigative options include chest X-ray (to rule out other respiratory causes of chest symptoms such as pneumonia), low limb Doppler to rule out lower limb VTE ventilation perfusion (V/Q scan) computed tomography pulmonary angiography.

43. Treatment: Treatment of confirmed or suspected VTE is Therapeutic low-molecular-weight heparin given daily in two divided doses according to the patient’s weight. In the case of a collapsed patient with pulmonary embolus, Intravenous unfractionated heparin Thrombolytic therapy or thoracotomy and surgical embolectomy. This complex management decision is taken by the multidisciplinary resuscitation team including senior physicians, obstetricians and radiologists .

44. Uterine Inversion Partial Inversion Complete Inversion Four Degrees of Inversion Early Diagnosis and Prompt Correction Risk Factors : Think! Full dilatation sections Malpresentations IV oxytocin prior to a decision to deliver by caesarean section Unsuccessful instrumental delivery Prolonged second stage Hyperstimulated uterus

45. Management Manual Replacement Replacement Under anesthesia Hydrostatic Replacement Hysterectomy

46. Uterine rupture Prevention Reduce rates of primary caesarean section. Avoid vaginal delivery in women with previous myomectomies in which the endometrial cavity has been breached. Management Urgent laparotomy Vaginal examination Fetus delivered by the quickest route possible

47. Impacted head at caesarean section Prevention : How? Risk factors : Same as that of Uterine Rupture Full dilatation sections Malpresentations IV oxytocin prior to a decision to deliver by caesarean section Unsuccessful instrumental delivery Prolonged second stage Hyperstimulated uterus

48. Management Allow the uterus to relax before disimpacting the head. Disengagement of the head requires flexion and rotation of the head into the transverse position prior to delivery by lateral flexion. use of a uterine relaxant such as glyceryl trinitrate (GTN) spray or terbutaline BUT.....! risk of postpartum haemorrhage following the use of uterorelaxant agents. BRAIN TEASER : GTN is also used for? (Hint : Anal Disorder)

49. LET’S GUESS…. A 28-year-old woman, G3P2, gave birth vaginally to a healthy infant weighing 3.5 kg after an uncomplicated pregnancy. However, within one hour post-delivery, she experiences excessive bleeding. She is hypotensive (blood pressure 90/60 mmHg), tachycardic (pulse 120 bpm), and has a distended uterus with clots . What is the most likely cause of her condition? Uterine rupture Retained placental tissue Uterine atony Cervical laceration

50. 29-year-old woman, G2P1, at 34 weeks gestation, presents to the emergency department with complaints of severe headache, blurred vision, and epigastric pain . She has a history of hypertension that was diagnosed early in her pregnancy and has been poorly controlled. On examination, her blood pressure is 180/110 mmHg, and she has mild pedal edema . Shortly after admission, she experiences a generalized tonic- clonic seizure . What is the most appropriate initial management? Administer intravenous hydralazine Perform emergent cesarean section Administer intravenous labetalol Administer magnesium sulfate

51. A primary gravida 34 weeks pregnant presents with painless vaginal bleeding .The uterus is relaxed and fetal heart sounds are normal. What is the possible cause? Placental Abruption Placenta previa Vasa Previa Cervical erosion

52. A 29-year-old woman, gravida 2 para 1, presents to the labor and delivery unit at 38 weeks' gestation in active labor. Her prenatal course has been unremarkable. She had a previous vaginal delivery without complications. Upon admission, her cervix is dilated to 8 cm, and fetal heart rate monitoring is reassuring. However, during the second stage of labor, the progress slows, and the fetal head does not deliver despite adequate maternal pushing efforts. What is the most appropriate initial maneuver to manage this situation? A) Suprapubic pressure B) McRoberts maneuver C) Rubins ' maneuver D) Woods' screw maneuver E) Zavanelli maneuver

53. A 28-year-old woman, gravida 2 para 1, presents to the labor and delivery unit at 38 weeks' gestation with complaints of leaking clear fluid per vagina for the past two hours. Fetal heart rate monitoring shows variable decelerations. Upon vaginal examination, the presenting part is not engaged, and a pulsating umbilical cord is felt alongside the presenting part. Which of the following findings on vaginal examination is consistent with the diagnosis of umbilical cord prolapse? A) Ruptured membranes with clear amniotic fluid B) Presence of meconium-stained amniotic fluid C) Pulsating umbilical cord felt alongside the presenting part D) Station +2 of the presenting part E) Absence of fetal heart rate accelerations

54. What risk factor has the highest association with uterine rupture in a woman with a previous caesarean section? A) Spontaneous onset of labour . B) Severe pelvic girdle pain. C) The use of oxytocin in labour . D) Prostaglandin E2 induction of labour . E) Women with systemic lupus erythematosus.