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13.06.07 Obstetric emergencies

Eclampsia
  • Definitions
    • Pre-eclampsia = Pregnancy-induced HTN with proteinuria and/or oedema. Any organ system may be affected.
    • Severe pre-eclampsia = DBP >100 mmHg, SBP >170 mmHg on 2 occasions, +/- heavy proteinurea
      • Diastolic more important for baby (foetal blood flow)
      • Systolic more significant for mum (cerebrovascular risk)
    • Eclampsia = The appearance of one or more convulsions superimposed on pre-eclampsia (risk only 1% even in severe PET)
      • +/- Hypereflexia, nausea, vomiting, headaches, cortical blindness, HELLP syndromepulmonary oedema, oliguria
  • Timing - Don't forget about after delivery!
    • 45% pre-delivery
    • 18% intra-partum
    • 37% post-partum
  • Foetal assessment
    • Fetal growth (remember normal growth may = IUGR in a diabetic mum)
    • Liquor volume (=> placental function)
    • Umbilical artery/fetal vessel doppler 
    • CTG (poor predictive value)
  • Management
    • Control BP (but SLOWLY - no sudden drops)
      • Labetalol
      • Methyldopa
      • Nifedipine
      • Hydralazine
    • Avoid fluid overload
    • Seizures
      • Prophylactic MgSO4
      • MgSO4, diazepam or thiopentone for treatment
      • Left lateral position
      • High-flow oxygen
    • Steroids to prepare baby for delivery
    • DELIVERY
      • CS if <32 weeks
      • Avoid ergometrine (raises BP) - Give syntocinon (oxytocin) if necessary
  • Follow-up
    • Recurrence up to 50% if complicated
    • BP can take up to 3 months to return to normal

Massive haemorrhage
  • Definition
    • >1000 ml for vaginal delivery
    • >1500 ml for CS
  • Very difficult to measure! (May be internal)
  • Causes
    • Uterine atony => failure to contract after delivery
    • Placental previa
    • RPOC
    • Genital tract injury
    • Uterine rupture
    • Uterine inversion => inability to contract
    • Fibroids
    • Ectopic pregnancy
    • Coagulopathy
  • Mnemonic
    • T one 
    • T issue
    • T rauma
    • T hrombin

Shoulder dystocia
  • Definition "Arrest of spontaneous delivery due to impaction of the anterior shoulder against the symphysis pubis"
  • Incidence 0.15 - 2% (No standard definition)
  • Risk factors
    • Macrosmia (big baby syndrome)
    • Maternal obesity
    • DM
    • Prolonged pregnancy
    • Advanced maternal age
    • Male baby
    • Previous SD
    • Previous macrosmia
    • Prolonged labour
    • Use of oxytocin
    • Assisted delivery
  • Fetal morbidity
    • Cerebral hypoxia
    • Cerebral palsy
    • Fractures (clavicle, humerus)
    • Brachial plexus injury
  • Umbilical cord pH falls by 0.04 units/min after head delivery => Need to delivery shoulder QUICKLY (within 5 mins)
  • Management
    • SENIOR HELP
    • Move mum
    • Manoeuvres
    • Cuts 

Umbilical cord prolapse
  • Incidence 0.2%
  • Fetal mortality 25-50%, due to:
    • Mechanical compression
    • Spasm of cord vessels from cold environment
  • Risk factors
    • Prematurity
    • Polyhydramnios
    • Multiple pregnancy
    • Anencephaly
    • Contracted pelvis
    • Pelvic tumours
    • Low grade placenta previa
    • Log cord
    • Iatrogenic (amniotomy, scalp electrode application, external cephalic version)

Amniotic fluid embolus
  • Presents with PE symptoms
  • Pathophysiology relates to maternal response to foetal cells
  • Can lead to DIC

Notes
  • Clomifene
    • SERM
    • Increases gonadotrophins by relieving negative feedback at hypothalamus => Ovulation induction
    • Used in PCOS and for IVF
  • Sex hormone-binding globulin (SHBG)
    • Glycoprotein that binds to androgens and oestrogens
    • Binds 98-99% of total fraction in serum
    • Decreased by: Androgens, anabolic steroids, PCOS, hypothyroidismdiabetesobesityCushing's syndrome, acromegaly
    • Increased by: Oestrogenic states (e.g. COCP), pregnancyhyperthyroidismcirrhosisanorexia nervosa
  • PET = Pre-eclampsia/toxemia
  • Breech position
    • 4% at term
    • 50% at 28 weeks
  • Most common intrapartum spesis is Gram -ves (E. coli)
  • Syntocin in multiple pregnancy => Uterine rupture?
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