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 syndrome, pulmonary 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, hypothyroidism, diabetes, obesity, Cushing's syndrome, acromegaly

    • Increased by: Oestrogenic states (e.g. COCP), pregnancy, hyperthyroidism, cirrhosis, anorexia 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?