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43 Cards in this Set
- Front
- Back
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What are the main obstetric and gynaecological emergencies? |
Ectopic pregnancy Placenta Praevia Placental abruption Pre eclampsia Cord prolapse Shoulder dystocia Post partum haemorrhage Toxic shock syndrome |
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What are the predisposing factors for an ectopic pregnancy? |
Pelvic inflammatory disease Previous tubal pregnancy Tubal surgery Tubal disease (endometriosis) Infertility IUCD POP/Morning after pill |
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What is the classical triad of an ectopic pregnancy? |
Amenorrhoea Abdominal pain Vaginal bleeding abdominal pain typically precedes the bleeding pain initially unilateral, then diffuse as blood irritates peritoneum |
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What investigations should be done in suspected ectopic pregnancy? |
Pregnancy test - 95% positive Ultrasound - TVUSS will detect from 5 weeks HCG quantitative measurement FBC Group and Save |
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What features may be seen on TVUSS? |
ectopic pregnancy free fluid in pouch of douglas adnexal mass embryonic sac |
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How is an ectopic managed? |
Resuscitate shocked patients Laparotomy if haemodynamically unstable Laparoscopy if haemodynamically stable Salpingotomy if contralateral tube disease Salpingectomy if healthy other tube or completed family |
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How might you treat a stable, asymptomatic woman with an early ectopic and falling HG levels? |
Intramuscular methotrexate |
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What should be given to Rhesus-negative women? |
Anti-D immunoglobulin |
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What is placenta praevia minor/major? |
Low-set placenta that either encroaches (major) or does not (minor) on the cervical os |
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What are the risk factors for placenta praevia? |
High parity Multiple pregnancy Rhesus disease Previous myometrial damage (curettage/Csection) Previous placenta praevia |
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What are the clinical features of placenta praevia? |
Painless vaginal bleeding Malpresentation of the foetus Uterine hypotony |
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What are the key features of assessment when a patient presents with a possible placenta praevia? |
- Haemodynamically stable - pulse and blood pressure - Abdominal palpation - high presenting part and soft atonic uterus - CTG to check for foetal and uterine activity - Speculum to assess bleeding, liquor and dilatation - TVUSS if time permits to diagnose |
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What should you absolutely not do? |
A digital rectal examination, until placenta praevia has been excluded (may cause haemorrhage) |
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How would you manage minor haemorrhage in placenta praevia? |
ABCDE - ensure haemodynamically stable Obtain IV access Take blood for FBC, G+S, U&E, clotting If bleeding settles, assess degree of praevia If major, patient will need admitting Assess foetal growth and placental position every 2 weeks by ultrasound Elective caesarean if still present at 38 weeks Minor praevia can try spontaneous labour |
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How would you manage an active significant bleed in placenta praevia? |
Obtain IV access Take blood for FBC, U&E, clotting, G+S Crossmatch at least 2 units Begin IV fluid resuscitation while awaiting crossmatched blood Senior review |
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What are the complications of placenta praevia? |
Postpartum haemorrhage (give Syntocinon) Morbidly adherent placenta if previous scar |
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What are the factors associated with placental abruption? |
Hypertension Pre-eclampsia Smoking during pregnancy Low socio-economic status Previous placental abruption Trauma Male infant Intrauterine growth retardation |
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What are the clinical features of placental abruption? |
Sudden onset severe abdominal pain Vaginal bleeding Longitudinal lie Fundal size may appear large for dates (concealed haemorrhage) Tense, hard uterus Shocked patient Patient may be in labour Foetal heart sounds may be absent |
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What are the key points of assessment for placental abruption? |
Haemodynamic stability Abdominal palpation - tense, tender uterus CTG to check foetal and uterine activity |
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What's the management of placental abruption? |
Obtain IV access Take blood for FBC, U&E, clotting and crossmatch Begin IV fluid resuscitation while awaiting the blood Call senior colleagues for help Deliver the foetus as soon as possible |
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What are the complications associated with placental abruption? |
Disseminated intravascular coagulation (release of thromboplastin into maternal circulation) Post partum haemorrhage Renal tubular or cortical necrosis Foetal death |
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What are the clinical features of pre-eclampsia? |
Often asymptomatic until late in the disease Oedema (hands and face) HTN symptoms Hyperreflexia, clonus Fundi may have haemorrhages IUGR |
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What investigations would you do in pre-eclampsia? |
Send MSU to exclude infection 24hr protein or spot P:CR ratio FBC, U&E, G+S, Urate, LFT CTG Umbilical artery doppler |
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Management of Pre-eclampsia? |
Control BP and monitor regularly MgSO4 to prevent convulsions Fluid balance Haematology review if HELLP syndrome Steroids for foetal lungs Continue monitoring after delivery |
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What are the risk factors for cord prolapse? |
Breech presentation High presenting part (maybe secondary to Praevia or fibroids) Cephalon-pelvic disproportion Transverse lie Unstable lie Polyhydramnios |
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How is cord prolapse diagnosed? |
Palpation of cord in vagina suspect if foetal heart rate decelerates or bradycardia observed in woman at risk of prolapse |
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What is the management of cord prolapse? |
Keep hand in vagina and attempt to prevent compression Crash call obstetric reg Move woman onto all fours or left lateral position with head tilted down Avoid handling the cord to minimise spasm Decide whether vaginal delivery is possible Paediatrician must be present at delivery |
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What can be done if outside hospital and patient needs transfer? |
Catheterise and infuse 500ml of saline into the bladder to push the presenting part out of the pelvis and prevent compression |
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How long does a baby with shoulder dystocia have? What's the incidence of shoulder dystocia? |
4-5 minutes until hypoxic damage 0.2-2% of vaginal cephalic deliveries |
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What are the antepartum and intrapartum risk factors for shoulder dystocia? |
Macrosomia Diabetic mother Previous large infant Previous shoulder dystocia Post maturity Pelvic structural abnormality protracted cervical dilatation during first stage of labour protracted descent during second stage Prolonged second stage |
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What is the management of shoulder dystocia? |
Call for help Place patient in McRoberts' position This may require suprapubic pressure and gentle pulling of the head Give analgesia and perform a large episiotomy Wood's screw manoeuvre All fours |
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What are the complications of shoulder dystocia? |
clavicle fracture brachial plexus injury asphyxia (rare) Vaginal lacerations Post partum haemorrhage Uterine rupture |
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What are the definitions of primary and secondary postpartum haemorrhage? |
- Primary 500ml blood loss within 24hrs of delivery - Secondary Excessive blood loss 24hrs - 6weeks after delivery |
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What are the predisposing factors to postpartum haemorrhage that may be identified before labour? |
Antepartum haemorrhage Previous PPH Multiple pregnancy Grand multiparty Pre-eclampsia Coagulation disorders |
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What are the predisposing factors to postpartum haemorrhage that may be identified during labour? |
Emergency Caesarian section Elective Caesarian section Retained placenta Instrumental vaginal delivery Prolonged labour (>12hours) |
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What are the causes of PPH? |
Uterine Atony Retained products Cervical tears (3 and 9 o'clock) Vaginal tears Uterine rupture (in women with previous scar) |
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How can PPH be prevented? |
Identify risk factors and manage appropriately Syntocinon reduces PPH by 60% |
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How would you manage primary PPH? |
Assess Call for help Resuscitate Conservative manage of bleeding Exclude other causes Surgical management Consider ITU |
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What are the commonest Toxic Shock Syndrome toxins? |
TSST-1 (75%) Staphylococcal entertoxin B (20-25%) |
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What factors predispose to toxic shock syndrome? |
Postpartum infections Diaphragm Sinusitis Patients with burns Post-op skin infections Osteomyelitis |
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What are the diagnostic criteria for TSS? |
Temperature over 38.9 Hypotension/orthostatic syncope Diffuse macular erythematous rash Desquamation of skin on palms and soles Abnormalities in 3 or more organ systems GI Muscular Hepatic Renal Haematological CNS Mucous membranes All in the absence of other illnesses |
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What is the management of TSS? |
Remove trigger Irrigate copiously Fluid resuscitation Antibiotics Dialysis if renal failure Transfer to ITU |
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What is the prognosis for TSS? |
Mortality 5% Recurs in up to 40% (linked to failure to generate antibodies) Streptococcal TSS has a higher mortality rate |
