BREIF

How to Deal with Obstetric emergencies In a Very Simple and Practical Way

Dr.
AHMED
HAMDY

| 2011 24


Great thanks to all staff in
OB/GYNA department in faculty of
Medicine at Menofia University

..
And my sincere gratitude to :
Dr.Ibrahim Seif

Dr.Mohamed Zakaria

Dr.Sherif Sobhy

Dr.Mahy Nabil

Dr.Eman Badr

Dr.Rehab Zahran

Also,

I would like to thank all of my dear

colleagues for their support ..

2011 24

PART 1

Obstetric sheet

Complaints

12

Abdominal pain with pregnancy

13

-Is She in labor ?!

14

-Pre- eclampsia

19

- abruption concealed type

29

-Ectopic pregnancy

31

-Rupture Uterus

33

UTI with Pregnancy

35

ROM

37

Vomiting with pregnancy

43

-Emesis gravidarum
-Hyper-emesis gravidarum
-GIT disorder

2011 24

OBSTETRIC Sheet

-3 ..
complaint
" "

Sheet

-1 .. ..

.. ..
..
managment

-------------------------------------- 6
AGE - Married from
Parity - Abortion
Past History - L.M.P.

-2 ..
complaint ..
) (
24 2011

complaint

6
fixed
2
Past
history

2
LMP

Abortion

*
*
*

*

24 2011

2
Parity

*
*
*
*
*

*

married
?? from

Age

Infertility

= elderly PG
Precious baby

1- Age


elderly PG
35


Elective CS
- PRECIOUS -
BABY
frequency of visits
2- Married from ....

infrirtility

... )*( )(Rh)*( ..

:

)(CPD
) / / (
:

3- Parity :

contracted pelvis

) / / (
6

24 2011

His Heart Cannot Be Pure Whose Tongue Is Not Clean

4- Abortion :
- -
.. recurrent abortion . *
*
asc. duration (e.g.hypoplasia ) or desc. ( cervical
) incompetence
*
5- LMP :


EDD



DD/MM/Year
) 3 ( 9
) 4 (
24 2011

example :
LMP 5/2/2011
EDD 12/11/2011
2 9
LMP 8/3/2011
EDD 15/12/2011
3 9
LMP 5/4/2011
EDD 12/1/2012
3 3
LMP 8/7/2011
EDD 15/4/2012
3 3

!!
7

 .. 9

9
::
LMP 5/2/2011 EDD 12 /11/2011

- - - -

5/3 5/4 5/6 5/7 5/8 5/9

3 .. **
= 13 3
= 26 6
6- Past History :

24 2011

- - - -
-

.. ..

The Most Diagnostic Tool Is Passage Of Time . Hippocrates , Father Of Medicine

January

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June

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July

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October

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August

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November

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September

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December

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October

EDD LMP EDD

9

2011 24

PARITY + Abortions , Gestational age , complaint

Parity

P1
SVD
male
youngest 3ys

placenta accreta
menstural irregularities blood clots
recurrent abortion

- - 3

*LMP = */

Age

*EDD= */

MF

abortions

) Preg 39w, With (ROM , VB..

+2

2nd2m , D&C

1st 3m

1st 3m

SVD

2nd2m
, D&C

Male

D&C

P1

Youngest
3 years
IUD 3
years

....... .

scar perforation
Rupture uterus uterus
24 2011

10

Gestational age

PG ,preg +_ 36 wks with

preg +_ ??? wks

ectopic
) .. !! (

* = P3 .. ..

age of viability = 28 wks

6

*
P0 + 2
" " " " o

abortion

*

P0+0
primigravida = PG
24 2011

.. 28 ..
induction
28
28
11

COMPLAINT

complaint

complaint s

1 Abdominal pain with pregnancy
2- vaginal bleeding
) 3 ROM ( rupture of membranes
4- fetal kicks
exclusion complaint
5- Hyper-emesis Gravid-arum
6-PRE-ECLAMPSIA
..

24 2011

+
Others ..

) infection Gastroenteritis-
(Anemia hypotension etc
defloration injury
IUD
RAPE
query appendicitis in Virgin
Ectopic

) (

):

God Gives Every Bird Its Food, But He Doesn't Throw It Into The Nest

12

Recent Pregnancy

Labor

Genital

( term,preterm)

Late in
preg.
Recent
Pregnancy

*complicated
cyst , Fibroid

Medical

*Urinary
* GIT

Abruption
Rupture
Uterus

Early in
preg.

Associate
Recent
Preg.

EP

Abd.
Pain e'
Preg.
Extragenital

Surgical

13

*Appendicitis

2011 24

IS SHE IN LABOR
. :
..
.. ..

..
..
..

= 9
=

) (contractions
) ( cervix
3
PAIN
.. .. "
"
Contractions

/ TRUE or FALSE --
PV
..

24 2011

14

:
the most important is true labor pain which is
confirmed by concurrent cervical changes
if you doubt keep the patient under observation for a
while and reassess

TRUE and FALSE

History

FALSE

TRUE

4 3

if this tone become a true labor pains or the cx begin

to dilate, here you will confirm labor onset

this is particularily important in preterm patients

contractions <3/10min , <40
sec.
...
..

parameters 3

true
true

PV

15

3-5/10min , >40
sec

We Don't See Things As They Are , We See Them As We Are .

<4cm

4cm or more

2011 24

cervix efficient contr.

active phase

Pain Contractions

Cx

previous CS -1
Any Previous CS once contraction =
admission and close observation
There is a uterine scar fear of
Rupture uterus
associated problem e.g. VB, -2

>4cm

<4cm

<4cm

ROM,dec.fetal kicks
effacement 4 -3
%80 %70
..

Result
IN LABOR
Active
phase
For
admission

abd.pain e'
pregnancy
e.g.
UTIetc

......

6 3

True contractions =

) fully

False contractions = X

(
16

Hard Work Doesn't Guarantee Success, But Improve Its Chances.

2011 24

 ..

Routine :

-1

-2

)
(


)Instructions ( VIP

-2

-3

-4

true or false
4cm

-1

24 2011

17


1- Re-evaluation : - history - Pv - U/S

5 ) ( 500 2- Augmentation By : 505

-3 effacement ..
ripening of Cervix :
-4 : ..
-5 fully dialted and head on perineum

-6 :

505 510

10 .. 5
5

10

)520 ( 500 ringer + 20 syntocinone

PLACENTA :
2 ergometrine ( methergine ) I.M. or I.v. drip
) 522 ( 500 R + 20 synto + 2 methergine

)4 mesotac ( PGE2

" "

24 2011

18

placental ABRUPTION
..
PREECLAMPSIA

PRE-ECLAMPSIA

Elevated BP

" "
preeclampsia
Scientific base
Proteinuria

Non dependent edema

Pre-eclampsia

1- Placental Dysfunction
Normally : fertilized ovum zygot morula blasocyst 2 types of cells
syncytio-trophoblast cyto-trophoblast :
invation of deciduas

Invation of trophoblasts into deciduas erosion of elstic tissue of Spiral

arteries so converting them into large blood sinusoids , not responding to
maternal vasomotor changes

19

The Successful Man Is Average Man , But Focused

2011 24

viscosity

thrombo-embolism

metabolic and O2 needs

* PLACENTAL INSUFFICIENCY

spiral artey

IUGR , IUFD

..

GENERALIZED VASOSPASM
*Hypertension

* Hge AND NECROSIS

PREeclampsia

Kidney hematuria ,tubular

necrosis ARF

EYE retinal exudates, Hge

Brain hpoxia, Hge
Uterus accidental Hge
* Hypovolemia

spiral arteries
=================================
preeclmpsia
Generalized Segmented Vaso2- Spasm

organ perfusion

Volume

* spastic segmenet become

hypoxic permeability ptns to
extravascular

volume Pressure

edema and

2 factors

HYPOVOLEMIA

Hypovolemia more hypoxia

damage of wall Hge and
Necrosis
Dilated segment disruption of
*endothelium exposure of C.T.

20

2011 24

 volume volume
perfusion
organ Kidney Uterus

BP
Volume

Drop of BP
acute loss of blood during labor
hypotensive drugs
volume ..
SHOCK even with normal BP
management

target termination 100/160

blood loss 1000 CS

BP

Volume

BP

Trust Your Hopes , Not Your Fears

Volume

24 2011

Acute blood loss,

DRUGS

21

..

: pre-eclampsia


aldomet

Routine
:
PG , obese , F.H. of
HTN& DM

) (abruption Other symptom of severe Pre-eclampsiaVomiting , headache , epigastric pain ,
blurring of vision , hemi-paresis
Even blindness

24 2011

22

 Pre- eclampsia
Mild :
Bp 140/90 , ptnuria +1 ,+2
Severe :
Bp 160/100 , ptnuria +3,+4

mild .. .. home treatement
.. .. pre-eclampsia
-1

-2

)( monitor U.O.P.

-3

-4

-5

airway neuril eclampia

+
severe

) : neuril 10 .. fits 2
fits (
-6

loading dose
N.B.

-1 :

Mg
sulfate
2.5 g

slow I.V.
24 2011

Who is afraid of doing too much, always do too little .

23

 -2 severe 180 190

) ( 2 Nitroderm patch 5 + Capoten 25

-3 :

..

Back to the KOSHK

24 2011

Do What Is Necessary ,Then Do What Is Possible, Suddenly You Do The Impossible

24


-1

Re-evaluation :
History

-2

Sonar

:
o2
Chart

-3

( see later ) :

-4

:
-

: Loading

500 Ringer

: Maintainence -

4-6g Mg-sulfate
40

500

10

: CTG ) Pinnard (

-5

mild severe
severe ..

24 2011

25

 severe :
SEVERE PE

eclampsia

airway ,

-capoten
oral

neuril cagluconate

- nitroderm
patch

Papilledema

)NAD :

- if Diastole
> 110 :
)Tridil (VD

)(antidote
TRIDIL :
) ( slow set 5 tridil OPERATIVE
fully dilated ..
PE CS
spinal anasth. CS
sutures
Ooze .. ..
severe skin Transverse Mattresse

: mild or severe
) 4 mesotac ( PG
24 2011

26

POST-OPERATIVE

post-opertaive

uterus
contracted
or not

Vaginal
bleeding

tocolytic

Post-partum
hge

UOP
30cc/hour

) ( HTN - Atony

drain

BP

--- :
* --



* epilate cap.
)


(

post-operative
4 500 40
6 : 4
4

24 2011

Not just ' GO ' through life, but better ' Grow ' through life .

27

PT

RBS

LDH

kidney

liver

Hemolysis
)(HELLP

CBC

=


pT

60%
!!!!

LIVER

: ) human albumin 200

(

SGOT , SGPT : HELLP syndrome
KIDNEY
renal impairment : Urea
renal impairment : Creatinine
: PE
chronic HTN and PE

24 2011

28

PLACENTAL ABRUPTION - CONCEALED TYPE

( Premature separation of placenta from the uterine side-wall )
High risks with :

Severe PE ( more than 50% )

Poly-hydramnios ( sudden ROM sudden drop of

intra-uterine pressure )

Trauma

Abruption

ABRUPTION

PV

Only if
NO
bleeding

History

SUDDEN
SEVERE
Abd. PAIN

continous hardness

cont

history of
PE, HTN

tone

29

Knowledge speaks , But wisdom listens .

2011 24

N.B. Uterine tenderness suggests for Couverlaire uterus ( extra-vasation of blood into
) myometrium

-1

Vitals & Resuscitation :

+
500 :shocked

-2 ) (PE
PE
Retro-placental bleeding Shock
PE 10 airway
-3

) ( : 1500

) (

-4 for UOP , Urine sample for Ptnuria and urine analysis :

-5

) (

..
..
..

call
history : Reevaluation US
: CBC , PT
24 2011

30

ECTOPIC PREGNANCY
disturbed and undisturbed
) Disturbed ( acute , subacute,chronic
acute disturbed EP

Uni-Lat. Sudden Severe Abd. Pain
Vitals : Bp , Pulse
UNSTABLE
-1
-2
-3
-4
-5
-6

500

) 1500 (

: ) baby chek +ve ( medicolegal

UOP
Quantitaive -hCG
URGENT US : empty uterus , adnexal mass , internal hge

STABLE

: collapse
+ve
Quantitaive -hCG
: To exclude appendicitis
risk factors PID
.
PV
PV :
Bimanual : unilat adnexal tenderness ,
cx Cervical motion tenderness :
24 2011

Let us not look back in anger or forward in fear but look around for awareness

31

ECTOPIC PREGNANCY
Sever lower abdominal pain vaginal bleeding

Baby check +ve

Quantitaive subunit

TVUS empty

..

Qualitative

Quantitaive -subunit

hCG

< 1500

> 1500

Repeat after 48 hs

>66%

Early
n0rmal
IUP

Marked

Complete
aborion

Pulsating adnexal mass

+ empty uterus

Suboptimal

EP - Unhealthy IUP

TTT
STABLE

UNSTABLE

2 canula 1500
Methotrexate

Laparoscope salpingeCTomy
Salpingostomy : tube

Check CBCliver - kidney

32

Salpingostomy : sutures tube

2011 24

Rupture Uterus
During Labor

During Pregnancy

Spontaneous

Traumatic

* spontaneous : obst.
labor
* Truama : forceps ,
manual removal of
placenta

Rupture
Uterine
Scar

direct
trauma

surgical
trauma

* improper use of Ecbolics

: e.g.ergometrine
antepartum

Most
Common

Rupture During
Pregnancy
classic type

silent type
(scar dehiscence)
STABLE
minimal symptoms

Sudden
sever
abd.
pain

picture of
internal hge

u/s : fetus intrauterine ,

Vitals : SHOCKED

-
rigid - tender Rebound shifting dullness

33

, minimal Int. hge

collection in Douglas pouch

For laparotomy
2011 24

Rupture scar
Dehiscent scar

Scar opened , membranes ruptured , fetus Extra- utrine

Scar opened , membranes intact , fetus Intra utrine

Resuscitation ..

adbominal pain with pregnancy

Extragenital causes

UTI __________see below

GIT __________see Vomiting with Pregnancy

34

2011 24

UTI WITH PREGNANCY

UTI
. .. dysuria suprapubic loin to groin

UTI
preterm labor

: -1

16 1st trimester abortion

anti-biotic safe in pregnancy ( penicllins , Cephalosporines ) : -2
: UTI
Uterine cont. (* preterm labor )
Vaginal bleeding ( *abortion in 1st trimester )
PUS cells in Urine analysis

0-5 / HPF : Normal

5-30 :
urinary antiseptic + antispasmodic+ + analgesic
Rx : Uvamine retard cap. 12 /
Rx : urenix cap. 12/
Rx : Urosolvine (urate) or Epimag (oxalat)
3
Rx : Coliurinal alkalinization of Urine ( majority of cases
due to E.coli ) 3
Rx : Profenid rectal supp. 12

35

30-100 : same drugs + Oral Anti-biotics ( 2nd generation cephalosp.)

Rx : zinnat 500 cap. 12/
2011 24

:
3 )
.(

.

..
.

.

-1

-2

Instructions to prevent recurrence :

-3

Pus cells > 100 / HPF -1
Severe case : severe pain,with fever and rigors -2

:
septic shock PTL

:
I.V. Fluids : 2-3 litres/ day
I.V. AB :
Cefotax i.v. ( 3rd generation Cephsp.) till pt. afebrile ( at least
48 hs ) then oral AB for 2 weeks
Symptomatic ttt +

. - 1 wk interval
N.B. s
1- follow Up after Delivery :
urine analysis .. if persistent infection full uroogical investigation ,
.. Others say wait at least 12 week after delivery to allo anatomical changes
related to pregnancy to resolve .
2-NSAIDs : *****
Dont use more than 48 hs : prolonged use oligohydramnios
Dont use after 32 wks gestation premature closure of Ductus Arteriosus
Pulmonary HTN in newborn .

36

2011 24
A drug per definition must be toxic or it cannot be labeled as a drug.

RUPTURE OF MEMBRANES
- Introduction :
Term ROM : ROM at onset of labor
PROM : ROM a er completed 37w but before onset of labor
PPROM : Rom before completed 37w
Prolonged ROM : ROM of more than 24 h dura on
..

amniotic fluid

INFECTION

prolonged ROM
MATERNAL

Fetus

lung maturity :
AF contain growth
factors help in lung
maturity --> RDS

neonatal sepsis
cord compression
-> neonatal
asphyxia
skeletal
deformities
dec. skeletal ms
development

* ROM--> release of PG --> high risk for Preterm labor .

* Vaginal infections are great risk of infection in cases of ROM .
* if UTI present must be treated to avoid risk of Preterm labor .
37

2011 24

Maternal
Infections

Peurperal sepsis

Chorio-amnionitis

SHEET

complaint

6
ask abt
complications

confirm
diagnosis

:

GA

management

Preterm labor

Infection

Risk

factor

24 2011

38

 .. ROM history

GA

completed
37 w

No TRUE cont.

No P.V.
or Sterile Cusco with
Sterile Gloves -->
leakage of fluid

)
cont. (

TRUE cont. = Preterm

labor
Cx

AFI ?? :

EXIT

ENTER

infection -1
UTI or Vaginal infection

instructions -2
39

completed
37 w

1- Sure ROM
2- AFI : <5 or low normal
e.g. 6 , 7
3- not sure ROM but in
labor ( preterm )
2011 24

 ) ( ....

prophylaxis AB
2 ) (*

: (:

sure ROM
Soaked ) urine (
soaked ..
instructions

GA
Preterm >24 w & < 37 w

Pre-viable < 24 w

IN EGYPT : age of viabliity

is 28 w , so this pt for
induction of abortion

Term > 37 w

37

Term > 37 w

* prophylaxis

: breech CS . : ROM Induction 4/1 monomac 2 + cytotic 4

Cyto c ll Cx = 4cm , then Synto-cinone ( 505 )
) ( Cx is favorable ( Cx not favorable ) : CsCytotic : PG Monomac : nitrate Synto : Oxytocin

24 2011

The Greatest Truth Are The Simplest , And So Are The Great Men

40

Preterm >24 w & < 37 w

Fetal infection

Fetal Hge

Ampicilline for 1
week

RDS

induction of lung
maturity

DEXA

1.5 /
- -

Erythromycine for
10 days

Steroids in induction of lung maturity

-

Used only betw. 24 34 wks , after that not effective and not decrease RDS incidence .
Target : give pt. 24 mg in 24 h DEXA start acting 24 h after last injection and action continue for 7
days .
We don't use Prednisone as it not crossing Placenta

6 8 2

Target: 24 mg --

6 12
1 8 12 ) 8 2

4 6 (

.. 24
6

-1 + UTI or any infection
-2 .
-3 4 /
-4
-5 AFI
-6
24 2011

41

Unfortunately
They Enter Into Spontaneous Onset Of
Labor

Pre-viable <24 w

50 % WITHIN 12 H
75 % WITHIN 24 H
85 % WITHIN 48 H
95% WITHIN 72 H

I T CONSIDERED I NEVITABLE ABORTION FOR TERMINATION

510

OR

520 CYTOTIC 1/2

N.B. : 2\1 4/1

42

2011 24

Vomiting With Pregnancy

Early In
Preg.

Late

Mild

emesis gravidarum

Severe

GIT disorder

Hyper-emsis
Gravidarum

e.g. gastroenteritits

(morning sickness )

should exclude
PE ,
vomiting may
be the 1st
symptom of
SEVERE PE

Emesis Gravidarum : ( morning sickness )

% 50
N & V at morning


3

Cortigen B6
( NO prempiran in 1st Trimester )

Rx NAVOPROXIN tab. 1x3 :

( Navodoxine,Emetrex )

43

Experience is the name every one gives to their mistakes.

2011 24

HYPEREMESIS GRAVIDARUM
severe and persistent vomiting in first trimester , affecting general condition

hCG (X1000 mIU/ ml

100

-hCG
allergic re-action to the hormone
Peak at 10-12 wks 100.000 mIU : 48
10.000-20.000

80
60
40

( emesis graviadarum )

20
0

10

20

30

40

Gestational age ( weeks )

* Severe vomiting dehydration Hypovolemia electrolyte disturbance & ischemic

changes in different organs
e.g elevated liver enzymes, fatty degeneration, degeneration of renal tubules ,
Ketoacidosis, brain ischemia , retinal hge .. etc.

Confirm Diagnosis
Hyperemesis is different from emesis, must affect
the general condition of the patient

Shock

Dehydration

Rule of 100

- sunken eye
/dry tongue ..

* above 100 pulse,

* less than 100 pressure,
* more than 100 F
temperature (about 38.3)

Search for
complications

=
- Liver : Jaundice ( )

misdiagnose
fulminant hepatitis
liver failure

- DKA : disturbed consciousness

,
- Renal : oliguria ,

you first should check for vital signs and presence of any complication (if found the
patient may need to be managed in ICU)
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2011 24

viability

- baby check -->

Medicolegal

medico-legal

Never Glucose

- acetone : DKA
- urinnalysis : ptnuria
- UOP

. *
ABG *
. *
. K,Na *
.-hCG *

We don't give glucose as this may lead to encephalopathy , only Saline & Ringer

Lab.

Drugs

clinical
cortigen B6

vomiting

:: zantac
gastritis

( )

primpran
*

* Electrolytes
* Urinalysis :
Ptn,Aceton

Vitals
Vomiting
U.O.P
U/S : Viablity

Feeding

zofran

oral fluids .. then

semisolid .. then solid

Fundus Exam

45

2011 24

upper endoscopy hematemesis .. zofran

termination
psychological
======================================================================================================

GIT Disorder
Gasritis :

( Epigastric pain + vomiting )

- Give Cortigen B6 to stop vomiting now , and when needed + Zantac as home ttt ( safe in 1st trimester )
( Reflux is common complaint in pregnant female as Progesteron hormone causes relaxation of sphincters .)

Gastro-enteritis : ( Epigastric pain + vomiting + diarrhea )

Stop vomiting as above + Antinal cap. ( no Metronidazole during 1st trimester ).

If bacterial ( + fever ) give Anti-biotic safe in pregnancy .. ( see UTI )

inputs from blood-borne drugs or hormones reaches CTZ that communicates with the vomiting center, to
initiate vomiting
Vomiting center

CTZ : CHEMORECEPTOR TRIGGER ZONE

Dopamine
Histamine

SO THE A NTI -EMETIC DRUGS WILL BE :

DRUG
D2 Receptor
Antagonists
Anti-Histamines
Serotonin Receptor
Antagonists
Steroids

46

CTZ in
Medulla

Circulation

Serotonin

SCINTEFIC NAME
METOCLOPRAMIDE
DOMPERIDONE
MECLOZINE
C YCLIZINE

TRADE NAME
PREMPIRAN
MOTILIUM, MOTINORM
NAVOPROXINE , NAVODOXINE
EMETRIX

ONDESTERON

Z OFRAN

C ORTIGEN B6

Life is the art of drawing without an eraser.

SAFE WITH PREGNANCY

2011 24