Management of obstetric emergencies in primary care

Dr Shuhaila Ahmad Jabatan Obstetrik & Ginekologi Fakulti Perubatan Universiti Kebangsaan Malaysia 14/12/2005

Scope of the lecture:

Definition of condition considered to be an obstetric emergency Understanding the significance Identifying these conditions Instituting appropriate management Issues regarding these conditions Conclusion

Definition

Emergency:

An sudden serious change in a patients condition which requires immediate medical or surgical intervention A branch of medicine that concerns management of women during pregnancy, chldbirth and puerperium.

Obstetrics:

Tabers cyclopedic medical dictionary

Conditions

Antepartum haemorrhage Abruptio placentae Impending eclampsia Eclampsia Cord prolapse Malpresentation Fetal distress Postpartum haemorrhage Uterine atony Retained placenta Uterine inversion

Case 1
32 year old Gravida 3 Para 2 at 34 weeks of gestation went to see a GP for PV bleeding 1. What is your diagnosis? 2. Outline your immediate and subsequent management?

Antepartum haemorrhage
Defined as : any bleeding from the genital tract from 22 weeks of gestation until before delivery

Below 22 weeks of gestation is considered as threatened miscarriage.

Possible causes:

Placenta praevia Abruptio placenta Local causes Vasa praevia

Initial management

Unpredictable and patient can deteriorate rapidly Aim:

To resuscitate and stabilize the patient To reassess patient and to make a diagnosis Consider delivery or conservative management

Flow chart of management

Initial assessment

Severe bleeding/shock

mild/moderate

Consider delivery

history/examination/investigation

Salvageable/non-salvagable

diagnosis & management

Issues:

Vaginal examination

Best to avoid until diagnosis of placenta praevia is excluded Anti D antibodies must be given within 72 hours

Rhesus negative mother

Role of Kleihauer test

To calculate proper dosage of antiD Ab

Conclusion for APH

Be sure of the diagnosis Initial assessment improves patients outcome Aim to prevent further deterioration of patient Transfer patient to an appropriate hospital for further management

Case 2

A 19 year old single school drop-out in her first pregnancy complained of severe abdominal pain after being punched in the stomach by her boyfriend. She was pale and tachycardic. The uterus was about 28 weeks size, tender and hard. No fetal heart activity was detected.

Diagnosis?

Abruptio placenta

Detachment of a normally sited placenta before the delivery of the fetus

Incidence : 0.5 1.8% 2 types:

Revealed : 65 80% Concealed : 20 -35% - most dangerous

Aetiology

Unknown except for direct trauma to the uterus. Known association with:

Cigarette smoking (decidual necrosis) Sudden decompression of uterus-polyhydramnios Placental abnormality Hypertension ?Folic acid deficiency

Outline your management if you are the attending doctor.

Resuscitate and stabilize the patient Do relevant investigations Consider delivery Anticipate PPH

Investigation

FBC Hb & platelet count Coagulation profile / bleeding time ? role of ultrasound scan

Management :

Active resuscitation Need to correct DIVC Consider delivery in most cases.

SVD should be chosen if there is fetal death If baby is alive, CS is reported to improve fetal outcome.

Issues :

Complications :

Maternal Fetal

Maternal complications

Maternal mortality Hypovolumic shock DIVC Acute renal failure Postpartum haemorrhage Recurrence

DIVC

Occurs in 25 to 30% of severe cases The ultimate treatment is delivery of the fetus and the placenta Meanwhile, correction of DIVC must continue

Postpartum haemorrhage

Due to:

couvelaire uterus Inhibitory action of FDP towards myometrial contraction Blood transfusion and correction of DIVC Oxytocics Surgical treatment if failed medical treatment

Treatment :

Recurrence risks:

One episode :

8 to 17%

Two or more episodes:

25 to 30%

Fetal complications

Perinatal mortality Prematurity Intrauterine growth retardation Fetal anemia and transient coagulopathy

Perinatal mortality

4.4% to 68% depending on:

Severity of abruptio placenta Timing of delivery Gestation of the pregnancy Neonatal facilities

Conclusion

Mainly a clinical diagnosis Ultrasound has a limited role DIVC sets in fast Appropriate resuscitative measures and timely delivery greatly influence both maternal and fetal outcome.

Case 3
21 year old primigravida at 36 weeks has refused hospital admission despite having persistent headache and blurring of vision since yesterday. Her blood pressure is 170/95mmHg and urine albumin 3+. Easy diagnosis,yes?

Eclampsia / Impending eclampsia

Eclampsia :

Occurrence of convulsion in a women whose condition meets the criteria of preeclampsia and not caused by coincidental neurological disease

Impending eclampsia

Is there such a condition? Preeclampsia with mainly neurological symptoms

Significance of this condition

Hypertensive disorder is the second leading cause of maternal mortality in Malaysia

Eclampsia encompasses one-third of the reason

Is it preventable?

If you are the attending doctor in the Pusat Kesihatan, outline your initial management.

Management:

Aim:

To To To To

treat convulsion prevent convulsion control the blood pressure transfer to hospital with facilities for:

Ceasarean section Blood transfusion Intensive care for mother and newborn

Treat convulsion

Magnesium sulphate

Treatment of choice Deep IM injection of 5 gm to each buttocks (total 10 gm) Intravenous slow bolus 4 gm

Diazepam

Intravenous or intramuscular bolus 10 mg

Prevent convulsion

Magnesium sulphate

Intramuscular 5 mg in alternate buttocks every 4 hourly for 24 hours Intravenous infusion : 1 to 2 mg/hour for 24 hours Intravenous infusion of 40mg in 500 ml of normal saline at 10 dpm.

Diazepam

To control blood pressure

Nifedipine 10 mg slow release Intramuscular Hydrallazine 2.5-5.0 mg every 20 minutes Intravenous Hydrallazine infusion Intravenous and intramuscular Labetolol Monitor BP every 15 minutes

Transfer to hospital

Accompanied preferably by a doctor Keep patient in left lateral position Insert an airway Give oxygen via nasal prong/ventimask Insert Foleys catheter Monitor urine output and vital signs

If you are the receiving doctor in the hospital, how would you further manage this patient?

Consider delivery!

Role of Dexamethasone Timing of delivery Method of delivery

CS is the preferred method if delivery is not imminent Prophylactic instrumental delivery may be feasible if patient is already in second stage of labour

How long Mg SO4 should be infused? Should the antihypertensive be continued postpartum? What is the critical period during the postpartum where patients could develop eclampsia?

Conclusion

The initial management of patient influences the outcome of the patient Institution of anticonvulsant (Magnesium sulphate) has proven to reduce complications especially maternal deaths Eclampsia could be prevented by early detection of PIH/preeclampsia.

A Gravida 4 Para 3 at 38 weeks gestation has been in the ward for further management of unstable lie. As the house officer on call, you are called by the staff nurse to review this patient as she has started leaking.

Will you attend to the patient urgently?

Definition of cord prolapse

Cord presentation:

Umbilical cord is the lowermost part of the fetus present in lower segment with intact amniotic membrane

Cord prolapse:

As above without intact amniotic membrane

Significance of this condition

It causes acute severe fetal distress It is preventable in many cases:

should be able to identify possible conditions which may predispose :

Abnormal lie Multiple pregnancies Grand multiparae Preterm labours Polyhydramnios Obstetric manipulation ( forceps delivery )

Management

Do not panic Reposition patient:

Traditional knee-chest position (facing downwards) Steep tredenlenburg position with left lateral tilt

Replace umbilical cord into the vagina and place a warm pad over the introitus

How to prevent cord compression ?

Manually elevate the presenting part

( placing a gloved hand in the vagina)

Vago in 1970 :

Inflating the bladder with 500 to 700 ml of normal saline

Urgent delivery Paediatric standby to resuscitate the baby

Issues

Timing :

Better outcome if interval between cord prolapse and delivery is short ( less than 15 minutes) Mainly caesarean section Instrumental deliveries is possible if deem fast and easy.

Deliveries:

A Gravida 3 Para 2 at 38 weeks of gestation with uncontrolled GDM is currently in labour.

What problems would anticipate in this labour?

Shoulder dystocia

Definition:

Difficulty in delivering the anterior shoulder after the head

The anterior shoulder is stuck behind the symphisis pubis Shoulder dystocia cannot be predicted

You are hoping she will end up with secondary arrest of labour but she managed to reach second stage of labour. Most unfortunately, your registrar was called off urgently for a ruptured ectopic pregnancy and you are instructed to conduct the delivery. To your dismay, she pushed and the head was out but it pressed hard against the perineum.

Management

Shout for help Aim:

To widen the pelvic inlet To rotate the shoulder to a bigger diameter of the pelvic inlet To reduce the diameter between the shoulders ( fracture both clavicles) Symphisectomy

After delivery of the fetus and placenta, there is torrential bleeding from the internal os. The patient becomes pale and hypotensive. Diagnosis, please?

Definition

Blood loss of more than 500 ml from the genital tract following delivery of the fetus

Primary :

within the first 24 hours Excessive blood loss after the first 24 hours

Secondary :

Significance of this condition

The major cause of maternal mortality in Malaysia So important, KKM has national guidelines and conducted echo-training nationwide.

any difference, anybody ?

It is a preventable condition

Problem arising:

Underestimation of blood loss Delayed intervention Managed by most junior staff

Causes

Uterine atony (79-90%) Retained placenta / cotyledons Trauma :

Uterine rupture Broad ligament haematoma Cervical tears Vaginal tears / haematoma Vulval tears / haematoma

Treatment

Aim:

Active resuscitation according to the degree of hypovolumic shock Treat the cause Prevent complications such as:

DIVC Renal failure Sheehan syndrome

Summary of management options:

Prevention:

Identify high risk patients Active management of third stage of labour Active resuscitation Oxytocics Look for possible cause and treat

General management:

When does a low risk patient becomes a high risk patient?

Prolonged labour Precipitated labour Instrumental or difficult deliveries Unsuspected abruptio placenta Retained placenta Uterine inversion

Modalities to arrest bleeding

Oxytocics

Ergometrine Best to be given as intravenous route Syntocinon Syntometrine (IM only) Haemabate (IM or intramyometrial)

Modalities to arrest bleeding

Uterine massage:

Rub at the fundus of the uterus To ensure contraction To expel blood and blood clots

Blood clots in uterine cavity prevents effective uterine contraction

Modalities to arrest bleeding

Bimanual uterine compression

To oppose the anterior and posterior wall together Reduce potential areas of bleeding Temporary measure

Modalities to arrest bleeding

Aortic compression

To arrest bleeding by reducing the perfusion via the common iliac arteries Have to be released intermittently to prevent ischaemia of lower limbs

Uterine atony

Failure of uterus to contract which results in excessive bleeding Possible cause:

Overdistension of uterus Grandmultiparae High dose / prolonged oxytocin infusion Precipitous or prolonged labour Abruptio placenta General anesthesia

Treatment

Massage the fundus of uterus continuously Oxytocics given as sequentially or together Examine placenta for completeness Early blood transfusion enhances uterine contractions Bimanual compression of the uterus Aortic compression

Surgical treatment

A last resort:

Conservative

Internal iliac ligation B-Lynch suturing Occlusion of uterine and ovarian arteries Uterine arteries embolization

Aggressive

hysterectomy

A junior medical student was conducting his first delivery. The baby was out and the staffnurse who was assisting him left him for a while. Unsupervised, he decided to perform CCT before there was any sign of placental separation What would be the consequence of his action?

Uterine inversion

Complete / incomplete:

Depends whether fundus has passed through the cervix

Acute:

Occurs within the first 24 hours post partum

Occurs after the first 24 hours but before 4 weeks Presents more than 4 weeks postpartum Extremely rare

Subacute:

Chronic:

Risk factors

Fundally sited placenta Overdistension of uterus Oxytocic use Incorrect technique in third stage of labour

How to diagnose?

Severe pain In shock Mass protuding in the vagina Indentation in the fundus of the uterus

Treatment

Alleviate pain

Parenteral analgesia (opiate) Manual under regional / general anaesthesia OSullivan hydrostatic correction Combined abdominal-vaginal approach

Correction of the inversion

Antibiotic coverage Ensure continuous uterine contraction

Manual replacement

Should be attempted first Oxytocic should be deferred first Placenta should not be detached prior to correction The first portion out should be replaced last With general anaesthesia, halothane further relaxes the uterus

References:

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors.WHO 2003 James DK,Steer PJ,Weiner CP,Gonik B eds.High risk pregnancy:Management options. 2nd ed. W.B Saunders. James M, Timothy D, Robert F, Micheal R eds.Obstetrics and Gynaecology: a problem solving approach.1st ed. W.B Saunders. Training manual on Hypertensive disorders in pregnancy.National Technical Committee Confidential enquiries into Maternal Death. Ministry of Health Malaysia 2003 Tabers Cyclopedic medical dictionary. 15th eds. F.A Davis

Thank you for not sleeping!!