Management of obstetric emergencies in primary care

Dr Shuhaila AhmadJabatan Obstetrik &

GinekologiFakulti 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 patient’s condition which requires immediate medical or surgical intervention

Obstetrics: A branch of medicine that concerns

management of women during pregnancy, chldbirth and puerperium.

Taber’s 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 managementInitial 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

Rhesus negative mother Anti D antibodies must be given

within 72 hours Role of Kleihauer test

To calculate proper dosage of antiD Ab

Conclusion for APH Be sure of the diagnosis Initial assessment improves

patient’s 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 Treatment :

Blood transfusion and correction of DIVC Oxytocics Surgical treatment if failed medical

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 treat convulsion To prevent convulsion To control the blood pressure To 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

Diazepam Intravenous infusion of 40mg in 500

ml of normal saline at 10 dpm.

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 Foley’s 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)

Deliveries: Mainly caesarean section Instrumental deliveries is possible if

deem fast and easy.

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

Secondary : Excessive blood loss after the first 24 hours

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 General management:

Active resuscitation Oxytocics Look for possible cause and treat

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 Syntocinon Syntometrine (IM only) Haemabate (IM or intramyometrial)

Best to be given as intravenous route

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

Subacute: Occurs after the first 24 hours but before 4

weeks Chronic:

Presents more than 4 weeks postpartum Extremely rare

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) Correction of the inversion

Manual under regional / general anaesthesia O’Sullivan hydrostatic correction Combined abdominal-vaginal approach

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

Taber’s Cyclopedic medical dictionary. 15th eds. F.A Davis

Thank you for not sleeping!!