OBSTETRIC EMERGENCY _IN PRIMARY CARE.pptx

8/18/2019 OBSTETRIC EMERGENCY _IN PRIMARY CARE.pptx

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OBSTETRIC EMERGENCIESIN PRIMARY CARE

Dr. Chew Kah Teik

Clinical Lecturer S!eciali"t

De!art#ent $% O&"tetric" G'naec$l$(')ni*er"iti Ke&an("aan Mala'"ia Me+ical Centre


2/93

+De,niti$n

O&"tetric"-

A branch of medicine that

concerns management of

women during pregnancy,chldbirth and puerperium

Emergency: An sudden serious change in

a patient’s condition which

requires immediate medical

or surgical intervention


3/93

+O&"tetric E#er(encie"

Mi"carria(e

Ect$!ic !re(nanc'

Placenta !rae*ia

A&ru!ti$ !lacenta Preecla#!"ia

Ecla#!"ia

C$r+ !r$la!"e

Sh$ul+er +'"t$cia

P$"t !artu# hae#$rrha(e


4/93

+Ca"e "cenari$

28-year-old woman presented to youwith a short history of lower abdominal

pain and vaginal bleeding. Her periodis overdue. Summarise your approachto diagnosis.


5/93

+

The history:

the ti#in( $% $n"et $% !ain/ the +i"tri&uti$n$% !ain/ the $ccurrence $% "'nc$!e an+"h$ul+er ti! !ain

the ti#in( $% $n"et an+ t'!e $% &lee+in(

$ther area" inclu+in( the u"e $%c$ntrace!ti$n/ ti#in( $% la"t #en"e"/#e+ical an+ "ur(ical hi"t$r'/ an+i+enti,cati$n $% $ther ri"k %act$r" +e"cri&e+a&$*e inclu+in( %ertilit' treat#ent" an+!re*i$u" STD


6/93

+

The examination: the (eneral clinical "tate

a&+$#inal an+ !el*ic !h'"ical "i(n"/e"!eciall' the cer*i0/ uteru" an+ a+ne0ae

Diferential diagnosis: relate+ t$ !re(nanc'

relate+ t$ n$n!re(nant ('naec$l$(ical+i"$r+er"

relate+ t$ n$n('naec$l$(ical +i"$r+er"


7/93

+

Investigation:

%ull &l$$+ c$unt an+ (r$u!in(

clinical "ituati$n #a' re1uire re"u"citati$nan+ $!erati$n with$ut an' %urtherin*e"ti(ati$n

i% clinical "ituati$n all$w" %urtherin*e"ti(ati$n/ urine !re(nanc' te"t 23hCG i%ne(ati*e4 an+ ultra"$un+ "can


8/93

+Earl' !re(nanc'

e#er(enc'

Pre"ente+ a" acutea&+$#inal !ain an+5$r*a(inal &lee+in(

Man' +i6erential +ia(n$"i"$% acute a&+$#inal !ain

Re1uire hi(h in+e0 $%

"u"!ici$u" i%-7a(inal &lee+in(

A&+$#inal !ain

Peri$+ $% a##en$rrh$ea Mi"carria(e

Ect$!ic!re(nanc'


9/93

+Mi"carria(e

Cau"e"-

Chr$#$"$#al

a&n$r#alitie" 8etal a&n$r#alitie"

Placenta a&n$r#alitie"

In%ecti$n

Me+ical +i"ea"e"

S!$ntane$u" l$"" $%!re(nanc' &e%$re9: week" $%

(e"tati$n

C$#!lete/inc$#!lete/

"e!"i"/ #i""e+/ine*ita&le

;"t tri#e"ter $r 9n+ tri#e"ter


10/93

+Mi"carria(e

Pre"entati$n-

L$wer a&+$#inal !ain

7a(inal &lee+in(

8e*er

Purulent *a(inal +i"char(e


11/93

+Mi"carria(e

In !ri#ar' care "ettin(/+ia(n$"i" $% #i"carria(ecan &e +i=cult/

!articularl' when the POCare n$t $&*i$u"

De,niti*e +ia(n$"i" i"&a"e+ $n the c$n,r#ati$n

$% !a""a(e $% POC $rultra"$un+ ,n+in("

I)GS

8etal ech$

En+$#etriu# thickne""

A+ne0al #a""


12/93

+Mi"carria(e

There%$re/ +i6erential+ia(n$"i" $% earl'!re(nanc' &lee+in( #u"t

inclu+e-N$r#al !re(nanc'

&lee+in(

Ect$!ic !re(nanc'

I% !$""i&le/ all ti""ue"h$ul+ &e retaine+ an+

"en+ t$ the recei*in(h$"!ital %$r


13/93

+Mana(e#ent

I% "i(ni,cant $% hae#$rrha(e/ "tan+ar+!r$t$c$l $% re"u"citati$n Bl$$+

8lui+

I% e*i+ence $% "e!"i"/ c$n"i+er anti&i$tic"

Pain #ana(e#ent- anal(e"ia

Tran"%er t$ h$"!ital


14/93

+Ect$!ic

!re(nanc'

I" thei#!lantati$n$% a!re(nanc'$ut"i+e theen+$#etrialca*it'


15/93

+Ect$!ic !re(nanc'

The inci+ence $% ect$!ic!re(nanc' in the )K i"a!!r$0i#atel' ;>

Gl$&all'/ the inci+encea!!ear" t$ &e in increa"in(tren+.

M$re "en"iti*e +ia(n$"tic#eth$+

ART

Increa"e+ !el*ic

in?a##ati$n +i"ea"e


16/93

+Ect$!ic !re(nanc'

Pre"entati$n"-

Acute a&+$#en

L$wer a&+$#inal !ain

Sh$ck

7a(inal &lee+in( cauti$n-an ect$!ic !re(nanc' i"u"uall' %ailin( an+ "$%allin( !r$(e"ter$ne le*el"%r$# the c$r!u" luteu#

can in+uce a with+rawal&lee+/ #i#ickin(#i"carria(e

Ri"k %act$r"-

Pre*i$u" ect$!ic Pre*i$u" tu&al

"ur(er'

I)CD

Su&%ertilit'

S#$kin(


17/93

+Ect$!ic !re(nanc'

Pre"entati$n"-

S'nc$!e

Sh$ul+er ti! !ain hae#$!erit$neu# +ue t$hae#$rrha(e %r$# thea6ecte+ tu&e cau"e" !ain

an+ +ia!hra(#atic irritati$n7$#itin(

Ga"tr$inte"tinal "'#!t$#"/

!articularl' +iarrh$ea an++i@@ine""/ in earl' (e"tati$nare i#!$rtant in+icat$r" $%ect$!ic !re(nanc'


18/93

+

D$e" a ne(ati*e !re(nanc' te"te0clu+e an ect$!ic !re(nanc'

Tu&al ru!ture ha" &een re!$rte+ with ane(ati*e urinar' an+ "$#eti#e" e*en ane(ati*e "eru# !re(nanc' te"t. Thi" i"e0tre#el' rare. A ne(ati*e te"t n$r#all'e0clu+e" a clinicall' "i(ni,cant ect$!ic!re(nanc' +ue t$ in"u=cient %uncti$nin(tr$!h$&la"t.


19/93

+Ect$!ic !re(nanc'

An intrauterine (e"tati$n"ac i" hi(hl' "!eci,c 2>4%$r e0clu"i$n $% an ect$!ic

!re(nanc'

Err$r" #a' &e +ue t$ a!"eu+$"ac $r heter$t$!ic!re(nanc'

Tran"*a(inal "cannin( cani+enti%' #$"t intrauterine!re(nancie" %r$# when

the hCG le*el reache"; iu5l 2the+i"cri#inat$r' le*el4

)ltra"$un+in*e"ti(ati$n"

I" the "in(le #$"tu"e%ul +ia(n$"tict$$l

T$ +etect an I)GS

$r i+enti%'%eature" $%ect$!ic!re(nanc'


20/93

+Ect$!ic Pre(nanc'- ultra"$un+ %eature"

8ree !erit$neal ?ui+

A c$#!le0 $r h$#$(en$u" a+ne0al#a""

An a+ne0al (e"tati$n "ac with $rwith $ut %etal !$le

A tu&al rin(F "i(n


21/93

+Ect$!ic !re(nanc'

In earl' *ia&le intrauterine!re(nancie"/ the le*el $%"eru# +$u&le" 2ri"e" &'

> $r #$re4 a!!r$0i#atel'e*er' tw$ +a'"

In %ailin( intrauterine an+c$ntinuin( ect$!ic

!re(nanc'/ the +$u&lin(ti#e %$r 3hCG i" u"uall'l$n(er

Plateauin( le*el" $% "erial 3

hCG #ea"ure#ent" in+icatethat %urther a""e""#ent i"nece""ar'

Beta hCG-

Le*el +$ n$t tellu" the l$cati$n $%

a !re(nanc'


22/93

+Ect$!ic !re(nanc'

Le*el" &el$w 9 "u((e"t a%ailin( !re(nanc'/irre"!ecti*e $% l$cati$n

Le*el" %r$# 9 t$ area""$ciate+ with a hi(h ri"k$% ect$!ic !re(nanc' inthe %ace $% 3hCG le*el"

a&$*e 9H iu5l

Le*el" "u((e"t a!r$(re""in( !re(nanc'/

#$"t $% which will &eintrauterine

Pr$(e"ter$ne- Ma' i#!r$*e

+ia(n$"ticaccurac' i% u"e+

in c$#&inati$nwith 3hCG


23/93

+Mana(e#ent

Sta&le


24/93

+Ca"e "cenari$

A 19 year old single school drop-out in herfirst pregnancy complained of severe

abdominal pain after being punched in thestomach by her boyfriend

!he was pale and tachycardic "he uteruswas about #$ wee%s si&e, tender and hard'o fetal heart activity was detected

(hat is the diagnosis)


25/93

+Ante!artu#hae#$rrha(e

Cau"e"-

Placenta !rae*ia 29>4

A&ru!ti$ !lacenta 2J4>4

7a"a !ae*ia

)terine ru!ture

Cer*ical le"i$n

Trau#a

C$#!licate" 9 H> $%all !re(nanc'

It i" +e,ne+ a"&lee+in( $% the(enital tract/

$ccurrin( %r$# 9:week" $% (e"tati$nuntil &irth


26/93

+Placenta Prae*ia

Blee+in( $ccur" whenuterine c$ntracti$n" +ilate

the cer*i0/ there&' a!!l'in(the "hearin( %$rce" t$ the!lacental attach#ent in thel$wer uterine "e(#ent

I" a !lacenta that i"!artiall' $r wh$ll'i#!lante+ int$ thel$wer uterine"e(#ent


27/93

+Placenta !rae*ia

Ri"k %act$r"-

Increa"e+ #aternal a(e

Increa"e !arit'

Pre*i$u" Cae"arean"ecti$n

Pre*i$u" uterine "ur(er'

Increa"e+ "ur%ace area $%!lacenta

S#$kin(

A&$ut > $%!re(nancie" are!rae*ia

S'#!t$#atic

!lacenta !rae*ia$ccur" in &etween.: an+ .> $%!re(nancie"


28/93

+Placenta !rae*ia

Pre"entati$n-

Painle"" *a(inal &lee+in(

7a(inal &lee+in( u"uall'&ri(ht re+

Sh$ck

S$%t/ n$nten+er uteru"


29/93

+Mana(e#ent

I% !r$%u"e &lee+in(/ re"u"citati$n an+ re%er t$neare"t h$"!ital %$r +eli*er' re(ar+le"" the(e"tati$nal a(e $% the %etu"

I% "ta&le/ a+#it t$ h$"!ital %$r e0!ectant#ana(e#ent


30/93

+A&ru!ti$ !lacenta

It i" $%ten an unantici!ate+e#er(enc'/ alth$u(h a "#all&lee+ can "u++enl' e*$l*eint$ a #a$r a&ru!ti$n

There%$re/ *i(ilance i"e""ential

Blee+in( &e(in" in the

+eci+ua &a"ali" an+ lea+" t$"e!arati$n $% the !lacenta%r$# it" attach#ent t$ theuterine wall

Thi" "e!arati$n can &e !artialan+ "el%li#itin( $r can e0ten+until there i" %etal h'!$0iaan+/ ulti#atel'/ +e#i"e

It i" +e,ne+ a" the

!re#ature"e!arati$n $% then$r#all' "ite+!lacenta %r$# the

uteru"


31/93

+A&ru!ti$ !lacenta

Bl$$+ i" "een at the *a(inaa" it track" +$wn the uteru"&etween the #e#&rane"

an+ the uterine wall I% there i" a lar(e !re""ure

(enerate+ in the uteru"/the &l$$+ can e0ten+ int$

the #'$#etriu#2C$u*elaire uteru"4

Thi" uteru" &ec$#e"weakene+ an+ can ru!ture

with increa"e+ intrauterine!re""ure +urin(c$ntracti$n"


32/93

+A&ru!ti$ !lacenta

Pre"entati$n-

Pain%ul *a(inal &lee+in(

Dark &l$$+

A&+$#inal !ain c$##$nl' c$n"tant !ain

)terine ten+erne"" %etal+i"tre"" $r I)D

E*i+ence $% DI7C

Sh$ck

The +ia(n$"i""h$ul+ &e

c$n"i+ere+ in an'!re(nant w$#enwith a&+$#inal!ain/ e*en with$ut

e*i+ence $% *a(inal&lee+in(


33/93

+

A&ru!ti$ !lacenta


34/93

+

A&ru!ti$ !lacenta


35/93

+A&ru!ti$ !lacenta- cla""i,cati$n

Class 0 Cla"" i" a"'#!t$#atic

Dia(n$"i" i" #a+e retr$"!ecti*el' &' ,n+in( an $r(ani"e+&l$$+ cl$t $r a +e!re""e+ area $n a +eli*ere+ !lacenta

Class 1

Mil+ $r n$ *a(inal &lee+in( with n$ #aternal $r %etal

c$#!r$#i"eClass 2

M$+erate $r n$ *a(inal &lee+in( with !$""i&le #aternale*i+ence $% &l$$+ l$"" 2tach'car+ia5#il+ h'!$ten"i$n &ut n$clinical c$a(ul$!ath'4

8etal +i"tre""

Class 3 Se*ere $r n$ *a(inal &lee+in( with #aternal c$#!r$#i"e

2tach'car+ia/ h'!$ten"i$n an+ c$a(ul$!ath'4

Ten"e/ ten+er uteru"/ w$$+' har+

Intrauterine %etal +eath


36/93

+A&ru!ti$ !lacenta


37/93

+A&ru!ti$ !lacenta

Intrauterine +eath


38/93

+Mana(e#ent $% an AP<


39/93

+Re"u"citati$n

Re"u"citati$n "h$ul+ %$ll$w the "tan+ar+ A2airwa'4/ B 2&reathin(4/ C 2circulati$n4 a!!r$achhi(h?$w $0'(en 2;;H l5#in4 an+ le%t lateral tilt

&a( an+ #a"k i% nece""ar'

lar(e &$re intra*en$u" acce"" !re%era&l' tw$;:(au(e cannulae

I7 ?ui+"

)! t$ 9 l cr'"tall$i+

)! t$ ;9 l c$ll$i+ until &l$$+ arri*e"C$n"i+er C7P

In+wellin( &la++er catheter


40/93

+


41/93

+Preecla#!"ia

Ge"tati$nal h'!erten"i$n $% at lea"t;:5 ##


42/93

+Preecla#!"ia

re"ult %r$# a c$#&inati$n$% i#!aire+ tr$!h$&la"t+i6erentiati$n an+

in*a"i$n +urin( the ,r"ttri#e"ter

re"ultin( in the %ailure $%tr$!h$&la"t cell" t$ +e"tr$'

the #u"culari" la'er $% the"!iral arteri$le" re"ultin(in the +e*el$!#ent $% a!$$rl' !er%u"e+ !lacenta

c$#!licatin( 9>$% !re(nancie"


43/93


44/93

+Preecla#!"ia

Ri"k %act$r"-

Pri#i(ra*i+a

A+*ance+ #aternal a(e

Pre*i$u" hi"t$r' $% !reecla#!"ia

O&e"it'

Dia&ete" #ellitu"

Pree0i"tin( h'!erten"i$n

APS


45/93

+Preecla#!"ia-!re+icti$n

Angiogenic actors

*a"cular en+$thelial(r$wth %act$r 27EG84

!lacental (r$wth %act$r2PlG84

"$lu&le en+$(lin 2"En(4an+ "8lt;

ha*e &een "h$wn t$ &ealtere+ in !re(nanc'

the u"e a" !re+icti*ete"t" ha" &een

+i"a!!$intin(

There i" "till n$clinicall' u"e%ul"creenin( te"t t$!re+ict !reecla#!"ia


46/93

+Preecla#!"ia-!re+icti$n

terine artery Do!!lervelocimetry

Increa"e+ i#!e+ance in

the uterine arterie" i" anearl' ra+i$(ra!hic%eature $% !reecla#!"ia


47/93

+Preecla#!"ia-!re*enti$n

L$w+$"e a"!irin ha" &een"h$wn t$ !re*ent the+e*el$!#ent $% !re

ecla#!"ia in w$#an at#$+eratet$hi(h ri"k $%!reecla#!"ia &'a!!r$0i#atel' ;;H>

A+*i"e w$#en at hi(h ri"k$% !reecla#!"ia t$ takeQH #( $% a"!irin +ail' %r$#;9 week" until the &irth $%

the &a&'

A"!irin

Antic$a(ulati$n

Calciu#

Anti$0i+ant


48/93


$#en at hi(h ri"k areth$"e with an' $% the%$ll$win(-

h'!erten"i*e +i"ea"e+urin( a !re*i$u"!re(nanc'

chr$nic ki+ne' +i"ea"e

aut$i##une +i"ea"e/"uch a" "'"te#ic lu!u"er'the#at$"i" $ranti!h$"!h$li!i+

"'n+r$#e t'!e ; $r t'!e 9 +ia&ete"

chr$nic h'!erten"i$n

A"!irinAntic$a(ulati$n

Calciu#

Anti$0i+ant


49/93


The u"e $% antic$a(ulant"/"uch a" l$w#$lecularwei(ht he!arin $run%racti$nate+ he!arin/are n$t rec$##en+e+ %$r

re+ucin( the ri"k $% !reecla#!"ia in either the(eneral !$!ulati$n $r inth$"e with a !re*i$u"

hi"t$r' $% !reecla#!"ia


Calciu#

Anti$0i+ant


50/93

+Preecla#!"ia-!re*enti$n R$utine calciu#

"u!!le#entati$n %$rhealth'/ nulli!ar$u" w$#eni" n$t rec$##en+e+ in the!re*enti$n $% !reecla#!"ia

There #a' &e "$#e &ene,tin calciu# "u!!le#entati$nin "$#e hi(hri"k!$!ulati$n" with a l$w

calciu# +iet


Calciu#

Anti$0i+ant


51/93


N$ &ene,t ha" &een+e#$n"trate+ with the u"e$% anti$0i+ant"/ "uch a"*ita#in C an+ E


Calciu#

Anti$0i+ant

O %


52/93

+Preecla#!"ia

Occurrence $% $ne $r #$rec$n*ul"i$n"/ n$tattri&uta&le t$ $ther

cere&ral c$n+iti$n" in a!atient with !reecla#!"ia

Ma' $ccur a" !art $% theinitial !re"entati$n $% !re

ecla#!"ia-> $% ,t" $ccur

antenatall'

;> $ccur intra!artu#

the re#ainin( ::> $ccur!$"t!artu#/ u"uall' inthe ,r"t 9:: h$ur"

Ecla#!"ia

Se*ere !reecla#!"ia

+Ecla#!"ia


53/93

+Preecla#!"ia

Ecla#!"ia

Se*ere h'!erten"i$n SBP ;##


54/93

+Preecla#!"ia-Mana(e#ent

Bl$$+ "h$ul+ &e "ent %$r-

"eru# electr$l'te" 2Na/K/ urea/ creatinine/ urate4

li*er %uncti$n te"t"2al&u#in/ ALT4

%ull &l$$+ c$unt 2


55/93


BP an+ !ul"e #ea"ure+ e*er' ;H#inute" until "ta&ili"e+ then hal%h$url'

in+wellin( catheter in"erte+ urine

$ut!ut #ea"ure+ h$url' whene*er I7?ui+" are (i*en. All urine te"te+ %$r!r$tein

O9 "aturati$n #ea"ure+ c$ntinu$u"l'

an+ charte+ with BP. I% "aturati$n

H>/ then #e+ical re*iew i"e""ential

?ui+ &alance "h$ul+ &e #$nit$re+*er' care%ull'. Detaile+ in!ut an+$ut!ut rec$r+in(" "h$ul+ &e charte+h$url'

re"!irat$r' rate #ea"ure+ h$url'

%etal well&ein( "h$ul+ &e a""e""e+care%ull' CTG/ !$""i&l' (r$wth"can/ li1u$r a""e""#ent an+

u#&ilical arter' D$!!ler

Ba"ic in*e"ti(ati$n

M$nit$rin(Antih'!erten"i*e

Antic$n*ul"ant

8lui+ #ana(e#ent

Deli*er'

+ Ai# t$ re+uce &l$$+


56/93


Ai# t$ re+uce &l$$+!re""ure t$ ;5;H2MAP ;9H ##


57/93


"irst agent o choice la#etalol

Initial 9 #( can &e (i*en $rall'2!ri$r t$/ $r in the a&"ence $%/ I7acce""4

I% n$ re"!$n"e in #inute"/ a"ec$n+ $ral +$"e can &e (i*en

I% there i" n$ initial re"!$n"e t$ $ralthera!' $r it i" n$t t$lerate+/!r$cee+ t$ (i*e a &$lu" $% H #( &'I7/ $*er at lea"t ,*e #inute"/

re!eate+ t$ a #a0i#u# $% 9 #(at ; #inute inter*al"

8$ll$win( thi"/ $r a" treat#ent %$r#$+erate h'!erten"i$n/ a la&etal$lin%u"i$n "h$ul+ &e c$##ence+U H#(5#l at : #l5h$ur *ia "'rin(e !u#!

in%u"i$n rate +$u&le+ e*er' #inute" t$ a #a0i#u# $% 9 #l 2;#(45h$ur until BP ha" +r$!!e+ an+ i""ta&ili"e+ at an acce!ta&le le*el

C$ntrain+icati$n "e*ere a"th#a/cauti$n in car+iac +i"ea"e

Ba"ic in*e"ti(ati$n


Antic$n*ul"ant

8lui+ #ana(e#ent

Deli*er'

+ $econd agent o choice


58/93


$econd agent o choice hydrala%ine

B$lu" in%u"i$n i" ;9 #($*er ;9 #inute"/

#ea"urin( BP e*er' H #in Ma' &e %$ll$we+ &' an in%u"i$n

$% : #( $% h'+ral@ine in :#l n$r#al "aline/ which "h$ul+run at ;H #l5hr 2;H #(5hr4

Ba"ic in*e"ti(ati$n


Antic$n*ul"ant

8lui+ #ana(e#ent

Deli*er'

+ Ma(ne"iu# "ul%ate i" T&'


59/93


Ma(ne"iu# "ul%ate i" T&' +ru( $% ch$ice

L$a+in( +$"e then in%u"i$n%$r 9: h$ur" $r until 9:h$ur" a%ter +eli*er'-

l$a+in( : ( I7 $*er H; #inute"

#aintenance : ( I7$*er : h$ur" 2; (5h$ur4

Ba"ic in*e"ti(ati$n


Antic$n*ul"ant

8lui+ #ana(e#ent

Deli*er'

+ Clinical re*iew "h$ul+ $ccur


60/93


Clinical re*iew "h$ul+ $ccure*er' : h$ur"-

c$ntinu$u" !ul"e

$0i#etr' 2alertanae"theti"t i% O9

"aturati$n H>4

h$url' urine $ut!ut

h$url' re"!irat$r' rate re?e0e" 2: h$url'4

Ce""ati$n $r re+ucti$n $%#a(ne"iu# thera!' i%-

re?e0 a&"ent

re"!irat$r' rate i";95#inute

Ba"ic in*e"ti(ati$n


Antic$n*ul"ant

8lui+ #ana(e#ent

Deli*er'

+ A+*er"e e6ect" $%


61/93


A+*er"e e6ect" $%#a(ne"iu# "ul%ate t$0icit'inclu+e-

#$t$r !aral'"i"a&"ent re?e0e"

re"!irat$r' +e!re""i$n

car+iac arrh'th#ia

N$te that Q> $% M(SO: i"

e0crete+ in the urine $li(uria 2 #l59: h$ur"4can lea+ t$ t$0icit'.

There%$re/ in the !re"ence $%$il(uria/ M(SO: "h$ul+ &e

re+uce+5withhel+

Anti+$te ; #l ;>

calciu# (luc$nate "l$wl'

Ba"ic in*e"ti(ati$n


Antic$n*ul"ant

8lui+ #ana(e#ent

Deli*er'

+ Care%ul ?ui+ &alance i"


62/93


Care%ul ?ui+ &alance i"ai#e+ at a*$i+in( ?ui+$*erl$a+

T$tal in!ut "h$ul+ &e li#ite+t$ #l5h$ur 2a!!r$0i#atel'; #l5k(5h$ur4

I% $0't$cin i" u"e+/ it "h$ul+

&e at hi(h c$ncentrati$n an+the *$lu#e $% ?ui+ inclu+e+in t$tal in!ut

Oli(uria "h$ul+ n$t

!reci!itate an' "!eci,cinter*enti$n/ e0ce!t t$enc$ura(e earl' +eli*er'

Ba"ic in*e"ti(ati$n


Antic$n*ul"ant

8lui+ #ana(e#ent

Deli*er'

+ Deli*er' "h$ul+ &e well


63/93


Deli*er' "h$ul+ &e well!lanne+/ $n the &e"t +a'/in the &e"t !lace/ &' the

&e"t r$ute an+ with the&e"t "u!!$rt tea#

Once "ta&ili"e+ an+ in thea&"ence $% ecla#!"ia/ a

+eci"i$n can &e takenre(ar+in( ai#in( t$!r$l$n( !re(nanc' t$i#!r$*e %etal $utc$#e

Deli*er' i" n$t nece""aril'&' cae"arean "ecti$n

Ba"ic in*e"ti(ati$n


Antic$n*ul"ant

8lui+ #ana(e#ent

Deli*er'

+


64/93

+Ca"e "cenari$

A *ravida + ara at $ wee%s gestation

has been refusing hospital admission for

unstable lie !he is being under your care in."!

(hile waiting to be seen in your clinic, she

has lea%ing- flooding/

(ill you attend to this patient urgently)

+ It $ccur" a%ter the


65/93

+C$r+ Pr$la!"e

It $ccur" a%ter the#e#&rane" ha*eru!ture+/ when the

u#&ilical c$r+ "li!" +$wnin %r$nt $% the !re"entin(!art $% the %etu" an+!r$tru+e" int$ the *a(ina

Rare $&"tetric e#er(enc'

A""$ciate+ with hi(h!erinatal #$rtalit'

+Can &e $*ert $r $ccult


66/93

+C$r+ Pr$la!"e

O*ert c$r+ !r$la!"e can &e +ia(n$"e+either &' "eein( the c$r+ !re"entin(%r$# the *a(ina/ $r un e0!ecte+l'

!al!ate+ +urin( a *a(inale0a#inati$n

Occult c$r+ !r$la!"e+ can $ccuran'ti#e +urin( la&$urU it can &e"u"!ecte+ with &ra+'car+ia/!r$l$n(e+ +ecelerati$n"/ an+5$r*aria&le +ecelerati$n" with CTG

A&n$r#al 8


67/93

+C$r+ Pr$la!"e

Ri"k %act$r"-

)nen(a(e+ !re"entin(!art

Mal!re"entati$n)n"ta&le lie

P$l'h'+ra#ni$"

Pre#aturit'

Gran+ #ulti!arit' 2 H4

Breech !re"entati$n

PPROM

ARM

+ S!ecial c$n"i+erati$n"


68/93

+C$r+ Pr$la!"e

S!ecial c$n"i+erati$n"

Pre""ure $% the !re"entin(!art $n the c$r+ #a'

re"trict u#&ilical c$r+ &l$$+?$w re"ultin( in acute %etalheart rate chan(e"/ which/i% !er"i"tent h'!$0ia lea+"

t$ a"!h'0ia The !rinci!le $% !reh$"!ital

#ana(e#ent i" t$ #$nit$rthe

c$r+ %$r !ul"ati$n" an+ u"e#aternal !$"iti$nin( t$!re*ent c$#!re""i$n

+


69/93

+Mana(e#ent

I cord !rola!se is s(s!ected) !erorm avaginal examination to determine

Cervical length * efacement * dilatation

$tation o !resenting !art

I the cord is !al!ated) determine i!(lsations are !resent ,itho(t(nnecessary mani!(lation o the cord-

+


70/93

+Mana(e#ent

I cord !rola!se is con.rmed cord!al!ated-) call or hel!

/osition !t head do,n ,ith hi!s

elevated in neechest) modi.ed $ims)or Trendelen#(rg-

ee! gloved hand in vagina or insertgloved hand into vagina i not already

!erorming digital vaginal exam- andexert (!,ard !ress(re on the etal!resenting !art to sto! com!ression othe cord

ee! hand in !osition (ntil delivery

+


71/93

+Mana(e#ent

D$ n$t atte#!t t$ re!lace c$r+ a&$*e the!re"entin( !art 2t$uchin( the c$r+ #a' cau"e*a"$"!a"#4

I% re1uire tran"%er t$ an$ther h$"!ital-

8illin( &la++er with H Q #L n$r#al"aline t$ ele*ate %etal hea+ %r$# !el*ic &ri#

t$c$l'"i"


72/93

+


73/93

+Ca"e "cenari$

A *ravida ara # at $ wee%s of gestation

with uncontrolled *0 presented in labourwith fully dilated os- pending delivery

(hat problems would anticipate in this

labour)

+ In "h$ul+er +'"t$cia/


74/93

+Sh$ul+er+'"t$cia

In "h$ul+er +'"t$cia/+i"!r$!$rti$n $ccur"&etween the &i"acr$#ial

+ia#eter $% the %etu" an+the anter$!$"teri$r+ia#eter $% the !el*icinlet/ re"ultin( ini#!acti$n $% the anteri$r

"h$ul+er $% the %etu"&ehin+ the "'#!h'"i"!u&i"

It i" a""$ciate+ with"eri$u" c$#!licati$n" %$r

&$th the #$ther an+ &a&'

Perinatal #$r&i+it'inclu+e" a"!h'0ia/ &irthtrau#a "uch a" &rachial!le0u" inur' an+ %racture+

cla*icle"/ an+ !er#anentneur$l$(ical +a#a(e

+h l+ It i" u"uall' &ec$#e"


75/93

+Sh$ul+er+'"t$cia

It i" u"uall' &ec$#e"$&*i$u" a%ter the %etalhea+ e#er(e" an+ retract"

u! a(ain"t the !erineu#/%ailin( t$ un+er($ e0ternalr$tati$n 2turtle "i(n4

It i" c$n,r#e+ when the

"tan+ar+ +eli*er'#an$eu*re" 2+$wnwar+tracti$n4 %ail t$ +eli*er the%etu" an+ the hea+ t$ &$+'

+eli*er' inter*al i"!r$l$n(e+ "ec$n+".

+Sh l+ Ri"k %act$r"-


76/93

+Sh$ul+er+'"t$cia

Pr$l$n(e" "ec$n+ "ta(e

A""i"te+ +eli*er'

Maternal +ia&ete" with $rwith$ut #acr$"$#ia

Pre*i$u" "h$ul+er+'"t$cia

A lar(e %etu" :.H k(2#acr$"$#ia4


77/93


78/93


79/93


80/93

+


81/93

+P$"t!artu#


82/93

+Pri#ar' PP<

3terine atony 459-9678etained placenta

cotyledons"rauma :3terine rupture.road ligament

haematoma2ervical tears;aginal tears haematoma;ulval tears haematoma

+ Acti*e #ana(e#ent $% the


83/93

+Pri#ar' PP<

thir+ "ta(e $% la&$ur l$werre+uce" the ri"k $% PP<

Pr$!h'la0i" $0't$cin"h$ul+ &e $6ere+ r$utinel'the #ana(e#ent $% thethir+ "ta(e $% la&$ur in all

w$#en a" the' re+uce theri"k $% PP< &' a&$ut >M$"t ca"e" $% PP<

ha*e n$ i+enti,a&leri"k %act$r"

+Pri#ar' PP< ri"k Etiology Risk factors


84/93

+Pri#ar' PP


85/93

+Pri#ar' PP


86/93

+Pri#ar' PP


87/93

+Pri#ar' PP


88/93

+Mana(e#ent


89/93

Mana(e#ent


90/93


91/93

+C$nclu"i$n


92/93

C$nclu"i$n

Pri#ar' !re*enti$n

I+enti%' !r$&le#"

Pr$#!t acti$n"

Seek hel! an+ i##e+iate &ut "a%e tran"%er t$h$"!ital

8re1uent/ re(ular $&"tetric" +rill" an+ trainin(

ritten !r$t$c$l an+ (ui+eline"


93/93

T&A 45

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OBSTETRIC EMERGENCY _IN PRIMARY CARE.pptx