Obstetrics and Gynae – Fellowship teaching 2013

Rachel Rosler

Basic concepts

• Two patients• Foetal survival depends on maternal stabilisation

and well-being• Vital signs may appear normal even in the event of

significant blood loss

Emergencies in first half pregnancy

• Ectopic• Abortion

– Don’t forget Rh-ve– Unstable – IVF, r/o ectopic, tissue os, oxytocin to D&C

• Gestational trophoblastic disease – 1/1700

• UTI– Don’t use trimethoprim

• Hyperemesis

Emergencies 2nd half pregnancy

• Hypertension– >140/90 / 20mmHg rise in systolic /10mmHg rise diastolic

• Preeclampsia– Hypertension, pathological oedema, proteinuria

• Eclampsia– Preeclampsia plus seizures >20/40 to 7/7 post partum– Headache, visual symptoms, oedema, abdo pain– Cx – splenic/liver haemorrhage, end organ failure, DIC, abruptio

placenta, ICH, foetal death

• HELLP– Haemolysis, Elevated LFTs, low platelets– Multigravid, BP variable, can be mistaken for gastro, hepatitis,

pancreatits, pyelonephritis

• Emergency Delivery

PV bleeding in second half pregnancy

• 4% of pregnant women have significant bleeding >20/40

• 1/3 of foetuses die with PV bleeding >20/40• Abruptio placenta• Placenta praevia• Marginal bleed• Vasa praevia• Premature labour and PROM• Lesions of lower Cx / lower GU tract

Post-partum emergencies

• Haemorrhage and infection – most common• Amniotic fluid embolus

– Rare but important

• Eclampsia• Peri-partum cardiomyopathy

Post partum haemorrhage

• Uterine atony – most common, Rx oxytocin• Uterine rupture – prior CS• Retained placenta• Uterine inversion• Coagulopathy• Laceration lower genital tract• Physiologic

Gynaecological Emergencies

• PID• Pelvic pain• Bleeding in the non pregnant patient• Sexual assault and contraception• Ovarian hyperstimulation syndrome

Question 1

• A 32 year old woman who is 33 weeks pregnant is referred to your emergency department because of a blood pressure of 140/95 and right upper quadrant pain for 24 hours. One hour after arriving in the emergency department, the patient begins to have a grand mal seizure. Describe your management. (100%) (2008/2)

• Likely eclampsia• 2 patients – viable foetus, maternal stabilisation is the

priority• Stop seizure• Prevent maternal hypoxia, left lateral position• Prevent/ treat secondary trauma• Manage hypertension, if present• Prevent of recurrent seizures• Evaluate for prompt delivery• Seek and treat alternative underlying pathology if indicated• Seek and treat complications of eclampsia• The definitive treatment of eclampsia is delivery, irrespective

of gestational age, to reduce the risk of maternal morbidity and mortality from complications of the disease.

Question 2

• Describe how the normal anatomical and physiological changes of pregnancy influence the assessment of a 32 week pregnant woman presenting with multiple trauma. (100%) (2007/2)

• Anatomical and physiological differences?

Anatomical and physiological differences

• A– Difficult intubation

• B– ↑TV, ↓FRC, ↑consumption of oxygen– Impaired ability to compensate for respiratory

compromise– Adequate ventilation and supplemental oxygen a priority

Changes in CVS

• ↑HR, blood volume, cardiac output• ↓blood pressure, SVR• Restriction of venous return from 20/40

• So what does this mean for a patient presenting to the ED?

Implication of CVS changes

• left lateral position (wedge under right hip)• Mother may lose 30-35% blood volume before

manifesting signs shock AT EXPENSE OF FOETUS

• ↑Volume of fluid required• Pressors may ↓uterine perfusion

GI

• Gastric reflux• Gallstones• ↑ALP (placenta)

• Early nasogastric• ↑Danger of aspiration

GU

• ↑Kidney size, renal blood flow and GFR• ↓ Urea and creatinine• Dilatation ureters and renal pelvises R>L

Haemopoietic / Endocrine

• ↓ Hb, platelets• ↑WCC, Fe consumption ESR

• CHO metabolism

Uterus

• Weight, volume, intra-abdominal at 12/40, blood flow of 600mlmin by term

• Subject to trauma, compression of IVC, engorgement of lower extremities and lower abdominal vessels, possible source of significant haemorrhage

• Trauma can cause amniotic fluid embolism, DIC, Rh immunisation

Question 3

• You have just reviewed an 18 year old female who believes she is in premature labour. She is Gravida 1 and Parity 0. She is approximately 26 weeks pregnant by dates. She has received minimal antenatal care.

• (a) Describe your assessment of this patient. (50%) • (b) Describe your management of this patient.

(50%) (2005/1)

• Viable pregnancy but premature and at high risk of complications

• Aims of assessment– Confirm labour– Identify stage of labour– Assess foetus – gestation and distress– Identify complications – Assess for maternal risk factors– Look for cause of premature labour

• Aims of management– Assure safe delivery, preferentially transfer in utero to

tertiary facility– Prepare for delivery – mother and baby– Slow labour for above– Treat any underlying cause or complication

Question 4

• A 32 year old multiparous woman presents via ambulance with marked per vaginal bleeding following the precipitous delivery at home of her term infant 15 minutes previously. The infant is well and is under the care of the neonatal service. The ambulance service has been unable to establish intravenous access and her blood pressure is now unrecordable.

• Outline your management of this patient. (100%) (2004/2)

• Critically unwell patient requiring aggressive resuscitation and treatment of underlying cause

• Tone - uterine atomy• Trauma - genital tract trauma• Tissue - retained placenta• Thrombin – coagulopathy• Early consultation with obstetrics• Disposition to OT or ICU

• Overall pass rate 51/64 (79.7%)

Case 1

• 25 year old female• 32/40 gestation• Presents with minor fall landing bottom• Now has mild lower abdominal and back pain• Noticed small amount of bright red PV bleeding• HR 95, BP 95/50

• So what causes bleeding in the second half of pregnancy?

PV bleeding in the 2nd half of pregnancy

• Antepartum haemorrhage– After 20/40– Up to 4% of pregnancies– Up to 1/3 of foetuses die

Differential diagnosis

• Incidental• Physiologic• Placenta praevia• Accidental haemorrhage• Vasa praevia

Placenta praevia

Abruption

• Foetal death in up to 30%• 2-4 litres may be concealed• Deceleration injury• Minor fall• Spontaneous• Minor bleeding if any,

usually associated with pain

• ONLY 50% SEEN ON ULTRASOUND

Vasa praevia

• Foetal vessels in amniotic membranes across cervical os

• Rupture• Bleeding is from the foetus

– Foetal bradycardia– Abnormal CTG

What to do

• Careful history• Examination

– Post 30/40 right hip elevated– DO NOT do a PV until site of placenta is determined by

ultrasound– PV – look for local cause bleeding, assess stage labour– CTG

• For four hours after minor trauma even in asymptomatic patients if over 24/40

Investigations

• FBC, coag screen, Kleihauer test, blood group, Rhesus factor, rhesus antibodies, cross match

• Pre-eclampsia screen if hypertension

• Ultrasound

Kleihauer test

• Identifies presence of fetal blood in the maternal circulation

• Helps to determine the amount of Anti-D to give• Only obtain on Rh negative patients• Giving 300mcg of Anti-D protects the mother from

30 mL of fetomaternal hemorrhage• Sensitive in detecting small foetomaternal

haemorrhage, but amount has no prognostic value

Management

• Incidental – none / specific• Placenta praevia – close observation• Small abruption – conservative• Large abruption – emergency caesarian section

• Transfer to hospital with obstetric facilities for admission and observation if foetus viable gestational age

Our lady

• 25 year old female• 32/40 gestation• Presents with minor fall landing bottom• Now has mild lower abdominal and back pain• Noticed small amount of bright red PV bleeding• HR 100, BP 95/50

Case 2

• 34 year old female• Approx 30/40 pregnant• Brought in by ambulance still fitting after 30minutes• No history available

• What causes seizures in pregnancy?

Seizures in pregnancy

• Seizures– Increased risk of injury to both mother and foetus– Status – life threatening to both mother and foetus at any

stage of pregnancy

• Epilepsy• New seizures

– Primary or secondary (glucose, drugs)

• Pregnancy related - eclampsia

Eclampsia

• Seizure in patient with pregnancy–induced toxaemia occuring after the 20th week of gestation to 7 weeks post partum

• PET– Hypertension– Oedema– Proteinuria

• Seizures are typically brief, self terminating, and usually preceded by a headache with visual symptoms

Treatment of eclampsia

• Control seizure• Control hypertension• Expedite delivery of the placenta

Management eclampsia

• Magnesium– 4-6g IV over 15 minutes– Infusion of 1-2g per hour– Monitor deep tendon reflexes and Mg levels

• Control BP– Mg– Hydralazine– Labetolol

Back to the case

• 34 year old female• Approx 30/40 pregnant• Brought in by ambulance still fitting after 30minutes• No history available

Management

• Left lateral position• Consider eclampsia• Consider glucose or other causes of seizure• Urgent control of seizures

– Benzodiazepine– Magnesium– Phenobarbital (consider in place of phenytoin)

• Assess and monitor foetal wellbeing• Urgent early referral for O+G and paediatrics

Case 3

• 28 year old female• 35/40 pregnant• 7th pregnancy, last one precipitous• Contractions 2 minutes apart• Feels that she wants to push• Peripheral centre, no O+G on site

General principles

• Safe transfer to delivery suite is always preferable to delivery in ED

• Known foetal abnormality or prematurity – do better if transferred in utero

• No time to transfer, or patient arrives fully dilated with foetal presenting part on perineal verge

= need to deliver in ED• High risk – concealed, obese unknown pregnancy,

intellectual impairment or mental illness

Prem labour

• Risk factors– PROM, Abruptio, drug abuse, Std, Infection, multiple

gestation, Poyhydramnios, cervical incompetence

• Is this really labour?• Tocolytics – post consultations, risk vs benefit,

salbutamol, terbutaline, mg, nifedipine, glucocorticoids – dex 6mg

Assessment

• Gestational age• Antenatal care• Progression of pregnancy• Past obstetric and medical history• Call for help early

Examination

• Vital signs• Gestational age• Progression of labour

– Frequency, regularity, duration and intensity of contractions

– Sterile PV

• Number of babies and foetal well-being• Presence or absence of complications of labour /

pregnancy

If foetal distress

• Oxygen• Left lateral• IV fluids• Seek advice

Preparation for delivery

• Staff• Equipment• Drugs

Labour

• 3 stages• First stage

– Onset regular contractions to full dilatation (10cm)

• Second stage– Dilatation cervix to delivery of baby

• Third stage– From birth baby to delivery of placenta

Second stage

• Delivery head• Delivery shoulders• Delivery body and legs

• 20-60 min primup• 10-30 min multi

Delivery head

• Clean and drape• Place dominant hand on

head to control delivery• Second hand with gauze

on perineum• Most common presentation

is OA• Episiotomy only if

necessary - mediolateral

Once head delivered

• Stop and check for meconium – suction if present• Check for nuchal cord

– 25-30%– Most loose and can be drawn over head– Clamp and cut cord if necessary

• Baby now lying laterally

Delivery shoulders

• Anterior shoulder under symphysis pubic

• GENTLE downward and backward traction on head

• Then lift baby up for delivery of posterior shoulder

• Rest happens rapidly – very slippery baby, always hold with 2 hands and give to assistant to check

• The baby’s head then “turtles” back into the perineum

• What is happening?

Shoulder dystocia

• Anterior shoulder does not deliver

• Significant foetal morbidity and mortality

• Foetal head retracts back into perineum

• Delivery within 5 minutes is essential to prevent asphyxia

Shoulder dsytocia - management

• IDC• McRoberts manoeuvre• Suprapubic pressure• Wood’s corkscrew

manoeuvre• Delivery posterior shoulder• Deliberate fracture of the

clavicle• Zavanelli’s procedure

                                                                                                 

              

Third stage

• After delivery baby• Clamp and cut cord 10cm from baby• Check for another baby• Administer oxytocin 10units IM or slow IV infusion• Wait for signs of placental separation• Then gentle backward and downward traction on

cord• Once placenta at introitus traction upward, grasp

placenta and gently rotate (inspect)

• The cord is visible in the birth canal before the baby• What do you do?

Prolapsed Umbilical Cord

• Elevate the patient’s hips, place oxygen, and wrap the cord in a moist sterile towel.

• Sometimes the best position may be on her hands and knees

• Only if the head is compressing the cord should you manipulate and elevate it.

• Do not attempt to reduce the cord.• Facilitate stat C-section.

Breech delivery• 3-4%• Allow foetus to deliver

spontaneously to umbilicus, one leg at a time

• Gentle traction to hips until scapulae visible

• Rotate trunk until anterior shoulder delivers

• Rotate trunk opposite direction for posterior shoulder

• Head – forceps or by placing index finger in baby’s mouth and flexing the head

Post partum haemorrhage

• Definition - >= 500ml blood loss within 24 hours of delivery

• Consequences– Hypovolaemic Shock – Coagulopathy  – Anaemia  – Blood Transfusion – Hysterectomy – Lactation difficulties – Death  

• What are the causes of post partum haemorrhage?

Aetiology

• Tone - uterine atomy• Trauma - genital tract trauma• Tissue - retained placenta• Thrombin - coagulopathy• An EMPTY, CONTRACTED, INTACT uterus will

not bleed in the absence of COAGULOPATHY.

Prevention

• Identify risk factors • Detect and treat antenatal anaemia • Active Management of Third Stage • IV access plus collect blood for group and cross

match if assessed as at risk.

Treatment

• Uterine atony: address with bimanual compression/massage of uterus.

• Retained placenta: attempt manual removal followed by Oxytocin or ergometrine.

• Uterine inversion: occurs in 1/2500 deliveries; can by manually reduced, then needs obstetrics consultation (+/- Oxytocin).

• Genital laceration(s): repair as indicated vs. obstetrics consultation.

• Underlying coagulopathy: treat as usual.