OBSTETRIC EMERGENCI

ES

Disediakan Oleh : Nassruto

OBSTETRIC EMERGENCIES

Labour is like a mountain climbing........

LABOUR IS LIKE A MOUNTAIN CLIMBING….

OBSTETRIC EMERGENCIES

• PPH (POST PARTUM HAEMORRHAGE)• APH (ANTE PARTUM HAEMORRHAGE)• Eclampsia and severe pre-eclampsia• Uterine inversion• Uterine rupture• Amniotic fluid embolism• Post partum collapse• Cord prolapse• Shoulder dystocia

PPH

• Leading cause of maternal death in Malaysia.• Bleeding > 500 cc from genital tract after delivery.• Primary PPH – occurring within 24 hours of delivery.• Secondary PPH – occurring after 24 hours.

Causes of primary PPH

• Atonic uterus• Genital tract trauma• Retained placenta• Bleeding disorders

Uterine atony

• Resuscitation• Rub up contraction, expel any clots, empty bladder.• Give/ repeat oxytocin. Run oxytocin infusion. Consider

other drugs such as PG.• Monitor patient closely.• If bleeding persists, consider transferral or surgical

intervention.

Genital Tract Trauma

• Vaginal tear• Cervical tear• Bleeding episiotomy wound

Retained Placenta

• Resuscitation • Removal of placenta

Bleeding disorders

• Rare• Treatment as the cause

Causes of secondary PPH

• Retained POC• Endometritis

ANTEPARTUM HEMORRHAGE

DEFINITION

• Bleeding from the genital tract from 24 weeks till delivery of the fetus.

• Causes :• Placenta praevia• Abruptio placenta• Local cause• Indeterminate APH• Vasa praevia

Placenta praevia

• Placenta is located partially or wholly in the lower segment.

• Painless PV bleed.• Abdomen soft, malpresentation or presenting part high.• No VE until confirmation.• Confirmed by ultrasound.

GRADE 1 – THE PLACENTA JUSTENCROACH ON THE LOWERUTERINE SEGMENT.

GRADE 2 – THE PLACENTA REACHES THE MARGIN OF THE CERVICAL OS.

GRADE 3 – THE PLACENTA COVERSPART OF THE OS.

GRADE 4 – THE PLACENTA IS CENTRALLY PLACED IN THE LOWERUTERINE SEGMENT.

DIAGNOSIS

• DIAGNOSIS IS BY ULTRASOUND

management

• Resuscitation• IV lines and blood transfusion.• Conservative or delivery depends on gestation, amount of

blood loss and whether patient having contraction.• Delivery by CS for major placenta praevia

COMPLICATION

• PPH.

• PLACENTA ACCRETA

• IATROGENIC PREMATURE DELIVERY.

ABRUPTIO PLACENTA

PREMATURE SEPERATION OF A PLACENTABEFORE THE DELIVERY OF THE FETUS.

RISK FACTOR

• TRAUMA• PREVIOUS HISTORY OF ABRUPTIO• MATERNAL HYPERTENSION• CIGARETTE SMOKING• UTERINE DECOMPRESSION

• Painful PV bleeding.• Abdomen tense (dashwood rigidity), tender.• Fetal part and heart may be difficult to palpate.• Ultrasound may show evidence of retroplacental clots.• Revealed and concealed type.• Amount of loss may not be proportionate to degree of

shock.

Blood clots from premature placenta separation accumulate and sips into muscle but the amount of PV bleed may not be proportionate to the amount of placenta separation.

In revealed type, the amount of blood loss is proportionate to the degree of placenta separation.

DIAGNOSIS

• HISTORY AND PHYSICAL EXAMINATION.

• ULTRASOUND – to rule out placenta praevia and retroplacental blood clots may be seen as an area of lucency.

• CTG – may show evidence of fetal distress.

MANAGEMENT

• Resuscitation• IV lines, blood transfusion and blood products

transfusion.• If cervix favorable and no fetal distress aim for vaginal

delivery. • If evidence of fetal distress, then for CS.

COMPLICATION

• Hypovolumic shock.• Acute renal failure.• Couvelairre uterus and uterine atony.• PPH.• DIVC.• Perinatal morbidity and mortality.

APH- LOCAL CAUSE

• CAUSES : Polyp, erosion, infection or cancer of the cervix.

• Needs treatment for polyp if excessive PV bleed.• For cancer of cervix treatment depends on staging and

period of gestation.

APH – VASA PRAEVIA

• Bleeding from the fetal blood. • Valemantous insertion of the blood vessels.• PV bleed and evidence of fetal distress.• Needs immediate delivery of the fetus.

UTERINE RUPTURE

• SPONTANEOUS• TRAUMATIC• PREVIOUS SCAR

UTERINE RUPTURE

• PREVIOUS SCAR IS COMMONEST. CLASSICAL C-SECTION RISK IS 4-5%. LSCS RISK 0.2% TO 0.5%.

• FAILURE TO RECOGNISE OBSTRUCTED LABOUR.• TRAUMATIC INSTRUMENTAL DELIVERY.

SIGNS AND SYMPTOMS

• Abdominal pain. Pain in between contraction.• Cessation of contraction.• Variable amount of vaginal bleeding.• Unexplained tachycardia and shock.• Fetal distress.• Palpable fetal part or disappearance of presenting part

from pelvis.

MANAGEMENT

• Initial resuscitation.• Emergency laparatomy.• Repair of rupture or hysterectomy depending on factors

like stability of patient, completion of family and how bad the rupture is.

• Future pregnancy- CS at 36-37 weeks.

UTERINE INVERSION

• Uterus become inverted partially (fundus above cervix ) or completely ( fundus below cervix ).

• Acute inversion occur in the first 24 hours.• Causes include fundally implanted placenta, poor

management of third stage

DIAGNOSIS

• Pain, hemorrhage or shock in the presence of an inverted uterus or indented uterus abdominally.

• Degree of shock may be out of proportion to the amount of blood loss.

MANAGEMENT

• Immediate resuscitation.• Manual replacement of the placenta.• If fail, O’Sullivan hydrostatic method or manual

replacement under GA.• After succesful replacement, judicious use of oxytocin

and MRP if placenta is still retained.

PREGNANCYPREGNANCYIS IS SPECIAL,SPECIAL,LETLETMAKE MAKE IT IT SAFESAFE

THANK YOU…………….THANK YOU…………….