3BASIC PRINCIPLES FOR OBSTETRIC EMERGENCIES. Physiological changes in pregnancy modify:Presentation of the problemNormal physiological variablesResponse to treatmentBoth mother & fetus are affected by the pathology & subsequent treatment.Mother’s welfare always takes precedence over fetal concerns ---Fetal survival is usually dependant on optimal maternal management.
5MASSIVE OBSTETRIC HAEMORRHAGE Major contributor to maternal mortalityDefinitionBlood loss requiring replacement of patient’s total blood volumeTransfusion requiring > 10 u of blood in 24 hs50% replacement of blood vol. <3 hs periodDifficult to estimate blood lossProblem of concealed bleedingUterusBroad lig.Peritoneal cavity2
6RECOGNISING SIGNIFICANT BLOOD LOSS 10 – 15%mlNormal BPNo signs.15-25%mlBP ~ 100mmHgDizziness, tachycardia25-35%ml.BP ~ 70-80mmHg.Restlessness,pallor, oliguria.35-45%ml50-70mmHgCollapse, air hunger, anuria
7Factors contributing to maternal death from catastrophic PPH GeneralIncreased oxygen and cardiac output requirements of pregnancy may hamper adequate blood / volume replacementPlacental bed perfusion 600 mls/minBlood loss underestimatedDelayed or inadequate managementInadequate resources / personnelSpecificFailure to anticipate coagulopathyPET, abruption, sepsis, IUFD, AFE.Abnormal placentationPlacenta praevia / accretaJehovah’s witness**
8Mechanism of DIC1) intravascular infusion of thromboplastic substances that initiate the extrinsic coagulation systemplacental abruption, IUFD2) conditions associated with endothelial cell damage, which activates both the extrinsic and intrinsic coagulation systemseclampsia/ PET3) indirect effects of other disease, such as G- sepsis, AFE etc
9Preventative Management PPH Detect and treat antenatal anaemiaActive Management of Third StageAdministration of a prophylactic oxytocinEarly cord clampingControlled cord traction of the umbilical cord.Advantage of active management = reduction in the incidence of PPH by 40%IV access plus collect blood for grouping and cross matching if assessed as at risk.
10Available from Royal Women’s Hospital, Carlton, Clinical Practice Guidelines:
11Management Principles Organisationrestoration of blood volumecorrection of coagulopathyevaluating response to treatmentmonitoring PR, BP, CVP, ABG, UOPIf resuscitation is adequate P & BP should return to normaltreat the causeabruptionplacenta praeviauterine ruptureplacenta accreta
12Available from Royal Women’s Hospital, Carlton, Clinical Practice Guidelines:
13NON-HAEMORRHAGIC OBSTETRIC SHOCK Uncommon but responsible for majority of maternal deaths in developed countries.-Amniotic fluid embolus-Acute uterine inversion
14Amniotic Fluid Embolism Passage of amniotic fluid debris into maternal circulationObstructs pulmonary circulationCardio-respiratory arrest
20Presentation Sudden collapse in 3rd stage Degree of shock inconsistent with blood lossShock is neurogenic in natureTraction on infundibular pelvic ligamentMay be no palpable fundusMass in vagina/introitus43
21Management Avoid mismanagement of 3rd stage of labour Once occurs Anti-shock measuresIf placenta still attached remove after uterus is replacedManual replacement of uterusO’Sullivans hydrostatic pressureSurgical correction44
27Risk Factors Macrosomia (>4kg) Intrapartum maternal diabetespost datesmaternal obesityhigh maternal wgt gain in pregnancyadvanced maternal ageprevious large infantprevious shoulder dystociaIntrapartumprotracted late active phaseprolonged 2nd stagedelay in head descent in 2nd stagemid-pelvic operative deliveryThe combination of macrosomia and delay in 2nd stage predicts 35% of shoulder dystocia
30PresentationHypertension, hyperreflexia, clonus, headache, visual changes, seizure20% have diastolic BP<90, normal reflexes, and urinary protein <2+70% of deaths due to intracerebral haemorrhage
31Management • Goals: – Stabilization of the mother/seizure control • MgSO4 therapy: 4-6 g over 20 min followed byinfusion of 1-3 g/hr, OR• Thiopental or diazepam followed by MgSO4infusion– Airway management– Avoiding aspiration
32Prolapsed Cord1/500 deliveriesMost occur during ARM
33Presentation Cord visible outside the introitus CTG abnormalities appearvariable decelerationsfetal bradycardiaNote: fetal or maternal injury due to hasty intervention
34Management Keep cord warm - replacing in vagina may help Keep pressure off cord by gloved hand in vagina lifting fetal part off the cordPositioning,Maternal O2, IV accessIf fetus is alive, operative delivery - CS if not able to deliver vaginallyIf fetus is dead, vaginal delivery if presentation allows
36Maternal cardiac emergency Acute:AMITocolytic therapyAortic dissecting aneurysmPeripartum cardiomyopathy:1 in 50000, 50% progress to end-stage heart failure (heart Tx), 50% recurrence.Suspect if acute SOB, chest pain, abN ECG, signs LVF/RVFTraumatic myocardial contusion: ie: MCA
37Drug OverdoseIllicit drugs: heroin, cocaine and amphetamines (these 2 can cause hypertension, ^ C.O., decrease Uterine blood flow, APH, cerebral haemorrhage, convulsions, arrhythmias).Drug overdoseDrug errorAnaphylaxisHypermagnesaemia:wide QRS on ECG, 5-6mmol/l lose tendon reflexresp. paralysis, SA and AV node blockcardiac arrest.Treatment: CaGluconate 10% 10ml slow IV
38CARDIO-PULMONARY ARREST Cardiac arrest rare in pregnancy (1 in deliveries)Usually associated with particular obstetric complications like amniotic fluid embolism, drug toxicity from Magnesium sulphate & local anesthetics.
39Technique for external cardiac massage: External cardiac massage in non-obstetric patient provides 30% cardiac output.After 20 weeks reduced further due to veno-caval compression.Relief of aorto-caval compression part of BLS:left lateral tilt --- decreased efficacy of compressionswedge 270 angle allows 80% of maximal force to be dissipatedrescuer’s thigh as wedge.Sodium bicarbonate controversial as it leads to fetal acidosis but pH has to be kept above 7.30 to prevent uterine vasoconstriction.International Liaison Committee on Resuscitation (ILCOR)“ if there is no response to ALS, peri-mortem caesarean delivery should be made within 5 minutes of arrest”
40TRAUMA Occurs in 6-7% of all pregnancies. Hospital admissions only % of all pregnancies.1% of all trauma cases are pregnant.Maternal deaths associated most commonly with head injuries & severe hemorrhage.Fetal deaths associated with placental abruption & maternal death.
41Management Initial resuscitation should follow normal plan of ABC. Hypotension may not be present until 35% or more blood volume is lost.Aorto-caval compression releaseRule out pelvic fractures, uterine injury & retro-peritoneal hemorrhageFetal monitoring with cardio-tocographic monitorRh immunoglobulin – within 72 hours.Radiation hazards:1st trimester >5 radsChest x-ray < 5 radsPelvic film <1 radsAbdomino-pelvic CT scan rads
42BURNSIncreased levels of prostaglandins predispose to pre-term labour.Replacement of fluids vis-à-vis increased volumes in pregnancy.Inhalational injury- hypoxia & carbon monoxide poisoningInfections- prophylactic antibiotics controversialTopical Povodine iodine- affects fetal thyroid functions