Obstetric Emergencies PDF

Obstetric Emergencies Dr. Enas Salah Abdulelhafiz Mohamedahmed Gaily specialist of Obstetric & Gynecology MD SMSB Assistant professor NAPATA collage Also instructor MBBS Red Sea university Obstetric emergencies Non-haemorrhagic shock: Amniotic fluid embo...

Obstetric Emergencies Dr. Enas Salah Abdulelhafiz Mohamedahmed Gaily specialist of Obstetric & Gynecology MD SMSB Assistant professor NAPATA collage Also instructor MBBS Red Sea university Obstetric emergencies Non-haemorrhagic shock: Amniotic fluid embolism Acute uterine inversion Cord prolapse Retained placenta  NON-HAEMORRHAGIC OBSTETRIC SHOCK Uncommon but responsible for majority of maternal deaths in developed countries. -Amniotic fluid embolus -Acute uterine inversion  Amniotic Fluid Embolism(AFE) Incidence _1:80,000 Pathophysiology: occur when amniotic fluid and associated debris enters the maternal circulation, causing a devastating anaphylactic type reaction can occur during labour,CS, or postpartum. Presentation: Initial symptoms: breathlessness, chest pain, feeling cold , nausea , vomiting, cyanosis , Hypotension, Seizure activity not uncommon. May be: cardiopulmonary arrest , DIC, pulmonary oedema. Diagnosis : clinical acute hypoxia (dyspnea ,cyanosis, respiratory arrest , acute hypotension or cardiac arrest ,coagulopathy with no other clinical condition or explanation. Investiagation : 1.FBC 2. Clotting factors & fibrinogen to assess coagulopathy 3.CXR for pulmonary oedema 4. ECG for ischaemia & infarction 5.ABG & electrolytes Manangement 1. Immediate resuscitation CRP with oxygen and fluids 2. MDT ; obstetric ,anaesthesia, heamtological and neonateal teams 3. Deliver baby by quickest mode 4. Correct coagulopathy with FFP, cryoprecipiate , platelet transfusion 5. Circulatory support with CENTRAL VENOUS LINE , inotropes may be needed. Prognosis high mortality up to 61%  Acute Uterine Inversion Most commonly arises from mismanaged 3rd stage  Acute Uterine Inversion Definition : sudden postpartum condition When the uterus turns inside out Incidence : very rare 1:2000 Risk factors : 1.Abnormal placentation ,e.g accerta 2.Fundal placental insertion. 3.CCT in uncontracted uterus. Presentation Sudden collapse in 3rd stage Unable to palpate fundus abdomenally Shock is neurogenic in nature Traction on infundibular pelvic ligament May be no palpable fundus Mass in vagina/introitus  Management: Avoid mismanagement of 3rd stage of labour Once occurs CALL FOR HELP & maternal resuscitation. 2 large bore cannulae &ensure adequate analgesia and catheter inserted Blood for FBC ,Coagulation,cross match 4 -6 units of blood If placenta still attached leave it and remove after uterus is replaced. attempt a Manual replacement of uterus with tocolytic drugs. O’Sullivans hydrostatic pressure. Arrange for transfer for theatre and reduction under GA Surgical correction. COMPLICATIONs 1.Sever maternal shock 2.Haemorrhage (primary or secondary ) 3.Sepsis.  Retained placenta Definition : the placenta and membranes are undelivered 30min (active management) & or 60 min (physiological) after the vaginal delivery of the fetus. Incidence :0.6% -2% Causes : 1.Failed placental separation e.g morbid adherence. 2.Cord detachment. Risk factors : 1.Previous retained placenta. 2.Preterm delivery. 3.Previous uterine surgery. 4.Young maternal age. Management 1. Inform anaesthetsit , senior obestetrician, 2. IV LINES & IV FLUID replacement 3. FBC & Group and safe. 4. Insert catheter. 5. Ensure adequate and reassess. 6. Give oxytocin inj. 7. If undelivered proceed to a manual removal of placenta in theatre  Complication : 1.PPH. 2.Endometritis. 3.Trauma. 4.Recurrence.  Prolapsed Cord 1/500 deliveries Most occur during ARM Definition Cord prolapse Descent of the umbilical cord through the cervix alongside (occult) or past the presenting part (overt) in the presence of ruptured membranes. Cord presentation ; presence of loop of umbilical cord between the fetal presenting part and the cervical os with intact membrane Dr Maryam Presentation Cord visible outside the introitus CTG abnormalities appear variable decelerations fetal bradycardia Note: fetal or maternal injury due to hasty intervention  Risk factors of umbilical Cord Prolapse General Obstetric Long umbilical procedure cord Amniotomy Abnormal before fetal location on head is placenta engaged : main Small or preterm reason infant. IUPC placement Polyhydramnios. Multiple External gestation. cephalic version Dr Maryam MAGAMEMENT Intervention Assess fetal viability Call for assistance Prepare for emergency c-section Relieve pressure from cord (usually presenting part) Continuous manual relief of pressure from presenting part Avoid excessive manipulation of cord Re-position client: Trendelenburg, or knee-chest Prepare for emergency delivery Administer oxygen by mask 10-15L/min Fill maternal bladder with 500-700 cc NS Tocolytics 0.25 mg terbutaline Sc Continuous fetal monitoring Possible neonatal resuscitation (notify neonatal team per hospital protocol) Dr Maryam  Delivery mode : CS should be performed unless ; fully dilatation vaginal delivery can be done by assisted vaginal delivery.