Transcript obstetric emergencies

OBSTETRIC
EMERGENCIES
Dr. Malak Al Hakeem
MAJOR HAEMORRHAGE
Definition
• Blood loss >25% of circulating volume.
• >1500 mL blood loss
• heavy continuing blood loss (it would be
irresponsible to wait until 1500 mL of blood
have been passed before implementing
prompt management).
Common causes of major obstetric
haemorrhage
A) Antepartum
• Placenta praevia
• Abruptio placenta
• Uterine rupture
• Difficult haemostasis at Caesarean section
B) Postpartum
• Uterine atony
• Lower genital tract trauma (perineal,
vaginal and cervical lacerations; uterine
rupture)
• Retained products of conception
• Uterine inversion
• Amniotic fluid embolism.
MANAGEMENT
The aims are:
1- to stop blood loss
2- to resuscitate the patient and restore/maintain
oxygen carrying volume to tissues.
• Summon all extra staff especially a senior
anesthetist. Inform blood bank.
• Take 20 mL of blood for cross match (at least six
units), FBC, clotting studies, renal and liver
function tests.
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Administer oxygen by face mask.
Insert two 14 G iv lines.
Insert a Foley catheter.
Give a plasma expander (crystalloid or colloid).
Beware, of, fluid overloading especially those
with severe pre-eclampsia.
• Give blood as soon as possible. Wait for
cross-matched blood if the blood pressure
improves with fluids and remains stable.
• Otherwise give ABO compatible blood or
even O Rhesus -ve blood if the loss is
more than 40%.
• Use a compression cuff if the volume
expansion is needed rapidly.
• Consider central venous pressure (CVP)/Arterial
lines.
• Recheck, clotting parameters and blood
biochemistry at regular intervals .
• Give FFP, platelets and cryoprecipitate as
appropriate (via consultation with consultant
haematologist who should be involved).
• Consider transfer to intensive treatment unit.
Severe Preeclampsia
•
BP > I60/110 with protienuria > 3gms.
• Persistent symptoms of epigastric pain,
headache, nausea, vomiting and visual
disturbance.
• Hyperreflexia , papilloedema, epigastric
tenderness, cyanosis, and pulmonary Oedema
• worsening biochemistry (uric acid,, Urea , and
liver enzymes.)
• abnormal coagulation profile(platelets,
fibrinogen, fibrinogen degradation products
(FDP)) PT and APPT.
• decreasing urinary output
• The major risks from uncontrolled severe
hypertension are cerebrovascular
accidents and placental abruption.
• Pre-eclampsia carries additional risks of
eclampsia, pulmonary Oedema (often
iatrogenic due to fluid overload) and DIC..
Management Of Sever PET
• If the patient has severe hypertension,
symptoms or signs suggestive of severe
disease or rapidly deteriorating blood test
results, involve senior staff, obtain
intravenous access and then;
1) Transfer to delivery suite
2) Stabilize the blood pressure
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Aim to bring the blood pressure to (140160)/(90-100). This should be gradual.
Patients with pre-eclampsia have a lower
circulating blood volume and may tolerate a
drop in BP poorly.
Excess reduction of BP decreases placental
perfusion.
HYPOTENSIVE DRUGS
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Hydralazin IV 10 mgs. State, followed by
infusion ( 5-40mg/hour).
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Labetelol 20 mgs. State, followed by
infusion ( 20-160mg/hour).
3) Fluid management
• Aim to restrict fluid intake to 100 mL/h
(remember to calculate the fluids used in
antihypertensive and synto. infusions).
• Urine volume of <30 mL/h can be
tolerated for a few hours as the risks of
acute tubular necrosis are outweighed by
those of pulmonary and cerebral oedema.
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• Central
venous pressure measurements
(or even pulmonary capillary wedge pressure)
may be necessary to accurately monitor fluid
status.
• Diuretics should not be used to increase urine
output unless there is good evidence of fluid
overload.
• Extra colloid can be used if the central venous
pressure is low but 'blind' fluid challenges are to
be avoided.
4)
Seizure prophylaxis
• Eclamptic fits can be prevented by using
intravenous magnesium sulphate infusion.
• Give 4-6 gms. of mg. Sulphate IV state
followed by 1-3 gms hourly.
5) Delivery
• Delivery of the placenta is the only way of
actually treating the underlying patho physiological processes of pre-eclampsia.
• The options are induction and Caesarean
section according to cervical status.
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An epidural may be helpful in reducing blood pressure
by producing vasodilatation and reducing afferent pain
stimulation.
• It is safer than a spinal or general anaesthetic if
Caesarean section is required.
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A coagulopathy is a contraindication to regional
anaesthesia and platelet counts of <100 may limit the
options for analgesia
• Don't use methergin or syntometrine in third stage due to
its hypertensive action.
6) Continuous observation and
monitoring
• Vigilance must be maintained throughout
for complications and deterioration in
maternal or fetal condition.
• BP and urine output hourly.
• Oxygen saturation by pulse oximetry.
• Central venous pressure if oliguric.
• Serial measurements of platelet count,
clotting times, renal and liver functions and
serum magnesium levels if having
magnesium sulphate.
7) After delivery
• Continue intensive treatment for at least
24 hours after clinical, biochemical and
haematological indices have stabilised.
• Antihypertensive medications may be
necessary for a number of days
postpartum. Advise at least a 5-day
hospital stay after the delivery.
8)
Follow-up
• This should be at 6 weeks to test urine
and BP. If the BP remains raised or
protienuria persists, investigate for renal or
connective diseases.
ECLAMPSIA
• Occurrence of convulsions in association
with signs and symptoms of preeclampsia.
• An incidence of 4.9:10 000 maternities in
the UK (1:2000).
• About 40% occur before labour, 20%
during labour and 40% after delivery (up to
7 days).
• Eclampsia is more likely to occur in
teenagers (x3) and in multiple pregnancy
(x6).
• The differential diagnosis includes cerebral
bleed, local anaesthetic toxicity, and
epilepsy.
TREATMENT
• Summon help.
• Obtain iv access and if still fitting give
diazepam bouls 10 mg iv.
• Check airway for obstruction and give
oxygen.
• Stabilize blood pressure (as for preeclampsia).
• Transfer to delivery suite and inform senior
obstetric and anaesthetist consultants
• Commence magnesium sulphate with a
bolus dose of 4 -6 g (20 -30 mLs of 20%
solution) given over 20 minutes.
• Maintenance dose is 1 -3 g/h (5 g in 500
mL normal saline and run at lOOmL/h).
• Magnesium sulphate causes central and
therefore respiratory depression.
• Respiratory rate, oxygen saturations and
patellar reflexes should be recorded
regularly before giving it to detect toxicity.
• This is more likely if renal function is poor.
• One gram of calcium gluconate iv over
2—3 minutes is used to reverse toxic
effects of mg. Sulphate.
THROMBOEMBOLISM
Incidence
• An incidence of 1 per 1000 on going
pregnancies and 2 per 1000 recently
delivered pregnancies.
• Venous thromboembolism (VTE) is the
commonest cause of direct maternal
death.
Risk factors for thromboembolism
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immobility
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surgery (relative risk of VTE is increased 10 times after LSCS)
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thrombophilias (lupus anticoagulant; antithrombin III, protein S
and C deficiencies and activated protein C resistance)
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multiparity
obesity
age over 35
previous history of TE
family history of TE
infection
pre-eclampsia.
DIAGNOSIS
• Most cases present in the third trimester
and up to 6 weeks after delivery with leg
pain, swelling and erythema or dyspnoea,
chest pain and sometimes haemoptysis.
Diagnosis on clinical features alone is
unreliable
• For suspected deep vein thrombosis
arrange Doppler flow ultrasound. This
has a high sensitivity (94%) for
iliac/femoral vein thrombosis although it
may not be able to distinguish external
compression from occlusion and will not
exclude calf vein thrombosis
• limited venography is the investigation of
choice for suspected below knee
thrombosis. The radiation dose to the fetus
is small and is justifiable in view of
maternal risk
• If a pulmonary embolus is suspected
check arterial blood gases and a chest Xray (with shielding of the abdomen there is
no risk to the fetus and it excludes other
causes of chest pain). A perfusion lung
scan should be carried out and once
again the radiation risk should be
considered less than the risk of missing
the diagnosis.
Treatment
• Treatment with iv heparin should
commence as soon as the clinical
diagnosis of a DVT or PE is made or
strongly suspected.
• Start an intravenous infusion of 1000-1500
IU heparin/h after a loading dose 500010000 IU.
• Check the activated partial thromboplastin
time (APTT) 6 hours later and adjust to
maintain a level of 1.5-2.0 .
• After resolution of clinical symptoms
convert to subcutaneous heparin( during
pregnancy) 10000 iu bd subcutaneously or
low molecular weight heparin 2500-5000
units per day monitored by factor Xa
heparin assay (appropriate range = 0.20.4).
• Check maternal platelet count at regular
intervals, especially around a week to ten
days after commencing treatment. Heparin
can cause an immune-mediated
thrombocytopenia with paradoxical
thrombotic episodes
• For delivery reduce the heparin to 50007000 IU bd and normalize the APTT. Have
FFP available for bleeding.
• Resume iv heparin 20 000-30 000 IU/24 h
after delivery and then convert to warfarin
for 6-12 weeks. Warfarin is safe to use
whilst breastfeeding.