Hannah Jeffery Charlotte Marshall Hannah Wallace FY2 Case 1 A 25 year old female patient walks into ED complaining of left sided abdominal pain and PV spotting following 9 weeks of amenorrhoea Whilst in the waiting room she collapses ID: 1033304
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1. Obstetric and gynaecological emergencies Hannah Jeffery Charlotte Marshall Hannah Wallace (FY2)
2. Case 1A 25 year old female patient walks into ED complaining of left sided abdominal pain and PV spotting, following 9 weeks of amenorrhoea. Whilst in the waiting room she collapses.
3. Differential diagnosis?
4. Initial management ABC…Oxygen, monitor saturations 2 x large bore cannulae ACF, IVI, monitor BP and HR
5. InvestigationsUrine dip and urine pregnancy testBloods: FBC, x-match, U&E, lactate, CRP, βHCG, clotting Imaging?
6. Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 46956
7. InvestigationsUrine dip and urine pregnancy testBloods: FBC, x-match, U&E, lactate, CRP, βHCG, clotting Imaging? USS abdomen/pelvis (TV): empty uterus, donut shaped mass in left adnexa, free fluid in pelvis
8. Definitive management?
9. By Mikael Häggström - File:Ectopic pregnancy1981.jpg by Urskalberer81, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=31193206
10. Definitive management Laparoscopic (or open) salpingectomyAnti-D if Rh negative
11. Ectopic Pregnancy1-2% of all pregnancies
12. Risk factors
13. Risk factors IVFPrevious ectopic pregnancyPIDIUCDSmokingAdvancing maternal age History of subfertility Endometriosis Previous pelvic/abdominal surgery History of multiple terminations 24% of women who have ectopic pregnancy have no risk factors
14. Subacute presentation HistoryColicky abdominal pain (right, left or central)Dark red PV spotting Shoulder tip painAmenorrhoeaNausea/vomiting + diarrhoea Examination Abdominal +/- rebound tendernessCervical excitation + adnexal tenderness Speculum: closed os↑HR and ↓BP
15. ManagementExpectant – Serial serum βHCG if βHCG <1000 and asymptomaticMedical - MethotrexateβHCG < 1500USS – CRL < 35mm unruptured ectopic and no FHSurgical – salpingectomy/salpingotomyHaemodynamically unstableAdnexal mass > 35mm or FH seen on USS
16. Case 2 A 21 year old female patient presents with sudden onset right sided abdominal pain and associated nausea and vomiting
17. Differential diagnosis?
18. Ovarian torsion History Sudden onset lower abdominal painNausea and vomiting (+/- diarrhoea)Strenuous exercise Examination Palpable adnexal mass in 50% Tender on lower abdominal palpation?fever
19. Investigations Urine dip and UPTBloods: FBC, UE, LFT, G+S, clotting, lactateImaging?
20. Case courtesy of Dr Andrew Dixon, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/9542">rID: 9542</a>
21. Investigations Urinary pregnancy test Bloods: FBC, UE, LFT, G+S, clotting, lactateImagingUSS abdomen/pelvis (TV) – right ovarian cyst, free fluid, absent venous flow
22. Management
23.
24. Management Laparoscopic cystectomy +/- salpingo-oophorectomy
25. Risk factors Ovarian neoplasm (40%) – dermoid cyst Ovarian cyst (40%)Hyperstimulation (IVF) Paraovarian cyst PregnancyHydrosalpinx Sudden increased intra-abdominal pressureStrenuous exercise
26. Cyst ruptureCommonly functional cystsSpontaneous or triggered by exercise/SIUsually resolves spontaenouslyCyst haemorrhage Commonly functional cystsBleeding into the cyst due to fragile vasculature Bleeding rarely severe enough to cause shock Usually resolve with expectant management
27. Management Expectant (simple cysts) <5cm – no follow up5-7cm – annual USS SurgicalPersistant simple cysts >5cmSymptomatic/ cyst accidents Malignant neoplasms
28. Case 3 A 36 year old female patient presents with a 7 day history of worsening lower abdominal pain, exacerbated by SI. She has started feeling feverish and generally unwell. She had a coil fitted 3 weeks ago.
29. Differential diagnosis?
30. Acute PID History Abdominal pain, usually bilateral Deep dyspareunia Abnormal/purulent discharge Abnormal vaginal bleeding (post coital, inter-menstrual, menorrhagia)RUQ/ right shoulder tip pain Examination Abdominal examinationBilateral lower abdominal tenderness +/- peritonismSpeculum Offensive discharge Coil threadsBimanual examCervical excitation Adnexal tenderness Fever
31. Investigations Urine dip + UPTBloods: FBC, CRP, U&E, LFT (clotting/G+S), BLOOD CULTURES if pyrexialSwabs:Endocervical High vaginal swab Imaging?
32. Investigations Urine dip + UPTBloods: FBC, CRP, U&E, LFT (clotting/G+S)Swabs:Endocervical High vaginal swab Imaging? USS abdo/pelvis (TV): multiloculated complex retro-uterine/adnexal mass, commonly bilateral, debris in the pelvis
33.
34.
35. Management?
36. Management IV access: bloods, IVI Antibiotics: (don’t delay if suspicious of PID)IV ceftriaxone + IV/PO doxycycline (24 hours+)14 days doxycycline + metronidazoleRemove IUCD Send for culture ? Acinomyces Analgesia SurgeryLaparoscopy – divide adhesions and drain abscessUSS guided drainage
37. Advice on discharge?
38. Advice on discahrgeAttend GUM clinic to full STI screen and contact tracingAvoid unprotected SI until treated and attended GUM
39. Risk Factors Young age at first SI↑ # sexual partners <25 years Recent new partner STI in patient/partnerRecent TOPIVF/IUIIUCD insertion
40. Case 4A 30 year old female patient presents with a 2 day history of crampy lower abdominal pain and PV bleeding. She initially thought this was her period, which is quite late but she does have an irregular cycle, however she is now having to change pads every hour and is feeling lightheaded.
41. Differential diagnosis?
42. Initial managementBasic observations UPTIV access, bloods – FBC, clotting, G+S, βHCG, U&E, IVI Examination:Abdominal exam: lower abdominal tendernessSpeculum: os open? POC? – remove if possibleAnalgesia and anti-emetics
43.
44. Investigations Imaging?
45. Investigations ImagingUSS abdo/pelvis (TV)
46. MiscarriageThreatened Inevitable Complete Incomplete – mixed echos in the uterus MissedGestation sac, yolk sac, fetal pole CRL > 7mm and no fetal heart (x 2 sonographers)
47. Definitive management Threatened – advice Complete – UPT 3 weeks Serial βHCG if no previously confirmed IUP (↓50%)Inevitable/Incomplete/Missed Expectant – UPT 3 weeks Medical – misoprostol – repeat USS/UPT 3 weeks Surgical Manual vacuum aspiration (LA) Manual evacuation of RPOC (GA)Anti-D if surgical or medical or miscarriage > 12 weeks
48. Shoulder Dystociahttp://www.illustratedverdict.com/projectreview/IllustratedVerdict0309.asp
49. Shoulder DystociaBony entrapment of the anterior shoulder under the symphysis pubisRisk Factors:
50. Shoulder DystociaBony entrapment of the anterior shoulder under the symphysis pubisRisk Factors:Large babyDiabetic mumPrevious shoulder dystociaIncreased BMI of mumInduction of labour
51. ManagementMcRobert’s manoeuvre Suprapubic pressurehttps://en.wikipedia.org/wiki/McRoberts_maneuver
52. ManagementMcRobert’s manoeuvreSuprapubic pressureEpisiotomy and Wood’s Screw manoeuvre180 degree shoulder rotation of the posterior shoulderDelivery of the posterior shoulderIf unsuccessful, repeat above in changed position
53. ManagementMcRobert’s manoeuvreSuprapubic pressureEpisiotomy and Wood’s Screw manoeuvreRepeatSymphisiotomyZavanelli manoeuvre Replacement of the headCaesarean section
54. ComplicationsMaternal:PainPerineal traumaPPHFetal:Nerve damage - Erb’s palsyHypoxiaFetal deathBladder ruptureUterine rupturePsychologicalClavicular/humeral fracture
55. Cord Prolapsehttps://teachmeobgyn.com/labour/emergencies/cord-prolapse/
56. Risk Factors?
57. Risk FactorsMultiparityLow birth weightPreterm labourBreech presentationTransverse lieSecond twinPolyhydramniosLow lying placentaArtificial rupture of membranesExternal cephalic versionInternal podalic version
58. Why is it bad?
59. Adverse OutcomesFetal hypoxiaFetal deathVasospasmCord compression
60. Identification and ManagementFetal bradycardia on auscultation / CTGVaginal examinationMinimal handling of cord loops outside vaginaElevate presenting partFill urinary bladderKnee-chest or left lateral positionTocolysis to reduce contractions
61. Definitive ManagementCaesarean sectionCategory I or II depending on fetal CTGOr can attempt vaginal birth (usually instrumental) if fully dilated
62. Uterine Rupturehttps://teachmeobgyn.com/labour/emergencies/uterine-rupture/
63. Uterine RuptureFull thickness disruption of uterine muscle and overlying serosaIncomplete - peritoneum intactComplete - torn peritoneum, can result in escape of uterine contents
64. Risk Factors
65. Risk FactorsPrevious caesarean section (classical)Previous uterine surgeryInduction of labourObstructed labourMultiple pregnancyMultiparity
66. Clinical FeaturesSevere abdominal pain (persisting between contractions)Shoulder tip painVaginal bleedingRecession of presenting partScar tenderness and/or palpable fetal partsTachycardia and hypotensionFetal distress
67. ManagementResuscitate: oxygen, cannula x2, bloodsIV fluids and/or blood transfusionsAnalgesiaEmergency caesarean sectionUterine repair / hysterectomy
68. Amniotic Fluid EmbolismRare but often fatalAmniotic fluid enters the maternal circulationTriggers a serious reaction, resulting in cardiorespiratory collapse and bleeding
69. Risk FactorsNo clear consensusThought to be related to abnormalities of amniotic fluid, uterus or placentaMultiple pregnancyIncreasing maternal ageInduction of labourUterine rupture
70. Clinical FeaturesSudden onset:Hypoxia / respiratory arrestHypotensionFetal distressDICSeizuresShockConfusionCardiac arrest
71. ManagementABCDE approachOxygenCannula x2 and bloods (including ABG)CXRECGInvolve anaesthetics, ITU, haematologyDelivery of fetus if possible (may be perimortem section)Diagnosis usually only confirmed at post-mortem
72. Next Emergency...What is the leading cause of death in pregnant women within the UK?
73. PE in PregnancyThe leading cause of death among pregnant women in the developed worldChest pain, shortness of breath, haemoptysisTachycardia, hypoxia, tachypnoea, fetal distressInvestigations: Bloods, ABG, ECG, CXR, CTPAManagement: Resuscitation, LMWH
74. Case 5A 37 year old woman gives birth to twins after a long labour. It was a vaginal delivery and there were no complications. Within a few hours of delivery she starts to feel unwell and her blood pressure starts to drop. What do you think could be happening?The midwife notices that she is bleeding vaginally and predicts she’s lost around a litre of blood.What are you going to do?
75. Postpartum haemorrhage Call for helpActivate a major haemorrhage protocol if indicatedABCDE assessmentMassage the uterus / perform bimanual compressionGive drugs to contract the uterus
76. Postpartum HaemorrhageSyntometrine IM 1 ampOxytocin infusion 40 units (10 units/hr)Ergometrine 500 micrograms IV/IMMisoprostol 1000 micrograms PRCarboprost 250 micrograms every 15 min (up to 8 doses)
77. Postpartum haemorrhage Call for helpActivate a major haemorrhage protocol if indicatedABCDE assessmentMassage the uterus / perform bimanual compressionGive drugs to contract the uterusExamination under general anaesthetic +/- laparotomyInsert a Rusch balloon / B-lynch sutureConsider internal iliac or uterine artery ligation If all else fails - hysterectomy
78. Postpartum HaemorrhagePrimary PPH – blood loss of >500mL within 24 hours of deliveryMajor PPH >1000mLSecondary PPH – excessive blood loss from the genital tract after 24h from delivery, usually 5-12 days later
79. Postpartum HaemorrhageCauses – 4 TsTone Tissue TraumaThrombin
80. Postpartum HaemorrhageRisk Factors:AntenatalPrevious PPH / retained placentaBMI >35Maternal Hb <85 at onset of labourAntepartum haemorrhageMaternal age >35MultiparityUterine malformation / fibroidsA large placental siteOverdistended uterusIn labourProlonged labourInductionOxytocin usePrecipitate labourOperative birthCaesarean section
81. Case 6A 32 year old lady and her husband present to triage. She is 34 weeks pregnant. He is worried that he killed the baby as they were having sex and she began bleeding.What do you think is happening?She is still actively bleeding and you are struggling to get a good blood pressure reading. What are you going to do?
82. Antepartum HaemorrhageABCDE assessmentGive anti-DCall for helpEstablish a diagnosisThe next steps are dependent on stage of pregnancy & diagnosisTerm? Induction of labourShe may need admission until deliveryShe may need a section to deliver the baby as soon as possible
83. Antepartum Haemorrhagebleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.Why is it important?Complicates 3-5% pregnanciesA leading cause of perinatal and maternal mortality worldwideAssociated with cerebral palsyLinked to up to 1/5th preterm births
84. Antepartum haemorrhageImportant causesPlacenta praevia and placental abruptionNeed to remember that some bleeding can be concealed. Minor - <500mLMajor – 500 – 1000mLMassive - >1000mL +/or clinical shock
85. Antepartum HaemorrhagePlacental AbruptionPlacenta PraeviaPremature separation of the placenta from the uterusPlacenta overlaps and implants on the cervixBleeding may be concealedVisible bleedingPainfulPainlessTender, woody abdomenSoft, non-tender abdomenFoetal distress / high HRNormal foetal HR
86. Antepartum Haemorrhage
87. Antepartum Haemorrhage
88. Antepartum HaemorrhageMaternal complicationsAnaemiaInfectionShockRenal tubular necrosisConsumptive coagulopathyPPHProlonged hospital stayPsychological sequelaeComplications of transfusionFoetal complicationsHypoxiaSmall for gestational agePrematurityFoetal death
89. Case 7A 19 year old woman at 38 weeks gestation comes in via ambulance having had a tonic clonic seizure at home following a headache and abdominal pain. What do you think is happening?What are you going to do?
90. EclampsiaCall for helpABCDEMagnesium sulphate – 4g IV/ 5-10 mins, then 1g/hr over 24 hours. Treat further fits with 2g. (Stop magnesium sulphate if her resp rate falls or she loses tendon reflexes. Give calcium gluconate for toxicity.)Manage blood pressure with nifedipine 20mg / labetolol 200mg / hydralazine 5mgRestrict fluids to 80ml/hr Delivery is the only cure. Monitor foetal heart rate and deliver as soon as the mother is stable
91. Pre-eclampsiaSymptoms & Signs:HeadacheVisual disturbanceRUQ painVomitingOedema – hands/face/feetBrisk reflexes / pathological clonusFalling plateletsDerranged LFTsAbnormal U&EsProteinurea
92. Pre-eclampsiaComplications:Maternal Intracranial haemorrhageeclampsiaPlacental abruptionDICHELPP syndromeRenal failurePulmonary oedemaRespiratory arrest Foetal Intrauterine growth restrictionOligohydramniosHypoxia as a result of placental insufficiencyPlacental abruptionPremature delivery
93. Pre-eclampsiaRisk factors:First pregencyMultiple pregnanciesNew father (para >1)Age <20 yrs / >40 yrsBMI >35Family historyHypertension in previous pregnancyCKDAutoimmune diseaseDiabetesChronic hypertension
94. To SummariseMany emergencies possible in O+GABCDE approachCall for help!
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96. Thank you for listening