****! Obstetrics in the ED - PowerPoint Presentation

****! Obstetrics in the ED Ben Shepherd

ANTEPARTUM FUN

BLEEDING IN LATE PREGNANCYAntepartum Haemorrhage (APH) = PV Bleeding > 20/40 gestationCauses: Grading:Spotting (streaking/spotting/staining on pad or undies)Minor <50mLMajor 50-1000mL, but no shockMassive = >1000mL or shockFeto-placental*Placenta Praevia*Placental Abruption*Others (rare)Placenta accreta/percreta/increta, Vasa praevia, Uterine RuptureGenital Tract*Cervical*Vaginal

PLACENTA PRAEVIADefinition = placental location below presenting part of fetusUsually means adjacent to, or covering internal cervical os Grade 1 – 4: Depending on degree of coverage2cm from os considered “clear”Hallmark = painless bleedingSmall bleed can ‘herald’ a bigger bleedManagementAdmit all, if time & gestation <35/40, give/consider corticosteroids/MgSO4Resuscitate if required Assess maternal & fetal condition (C/S if either is compromised)Elective C/S at 37/40 if stable

Uterine Rupture Vasa PraeviaPlacenta Accreta/Increta/PercretaOTHER CAUSES of APH

PLACENTAL ABRUPTIONSeparation of placenta with associated bleeding from exposed vesselsCan be spontaneous or following trauma (direct abdominal trauma or even deceleration/seat-belt injury) Typically associated with abdominal pain & uterine tenderness/irritabilityConcept of concealed vs. revealed abruptionEven minor abdominal trauma in pregnant woman, needs:CTG 4hrsBloods (FBC, Kleihauer)Obstetric AssessmentManagementResuscitate if required (coagulopathy can occur early)Assess maternal & fetal condition & usually deliverOften labour well & can deliver vaginallyC/S if maternal/fetal compromiseTYPES OF ABRUPTION

Pre-Eclampsia Poorly understood pathogenesis, disorder of placentation> 20 / 40*Diagnosis = High BP + ANY end-organ dysfunctionBP > 140/90* + any of:Kidney involvementUrine protein [dipstick >+ suggestive], protein:creatinine ratio > 30Oliguria/Elevated CrNeurologicalHeadaches, visual changes, hyperreflexia, clonus*Seizures = EclampsiaHepatic [transaminases, subcapsular haematoma/rupture]Haematological [haemolysis, low platelets]CVS [pulmonary oedema] Fetal [ IUGR]

Mx PrinciplesPre-Eclampsia EclampsiaCure = delivery*Balance maternal condition vs. prematurityBP lowering if >160/110, definitely >170/110 [aim 140/90]Seizure prophylaxis if severe [MgSO4]Cure = delivery*Seizures typically self-terminateMgSO4 = mainstayThen follow status algorithmThink of other causes if prolonged, focal, resistant to Rx

INTRAPARTUM & POSTPARTUM FUN

VAGINAL DELIVERY If woman comes in labouringRelax and gather appropriate staff & equipment (resuscitaire on, birth pack in resus, 10u syntocinon)Note: It’s a big department, someone is usually aroundCheck mums vitals on arrival (BP quite important (<140/90) fetal heart rate (doppler or US) -- > 110-160 is normalIf head not on view -- > check presentation Abdominal palpation if comfortable, probably USIf head NOT on view (or labia parting) consider transfer to B/Suite*Birth suite a better place for woman to deliverBut better in ED than the corridorIf its ShowTime:Relax (Its likely to be absolutely fine)Re: IV Access: Your discretion (err towards)Re: Monitoring (Do a full maternal set on arrival, do FHR at end of each contraction)Re: Actual process of delivery - not much to itRe: Episiotomy -- > unless you’re experienced and certain she needs it, don’t do it Re: Oxytocic: (Err towards) -- > usually given with delivery of anterior shoulder -- > syntocinon 10u (1 vial) IM Re: Cutting Cord -- > no rush if mum ok & baby crying* -- > leave 5cm cord -- > 2 clamps, cut in middle -- > feels like cutting raw calamari Re: Placenta -- > Leave it alone (no problem unless significant bleeding)

Deliver Syntocinon IMCheck babyCut cordDeliver placenta

Placenta Delivery& Cutting the Cord Probably Cut the cord early & fairly long ~5cmBut if mum and baby are well – doesn’t matterNot gonna talk about active vs. physiological 3rd stageBut do activeFirstly NO rush to deliver placenta unless bleedingNormal time ~5-30minIf you’re hell bent, remember to used ‘controlled cord traction’ and await signs of separation:Rush of bloodCord lengthensFundus rises

SHOULDER DYSTOCIA Bony entrapment of shoulder behind symphysis pubisDiagnosed by delivery of head with failure to deliver shouldersBig issue -- > cord trapped & occluded -- > rapid hypoxia/acidosisSimplified approach1. Call for Help & Expect Neonatal Resus2. Lie flat & Legs Up (Knees to nipples)3. Pressure Suprapubically4. Roll on All 4sNote: Other manoeuvres we will demonstrate only (no benefit in memorising)

VAGINAL BREECH BIRTH Uncommonly done (even) in B/Suite, usually only 2nd twinsBegan with ‘Term Breech Trial 2000’Exacerbated by lack of experienceMain risk = entrapped headKey = sit on hands -- > baby likely to deliver itselfIf not delivering -- > few manoeuvres we will demonstrate (no value in memorising today)By the time you need to use the manoeuvres, someone from O&G should be thereExpect the baby to be flat

Post Partum Haemorrhage Causes: 4 TsToneTraumaTissueThrombinManagement in EDCheck TsRub fundus & Call for HelpIVC & Resuscitate [consider MTP/ROTEM/?TXA]Give some drugsBimanual compression

PPH Drug Revision Ergometrine 250mcg IV / IMAlpha agonist = High BPSyntocinon5u IV bolus +/- repeat10-20u IMInfusion 40u/1L q4h = 1u IV q 6minMisoprostol1000mcg PR [can be given buccally – works quicker]Prostagladin F2alphaOriginally intramyometrial, now IMI

Uterine InversionUsually iatrogenic Analgesia +/- DissociateClues:Severe painVisible uterusShockReplace fundus, then bimanual compressionMay need tocolyticTerbutaline 250mcg scGTN 50mcg IV [s/l might be quicker]Do NOT remove placenta [will be done in OT]

QUESTIONS?