1. Obstetric Emergencies
Dr Mohamed Abdul Hakim Kotb,MBBCH,MSC,MD
Anaesthesia & ICU

2. Obstetric emergencies
Massive obstetric haemorrhage
Non-haemorrhagic shock:
Amniotic fluid embolism
Acute uterine inversion
Shoulder dystocia
Eclampsia
Cord prolapse
Cardiac Arrest
Anaphylaxis
TRAUMA

3. BASIC PRINCIPLES FOR OBSTETRIC EMERGENCIES.
Physiological changes in pregnancy modify:
Presentation of the problem
Normal physiological variables
Response to treatment
Both 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.

5. MASSIVE OBSTETRIC HAEMORRHAGE
Major contributor to maternal mortality
Definition
Blood loss requiring replacement of patient’s total blood volume
Transfusion requiring > 10 u of blood in 24 hs
50% replacement of blood vol. <3 hs period
Difficult to estimate blood loss
Problem of concealed bleeding
Uterus
Broad lig.
Peritoneal cavity 2

6. RECOGNISING SIGNIFICANT BLOOD LOSS
10 – 15% ml
Normal BP
No signs.
15-25% ml
BP ~ 100mmHg
Dizziness, tachycardia
25-35%
ml.
BP ~ 70-80mmHg.
Restlessness,pallor, oliguria.
35-45% ml
50-70mmHg
Collapse, air hunger, anuria

7. Factors contributing to maternal death from catastrophic PPH
General
Increased oxygen and cardiac output requirements of pregnancy may hamper adequate blood / volume replacement
Placental bed perfusion 600 mls/min
Blood loss underestimated
Delayed or inadequate management
Inadequate resources / personnel
Specific
Failure to anticipate coagulopathy
PET, abruption, sepsis, IUFD, AFE.
Abnormal placentation
Placenta praevia / accreta
Jehovah’s witness**

8. Mechanism of DIC
1) intravascular infusion of thromboplastic substances that initiate the extrinsic coagulation system
placental abruption, IUFD
2) conditions associated with endothelial cell damage, which activates both the extrinsic and intrinsic coagulation systems
eclampsia/ PET
3) indirect effects of other disease, such as G- sepsis, AFE etc

9. Preventative Management PPH
Detect and treat antenatal anaemia
Active Management of Third Stage
Administration of a prophylactic oxytocin
Early cord clamping
Controlled 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.

10. Available from Royal Women’s Hospital, Carlton, Clinical Practice Guidelines:

11. Management Principles
Organisation
restoration of blood volume
correction of coagulopathy
evaluating response to treatment
monitoring PR, BP, CVP, ABG, UOP
If resuscitation is adequate P & BP should return to normal
treat the cause
abruption
placenta praevia
uterine rupture
placenta accreta

12. Available from Royal Women’s Hospital, Carlton, Clinical Practice Guidelines:

13. NON-HAEMORRHAGIC OBSTETRIC SHOCK
Uncommon but responsible for majority of maternal deaths in developed countries.
-Amniotic fluid embolus
-Acute uterine inversion

14. Amniotic Fluid Embolism
Passage of amniotic fluid debris into maternal circulation
Obstructs pulmonary circulation
Cardio-respiratory arrest

15. AMNIOTIC FLUID EMBOLISM
Clinical features
Multiparous women
Precipitous labour
Presence of intact membranes
Sudden dyspnea
Hypotension
Seizure activity not uncommon
If survive initial insult
70% suffer non-cardiogenic pulmonary oedema
ARDS 39

16. AMNIOTIC FLUID EMBOLISM
Diagnosis
Consider in all obstetric patients with sudden collapse.
Differential
PTE
Septic shock MI
Aspiration pneumonia
Allergy to drug 40

17. Management Secure airway treat cardiovascular collapse
central venous line
acute left ventricular failure: digoxin
dopamine
correct coagulopathy
treat metabolic/electrolyte abnormalities

18. Acute Uterine Inversion
Most commonly arises from mismanaged 3rd stage

20. Presentation Sudden collapse in 3rd stage
Degree of shock inconsistent with blood loss
Shock is neurogenic in nature
Traction on infundibular pelvic ligament
May be no palpable fundus
Mass in vagina/introitus 43

21. Management Avoid mismanagement of 3rd stage of labour Once occurs
Anti-shock measures
If placenta still attached remove after uterus is replaced
Manual replacement of uterus
O’Sullivans hydrostatic pressure
Surgical correction 44

22. Shoulder Dystocia

23. Erb’s palsy

24. ‘It all comes,’ said Pooh crossly, ‘of not having front doors big enough’

25. ‘It all comes’, said Rabbit sternly, ‘of eating too much’

27. Risk Factors Macrosomia (>4kg) Intrapartum
maternal diabetes
post dates
maternal obesity
high maternal wgt gain in pregnancy
advanced maternal age
previous large infant
previous shoulder dystocia
Intrapartum
protracted late active phase
prolonged 2nd stage
delay in head descent in 2nd stage
mid-pelvic operative delivery
The combination of macrosomia and delay in 2nd stage predicts 35% of shoulder dystocia

28. Eclampsia
1/1500

29. Complications Cerebrovascular injury pulmonary oedema coagulopathy
maternal/fetal death
HELLP syndrome

30. Presentation
Hypertension, hyperreflexia, clonus, headache, visual changes, seizure
20% have diastolic BP<90, normal reflexes, and urinary protein <2+
70% of deaths due to intracerebral haemorrhage

31. Management • Goals: – Stabilization of the mother/seizure control
• MgSO4 therapy: 4-6 g over 20 min followed by
infusion of 1-3 g/hr, OR
• Thiopental or diazepam followed by MgSO4
infusion
– Airway management
– Avoiding aspiration

32. Prolapsed Cord
1/500 deliveries
Most occur during ARM

33. Presentation Cord visible outside the introitus
CTG abnormalities appear
variable decelerations
fetal bradycardia
Note: fetal or maternal injury due to hasty intervention

34. Management Keep cord warm - replacing in vagina may help
Keep pressure off cord by gloved hand in vagina lifting fetal part off the cord
Positioning,Maternal O2, IV access
If fetus is alive, operative delivery - CS if not able to deliver vaginally
If fetus is dead, vaginal delivery if presentation allows

35. Anaphylaxis
vasodilatation, smooth muscle contraction, glandular secretion, increased capillary permeability
Management:
oxygen
colloid
bronchodilator
adrenaline (despite Ux stimulatory effect)
anti-histamine (if angioneurotic oedema)
steroid (for refractory bronchospasm)

36. Maternal cardiac emergency
Acute:
AMI
Tocolytic therapy
Aortic dissecting aneurysm
Peripartum 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/RVF
Traumatic myocardial contusion: ie: MCA

37. Drug Overdose
Illicit drugs: heroin, cocaine and amphetamines (these 2 can cause hypertension, ^ C.O., decrease Uterine blood flow, APH, cerebral haemorrhage, convulsions, arrhythmias).
Drug overdose
Drug error
Anaphylaxis
Hypermagnesaemia:
wide QRS on ECG, 5-6mmol/l lose tendon reflex
resp. paralysis, SA and AV node block
cardiac arrest.
Treatment: CaGluconate 10% 10ml slow IV

38. CARDIO-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.

39. Technique 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 compressions
wedge 270 angle allows 80% of maximal force to be dissipated
rescuer’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”

40. TRAUMA 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.

41. Management Initial resuscitation should follow normal plan of ABC.
Hypotension may not be present until 35% or more blood volume is lost.
Aorto-caval compression release
Rule out pelvic fractures, uterine injury & retro-peritoneal hemorrhage
Fetal monitoring with cardio-tocographic monitor
Rh immunoglobulin – within 72 hours.
Radiation hazards:
1st trimester >5 rads
Chest x-ray < 5 rads
Pelvic film <1 rads
Abdomino-pelvic CT scan rads

42. BURNS
Increased levels of prostaglandins predispose to pre-term labour.
Replacement of fluids vis-à-vis increased volumes in pregnancy.
Inhalational injury- hypoxia & carbon monoxide poisoning
Infections- prophylactic antibiotics controversial
Topical Povodine iodine- affects fetal thyroid functions

43. Thank You
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