OB/GYN Emergencies

Awan Nurtjahyo

Definition of
Obstetric Emergencies:
An emergency is an occurrence
of serious and dangerous nature,
developing suddenly and
unexpectedly, demanding
immediate attention.

Overview:
Obstetric emergencies - cause damage and
death to mothers and babies. They require
quick, decisive and effective action from the
staff immediately available.
Maternal mortality rate

Thailand 44 per 100,000

Malaysia 39 per 100.000
Singapura 6 per 100.000
Indonesia 228/100.000 (2008)

Important

Early sign, transport to OBGYN, and first action

when tranport

Patient Exam
Sick/Not Sick
Patient History (know risk factors)
Vital Sign
Focused Exam
Initial Assessment (Correct life threats!)
Plan including transport
= Best Possible Patient Outcome!

OB Emergencies
Severe pre-eclampsia
Antepartum haemorrhage
Postpartum haemorrhage
Breech Presentation
Prolapsed Cord

Gyn Emergencies
Ectopic pregnancy
Miscarriage
Ruptured Ovarian Cyst, Ovarian Torsion,
and Tubo-ovarian Abscess

Pre-eclampsia
A pregnancy-induced hypertension
20 weeks gestation
Previously normotensive
140/90 mmHg on at least two occasions
+ proteinuria 0.3g in 24h
oedema
Multisystem disease

Severe pre-eclampsia
Diastolic blood pressure 110 mmHg on
two occasions
Or systolic blood pressure 170mmHg on
two occasions
Significant proteinuria (at least 1g/litre)

Clinical features
History

Usu. asymptomatic
Headache
Drowsiness
Visual disturbance
Nausea/vomiting
Epigastric pain

Examination

Oedema (hands and face)

Proteinuria on dipstick
Epigastric tenderness (liver involvement)

Complications (Mother)
Head/brain
Eclampsia, Stroke/ cerebrovascular haemorrhage

Heart
Heart failure

Lung
Pulmonary oedema, Bronchial aspiration, ARDS

Liver
Hepatocellular injury, liver failure, liver rupture

Kidneys
Renal failure, oliguria

Vascular
Uncontrolled hypertension, DIC
HELLP

Complications (fetal)
IUGR
Oligohydramnios
Placental infarcts
Placental abruption
Uteroplacental insufficiency
Prematurity
PPH

Investigations
Maternal
FBC platelets (HELLP)
Coag screen if platelets abnormal
U&Es (urate, renal failure)
LFTs (liver involvement)

Fetal
USS
Fetal size/growth, amniotic fluid volume, umbilical
cord blood flow

CTG

Management
No cure except delivery; Aim to minimise risk
to mother in order to permit continued fetal
growth
Antihypertensives
Methyldopa
Nifedipine

Eclampsia
Magnesium sulphate

Induction of labour
Antenatal steroids

Patient CareSeizures

Antepartum haemorrhage
Bleeding at > 24weeks (<24 weeks is
miscarriage)

a) Placental abruption
b) Placenta praevia

Definitions
Placental abruption: part of the placenta becomes detached from the uterus

Placenta Praevia: The placenta is inserted wholly or in part into the lower segment of the uterus and therefore lies in front of the presenting part.
AVOID PV exam; placenta
praevia may bleed catastrophically

Risk factors
Placental Abruption
Increased blood pressure
Trauma
Drug use - cocaine
Smoking/poor nutrition
Chorioamnionitis
Twins/polyhydramnios

Placenta praevia
increased maternal age
multiple births
previous cesarean
placenta previa

Signs and symptoms

Placental abruption

Placenta praevia

Shock out of keeping with visible loss

Shock in proportion to visible loss

Pain constant

No pain

Tender, tense uterus (hypertonic)

Uterus not tender (hypotonic)

Normal lie and presentation

Both may be abnormal

Fetal heart absent/distressed

Fetal heart usually normal

Coagulation problems

Coagulation problems rare

Beware pre-eclampsia, DIC, anuria

Small bleeds before large

Patient Care

Postpartum Hemorrhage
Defined as >500 cc blood loss.
Risk factors
Overdistended uterus: polyhydramnios,
twins
pitocin stimulated labor
general anesthesia
amnionitis
retained placental fragments

Postpartum Hemorrhage
Primary: within 24hrs of delivery
Secondary: 24hrs-6weeks post delivery

Patient Care

Breech Presentation
Most common
abnormal delivery
Buttocks first or
both legs first
Increased risk of
prolapsed cord
Possible meconium
staining

Patient Care

Prolapsed Cord
Position mother head down and buttocks
raised.
Provide high-concentration oxygen.
Check for pulses and wrap cord.
Insert several fingers into vagina to push
up on babys head.
Transport.

Prolapsed Cord

Ectopic Pregnancy
Normal pregnancyegg divides in the
oviduct (fallopian tube)
Ectopic pregnancyegg implanted
outside the uterus
Acute abdominal pain
Vaginal bleeding
Rapid and weak pulse (later sign)
Low blood pressure (a very late sign)

Risk factors
Previous ectopic pregnancy
Inflammation or infection
Fertility issues
Structural concerns
Contraceptive choice

Patient Care

Miscarriage and Abortion

Delivery before 22 week
Called spontaneous abortion or
miscarriage
Induced abortion
Results from deliberate actions to stop
pregnancy

Full attention for septic abortion

Signs and Symptoms

Cramping abdominal pains
Associated with 1st stage of labor

Bleeding
Moderate
Severe

Discharge
Tissue
Blood

Be carefull fever (septic abortion)

Patient Care

Ruptured Ovarian Cyst, Ovarian

Torsion, and Tubo-ovarian Abscess
Ovarian cyst
Fluid-filled sac on or within an ovary
Functional cyst is the most common
Corpus luteum cyst develops if the sac seals itself
after release of the oocyte.

If the cycle of forming sacs is repeated

excessively, polycystic ovaries may develop.
Lack of progesterone and high levels of androgens

Ruptured Ovarian Cyst, Ovarian

Torsion, and Tubo-ovarian Abscess
Ovarian torsion occurs when a cyst does not
self-resolve and grows to a significant size.
Sudden onset of severe lower abdominal pain
Nausea and vomiting

Tubo-ovarian abscess is encountered

secondary to a primary infectious agent.
Fallopian tubes or ovaries become blocked by an
infectious mass.

Clinical features
A patient with an ovarian cyst may report:
Dull, achy pain in the lower back and thighs
Abdominal pain or pressure
Nausea and vomiting
Breast tenderness
Abnormal bleeding and painful menstruation

A ruptured ovarian cyst usually presents:

Lower abdominal pain (sharp)
Abdominal distention and tenderness
Dizziness
Weakness
Syncopal episode

Clinical features
A tubo-ovarian abscess may present with:
Severe abdominal pain
Guarding and rebound tenderness
Nausea and vomiting
Abdominal distention
Fever

Patient Care
Treat for shock.
Ensure adequate
airway.
Keep the patient left
laterally recumbent.
Initiate IV fluid
therapy.
Give nothing by
mouth

Consider urethral
catheterization
Anticipate vomiting
Keep the patient
warm.
Monitor the patient's
ECG
Transport.

For patients with ovarian torsion:

Start an IV for pain medications and dehydration.
Administer antiemetics