Obstetrics Emergencies in Primary Care

Preeclampsia
Definition
- HPT with significant proteinuria
o 24H urine protein > 300mg/day
o Urine PCR > 30mg/mmol/L
- De novo or superimposed on chronic HT

Major risk factors

- HT disease in previous pregnancy
- CKD
- DM
- HT
- Autoimmune disease

Moderate risk factors

- Primigravida
- Birth interval > 10 years
- Multiple pregnancy
- FHx of PE
- Age > 40 years old
- BMI > 30

1 major or 2 moderate

Prevention
- Aspirin 150mg OD until 36 weeks
- Start at 12 weeks gestation for max benefit
- Take at night
- Monitor potential SE
- Stop at 36 weeks
- Contraindications:
o Asthma

- Calcium carbonate 1g BD
o Benefit in those with poor intake of calcium, and start to take at 20 weeks

PE profile
- FBC
- LFT
- RP
- SUA: to monitor in preeclampsia  higher SUA  higher risk of IUD
- Coag
Grades
- Mild 140-149/80-89
- Moderate 150-159/90-99  start antiHPT
- Severe >160/100-110
o Nifedipine, labetolol, hydralazine
o Bring down BP gradually
Severe PE

- Severe HPT and proteinuria or

- Mild or moderate HPT and proteinuria with > 1 of:
o Headache
o Vision
o Hypochondriac pain
o Papilledema
o Clonus > 3 bears
o Liver tenderness
o HELLP syndrome
o PLT < 100
o Abnormal liver enzymes

Eclampsia
- GTC seizure in someone with PE
- 1-2% of preeclamptic pregnancy
- May occur
o 38% antepartum
o 18% intrapartum
o 44% postnatally – usually within first 48H

Mx
- Resuscitation
o Prevent hypoxia – ensure airway patent. If patient has postictal drowsiness and
tongue is floppy  just insert airway
o Prevent maternal injury
- Prevent recurrence
o MgSO4
 Loading dose: IM 10g + 1ml lignocaine 2% in each buttock
 Maintenance: IM 5g alternate buttock every 4H
- Control BP
- Arrange for delivery
APH
Definition: any PV bleeding occurs after 22 weeks (threshold of viability)

Causes
- Placenta previa
- Abruptio placenta
- Vasa previa
- Local cause: trauma, infection, ectropion
- Indeterminate APH

Principles of management
- Recognize APH and assess severity:
o Spotting
o Minor
o Major (a lot but hemodynamically stable)
o Massive (hemodynamically unstable)
- Communication and call for help
- Resuscitation
- Identify and treat the cause of APH
- Monitoring and documentation

Clinical evaluation
- History
o Gestational age
o FM
o Details of bleeding
o Abd pain: ? abruptio
o Contraction: ? PP
o Precipitating factor: trauma/fall
o Placental site
o Blood group
- Examination
o Digital examination should not be performed until placenta previa is ruled out!
o Vital signs
o Evidence of shock
o Abd examination
 ? FH
 Soft, tender, woody hard
 Lie, presentation, fetal viability - daptone
o Speculum
 Assess the bleeding site, amount, active

Abruptio placenta
- Premature separation of normally located placenta from the uterus prior to the delivery of
the fetus
 - Usually abdp pain
- Bleeding – revealed/concealed/mixed
- Low threshold for blood and blood products transfusion
- If already in labour  just allow labour to progress pro
- Caesarean section if
o Evidence of fetal compromise
o Unfavourable cervix
o Other obstetrics indication
- Abruptio + IUD  think of DIVC  send to hospital fast!!!

To do:

- Transfer to hospital with blood bank ASAP

- 2 large bore cannula
- CBD
- Ongoing fluid resuscitation
- Keep patient and next of kin informed of progress and risk of IUD

Placenta previa
- Placenta implanted partially or entirely in the lower segment of the uterus
- Usually revealed
- May have multiple episodes of small bleeds
- If bled  hospitalized until delivery
- IM dexa 6mg BD X 2/7 or 12mg OD
- Tocolysis if in labour until dexa completed
- Admission at 34 weeks onwards if bleeding
- Terminate (delivery) if
o Torrential bleeding regardless of gestation
o Fetal distress
o Labour

Local causes
- Do not attribute bleeding to local cause UNLESS bleeding is demonstrable from the lesion

Vasa previa
- Rare
- Dangerous
- Presence of velamentous cord insertion at the lower segment of the uterus
- Torn either doing SROM or ARB
-  exsanguination and fetal distress
Preterm Labour
- Progressive cervical effacement and dilatation in presence of regular uterine contraction

Risk factors:

- Previous preterm labour

- Intrauterine, extrauterine infections
- Cervical incompetence
- Uterine cause: abnormalities, overdistension
- Social: low BMI, short pregnancy interval, powerty, smoking, alcohol, drugs, stress
- Others: APH, PE

Clinical assessment: Hx + PE

- Establish lie, presentation

- VE: cervical dilatation?
- UFEME

Refer for tocolysis/delivery to hospital with NICU back up

Consider corticosteroid if preterm labour

VTE
- Includes
o DVT
o PE
- 3rd commonest direct cause of maternal death in Msia
- Hypercoagulable state 4-6 fold
- In postnatal period VTE risk is higher
- Caesarean section: 10-20 fold increase
- VTE risk assessment – pre-pregnancy, antenatally, postpartum
- Thromboprophylaxis should be offered to those with intermediate and high risk

DVT
Symptoms & signs

- Unilateral pain, discomfort, swelling

- 90% left leg
- May also come with pelvic pain if the clot happens higher up

PE
Sx vary depending on how much lung is involved, size of clot

- Sudden SOB
- Sudden chest pain
- Sweating
- Irregular heart beat

V/S, SPO2

Ix

- FBC, CRP
- D-dimer not indicated
- ABG
- ECG
- CXR
o Exclude other causes
o Normal in 50% of PE
o Non-specific changes
- Doppler USG
- Ventilation / perfusion (V/Q) scan
- CTPA
Sepsis
- Life-threatening condition defined as organ dysfunction resulting from infection during
pregnancy, childbirth, post-abortion or postpartum period

Risk factors:

- Obesity
- DM
- Immunosuppressed
- Anemia
- Vaginal infection
- Pelvic infection
- Amniocentesis/invasive procedures
- Cervical cerclage
- PROM
- Caesarean section
- Wound hematoma
- Retained POC
- Group A strep infection

Source:

- Genital tract sepsis

- Chorioamnionitis
- Mastitis
- UTI
- Pneumonia
- Skin and soft tissue infection
- Gastroenteritis
- Pharyngitis

Organisms:

- GAS
- E. coli
- S. aureus
- S. pneu
- MRSA
- Clostridium

Symptoms:
- Fever
- Diarrhea, vomiting
- Red, tender, engorged breasts
- Maculopapular rash
- Abdo/pelvic pain
- Wound infection

Quick SOFA (qSOFA) Criteria

- RR 22 or more
- Altered mentation
- SBP 100 or less
- 1 only: refer to hosp to monitor, 2 or more: initiate sepsis care bundles
Cord Prolapse
Umbilical cord protrudes below the presenting part after the rupture of membrane

May lead to fetal hypoxia

- Compression of umbilical vessels by presenting part

- Vasospasm from exposure of umbilical cord

Risk factors

- Abnormal lie
- Multiple
- Polyhydramnios
- Prematurity
- High presenting part
- Amniotomy

Mx

- Call for HELP

- Monitor FH
- Arrange for immediate referral
- Relieve cord compression
o Elevate maternal buttock with 2 pillows
o Push fetal head upwards
o Inflate bladder with 500mls NS
o Trendelenburg position or Knee chest position
- Prevent cord spasm
o Consider tocolytic agent: IV salbutamol 2.5mg STAT
o Minimize excessive handling of the cord
o Wrap the exposed cord with warm gauze
Secondary PPH (after 24H)

Causes:

- Endometritis
- Retained POC

Management

- Resuscitation with fluids

o V/S monitoring
o Insert CBD
o Syntometrine (ergometrine (peripheral vasoconstriction; contraindicated in cardiac
disease / hypertension as can cause heart failure) + oxytocin) /syntocinon 1amp
(40u) STAT run fas
- Assess severity