OBSTETRIC EMERGENCIES

BY
JANET AMA TAKYIWA
 OBJECTIVES
By the end of this lecture, students will be able to:
1. Explain what antepartum haemorrhage (APH)
2. State and explain at least three causes of APH and their
management.
3. Explain postpartum haemorrhage
4. state and explain at least two types of PPH
5. state and explain the four causes of PPH and their management.
6. Understand and explain pre-eclampsia and eclampsia, risk factors,
types and their management.
OBSTETRIC EMERGENCIES
ANTEPARTUM HAEMORRAHGE (APH)

Antepartum haemorrhage (APH) is defined as genital tract bleeding

from 20 weeks of gestation onwards up to the delivery of the baby.

The causes could be considered as both major and minor

Major causes

• Abruptio placenta

• Placenta previa
Cont’d

Minor causes

• Marginal placental bleeding

• Trauma to the cervix or vagina

• Cervical ectropion

• Local inflammation of the cervix/vagina

Cont’d
• Cervical or vaginal growth eg. Carcinoma of the cervix or polyps
• Varicosities of the lower genital tract
• Vasa praevia
• Placental abnormalities leading to unexplained APH
Cont’d

Associated factors

• High maternal age

• mother with previous abruption is six times more likely to have another
abruption

• Trauma

• Underlying thrombophilia eg factor 5 Leiden, protein S & C deficiency etc

 placenta praevia
• placenta praevia abnormally low placental implantation that partially
or completely covers the internal cervical os.
Cont’d
• Placenta praevia increases the likelihood of APH due to poor attachment of
the placenta to the uterine wall
• It accounts for one third of all cases of APH
Causes
• increasing maternal parity
• advancing maternal age
• increasing placental size (multiple pregnancy)
Cont’d

• endometrial damage (previous dilation and curettage)

• previous Caesarean section,

• uterine scars and pathology (previous myomectomy or endometritis)

• placental pathology (marginal cord insertions and succenturiate lobes)

• previous placental praevia

• curiously, cigarette smoking

Placenta praevia classification/types
Placenta praevia classification/types
It can be classified as:

• Type I/Low implantation : if implantation is in lower segment but does not reach
the internal os

• Type II/Marginal placenta: placenta reaches the internal os but does not cover it

• Type III/ Partial previa: placenta covers the internal os but not at full dilatation

• Type IV/ Complete previa: placenta covers internal os even at full dilatation of
cervix.
 Clinical symptoms

Typical symptoms of placenta praevia include:

• Painless vaginal bleeding

• Light contractions may be present

• High presenting fetal part commonly with unstable lie

• Ultrasound scan is the investigation of choice to diagnose this

condition.
Cont’d

• NB: Vaginal examination should be avoided when there is vaginal bleeding.

Both mother and baby could bleed to death if the placenta detaches.

• Minor haemorrhage- blood loss less than 50 ml that has settled

• Major haemorrhage - blood loss of 50-1000 ml, with no signs of clinical

shock. Massive haemorrhage-blood loss greater than 1000 ml with signs of
clinical shock
Placenta accrete or placenta accreta spectrum
(PAS)
 Placenta accrete or placenta accreta spectrum
(PAS)
• Placenta accreta puts the mother at risk of severe blood loss and
other complications. The rates of maternal death, transfusion,
prolonged hospital stay and hysterectomy are all increased for
women with accrete

• Placenta accreta spectrum (PAS) is made up of three different levels

of invasion: placenta accreta, placenta increta, and placenta percreta.
Cont’d

• Placenta Accreta: is when the placenta attaches too deeply into the uterine
wall

• Placenta increta: is when the placenta attaches into the uterine muscles

• Placenta percreta: occurs when the placenta goes completely through the
uterine wall invading near by organs like the bladder resulting in complete
rupture of the uterus
 Risk factors for placenta accreta
Risk factors for placenta accreta include
• placenta previa with or without previous uterine surgery
• prior myomectomy
• prior cesarean section
• Asherman’s syndrome
• uterine fibroids
• maternal age greater than 35 years
 Vasa previa
• Definition: Vasa previa is the term commonly used when fetal
blood vessels in the membranes run across the cervix in front
of the presenting part. There are two main types. These are:
type 1 and type 2 vasa previa
Cont.’d
• Type I: which involves velamentous cord insertion and fetal vessels
running freely within the amniotic membranes and overlying the
cervix or in close proximity of it (2cm from os)
Cont’d
• Type 2 vasa previa: the placenta has two or more unnecessary lobes
with fetal blood vessels connecting them, flowing over or near the
cervix
 diagnosis
• Full Blood Count, urea and electrolytes and LFTs to exclude pre-
eclampsia
• Clotting profile for abnormal blood clotting
• Kleihauer test
• Blood for grouping and crossmatch
• Cardiotocography (CTG) is used to monitor the fetus
• Ultrasound scan (Transabdominal Sonography/Transvaginal
Sonography has been used safely in the presence of placenta praevia)
 Management of placenta previa

• Placenta praevia is typically identified at the 16-20 week scan. If

placenta praevia is identified the mother is rescanned at 32
weeks and if it is still present, again at 36 weeks.

• If placenta praevia is still present at 36 weeks gestation, delivery

via caesarean section is recommended, due to the significant risk of
spontaneous labour and associated haemorrhage.
Cont’d

• To reduce Respiratory Distress Syndrome (RDS), therapy with

corticosteroids is given to mothers delivering before 34 weeks.

• Close observation and the use of syntocinon in iv infusion is vital to

avoid postpartum haemorrhage which is common in the
postoperative period
 PLACENTAL ABRUPTION
• Placental abruption is the complete or partial separation of the
placenta before delivery
• It is one of the leading causes of vaginal bleeding in the second half of
pregnancy
• The majority of placental abruptions occur before 37-weeks gestation
Cont’d

• It occurs around 25 week of pregnancy and its characterized by

vaginal bleeding, lower abdominal pain and low blood pressure.
 Risk factors
Risk factors for abruption include:
• prior abruption
• Smoking
• Trauma( fall, accidents)
• cocaine use
• multifetal gestation
• hypertension
• Preeclampsia
Cont’d
• Thrombophilias
• advanced maternal age
• preterm
• premature rupture of the membranes
• intrauterine infections
• hydramnios
 classification of placental abruption
• The classification of placental abruption is based on the following clinical
findings:
• Class 0: Asymptomatic
• Discovery of a blood clot on the maternal side of a delivered placenta
• Diagnosis is made retrospectively
• Class 1: Mild
• No sign of vaginal bleeding or a small amount of vaginal bleeding.
Cont’d

• Slight uterine tenderness

• Maternal blood pressure and heart rate

• No signs of fetal distress

Class 2: Moderate

• No sign of vaginal bleeding to a moderate amount of vaginal bleeding

Cont’d

• Significant uterine tenderness with tetanic contractions

• Change in vital signs: maternal tachycardia, orthostatic changes in

blood pressure.

• Evidence of fetal distress

• Clotting profile alteration: hypofibrinogenemia

Cont’d

• Class 3: Severe

• No sign of vaginal bleeding to heavy vaginal bleeding

• Tetanic uterus/ board-like consistency on palpation

• Maternal shock

• Clotting profile alteration: hypofibrinogenemia and coagulopathy

Cont’d

• Fetal death

Classification of 0 or 1 is usually associated with a partial, marginal

separation; whereas, classification of 2 or 3 is associated with complete
or central separation.
 Types of abruption
• Revealed placental abruption: blood tracks between the membranes
and the decidua, and escapes through the cervix into the vagina
 Cont’d

concealed placental abruption: occurs

when blood accumulates behind the
placenta, with no obvious external bleeding
Cont’d
• Mixed placental abruption: in this type, some part of the blood
collect inside (concealed) and some are expelled out ( revealed).
 Maternal consequences

This may include:

• obstetric hemorrhage

• need for blood transfusions

• emergency hysterectomy

• disseminated intravascular coagulopathy

• renal failure
 Neonatal consequences

This may include:

• preterm birth and low birth weight

• perinatal asphyxia

• stillbirth

• neonatal death
 diagnosis
• Diagnosis is mainly clinical with:
• bleeding per vaginuum
• Abdominal pain
• Uterus is tender and irritable
• In severe abruption, there may be maternal hypotension, tachycardia,
and evidence of fetal distress
 management
• Immediate delivery of the fetus if the fetus is matured or if mother and
fetus are in distress
• Blood transfusion to maintain blood volume, blood pressure and blood
plasma to maintain fibrinogen level may be required
• Maintain iv fluids
• Vaginal delivery may be preferred to C/S except in the case of fetal distress
• Excessive bleeding from the uterus may required hysterectomy
 POSTPARTUM HAEMORRHAGE (PPH)

• PPH can be defined as blood loss >1000 ml after vaginal or cesarean

delivery) requiring a blood transfusion

• PPH causes up to 60% of all maternal deaths in developing countries.

The majority of these deaths occur within 4 hours of delivery,
indicating they are a consequence of events in the third stage of
labour (Ramanthan, 2006).
 Types of postpartum haemorrhage

• Primary (immediate) postpartum hemorrhage is defined as excessive

bleeding that occurs within the first 24 hours after delivery

• Secondary (late) postpartum hemorrhage is defined as excessive

bleeding occurring between 24 hours after delivery of the baby and 6
weeks postpartum
 Causes of Postpartum haemorrhage

It is helpful to think of the causes of PPH in terms of the four T‘s:

• Tone - uterine atony

• Tissue - retained placenta or clots

• Trauma - uterine, cervical, or vaginal injury

• Thrombin - pre-existing or acquired coagulopathy

 Predisposing factors

• History of previous PPH

• Large for gestational age newborn (> 4 kg)

• Placenta praevia/ accreta

• Hypertensive disorders
Cont’d

• Obesity

• High Parity

• Bleeding disorders

• Induction and/or augmentation

• First stage labour > 24 hours

Cont’d

• Delay in progress of second stage

• Precipitate labour

• Instrumental delivery

• Caesarean section

• Retained placenta

• Lacerations
 diagnosis
• Timely recognition of patients at increased risk of PPH prior to
delivery

• Assessment of signs and symptoms is more clinically useful than

blood estimation alone.

These include:

• feeling unwell

• lightheaded and/or fainting

Cont’d

• pallor, cold peripheries and/or goose bumps

• hypotension and/or tachycardia (occasionally bradycardia)

• agitation and/or confusion

 investigation
• Full blood count
• Blood for grouping and crossmatching
• Clotting time test can be done
 Management of pph

• Fluid replacement with N/S or R/L

• Transfuse blood

• Oxygen therapy if needed

• Observation( BP, pulse and respiration)

• Maintain hourly urine output

Cont’d

• The medications most commonly used in PPH management are

uterotonic agents, which cause the uterus to contract

• External uterine massage and bimanual compression are generally

used as first-line treatments

• These medications include oxytocin (Pitocin®), prostaglandin

E1/misoprostol (Cytotec®), methylergonovine etc
Cont’d
• These compression techniques encourage uterine contractions that
counteract atony and assist with expulsion of retained placenta or
clots.
Cont’d

• Procedures used in PPH management include manual removal of the

placenta, manual removal of clots, uterine tamponade, and uterine
artery embolization

• Surgical options in the event of failure of other measures to control

bleeding include curettage, uterine artery ligation, uterine hemostatic
compression suturing, and hysterectomy.
curettage, uterine artery ligation
uterine hemostatic compression suturing
 Prevention

• active management of the third stage of labour (AMTSL) is associated

with reduced maternal blood loss, reduced postpartum hemorrhage,
reduced postpartum anemia, reduced need for blood transfusions
and a decrease in the incidence of prolonged third stage of labour
 PRE-ECLAMPSIA
• Pre-eclampsia is a multisystemic disease characterized by the development
of hypertension after 20 weeks of gestation, with the presence of
proteinuria or, in its absence, of signs or symptoms indicative of target
organ injury

• Pre-eclampsia is a hypertensive disorder of pregnancy (HDP).

• It impacts 2% to 8% of all pregnancies and is a major cause of maternal

and perinatal morbidity and mortality
 Risk factors
• maternal age under 20 years old or over 40 years old
• history of pre-eclampsia
• previous hypertension
• autoimmune diseases
• obesity
A woman is at moderate risk for pre-eclampsia if she has not more than
one risk factor
A woman is at high risk for pre-eclampsia if she has two or more risk
factors for the disease
 Signs/symptoms
• Headaches
• visual disturbances (including blindness)
• epigastric pain
• nausea and vomits
• hepatic and renal insufficiency
• pulmonary edema
Cont’d

• abnormal oedema over face, hands, abdomen and vulva

• The clinical signs involve multiple organs, including the liver, kidneys,
heart, lungs, brain, and pancreas
 types

• This disease can be divided into mild and severe forms, according to
the severity and type of the symptoms

• The mild form of pre-eclampsia is characterized by systolic blood

pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90
mmHg, and proteinuria >300 mg/24 hr.
Cont’d

• The severe form of pre-eclampsia is characterized by severe

hypertension (SBP > 160 mmHg or DBP > 110 mmHg), or severe
proteinuria (>2 g/24 hr), or signs and symptoms of target organ
damage.
 consequences

• intrauterine growth restriction

• placental hypoperfusion

• premature placental disruption

• in most serious situations, termination of pregnancy

• fetal and maternal death

 prevention

• From 12 weeks of gestation until delivery, a dose of 75–100 mg of

aspirin should be administered to high risk women

• Calcium supplementation is related to a reduction in the risk of pre-

eclampsia and in preterm birth

• antihypertensive therapy should be initiated only if SBP > 150–160

mmHg or if DBP > 100–110 mmHg
Cont’d

• It should be noted that angiotensin-converting enzyme (ACE)

inhibitors and angiotensin receptor antagonists (ARA) should be
avoided during pregnancy because of their teratogenic effects
 ECLAMPSIA

• It is defined as pre-eclampsia with the abrupt development of

seizures or coma during the gestational period or post-partum, non-
attributable to other neurologic diseases that can justify the
convulsive state (namely epilepsy or cerebral stroke)

• Eclampsia represents the consequence of brain injuries caused by

pre-eclampsia.
Cont’d

• The incidence of eclampsia is approximately 1 in 1500 pregnancies

and of these about 20% occurs in the antenatal period, 25% occur
intrapartum and 35% with in the first few hours after delivery.

• Eclampsia is characterized by convulsions and coma.

• Eclampsia is the rarest and most severe of all the hypertensive

disorders of pregnancy, with a high maternal and fetal mortality
 Risk factors

• gestational or chronic hypertension (high blood pressure)

• being older than 35 years or younger than 20 years.

• pregnancy with twins or triplets.

• first-time pregnancy.

• diabetes or another condition that affects your blood vessels.

• kidney disease
 Signs/symptoms

• elevated blood pressure

• swelling in your face or hands

• headaches

• excessive weight gain

• nausea and vomiting

Cont’d

• vision problems, including episodes with loss of vision or blurry vision

• difficulty urinating

• abdominal pain, especially in the right upper abdomen

• seizures

• loss of consciousness

• agitation
 Management of eclampsia and preeclampsia

• The anticonvulsive therapy is the most important therapy for eclampsia

• Recording and monitoring of BP and urine protein examination of all

labouring women

• Timely identification of danger signs

• Giving inj MgSO₄ in all mothers having Severe pre-eclampsia and Eclampsia
 Management with Inj. MgSO4
Management with Inj. MgSO4 should be given in following conditions:
• Eclampsia
• Severe PE:
• >= 160/110 with proteinuria 3+ or 4+
• PE with presence of any symptoms like headache, blurring of vision,
epigastric pain or oliguria and abnormal edema over face, hands, abdomen
and vulva
 Role of Anti-hypertensive
• Anti - Hypertensive need to be given if Diastolic BP > 100 mmHg
• Tab Alpha-Methyl Dopa or tab Labetalol can be used for controlling
BP
• Target should be to maintain diastolic BP between 90-100 mmHg
• In case of severe Pre eclampsia, use of tab Nifedipine or Inj. labetalol
is recommended for initial control of BP
 Administration of MgSO4
• First dose (at Non-FRU level): Total 10 grams

• 5 g (10mL) magnesium sulphate deep IM in each buttock

• Patient should reach FRU in 2 hours for further management

Cont’d
Loading dose (at FRU level): Total 14 grams

• 4 g (8mL) magnesium sulphate diluted with 12 ml NS or distilled

water in 20 ml syringe i.e. 20%, and given slow IV in 5-10 minutes

• 5 g (10mL) magnesium sulphate with 1 ml 2% lignocaine deep IM in

each buttock
 Administration of MgSO4- Maintenance Dose

• 5 g (10mL) magnesium sulphate with 1 ml 2% lignocaine deep IM in

alternate buttock every 4 hours

• To be given for 24 hours after last convulsion or delivery- whichever

occurs later
Administration of MgSO4- Toxicity Signs
• Watch for toxicity signs before every maintenance dose

▪ Urine output: < 25-30 ml/hour

▪ Deep Tendon Reflex (knee jerk): Absent

▪ Respiratory rate: < 16/minute

Cont’d

• NOTE- With hold the next dose in case of presence of any toxicity sign

• Give antidote Inj Calcium gluconate (10 ml 10 % in 10 minutes) slow

IV for respiratory toxicity