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Emergency-Obstetrics -Dept 1 PREFACE On behalf of department of Obstetrics & Gynaecology it gives us immense pleasure to bring out a booklet titled ‘Emergency Obstetrics – An update’ on the occasion of CME & workshop on ‘Obstetrics Emergencies- Skills & Drill’ on 12th and 13th October 2018. It is a well-known fact that pregnancy is a physiological process that brings happiness to a pregnant mother and everybody around her as well. Unfortunately this joyful event may turn into situation endangering the life of both mother and fetus, which is termed as obstetric emergencies. The most common emergencies are postpartum hemorrhage, fetal distress, severe pregnancy induced hypertension/ eclampsia, antepartum haemorrhage and shoulder dystocia. Other less prevalent but fatal conditions are amniotic fluid embolism, umbilical cord accident and uterine inversion. Although these emergencies occur infrequently, all the health care members need to remain vigilant always to diagnose these conditions and initiate the appropriate management, which will help to reduce maternal and perinatal mortality. Reduction of maternal and perinatal mortality is essential, as they are the key health care indicators of the society. This booklet is an effort not only to compile but also to reinforce and update the existing knowledge on Obstetric Emergencies. We express our gratitude to all the contributors of this booklet. We hope this will be a useful source of information with recent advance for the practicing obstetrician, general physician, midwifery staff, postgraduate students in obstetrics &gynaecology and undergraduate students. Organizing Team 2 CONTENTS Sl. Title Page No. 1. Cord accidents 3 2. Preterm labour / PPROM 9 3 Obstetric Coagulopathy 26 4 Eclampsia/ Hypertensive emergencies 38 5 Assessment of blood loss PPH 51 6 Uterine Inversion 58 7 Sepsis in Obstetrics and Gynaecology 70 8 Shoulder Dystocia 78 9 Non- obstetric causes of acute abdomen in pregnancy 82 10 Amniotic fluid Embolism 89 3 UMBILICAL CORD ACCIDENTS Dr Ashwini V, Prof Rani Reddi ABSTRACT Obstruction or disruption of blood flow through the umbilical vessels can lead to severe fetal compromise. Obstruction is usually mechanical in nature and is associated with compression of the umbilical cord and umbilical vessels. Disruption of umbilical or fetal vessels is usually traumatic in origin. These conditions have in common a loss of blood flow to the fetus and an association with adverse perinatal outcome. Key words: Cord accidents, cord prolapse. INTRODUCTION Umbilical cord accidents account for approximately 20% of all stillbirths worldwide. Cord accidents occur when there is diminished blood flow in the umbilical cord due to mechanical compression or circulatory compromise due to structural lesions like knots, loops, strictures, hematomas, cysts, thrombosis and vessel dilatation. The circulatory failure may be acute or chronic. Cord accidents can result in intrauterine growth restriction, intrauterine death of fetus, meconium staining of liquor, hydrops fetalis, and neurological deficits. Etiopathogenesis Umbilical cord development is different from that of the placenta. It develops from the primitive ridge of the embryo. It contains the 2 umbilical arteries and 1 umbilical vein covered by the wharton’s jelly and the amnion. The umbilical cord is 50- 60 cm in length on an average. It is usually the same length as the fetus. It grows throughout the pregnancy. There is coiling of the umbilical cord usually to the left side i.e. counterclockwise (7:1). The average coils are 0.2 coils per 1 cm of cord. The cord coiling is said to occur due to fetal activity. The cord inserts into the center of the placenta usually. Cord accidents can happen due to mechanical compression associated with abnormal length, abnormal coiling, knots, entanglements, constriction, prolapse, furcated insertion and velamentous insertion. Cord disruption can occur due to 4 trauma,amniocentesis or fetal blood sampling which may lead to cord accidents. Cord disruption can also result from increased cord friability in conditions like meconium associated damage to cord, necrotizing funisitis, aneurysms, hemangiomas etc. Cord compression Abnormally long cords is defined as cord length more than 70-90 cm. Long cords can result from excessive fetal movements or because of genetic factors. Such cords are prone to entanglements and prolapse. Moreover excessively long cords require increased perfusion pressure because of greater resistance to flow. Short cords are seen in fetuses with reduced activity, uterine anomalies restricting the movements, amniotic bands and skeletal dysplasia. A cord less than 30 cm at term is short cord. Cord lengths of less than 15 cm have a strong association with fetal anomalies (abdominal wall defects, spinal and limb deformities). During labor cord rupture, premature separation of the cord from the placenta and abruption may lead to fetal hemorrhage and compromise. Cord entanglements around the body of the fetus can result in nuchal cord. They can be locked type or unlocked type. The locked type is associated with higher morbidity. They can cause cord compression when the entanglements become tighter during the fetal descent in labour after membrane rupture. There is a significant correlation between presence of tight nuchal cord at delivery and cerebral palsy. The neonates also have a low APGAR score and an increased frequency of stillbirths. True knots may be loose or tight. Loose knots may tighten during fetal movement or during descent during delivery. The incidence is 0.4-1.2%. The incidence is increased in polyhydramnios and in excessively long cords. It is also a frequent complication of monochorionic monoamniotic twin pregnancies. Cord coiling when excessive causes obstruction of blood flow by either mechanical compression or thrombosis. Also hypercoiling is associated with excessively long cords. Lack of coiling indicates fetal inactivity and is associated with fetal distress, anomalies, increased perinatal morbidity and mortality. Cord prolapse is defined as the decent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured 5 membranes. Cord presentation is presence of the umbilical cord between the fetal presenting part and the cervix with or without intact membranes. Incidence varies from 0.1 -0.6%. The incidence is higher in malpresentations. There is also a higher incidence in multiparity, low birth weight, preterm labour, fetal congenital anomalies, second twin, polyhydramnios, unengaged presenting part, low lying placenta, artificial rupture of membranes with high presenting part, external cephalic version, stabilizing induction in labour, insertion of intrauterine pressure transducer and large balloon catheter induction of labour. Cord prolapsed should be suspected in cases of bradycardia and variable fetal heart decelerations. The distress is due to direct compression of the vessels or due to reactive vasoconstriction caused by exposure of the cord to cold air. Velamentous insertion of the cord occurs when the cord inserts into the membranes near the placenta instead of over the placental surface. The velamentous vessels from the cord run in the membranes between the placenta and the membranous cord insertion. As there is no protection provided by the Wharton’s jelly these vessels are prone to compression, rupture, thrombosis and disruption particularly after membrane rupture. In furcate cord insertion the vessels separate from the cord substance before reaching the surface of the placenta. Since there is no Wharton’s jelly they are more prone to injury and thrombosis. When the velamentous vessels cross the cervical os it is termed as vasa previa. Severe fetal compromise can occur when the vessels are injured. It may also result in intrauterine death. Thrombosis of the velamentous vessels has been associated with neonatal thrombocytopenia, purpura and fetal death. Cord disruption Meconium present for a prolonged period can damage the umbilical cord and fetal vessels and result in disruption of the cord. This is because it contains noxious materials like bile salts, acids, enzymes and other chemical substances. The cord can also become ulcerated in rare cases. Meconium in the amniotic fluid also causes vasoconstriction of the umbilical vessels. Stricture of the umbilical cord is seen in the insertion at the fetal side. The Wharton’s jelly is usually absent and there is stricture of the vessels at the insertion site. 6 Cord hematomas can result from trauma, short cord, entanglement, amniocentesis and cordocentesis. Management Ultrasound with Doppler can be useful in detecting patients at risk for cord accidents. Antenatal ultrasonogram can be used to diagnose hypercoiling, hypocoiling, nuchal cords, velamentous insertion, vasa previa, cord presentation and sometimes true knots and entanglements. Routine ultrasound examination is not sufficiently sensitive or specific for identification of cord presentation antenatally and should not be performed to predict increased probability of cord prolapse. Selective ultrasound screening can be considered for women with breech presentation at term who are considering vaginal birth. With transverse, oblique or unstable lie, elective admission to hospital after 37+0 weeks of gestation should be discussed and women in the community should be advised to present urgently if there are signs of labour or suspicion of membrane rupture. Women with non-cephalic presentations and preterm prelabour rupture
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