Obs/Gynae - Complications During Pregnancy

Abnormal

Revealed – evident blood loss • E.g. miscarriage and placenta previa

Concealed – occurs within the abdomen / uterus • E.g. ruptured ectopic pregnancy and placental abruption

Miscarriage

Ectopic pregnancy/Ruptured Ectopic pregnancy

Placenta praevia

Placental abruption

Loss of pregnancy before 23 completed weeks gestation.  

Commonly seen at 6 – 14 weeks gestation; can occur after 14 weeks

15% of confirmed pregnancies result in miscarriage

Fetal cause – chromosomal, genetic or structural abnormalities of the fetus

Maternal cause – maternal age, structural abnormalities of the genital tract, infections, maternal diseases and environmental factors

Products of conception are partly passed through the cervix, become trapped leading to blood loss

– Mother may present with level of shock out of proportion to the amount of blood loss

Situation resolves with removal / expulsion of the products – complete miscarriage or surgical removal

Incomplete miscarriage – remnants of placenta remain within the uterus causing excessive bleeding and can be fatal; commonly complication of septic miscarriage

Bleeding - Light or heavy, often with clots and/or jelly-like tissue

Pain - Central, crampy, suprapubic, or backache Can be as intense as labour pains

Signs of pregnancy subsiding (E.g. nausea; breast tenderness)

Hypotension and bradycardia

50ml.

A B C D issues – rapid transport

Oxygen

Assess blood volume lost

Early call for Paramedic

History of fetal movement

Pain relief

Transport to hospital (ED) – pre alert

The egg implants somewhere other than the uterine wall

Presents at around 6-8 weeks gestation

Usually only one missed period



Estimated rate of ectopic pregnancies is 11:1000

Previous ectopic pregnancy

Previous surgery on the uterine tube

An intra-uterine contraceptive device fitted

Sterilisation or reversal of sterilisation

Endometriosis

Previous infections

Acute localised, lower abdominal pain

Vaginal bleeding or spotting – may present as brownish vaginal discharge

Amenorrhoea

Signs of blood loss within the abdomen with tachycardia and skin coolness

Nausea, vomiting and unusual bowel symptoms

Unexplained dizziness and fainting

A B C D issues – rapid transport

Oxygen

Assess blood volume lost

Early call for Paramedic

Pain relief: Paracetamol; Entonox

Transport to hospital (ED) – pre alert

Vaginal bleeding in late pregnancy (after 24 weeks) is confined to placental separation

Placenta Praevia • Placental Abruption

3-5%

The placenta is partially / wholly implanted in the lower uterine segment

Segment grows and stretches ++ after 12th week of pregnancy

Later weeks may cause placenta to separate and severe bleeding can occur

Usually presents at 24-32 weeks with small episodes of painless bleeding

Complete - placenta central over cervix. High risk of bleeding.  WIll need c-section. 

Partial - Placenta over internal cervical os (mouth). Risk of severe haemorrhage – will require caesarean section

Marginal - Placenta is located lower segment of uterus. Vaginal delivery possible with moderate risk of bleeding

Low-lying - Placenta mainly located upper segment of uterus. Vaginal delivery possible with mild risk of bleeding

Previous history of placenta praevia

Previous caesarean section or other uterine surgery

Advanced maternal age

Multiparity / increasing parity

Smoking

Cocaine use during pregnancy

Previous spontaneous or induced abortion

Deficient endometrium due to past history of e.g. endometritis, manual removal of placenta, curettage

Assisted conception

Premature separation of a normally situated placenta occurring after the 22nd week of pregnancy

Bleeding occurs between the placenta and wall of the uterus, where the placenta has detached from the uterine wall

Estimated occurrence is 6:1000 births

Previous abruption carries the highest risk

Pregnancy Induced Hypertension / Pre-eclampsia

Trauma – RTC, domestic violence, Iatrogenic e.g. external cephalic version

Multiple pregnancy e.g. twice as common with a twin pregnancy

Multiparity

Threatened miscarriage earlier in current pregnancy

Smoking and substance abuse e.g. cocaine, amphetamine use

Previous caesarean section

Intrauterine infections

Polyhydramnios

Continuous severed / sudden abdominal or back pain

Placental abruption commonly have concealed bleeding but may also have revealed bleeding

There is a risk of underestimating the amount of blood loss

50ml of revealed blood loss in pregnancy is considered significant

Tender abdomen – rigid or ‘woody’, no signs of relaxation

A B C D issues – rapid transport

Oxygen

Assess blood volume lost

Early call for Paramedic

Take soaked pads to the hospital

History of fetal movement

Pain relief

Transport to nearest Obstetric Unit – pre alert

Think woman positioning

Can be:

• Complete – tear in the wall of the uterus (with or without explusion of fetus)

• Incomplete – tearing of uterine wall but not perimetrium

Rare and tends to occur during labour

Previous caesarean section, most common cause

High parity

Obstructed labour e.g. shoulder dystocia, pressure or excess thinning of uterus

Previous uterine trauma from assisted birth e.g. forceps

Trauma – e.g. blast injury or accident i.e. seatbelt injury in RTC

Maternal tachycardia and signs of shock

Sudden collapse of mother

Severe abdominal pain

Vaginal bleeding

Uterine contractions may stop

Fetus may be palpable in abdomen

Scar pain and tenderness

May have minimal pain or blood loss

Labour may progress normally

Disproportionate signs of haemorrhagic shock in the third stage of labour – may manifest as postpartum haemorrhage

Time critical transfer to ED.

Nearest obstetrics unit

A generic term for a significant rise in blood pressure after 20 weeks gestation, in the absence of proteinuria or other features of pre-eclampsia.

PIH (pregancy induced hypertension) associated with proteinuria with or without oedema

Is relatively common condition but can be fatal for mother and baby - commonly occurs 24-28 weeks gestation

Primarily a placental disorder – poor placental perfusion

Severe - >160 / 110mmHg

Incidence of severe pre eclampsia is approximately 5:1000

10 years or more since last pregnancy

Primiparity or first pregnancy with new partner

Previous severe pre-eclampsia

Essential hypertension

Diabetes (type I or II)

Obesity

Twins or higher multiples

Renal disease

Advanced or Young maternal age (over 40 or less than 16 years)

Pre existing cardiovascular disease

Severe:

BP > 160/110 with proteinuria and any one or more of the following:

• • Headache (severe and frontal)
• • Visual disturbances
• • Epigastric pain
• • Side sided upper quadrant abdominal pain • Muscle twitching or tremor
• • Nausea
• • Confusion
• • Rapidly progressive oedema

– Is it Mild / Moderate or Severe?

– Assess <c> A B C D E F • Are there any TIME CRITICAL features?

• If YES, pre-alert to Nearest Obstetric Unit • If NO, continue with thorough assessment

– Observations – BP, Blood Glucose, SP02 [maintain 94-98%], positioning

• – Consider early call for Paramedic assistance
• • Management of seizure
• • Caution – ambulance lights and sirens

The new onset of convulsions during pregnancy or postpartum, generally in a woman with pre-eclampsia

Presents as generalized tonic / clonic convulsion – identical to epilepsy

1/3 of cases present for first time post delivery (within 48 hours)

BP may only be mildly elevated at presentation

– Rapid assessment <c> A B C D E F

• Patient past medical history

• Consider non self limiting or recurrent convulsions – Epileptic convulsion VS Eclampsic convulsion?

• Early call for Paramedic / APP assist but do not delay – Can administer Diazepam / IV Magnesium

– Observations – BP, Blood Glucose, SP02 [maintain 02 at 94-98%]

– Positioning – full lateral (i.e. recovery position) or if interventions required, supine with manual uterine displacement (MUD)

– Pre-alert to Nearest Obstetric Unit

• A complication of pre-eclampsia / Eclampsia – Haemolysis
• – Elevated Liver Enzymes
• – Low Platelet count

• Typically manifests between 32-34 weeks gestation, can present postpartum

Entry of amniotic fluid into the maternal circulation via the placental bed

Risk Factors

• – Termination of pregnancy
• – Amniocentesis
• – Placental abruption
• – Trauma
• – C section
• – Prior to and up to 30 mins post delivery

Signs & Symptoms

• – Often rapid collapse in advanced labour
• – Dyspnoea
• – Cyanosis
• – Acute hypotension
• – Cardiac arrest
• – May have feeling of impending doom, agitation, restlessness

Pulmonary embolism [PE] is an obstruction of the pulmonary vessels reducing perfusion

Can be small, major or massive

Risk Factors

• – Age (esp >35)
• – Obesity
• – Previous History of PE
• – Gross varicose veins
• – Major concurrent illness e.g cancer
• – Prolonged immobility
• – Long haul travel
• – Lower segment C-section
• – Prolonged labour (>12 hrs)
• – Surgical procedures during pregnancy

Signs & Symptoms

• – Dyspnoea
• – Tachycardia
• – Pleuritic / substernal chest pain
• – Apprehension
• – Cough
• – Haemoptysis
• – Syncope / sudden collapse
• – Signs of DVT – check legs

Can be – Directly related – i.e. pregnancy or genital tract related – Indirectly related e.g. influenza, pneumonia, E-coli, Group A & B strep

High risk factors:-

– Impaired immune system due to illness / drugs

– Gestational diabetes, diabetes or other comorbidities

– Undergone invasive procedures e.g. C-section, forceps delivery, removal of retained product of conception

– Prolonged rupture of membranes

– Been in close contact with people with Group A strep

– Have continued vaginal bleeding or offensive vaginal discharge

Signs and Symptoms:-

• • History of infection
• • SBP < 90 mmHg
• • Tachypneoa
• • Body temperature < 36°C or > 38°C
• • Cardiovascular compromise – tachycardia; prolonged capillary refill (> 2 seconds)
• • Altered mental state
• • Diarrhoea or vomiting
• • Mottled skin or Rash – generalised / purpuric (non-blanching)
• • Abdominal / pelvic pain
• • Offensive vaginal discharge or wound
• • Productive cough
• • Not passed urine in last 12-18 hours