Obstetric Emergencies

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Obstetric Emergencies

Sep 20, 2015 0

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Summary Writer: Elizabeth Campbell

Editor: James Edwards

Interviewer: James Edwards

Interviewee: Nhi-Nguyen

In this podcast, James talks to Dr Nhi Nguyen about the management of obstetric emergencies on the wards.

About Dr Nhi Nguyen

Nhi Nguyen is a Staff Specialist in the Department of Intensive Care Medicine and Co-Director of Prevocational Training and Education at Nepean Hospital. Nhi provides advice on the antenatal and peripartum management of pregnant patients with medical problems and has an interest in the critically ill obstetric patient.

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Obstetric Emergencies

With Dr Nhi Nguyen, Intensive Care Specialist, Obstetric Physician, and Director of Prevocational Education and Training at Nepean Hospital, New South Wales, Australia.

Introduction

Obstetric emergencies can be confronting or frightening for doctors of all levels of experience. Our management goals are the same for pregnant patients as they are for non-pregnant patients, however, the wellbeing of both mother and baby must be considered. In general terms, what is good for the mother is good for the baby. The physiological changes of pregnancy can affect the interpretation of physical signs. It is important to escalate quickly to involve consultants in the management of obstetric emergencies.

Case

A 29-year-old woman who is G1P0 presents at full term in labour. She is admitted to the delivery ward, then a rapid response call is made for a seizure and decreasing level of consciousness.

1. What is your immediate management of this patient?

Follow the basic principles of Airway, Breathing, Circulation
Often seizures are brief, and simple measures are all that is required
Place patient in left lateral position – consider aortocaval compression
Provide high-flow oxygen
Commence IV fluids
The most common causes of seizures are the same as in other patients. However, a seizure in pregnancy can be a manifestation of eclampsia
Consider Midazolam 2.5mg IV if the seizure is ongoing
Involve the obstetrician

2. What are the other important diagnoses to consider in this patient?

Inspect the patient’s Obstetric Card for a history of a seizure disorder
Eclampsia – especially if there is a background of hypertension in pregnancy
- Pre-eclampsia: hypertension plus end-organ damage, which occurs after 20 weeks gestation. Symptoms: headache, epigastric pain
Local anaesthetic toxicity following an epidural, or adverse drug reaction
Hypoglycaemia – growing number of patients with gestational diabetes, who may be on insulin and require a dextrose infusion during delivery

3. What other diagnoses should we consider if the patient had collapsed, without a seizure?

Postural hypotension
Hyperventilation associated with inhalational analgesic (such as nitrous oxide) – can lead tohypocarbia and unconsciousness
Medication related
Rare: aortic dissection, myocardial infarction, stroke

4. General management principles

Prevention of further seizures, and delivery of the baby are the most important principles
Loading dose of magnesium 4g IV (Note: each 10mmol ampoule is roughly 2.5 g magnesium)for prevention of further seizures
Very little role for agents such as phenytoin

5. Examination features

Oedema
Hyper-reflexia
Sustained clonus

6. Investigations

Take home messages

Scary situation
Delivery of the baby is vitally important
Simple measures can make a big difference: left lateral positioning of patient, high-flow oxygen, establish IV access, magnesium load 4g IV, expedite delivery

Case 2 –A 35 year old lady, who is G4P3 and 27 weeks pregnant presents to the delivery ward complaining of shortness of breath.

1. What is the approach to the assessment of this patient?

Most women are short of breath in the second trimester of pregnancy – the art of this assessment is to identify which symptoms are truly concerning
Be mindful of the “well” paradigm – patients and staff can normalise pregnancy and downplay symptoms
Careful history is crucial
Important diagnoses:
- Pulmonary Embolism
  - Hypercoagulable state in pregnancy and gravid uterus increases risk of DVT
  - Clinical suspicion must be high, irrespective of history
  - Investigations:
    - CXR – exclude pneumonia
    - V/Q scan – good negative predictor, less radiation exposure
    - CTPA
    - D-dimer – unreliable
  - Women who have significant morbidity or mortality from PE often have unrecognisedsymptoms
  - If in doubt, the safest option is to admit for observation and commence enoxaparin
- Cardiomyopathy of pregnancy
  - Rare
  - Cardiac ECHO

2. Features of history and examination

History:
- History of asthma, allergy, cardiac disease
- Are the symptoms similar to pre-pregnancy illnesses (with an exacerbation now due to the increased physiological demands of pregnancy) or is this a new condition?
Examination:
- Signs may be hidden by the physiological changes of pregnancy
- Tachycardia is often present in pregnancy. If not tachycardic, this goes against a diagnosis of PE
- Clinical exam is unreliable in excluding DVT

3. Which consultants should be involved?

Obstetrician
Obstetric medical service
Respiratory physician

Take home messages

Spend time on a very careful history
Be open to a broad spectrum of diagnoses and constantly reassess, especially if the patient does not respond to treatment
Women don’t present to hospital without being concerned
Morbidity and mortality is often due to symptoms which are ignored
Be mindful of the hypercoagulable state which persists for six weeks post-partum