Obstetric and gynaecological emergencies

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Obstetric and gynaecologicalemergenciesHannah JefferyCharlotte MarshallHannah Wallace.
A 25 year old female patient walks into EDcomplaining of left sided abdominal pain andPV spotting following 9 weeks ofamenorrhoea Whilst in the waiting room shecollapses .
Differential diagnosis Initial management ABC Oxygen monitor saturations 2 x large bore cannulae ACF IVI monitor BP.
Investigations Urine dip and urine pregnancy test Bloods FBC x match U E lactate CRP HCG clotting Imaging .
Case courtesy of Dr Maulik S Patel Radiopaedia org rID 46956 Investigations Urine dip and urine pregnancy test Bloods FBC x match U E lactate CRP HCG clotting.
Imaging USS abdomen pelvis TV empty uterus donutshaped mass in left adnexa free fluid in pelvis Definitive management By Mikael H ggstr m File Ectopic pregnancy1981 jpg by Urskalberer81 CC BY SA 3 0 .
https commons wikimedia org w ... Definitive management Laparoscopic or open salpingectomy Anti D if Rh negative Ectopic Pregnancy.
1 2 of all pregnancies Risk factors Risk factors Previous ectopic pregnancy Smoking.
Advancing maternal age History of subfertility Endometriosis Previous pelvic abdominal surgery History of multiple terminations.
24 of women who have ectopic pregnancy have no risk factors Subacute presentation History Colicky abdominal pain right left or central Dark red PV spotting.
Shoulder tip pain Amenorrhoea Nausea vomiting diarrhoea Examination Abdominal rebound tenderness.
Cervical excitation adnexal tenderness Speculum closed os HR and BP Management Expectant Serial serum HCG.
if HCG 1000 and asymptomatic Medical Methotrexate HCG 1500 USS CRL 35mm unruptured ectopic and no FH Surgical salpingectomy salpingotomy.
Haemodynamically unstable Adnexal mass 35mm or FH seen on USS A 21 year old female patient presents withsudden onset right sided abdominal pain andassociated nausea and vomiting.
Differential diagnosis Ovarian torsion History Sudden onset lower abdominal pain Nausea and vomiting diarrhoea .
Strenuous exercise Examination Palpable adnexal mass in 50 Tender on lower abdominal palpation fever.
Investigations Urine dip and UPT Bloods FBC UE LFT G S clotting lactate Imaging Case courtesy of Dr Andrew Dixon a href https radiopaedia org Rad... From the.
case a href https radiopaedia org cas... 9542 a Investigations Urinary pregnancy test Bloods FBC UE LFT G S clotting lactate Imaging.
USS abdomen pelvis TV right ovarian cyst free fluid absent venous flow Management Management Laparoscopic cystectomy salpingo .
oophorectomy Risk factors Ovarian neoplasm 40 dermoid cyst Ovarian cyst 40 Hyperstimulation IVF .
Paraovarian cyst Pregnancy Hydrosalpinx Sudden increased intra abdominal pressure Strenuous exercise.
Cyst rupture Commonly functional cysts Spontaneous or triggered by exercise SI Usually resolves spontaenouslyCyst haemorrhage.
Commonly functional cysts Bleeding into the cyst due to fragile vasculature Bleeding rarely severe enough to cause shock Usually resolve with expectant management Management.
Expectant simple cysts 5cm no follow up 5 7cm annual USS Surgical Persistant simple cysts 5cm.
Symptomatic cyst accidents Malignant neoplasms A 36 year old female patient presents with a 7day history of worsening lower abdominalpain exacerbated by SI She has started.
feeling feverish and generally unwell She hada coil fitted 3 weeks ago Differential diagnosis Acute PID History.
Abdominal pain usually bilateral Deep dyspareunia Abnormal purulent discharge Abnormal vaginal bleeding post coital inter menstrual menorrhagia RUQ right shoulder tip pain.
Examination Abdominal examination Bilateral lower abdominal tenderness peritonism Speculum Offensive discharge.
Coil threads Bimanual exam Cervical excitation Adnexal tenderness Investigations.
Urine dip UPT Bloods FBC CRP U E LFT clotting G S BLOOD CULTURES if pyrexial Swabs Endocervical.
High vaginal swab Imaging Investigations Urine dip UPT Bloods FBC CRP U E LFT clotting G S .
Swabs Endocervical High vaginal swab Imaging USS abdo pelvis TV multiloculated complex retro .
uterine adnexal mass commonly bilateral debris inthe pelvis Management Management IV access bloods IVI.
Antibiotics don t delay if suspicious of PID IV ceftriaxone IV PO doxycycline 24 hours 14 days doxycycline metronidazole Remove IUCD Send for culture Acinomyces.
Analgesia Surgery Laparoscopy divide adhesions and drain abscess USS guided drainage Advice on discharge .
Advice on discahrge Attend GUM clinic to full STI screen andcontact tracing Avoid unprotected SI until treated andattended GUM.
Risk Factors Young age at first SI sexual partners 25 years Recent new partner.
STI in patient partner Recent TOP IVF IUI IUCD insertion A 30 year old female patient presents with a 2.
day history of crampy lower abdominal painand PV bleeding She initially thought this washer period which is quite late but she doeshave an irregular cycle however she is nowhaving to change pads every hour and is.
feeling lightheaded Differential diagnosis Initial management Basic observations IV access bloods FBC clotting G S HCG .
Examination Abdominal exam lower abdominal tenderness Speculum os open POC remove if possible Analgesia and anti emetics Investigations.
Imaging Investigations Imaging USS abdo pelvis TV Miscarriage.
Threatened Inevitable Complete Incomplete mixed echos in the uterus Missed.
Gestation sac yolk sac fetal pole CRL 7mm and no fetal heart x 2 sonographers Definitive management Threatened advice Complete UPT 3 weeks.
Serial HCG if no previously confirmed IUP 50 Inevitable Incomplete Missed Expectant UPT 3 weeks Medical misoprostol repeat USS UPT 3 weeks Surgical.
Manual vacuum aspiration LA Manual evacuation of RPOC GA Anti D if surgical or medical or miscarriage 12 weeks Shoulder Dystociahttp www illustratedverdict co... .
Shoulder DystociaBony entrapment of the anterior shoulder underthe symphysis pubisRisk Factors Shoulder Dystocia.
Bony entrapment of the anterior shoulder underthe symphysis pubisRisk Factors Large baby Diabetic mum.
Previous shoulder dystocia Increased BMI of mum Induction of labour Management1 McRobert s manoeuvre.
2 Suprapubic pressurehttps en wikipedia org wiki Mc... Management1 McRobert s manoeuvre2 Suprapubic pressure.
3 Episiotomy and Wood s Screw manoeuvre180 degree shoulder rotation of theposterior shoulderDelivery of the posterior shoulderIf unsuccessful repeat above in changed.
Management1 McRobert s manoeuvre2 Suprapubic pressure3 Episiotomy and Wood s Screw manoeuvre5 Symphisiotomy.
6 Zavanelli manoeuvreReplacement of the headCaesarean section Complications Pain Bladder rupture.
Perineal trauma Uterine rupture PPH Psychological Nerve damage Erb s palsy Hypoxia Clavicular humeral fracture Fetal death.
Cord Prolapsehttps teachmeobgyn com labour ... Risk Factors Risk Factors Multiparity Polyhydramnios.
Low birth weight Low lying placenta Preterm labour Artificial rupture of Breech membranespresentation External cephalic version Transverse lie Internal podalic version.
Second twin Why is it bad Adverse Outcomes Fetal hypoxia Fetal death.
Vasospasm Cord compression Identification and Management Fetal bradycardia on auscultation CTG Vaginal examination.
Minimal handling of cord loops outside vagina Elevate presenting part Fill urinary bladder Knee chest or left lateral position Tocolysis to reduce contractions.
Definitive ManagementCaesarean section Category I or II depending on fetal CTGOr can attempt vaginal birth usually instrumental if fully dilated.
Uterine Rupturehttps teachmeobgyn com labour ... Uterine RuptureFull thickness disruption of uterine muscle andoverlying serosa.
Incomplete peritoneum intactComplete torn peritoneum can result inescape of uterine contents Risk Factors Risk Factors.
Previous caesarean section classical Previous uterine surgery Induction of labour Obstructed labour Multiple pregnancy.
Multiparity Clinical Features Severe abdominal pain persisting betweencontractions Shoulder tip pain.
Vaginal bleeding Recession of presenting part Scar tenderness and or palpable fetal parts Tachycardia and hypotension Fetal distress.
Management Resuscitate oxygen cannula x2 bloods IV fluids and or blood transfusions Analgesia Emergency caesarean section.
Uterine repair hysterectomy Amniotic Fluid EmbolismRare but often fatalAmniotic fluid enters the maternal circulationTriggers a serious reaction resulting in.
cardiorespiratory collapse and bleeding Risk FactorsNo clear consensusThought to be related to abnormalities ofamniotic fluid uterus or placenta.
Multiple pregnancy Increasing maternal age Induction of labour Uterine rupture Clinical Features.
Sudden onset Hypoxia respiratory arrest Hypotension Fetal distress Seizures.
Confusion Cardiac arrest Management ABCDE approach Oxygen.
Cannula x2 and bloods including ABG Involve anaesthetics ITU haematology Delivery of fetus if possible may beperimortem section Diagnosis usually only confirmed at post mortem.
Next Emergency What is the leading cause of death inpregnant women within the UK PE in PregnancyThe leading cause of death among pregnant.
women in the developed worldChest pain shortness of breath haemoptysisTachycardia hypoxia tachypnoea fetal distressInvestigations Bloods ABG ECG CXR CTPAManagement Resuscitation LMWH.
A 37 year old woman gives birth to twins after a long labour Itwas a vaginal delivery and there were no complications Within a few hours of delivery she starts to feel unwell and herblood pressure starts to drop What do you think could be happening .
The midwife notices that she is bleeding vaginally and predictsshe s lost around a litre of blood What are you going to do Postpartum haemorrhage Call for help.
Activate a major haemorrhage protocol if ABCDE assessment Massage the uterus perform bimanualcompression Give drugs to contract the uterus.
Postpartum Haemorrhage Syntometrine IM 1 amp Oxytocin infusion 40 units 10 units hr Ergometrine 500 micrograms IV IM Misoprostol 1000 micrograms PR.
Carboprost 250 micrograms every 15 min upto 8 doses Postpartum haemorrhage Call for help Activate a major haemorrhage protocol if indicated.
ABCDE assessment Massage the uterus perform bimanual compression Give drugs to contract the uterus Examination under general anaesthetic laparotomy Insert a Rusch balloon B lynch suture.
Consider internal iliac or uterine artery ligation If all else fails hysterectomy Postpartum Haemorrhage Primary PPH blood loss of 500mL within 24hours of delivery.
Major PPH 1000mL Secondary PPH excessive blood loss from thegenital tract after 24h from delivery usually 5 12 days later Postpartum Haemorrhage.
Causes 4 Ts Tissue Trauma Thrombin Postpartum Haemorrhage.
Risk Factors Previous ectopic pregnancy. PID. IUCD. Smoking. Advancing maternal age . History of subfertility . Endometriosis . Previous pelvic/abdominal surgery . History of multiple terminations . 24% of women who have ectopic pregnancy have no risk factors

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