Emergency in obstetrics and gynecology

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Emergency in obstetrics and gynecology
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CASE 1
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???????
????????????????? ????33?? ????? ???????
??????????????????????????? ????????
G1P0 GA 40 weeks by date
LMP 22 ??. 43 ?? 5??? EDC 25 ?.?. 44
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ANC ?????.?????x6 ?????.????x5
TT
x2 Serology all negative TWG 10.6
kg
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CC ??????????????2.00 ?.(3??. 30???? PTA) PI
3 hr 30 min PTA ???????????????????????
???????? ????? ????????????
????????? PH ?????????????????
?????????????? ??????????????????
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MH Interval 28-30 days Duration 5
days Regular FH ??????????????????????
?????????????? ??????????????????????????
?? Social History ????????????????? ????????????
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• ANC ?????????
• ?? ANC ????????????? GA 7 weeks ?????.?????
• ???????????????????? 47 kg ??????? 150 cm
• BP 95/60 mmHg
• ?????????????????????????????????????????????
• ????????????????????????????????? ????????
  ???????
• ??????????
• Hct 31 Urine Albumin and Sugar all
  negative
• Serology all negative ,Rh

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• ???????ANC ?????.?????
• GA 30 wk ?????? PSM R/O Valvular Heart Disease
• ???Refer???????.????
• ???????????????? ANC ?????.?????????

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• ANC ?????.????
• Consult Cardiologist gt normal physiology
• CBC ??Hemoglobin 9.8 g Hct 27.7
• MCV 79.8 fl anemia 1 anisocytosis 1
  microcytosis
• ?????????? Hb typing ?????????
• Homozygous Hb E VS Beta Thalassemia Hb E
• ???????? normal Hb typing
• ????? GA 36 wk ?? ?.?. ?? ??? 56.8 ???? 56 kg ??
  2 wk
• ???????? USG

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• ?? USG
• GA 324 wk by USG
• Fetal Cardiac Pulsation positive
• AFI 8.36
• EFW 2106 gm
• Placental Grading 2
• FL/AC 24.08
• ??? Complete Breech

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Problem List ?
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• Problem List
• Weight loss during pregnancy
• Homozygous Hb E vs Beta Thalassemia Hb E
• Anemia with anisocytosis and microcytosis
• Complete breech presentation

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• ?????????????????
• Vital Sign BT 37 C PR 80 /min RR 16 /min
  
• BP 120/80 mmHg
• Other PE normal
• Uterus Height of Fundus 3/4 gt O
• Back of Fetus Right
• Presentation Breech
• FHS positive
• EFW 2800 gm

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• PV
• Pelvis adequate
• Cervix consistency soft
• Effacement 90
• Dilatation 4 cm
• Membrane intact

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Diagnosis
G1P0 GA 40 wk with transverse lie
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PLAN ?

• Plan
• confirmed by USG
• ??? USG ?? single alive fetus transverse lie ,
• placental site at fundus grade 2-3,term fetus,BPD
  9.2 cm,FL 7.2 cm
• plan LT C/S

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??? set OR for LT C/S ????????? spontaneous
rupture of membrane ????6.26?. ???????????????????
?? ???????????

• ???? FHS
• ??????????????,???????????
• PV

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???? 6.26?. ??????? clear amniotic fluid grossly
leakage PV ?? incomplete breech with prolapsed
cord FHS ???140/R ???? 100/R ???????????????
PROLAPSED CORD
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• Definition
• the cord lies beside the presenting part(occult
  cord)or below it
• the membranes are ruptured

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diagnosis

• Palpation of the cord or cord pulsation on
  vaginal examination
• visualization of the cord outside the vulva
• fetal bradycardia or variable deceleration

When the membrane rupture and any of the
foregoing predisposing factor are presentPV
should be performed to exclude cord prolapse
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Fetal Bradycardia

• Definition FHR lt 120 beats / min for 2 min or
  longer
• Prolong bradycardia sudden drop from normal
  FHR to value below 120 esp. lt 80/min
• Cause - decrease in maternal oxygen tension
  eg. apnea of seizure
• - decrease in umbilical blood flow eg.
  excessive uterine contraction , maternal
  hypotension , cord compression,
• abruptio placentae
• -fetal hemorrhage eg. vasa previa

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Pathophysiology of prolapsed cord 1.Umbilical
cord prolapses 2. Follows rupture of membrane 3.
Occurs when presenting part is ill fitting
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• 4. Fetal blood supply obstructed when cord out of
  uterus
• Drops in temperature
• Vasospasm of umbilical vessels
• Compression between pelvic brim and presenting
  part

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Risk factorsAny condition which interfere
presenting part engagement in the pelvis

• Malpresentation
• Transverse or oblique lie
• Breech esp. footling
• CPD
• Unengaged vertex
• polyhydramnios

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• Multiple pregnancy
• Grand multiparity anterior uterine obliquity
• Prematurity
• Pracenta previa
• Uterine fibroids
• Amniotomy with unengage presenting part
• Version of fetus

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How to manage?
???????????????? ??? IV fluid ??????????????? noti
fied anesthetist and pediatrist ?????? C/S
emergency
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• Management
• ??????? ????????????????????????????????????????
  ???????
• ?????????????????????
• ??? C/S ????? 10 ???????????? cord prolapse
  ????? perinatal mortality lt5
• ??????? perinatal mortality ???
  ???????????????prolapsed cord ???? 40 ????

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1. Remain calm , call for help 2.
Counseling 3. Turn off syntocinon therapy If
cord prolapse is confirmed 4.????????????????????
????? ???
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• 4.1 ?????????????????????????????
• 4.2 ????????????????????? ??????
• ????????????????????????????????????? ???
• ???????????????????? ( Trandelenberg s position)
• ???????????????????????????????????????????
• ??????????????? (Sims position)
• ??????????????????? Genu pectoral ( knee -chest
  position )

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• 4.3 ??? NSS 500-750 ml ????????????????
• ??? clamp ?????????????????? full bladder
• 5. Intrauterine resuscitation
• ??? NSS 1000 ml IV
• facial O2 100 via face mask 8L / min
• ??????? FHS ????????

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6. NPO 7. Matching and grouping ?????? PRC 2
units 8. ???????????????????? LT C/S ??????? 9.
?????????????????? ?????????? 10.
????????????????????????????????????????? ????????
? vasoconstriction 11. ????????????????????????
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??????????????????????
???????????????????????????

1. ??? FHS ?????????
2. ??? pulse ??? cord ??????
3. ??????? ultrasound ????????????????????????

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?????????????????????? ???????????????????????

• ?????????????????? ( spontaneous vaginal delivery
  ) ??????????????????????????????????????
• ????????? F/E , V/E
• ?? C/S ??????????????

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??? prolapsed cord ?????? second stage of labor
?????????????????? ?????????????????????????

• 1. Manage as for general management
• 2. Prepare for vaginal delivery ?? OR
  ????????????????????
• Episiotomy , F/E, Breech extraction
• 3. C/S ???????????????????????????????????????????
  ??????????

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Operative note

• Diagnosis G1P0 GA40 wk
• with incomplete breech and prolapsed cord
• Operation low transverse cesarean section
• Anesthetics

General anesthesia
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Operative finding A term gravid uterus, well
formed lower uterine segmentA term
baby,incomplete breech presentation, APGAR 1min1
Endotrachial tubeO2 therapy, 5min4,10min7(by
neonatalogist) then transfer to NICUNormal
placenta located at fundusturbid AF amount-
300ccboth tubes and ovaries were normal
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???????????6.30? ????????6.37?. (17?????????????
???prolapsed cord 11????)
Newborn male,alive, weight 2975 gm.
APGAR score(1min) 1,(5min) 4
stimulate breathing,resuscitation 5
min ??????????????
?????tone ,?????HR
???tube, suction, ???O2 pump????????????,
HRgt100, tone ???????????????????NR
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Placenta normal placenta weight 500 gm
cord length 40 cm.
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Complication of prolapsed cord

• Maternal
• Increased maternal morbidity , mortality due to
  the following
• complication from operative intervention eg.
  anaesthetic complication , maternal tissue
  trauma complication
• postpartum hemorrhage
• sepsis

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• Fetal
• Fetal complications depend on
• Fetal gestation
• Duration of prolapse prior to delivery
• Strength of contractions
• State of labor when prolapse occurred
• Rapidity of diagnosis and rapidity and
  efficiency of first-aid management
• Rapidity and efficiency of delivery

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THE END