Obstetrics and gynaecology


Obstetrics and gynaecology


Matthew G Wood


Outline





Initial Assessment




History


A history and examination focused on eliminating potential differential diagnoses will quickly identify the likely diagnosis


‘The pains have the character of a tightening feeling across the abdomen. Initially they were coming every 30 minutes lasting about 10 seconds, now they are coming at least every 10 minutes, lasting up to a minute and are becoming more painful. Anne now has to stop what she is doing when the pain comes on. There are no symptoms of infection, no symptoms of pre-eclampsia, fetal movements have been normal and there has been no vaginal blood loss. Anne’s pregnancy has been uneventful up to this point. The only other important fact noted from the history was that the patient thinks she had a procedure on her cervix about a year ago following an abnormal smear.’


The history of the pains are consistent with contractions which are increasing in frequency and intensity. There is a possibility that the patient also had a large loop excision of the transformation zone, which is a risk factor for preterm labour.



Examination




‘Heart rate is 80 bpm, capillary refill time is 2 seconds. The abdomen is soft with no specific areas of tenderness. SFH 31 cm, uterus is initially soft but tightenings are palpable, and no uterine tenderness. Fetus is in a longitudinal lie, cephalic presentation, three-fifths palpable.


Normal vulva and vagina, no blood or liquor seen. The cervix is posterior, 1 cm long, 1 cm dilated, no membranes or fluid leak seen. High vaginal swab taken and sent to microbiology. Fibronectin was positive’.


The examination findings support the diagnosis of threatened preterm labour.





Management [1,2]



ent Treat any potentially reversible cause of preterm labour:


ent Chase bloods and microbiology results. Regularly reassess the patient for signs of infection and have a low threshold for commencing treatment


ent Optimize conditions for delivery


ent Give dexamethasone 12 mg IM, followed by a further dose 12 hours later to help mature the fetal lungs


ent Obtain intravenous access


ent Prescribe a tocolytic agent e.g. atosiban (oxytocin receptor antagonist):


ent Initially 6.75 mg IV bolus over 1 minute


ent Then by IV infusion 18 mg/hour for 3 hours


ent Then by IV infusion 6 mg/hour for up to 45 hours


ent (Infusion usually prepared by using 75 mg atosiban made up to 100 mL with 0.9% NaCl, set at a rate of 24 mL/h for 3 hours, then 8 mL/h for 45 hours)


ent The purpose of the atosiban is to attempt to prolong the pregnancy to allow the corticosteroids to take effect


ent Continuous CTG monitoring while on atosiban


ent Neonatal team involvement:


ent Confirm neonatal unit has a bed for this premature delivery, otherwise an intrauterine transfer to another hospital may be needed


ent Neonatal team to discuss likely management of the neonate with Anne and her husband


ent VTE prophylaxis:


ent LMWH should be avoided as there is a risk the patient will go on to labour. Encourage adequate hydration and mobilization, but this is a low risk patient anyway.


ent If VTE prophylaxis is required in a high-risk patient consider unfractionated heparin.





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Figure 7.1



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Figure 7.2






Initial Assessment







Exposure



ent Examine the abdomen, assess for areas of tenderness and for a palpable mass consistent with a uterus. (At 12 weeks of gestation the uterus may just be palpable above the pubic bone)


ent Check the temperature


ent Perform a speculum examination. With a lubricated Cuscoe speculum attempt to locate the cervix and assess the current active blood loss. Gauze wrapped on sponge holder forceps will likely be needed to remove clots and blood in the vagina to visualize the cervix. The important points to assess are:


ent Extent of active bleeding


ent Cervical os open or closed (open suggests miscarriage inevitable)


ent Are products of conception visible at the os (if so try to remove with a sponge holder)


ent A digital vaginal examination (PV) can be performed (ensure you know there is no placenta praevia first as this is a contraindication to PV) to assess whether the cervical os is open when it has been difficult to visualize, and to assess size, position and mobility of the uterus


ent Catheterization can be done after pelvic examination.


‘The patient’s abdomen is soft with mild tenderness suprapubically and a mass consistent with a 12-week-sized uterus is palpable supra-pubically. On pelvic examination, there were 2 tennis-ball-sized blood clots removed from the vagina, an open cervix was seen with fresh blood trickling through the os, no products seen. Temperature is 37°C.’


Your working diagnosis after your initial assessment is an inevitable miscarriage with active blood loss and a haemodynamically compromised patient.




Initial Investigations



ent Bloods:


ent FBC–Assess for anaemia (may be falsely reassuring in an acute bleed prior to fluid resuscitation). Raised WCC can suggest infection which may be a cause of, or complication of miscarriage. Decreased platelets with active heavy bleeding is suggestive of consumptive loss/DIC requiring further investigation of clotting and replacement of platelets


ent Clotting–Raised PT/APTT with active bleeding needs urgent discussion with haematology and consideration of replacement of clotting factors with FFP or cryoprecipitate


ent U&Es–Baseline renal function should the patient require surgery under general anaesthesia


ent CRP–Additional marker of infection


ent Group, save and cross-match 2 units–Blood product replacement should be considered if haemoglobin<70 g/L, haemoglobin<80 g/L in a symptomatic patient, or if bleeding is heavy>1.5 L and ongoing. If surgical management is undertaken rhesus negative patients (over 12 weeks gestation) will require anti-D prophylaxis.



‘Haemoglobin is 100 g/L, and the rest of the blood tests are normal.’



Initial Management [1,3]





Reduce the blood loss



ent There are a number of medications that can be given to increase uterine muscle tone which causes constriction of the blood vessels transecting the myometrium, thereby reducing the blood loss


ent First line medication is ergometrine 500 micrograms with oxytocin 5 units (Syntometrine® 1 mL) given by intramuscular injection. A second dose can be repeated after 10 minutes if bleeding persists:


ent Both ergometrine and oxytocin can also be given by slow intravenous infusion


ent Care should be given using ergometrine IV and should be avoided entirely in patients with a history of hypertension as it can cause a severe hypertensive crisis


ent If bleeding is still uncontrolled after 2 doses of Syntometrine®, senior help is needed urgently for definitive management. However, further treatments are available:


ent Misoprostol (prostaglandin E analogue) comes in tablet form which can be given orally, rectally or vaginally. Rectal administration is usually preferred as the vaginal absorption can be reduced by blood loss and the oral route is more likely to cause the side effects of vomiting and diarrhoea. This is an unlicensed use of misoprostol. A commonly used dose is 800 micrograms PR


ent Carboprost (prostaglandin F analogue) can be given 250 micrograms by intramuscular injection (repeated at 15 minute intervals to a maximum of 8 doses)


ent VTE prophylaxis:


ent In this acute setting, the risk of haemorrhage is significant so pharmalogical prophylaxis should be avoided


ent Prescribe TED stockings and maintain adequate hydration


ent After definitive management of the haemorrhage LMWH should be considered.


Nov 18, 2017 | Posted by in PHARMACY | Comments Off on Obstetrics and gynaecology
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