This presentation mainly discuss about Abortion,Ectopic pregnancy, Preeclampsia/Eclampsia and Cord prolapse

1. Obstetric Emergencies
By: Hayelom Michael
September,2014
By:Hayelom Michael
1 10/1/2014

2. Out line
1.INTRODUCTION
2.ABORTION
3.ECTOPIC PREGNANCY
4.PREECLAMPSIA/ECLAMPSIA
5.CORD PROLAPSE
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3. INTRODUCTION
 Obstetrical emergencies are life-threatening medical
conditions that occur in pregnancy or during or after labor
and delivery.
 There are a number of illnesses and disorders of
pregnancy that can threaten the well-being of both mother
and child.
 Obstetrical emergencies may also occur during active
labor, and after delivery (postpartum).
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4. ABORTION
 Abortion: is the process of termination or expulsion of
the pregnancy before the 28th completed weeks of
gestation or less than 1000gm weight (in Eth & UK).
When the abortion occurs spontaneously, the term "
miscarriage" is often used.
 Abortion is one of the leading cause of maternal
mortality
 15% of clinically evident pregnancies end in
spontaneous abortion and a further 10-60% are
terminated by an induced abortion.
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5.  More than 80 % of spontaneous abortions are in the first
12 weeks
 Unsafe abortion is a leading cause of maternal mortality:
13% - worldwide
17% - east Africa
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6. Causes
Spontaneous abortion
 The causes of abortion can conveniently be divided in to
three groups :-fetal
-maternal
-paternal.
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7. Fetal causes
- Chromosomal abnormality or disease of the fertilized
ovum may account for 60% of spontaneous, first trimester
abortions.
- Malformation of the trophoblast and poor implantation of
the blastocyst may result in placental separation with
consequent hypoxia and impaired embryonic development.
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8. Maternal causes
 Disease acquired during pregnancy such as rubella or
influenza, especially if they are accompanied by acute
fever, interfere with transplacental oxygenation and may
precipitate abortion.
 Chronic disorders, for example renal disease accompanied
by hypertension, may have a similar effect.
 Drugs :- large doses of any drug are poisonous and should
be avoided
 - ABO incompatibility between mother and embryo may
 result in abortion.
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 -

9. Local disorders of the genital tract
 A retroverted uterus which is unable to rise out of the
pelvis may occasionally predispose to abortion.
 Physical defects of the uterus, such as sub mucosal
leiomyomas, uterine polyps, or uterine malformations
may prevent implantation adequate to support fetal
development
 Cervical incompetence
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10. Paternal causes
Since the paternal spermatozoon gives to the ovum
half of its chromosomes, defects may result in
abortions,
particularly if both partners share many common HLA
antigen
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11. Clinically
1. Threatened abortion
2. Missed abortion
3. Inevitable abortion
4. Incomplete abortion
5. Complete abortion
6. Septic abortion
7. Recurrent abortion
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12. 1. Threatened abortion
 It is presumed that a pregnancy is threatening to abort
when vaginal bleeding occurs before the 24th week
 vaginal bleeding (light).
 cramping lower abdominal pain
 Uterus softer than normal but correct size for date
 cervix is closed
 U/S essential & Shows the presence of fetal heart
activity
 There is chance of continuing the pregnancy to
viability.
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13. 2.Missed Abortion
 This is the term to the fetus w/c is died is retained its
placenta in the uterus for at least 4 weeks.
 Usually history of threatened abortion preceding it
 Why the pregnancy is not expelled is not known.
 Early ultrasonic scan may identify missed abortion
before the mother experiences any symptoms.
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14. Pain and bleeding may cease but the mother may
experience a residual brown vaginal discharge as
having an odor of decaying matter and it can be
offensive and distressing.
All other physiological signs of pregnancy will
regress, uterine enlargement will cease and a
pregnancy test will prove negative
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15. .
3. Inevitable abortion
When it is impossible for the pregnancy to continue it is
termed as inevitable abortion
Heavy vaginal bleeding.
Severe cramping lower abdominal pain which follows
the bleeding
Cervix is open/dilated, effaced, membrane ruptured
Uterus corresponds to dates
Tender uterus
But No expulsion of products of conception
No chance of continuing the pregnancy to viability.
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16. 4. Incomplete Abortion
 When the products of conception are only
partially evacuated during abortion.
Bleeding is profuse but the abdominal pain and
back ache may cease.
The cervix will be soft and purplish in color and
will be partly closed.
Prolonged retention of the tissues predisposes
the woman to infection and immediate medical
intervention is needed
16 Hayelom Michael 17/9/2014

17. 5. Complete abortion
A complete abortion is more likely to occur prior to
the 8th week of pregnancy and constitutes the
expulsion of the embryo, placenta and intact
membranes
Light bleeding
Closed cervix
 Uterus smaller than dates
Uterus softer than normal
History of expulsion of products of conception
Light cramping/lower abdominal pain

18. 6. Recurrent abortion
Three or more consecutive pregnancy losses at 28
weeks or less or with fetal weights less than 1000
gram
 primary recurrent miscarriage—no successful
pregnancies
secondary recurrent miscarriage—one prior live birth
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19. 7. Septic abortion
 Septic abortion is manifested by fever, malodorous
vaginal discharge, pelvic and abdominal pain, and
cervical motion tenderness.
 Peritonitis and sepsis may be seen.
 Trauma to the cervix or upper vagina may be
recognized if there has been a criminal abortion.
 Ultrasound may be helpful in ruling out retained
products of conception.
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20. ECTOPIC Pregnancy
 Is implantation of fertilized ovum outside the
endometrial cavity.
 Is the leading cause of pregnancy related death in the 1st
trimester.
 >1 in 100 pregnancies
 Recent evidence indicates that it is increasing in many
countries
 USA -5 fold
 UK -2 fold
 Recurrence rate 15% after 1st 25% after 2 ectopics

21. Etiology
 Risk Factors for Ectopic Pregnancy:
High risk Moderate risk Slight risk
Tubal surgery Infertility Previous pelvic/abdominal
surgery
Sterilization Previous genital infections Cigarette smoking
Previous ectopic pregnancy Multiple sexual partners Vaginal douching
In utero exposure to
diethylstilbestrol
Early age at first intercourse
(< 18 years)
Use of IUD
Documented tubal pathology

22. 22 10/1/2014

23.  95% is tubal
Ampula>55%
Isthmus-25%
Fimbria-17 %
Cornual-2 %
 Cervix<2%
 Abdomen<2%
 Ovary<2%
 Heterotopic Pregnancy
A uterine pregnancy in conjunction with an extra uterine
pregnancy
 1 in 30,000 pregnancies
2
3
Sites

24.  Ectopic Pregnancy remains asymptomatic until it
ruptures
 when it ruptures present in two forms: Acute & Chronic
Symptoms Signs
 Amenorrhea Tenderness
 Abdominal Pain CMT
 V. Bleeding Palpable mass
 Syncope Hypotension
Pelvic mass
2
4
Clinical presentation

25. Dx
1.Ultrasound scanning –
Abdominal/TVS
2.Serum Beta HCG level
3.Serum progesterone
4.D&C
5. Culdecentesis
6.Laparoscopy-gold
standard
2
5

26. @ 4-5 wks
 TVS can visualize a gestational sac at serum beta
HCG of 1500-2000 mIU/Lt
 All viable IU pregnancies can be visualized by trans
abdominal US for serum HCG levels> 6500mlu/ML
 Doubling time of serum HCG is 48 hours, if it takes
more than 7 days, ectopic pregnancy will be
confirmed.
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6
Discriminatory zone

27. Management
2
7
 Depends on the stage of the disease and the condition
of the patient at diagnosis
 Options
Surgical
Medical
Expectant

28. Preeclampsia /Eclampsia
 Preeclampsia refers to a systemic syndrome
characterized by widespread maternal endothelial
dysfunction presenting clinically with hypertension,
edema, and proteinuria during pregnancy.
Preeclampsia should be distinguished from gestational
hypertension that can develop in pregnancy without
proteinuria.
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29. Cont’d
Minimum criteria
BP ≥ 140/90 mm Hg after 20 weeks' gestation
Proteinuria ≥ 300 mg/24 hours or ≥ 1 + dipstick
Increased certainty of preeclampsia
BP ≥ 160/110 mg Hg
Proteinuria 5.0 g/24 hours or ≥ 2+ dipstick
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30. Cont’d
 Serum creatinine > 1.2 mg/dL unless known to be
previously elevated
 Platelets < 100,000/mm3
 Microangiopathic hemolysis (increased LDH)
 Elevated ALT or AST
 Persistent headache or other cerebral or visual
disturbance
 Persistent epigastric pain
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31. Risk factors
 Primigravida
 Multipara with change of
partner
 Chronic hypertension
 Chronic renal disease
 Diabetes mellitus
 Multifetal gestation
 Polyhydramnios
 RH Isoimmunized
pregnancy
 Hydatidiform mole
 Previous history of
preeclampsia
 Family history of
pregnancy induced
hypertension
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32. Classification
Mild pre-eclampsia: blood pressure ≥ 140/90 mmHg ±
oedema.
Severe pre-eclampsia:
- blood pressure >140/90 mmHg + proteinuria ±
oedema or
- diastolic blood pressure>110 mmHg or
- cerebral or visual disturbances.
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33. N.B. Imminent eclampsia : It is a state in which the patient is
about to develop eclampsia. Usually there are :
- blood pressure much higher than 160 /110 mmHg ,
- heavy proteinuria (+++or ++++),
- hyperreflexia,
- severe continuous headache,
- blurring of vision,
- epigastric pain.
Fulminating pre-eclampsia: a rapidly deteriorating pre-eclampsia
to be imminent eclampsia.
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34. 34
Criteria Mild preeclampsia Severe preeclampsia
Blood pressure < 160/110 > 160/110
Symptoms Absent Present
Proteinuria < 5 g/dl 24 hours
collection
> 5 g/dl; > 2+ on dipstick
Liver and Renal function Normal Abnormal
Platelet count Normal Thrombocytopenia
Pulmonary edema Absent Present
Convulsions Absent Present
HELLP syndrome Absent Present
Fetal growth restriction Absent Present
The presence of any 1 of the above findings is sufficient to lead to a classification
of the preeclampsia into the severe category

35. Clinical Feature
 The onset is typically insidious, characterized by
hypertension and edema, with proteinuria following
within several days.
 Headaches and visual disturbances are serious events and
are indicative of severe preeclampsia, often requiring
delivery.
 Eclampsia is heralded by central nervous system
involvement, including convulsions and eventual coma.
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36. Symptoms
 Visual disturbances: blurring of vision, flashes of light or
blindness.
 Epigastric or right upper quadrant pain: due to
enlargement and subcapsular haemorrhage of the liver.
 Nausea and vomiting : due to congestion of gastric mucosa
and/ or cerebral oedema.
 Oliguria or anuria: due to kidney pathology.
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37. Investigations
 Complete urine examination: for proteinuria, pus
cells, RBCs, casts,specific gravity, culture and
sensitivity .
 Kidney function tests: serum uric acid > 6 mg % is
abnormal during pregnancy. It is more specific for
pre-eclampsia than creatinine.
 Coagulation status :Platelet count, fibrinogen as DIC
may develop.
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38. cont’d
 Eye fundus examination.
 Tests for foetal well being: as
- ultrasound,
- daily foetal movement count,
- non-stress test,
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39. Complication
Fetal
 IUGR
 Oligohydramnios
 Placental infarcts
 Placental abruption
 Prematurity
 Uteroplacental insufficiency
 Perinatal death
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Maternal
 CNS seizures &
stroke
 DIC
 Renal failure
 Hepatic failure or
rupture
 Death

40. Management
Gestational HTN:
-Follow BP at out patient
-Deliver at term: induction
-Rout-vaginal,
-C/S only if C/I for vaginal
-Anticonvulsant during delivery and 24 hrs after delivery
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41. Mild Preeclampsia: conservatevely
-Follow BP more frequently
-Look for severity S/S or lab
-Deliver at term: Induction
-Rout: Vaginal unless C/I
Severe preeclampsia: aggressively
-Admit, prevent ECLAMPSIA
-Anticonvulsants
-Antihypertensive
IV hydralazine if DBP >110, SBP >160
Oral: Methyldopa, nifidipine, labetolol,
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42. HELLP Syndrome
: is the variant of preeclampsia i.e. characterized by:
-Hemolysis:
Fragmented RBC, jaundice, LDH
-Elevated Liver Enzymes
-Low Platelets
mgt :Immediate termination
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43. Eclampsia
o is the occurrence of generalized tonic clonic convulsion
and/ or coma in a women with preeclampsia.
o It’s one of the most serious and often fatal
complications of preeclampsia.
o Eclampsia is a preventable complication of
preeclampsia & has almost disappeared in countries
with universal ante natal, intra partum ad post partum
care provision
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44.  Eclampsia still complicates preeclampsia in parts of the
world where maternal health service are not accessed by
mothers.
 The majority of Eclampsia occurs intra partum(50%)
with the remainder equally occurring in the ante partum
& post partum period( 25% each)
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45. Management
Anti HTN
Anti convulsants:
Diazepam
MgSO4
NG tube
Air way and secretions
Broad spectrum antibiotic for aspiration pneumonia
Immediate termination
Rout: vaginal if in labor or favorable bishop by
induction, if not C/S
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46. Chronic HTN
Simple: Expectant, spontaneous
: Anti HTN
:Close follow up
Super imposed preeclampsia
: Consider as severe preeclampsia
Superimposed eclampsia
: As eclampsia

47. Cord Prolapse
Cord presentation and prolapse describe a situation in
which the umbilical cord is felt anterior to the fetal
presenting part on vaginal examination.
 If the membranes are intact it is a cord presentation
while with ruptured membranes it is identified as a
prolapsed cord.
 As long as the membranes are not ruptured, the risk of
compression and asphyxia is low.
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48. Cont’d
Cord prolapse can be:
Overt- being felt inside the
cervix, the vagina or even
hanging outside the
introitus.
Occult- with the cord
anterior to the presenting
part in the lower segment
but not felt on digital
vaginal exam
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49. Cont’d
 Cord prolapse can occur in:
vertex and frank breech presentations-0.5%
complete breech -5%
footling breech -15% and
shoulder presentation -20%.
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50. Etiology
 Malpresentations in labor
 PROM
 Amniotomy with a high fetal station
 Polyhydramnios with sudden membrane rupture
 Second twin delivery
 CPD in labor
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51. Complications
 Cord compression and constriction of umbilical
vessels due to cold exposure outside the introitus can
lead to fetal asphyxia and death.
 Partial cord occlusion may give the fetus some time
but in complete cord occlusion the fetus can die of
asphyxia in 5-7 minutes if cord compression is not
immediately relieved.
 There is increased maternal risk from cord prolapse
because of emergency operative vaginal or abdominal
delivery performed in order to salvage the fetus
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52. Dx
 In the vagina or inside the cervix anterior to the
presenting part
 Check for pulsation and its rate
 Replace the cord immediately into the vaginal ( not
inside the uterus) canal if outside the introitus
 If membrane is intact, cord presentation is diagnosed
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53.  In all malpresentations, a careful search for cord presentation or
prolapse should be made
 Occult cord prolapse can only be diagnosed by detection of
abnormal FHR patterns
 In cases of malpresentations, sonographic search can also be
made for cord anterior to the fetal presentation
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54. Management
Immediate management
If cord is pulsating:
 Put mother in knee-chest position
 Initiate oxygen administration by
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face mask 5L/min
 Insert bladder catheter and infuse
the bladder with 0.5L of saline
 Replace the cord into the vaginal
canal
 Push fetal presenting part upwards
via the examining hand in the
vagina to relieve compression of
the cord by the presentation
 Prepare for immediate delivery
Management is aimed toward relieving
pressure on the cord
There by relieving he compression and the
resulting fetal anoxia

55. Cont’d
Delivery :
Non-pulsatile cord:
 Manage as any other labor as the cord prolapse will
not alter the course of labor (dead fetus)
Pulsatile cord:
Second stage of labor:
 Expedite delivery by forceps delivery if other
conditions for forceps delivery are met.
 Breech extraction if other conditions for breech
extraction are met (full cervical dilation)
 First stage of labor:
 caesarean delivery.
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56. Referances
 Williams obstetrics 23rd edition
 Current diagnosis and treatment in obstetrics and
gynecology
 Essential of obstetric and gynecology 4th edition
 FMOH (2010): Management Protocol on Selected
Obstetrics Topics
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