19: Obstetrics and Gynaecology

section 19 Obstetrics and Gynaecology



Edited by Anthony F.T. Brown



19.1 Emergency delivery 585

19.2 Ectopic pregnancy and bleeding in early pregnancy 592

19.3 Bleeding after the first trimester of pregnancy 595

19.4 Abnormal vaginal bleeding in the non-pregnant patient598

19.5 Pelvic inflammatory disease 601

19.6 Pelvic pain 603

19.7 Pre-eclampsia and eclampsia 608


19.1 Emergency delivery



Stephen Priestley




Essentials



1 Perform a rapid assessment of pregnant patients arriving in labour at the emergency department in order to decide on the most appropriate site for management.

2 Equipment, drugs and protocols must be placed within emergency departments so that unexpected deliveries can be managed safely.

3 Establish and maintain lines of communication with regional obstetric services so that decisions regarding management of labour and transfer of mothers and babies are optimum.

4 Emergency department staff must be prepared to provide newborn resuscitation following an emergency delivery. Preparedness for newborn resuscitation requires preparation of a suitable, warmed area, special equipment and trained personnel, and a structured approach to assessment and intervention.


Introduction


Occasionally doctors working in emergency departments (EDs) are faced with caring for a patient in labour and are required to manage a spontaneous vaginal delivery. This situation is generally accompanied by much anxiety on the part of the ED medical and nursing staff, but it is important that a calm, systematic approach is taken to minimize the risk of an adverse fetal or maternal outcome. This chapter describes the management of a normal delivery in the ED.



The setting


There are a number of settings where childbirth may need to occur in an ED. Pregnant patients at different gestational ages may present to the ED in varying stages of labour. Immediate management will depend on the availability of obstetric services, the gestational age and on both the stage of labour and its anticipated speed of progression.


Safe transfer to a delivery suite when there is adequate time is always preferable to delivery in the ED. If there is no delivery suite available and/or there is no time for transfer to an appropriate facility, or the patient arrives with full cervical dilatation and the fetal presenting part is on the perineal verge, then arrangements need to be rapidly made to perform the delivery in the ED.



Precipitate labour


Patients who have precipitate labour – an extremely rapid labour lasting less than 4 h (more common in the multiparous) – may have to stop in the ED even when en route to the delivery suite, or another hospital, because of the rapidity of the labour.



Concealed or unrecognized pregnancy


The diagnosis of a concealed or unrecognized pregnancy may also be made in the ED. Concealed pregnancies occur most commonly in teenage girls who do not tell anyone that they are pregnant and receive no antenatal care, whilst unrecognized pregnancies occur most commonly in obese females who may present to the ED complaining of abdominal pains or a vaginal discharge and are found to be pregnant and/or in labour. Women with intellectual impairment or mental illness are another group that may present with an unrecognized pregnancy.



‘Born before arrival’


The term ‘precipitous birth’ or ‘born before arrival’ (BBA) is commonly associated with precipitate labour and refers to women who deliver their baby prior to arrival at a hospital, usually without the assistance of a trained person. Both the mother and the baby require assessment and may need resuscitation and completion of the third stage of labour on arrival in the ED. The incidence of BBA is low and in one series was found to occur 1 in 695 births (0.14%), whilst the incidence of precipitate labour is 17% in the total hospital population.1



History


Assessment of the patient in labour in the ED includes obtaining information regarding gestational age, antenatal care, progression of the pregnancy, past obstetric and a medical history. Always enquire if the patient has a copy of her antenatal care record with her. Then perform a physical and obstetric examination to confirm the progression of labour, the number of babies and the presence or absence of any complications related to the pregnancy and labour.


In hospitals where there is a delivery suite, a member of that unit should be called to attend the ED to either assist with immediate transfer to the delivery suite if possible, or with the assessment and conduct of the labour within the ED. Delivery in hospitals where there is no delivery suite should include immediate contact by telephone with the nearest or most appropriate obstetric unit to obtain advice and to organize transfer of the mother and newborn.



Gestational age


The gestational age may be determined from the last normal menstrual period (LNMP) if this is known. Naegle’s rule is the most common method of pregnancy dating. The estimated date of delivery (EDD) is calculated by counting back three months from the last menstrual period and adding seven days. As an example, if the last menstrual period is December 20, then the EDD will be September 27. This method assumes the patient has a 28-day menstrual cycle with fertilization occurring on day 14. Inaccuracy occurs because many women do not have regular 28-day cycles, or do not conceive on day 14, and many others are not certain of the date of their last period.



Gestational age estimation


Antenatal ultrasound is useful in estimating the estimated date of confinement (EDC) where dates are uncertain, remembering that scans performed later in the pregnancy are less accurate in dating the gestational age of the baby than those performed early in the pregnancy. Additionally, a rough estimation of the gestational age of the baby can be made by abdominal examination. Between 20 and 35 weeks there is a rough correlation between gestational age and the height of the uterine fundus measured in centimeters from the pubic symphysis.



Past obstetric history


The past obstetric history should include the duration and description of previous labours, the types of deliveries and the sizes of previous babies in addition to a history of a previous caesarean section, the use of forceps or vacuum extraction, a neonatal death and history of abnormal presentations, shoulder dystocia, prolonged delivery of the placenta or a post-partum haemorrhage.



Maternal medical conditions


Maternal conditions such as cardiac and respiratory disease, diabetes, bleeding diatheses, hepatitis B and herpes simplex should be documented. Note all drugs whether prescribed, over-the-counter or illicit that the patient is taking. The presence of any bleeding or other complications during the pregnancy should also be noted. Obtain the results of antenatal investigations, including a full blood count, blood group, hepatitis-B status, HIV and syphilis serology.


Take a careful history regarding the onset and timing of contractions and the presence and nature of fetal movements, in addition to a history of vaginal bleeding or discharge, which may represent the rupture of membranes.



Examination



General examination


Carry out a general examination with particular emphasis on vital signs, and the abdominal and pelvic examination. Examine the breast, nipples, heart and chest and perform a urinalysis looking for evidence of infection, glucose or proteinuria, which may be associated with pre-eclampsia (see Ch. 19.7).



Abdominal examination


Perform an abdominal examination to ascertain the height of the fundus, the lie and presentation of the baby and to make an assessment of the engagement of the presenting part. The presence of scars and extrauterine masses should be noted. Assess the frequency, regularity, duration and intensity of uterine contractions.



Fetal heart rate


Count the fetal heart for 1 min using an ordinary stethoscope, Pinard or a Doppler stethoscope, which should normally be between 110 and 160 beats/min. Count the fetal heart for at least 30 s following a contraction. If bradycardia is detected, give the mother oxygen and position her in the left lateral position to ensure that uterine blood flow and fetal oxygenation is optimized.


If post-contraction bradycardias persist despite these measures then give an intravenous fluid bolus and seek specialist obstetric advice. Note any vaginal bleeding or discharge and record the amount remembering haemorrhage may also be concealed. Assess the colour and character of any amniotic fluid, looking for evidence of meconium staining.



Vaginal examination


Perform an aseptic vaginal examination with the patient in the dorsal lithotomy position to assess the effacement, consistency and dilatation of the cervix, the nature and position of the presenting part (i.e. vertex or breech) and to exclude a cord prolapse. If unsure of the nature of the presenting part, a portable ultrasound can aid in diagnosis.


The exception to performing a vaginal examination is the gravid patient with active vaginal bleeding who should be evaluated with an ultrasound to exclude placenta praevia, before performing any pelvic examination.


If the membranes are intact, there is no indication to rupture them if the labour is progressing satisfactorily, as there is a risk of cord prolapse when the presenting part is not engaged in the pelvis.2 After the vaginal examination, apply a sterile perineal pad and allow the mother to assume whichever position gives her the most comfort, whilst avoiding the completely supine position with the potential for inferior vena cava (IVC) compression by the gravid uterus.



Considerations on transferring the patient


After this assessment the decision whether to transfer the patient to a delivery suite either within the hospital, or at a distant hospital, must be made. Cervical dilatation greater than 6 cm in a multiparous patient and 7–8 cm in the primiparous makes transfer to a distant hospital a hazardous procedure because of the risk of rapid progression to full cervical dilatation and imminent delivery of the baby. The availability and type of transport and personnel, and the distance to be travelled must be carefully considered. Consult with the obstetric unit regarding the safety of transfer and make arrangements for reception of the patient.



Management



Preparation for delivery


Ongoing assessment of maternal temperature, blood pressure, heart rate and contractions should be performed and recorded. Fetal heart rate should be counted every 15–30 min up to full cervical dilatation and every 5 min thereafter. The fetal heart rate is best measured with a Doppler device, commencing towards the end of a contraction and continuing for at least 30 s after the contraction has finished.


Unless there is a clear indication for an intravenous line such as a history of post-partum haemorrhage or antepartum haemorrhage, bleeding tendency, evidence of pre-eclampsia or history of a previous caesarean section, then placement for the normal delivery is unnecessary. Perform simple venepuncture for a haemoglobin and blood group, and put some blood aside for cross-matching.



Equipment and drugs


Obtain a delivery pack, sterile surgical instruments and oxytocic drugs and place close by (see Table 19.1.1). Resuscitation equipment and drugs should be available. Assemble personnel with clear task delegation, remembering that reassurance and emotional support for the mother and the mother’s partner is crucial during the entire labour. A specific member of staff may be delegated to provide this.


Table 19.1.1 Equipment and drugs required for emergency delivery








































Equipment Drugs
Three clamps – straight or curved (e.g. Pean) Adrenaline 1:10 000
Episiotomy scissors Oxytocin 10 units
Scissors Ergometrine 250 μg
Suture repair set Vitamin K 1 mg
Absorbable suture material Lignocaine 1%
Neonatal resuscitation equipment (ETT, laryngoscope etc) Naloxone 400 μg/1 mL
Blanket
Warmer
Sterile drapes
Huck towels
Sterile gloves
Soap solution
Sterile bowls
Umbilical vein catheters

ETT, endotracheal tube.


If a midwife or doctor experienced in delivery is available then they should assume control of the procedure and continue the assessment of the progression of labour and conduct the delivery of both the baby and the placenta. A doctor or nurse with some experience in neonatal or paediatric resuscitation should perform a rapid assessment of the newborn immediately after the delivery of the baby, to ascertain the need for resuscitation.



Conduct of labour


Labour is divided into three stages: The first stage is from the onset of regular contractions to full (10 cm) dilatation of the cervix. The second stage is from full dilatation of the cervix to delivery of the baby and the third stage is from the birth of the baby until delivery of the placenta. A full description of the detailed management of the three stages of labour is beyond the scope of this chapter, but a brief summary of the management of a normal vertex delivery is described.



First stage


Examine the patient abdominally and vaginally as necessary to follow the progress of the labour. As mentioned earlier, perform measurement and recording of maternal vital signs and fetal heart rate. Gently wash the perineum with a non-irritating soap solution such as 0.1% chlorhexidine, particularly when operative vaginal delivery by forceps or vacuum extraction is anticipated. Neither shaving, urinary catheterization nor enema administration is required.



Analgesia


Analgesics are helpful for the patient with significant discomfort and are not injurious to the fetus. The timing and dose of analgesia must be decided with due regard to the stage and rate of progression of labour. Intramuscular opiates such as pethidine 1–1.5 mg/kg are commonly used and provide some relief from pain with varying degrees of sedation. The provision of other forms of analgesia such as epidural anaesthesia is more commonly employed in a delivery suite rather than in the ED delivery. Do not give sedatives and analgesic drugs immediately before anticipated delivery because of potential depressive effects on the baby.


The average duration of the first stage of labour in primiparous patients is 14 h, and in subsequent pregnancies is 6–8 h.



Second stage


Spontaneous delivery of the fetus presenting by vertex is divided into three phases: delivery of the head, delivery of the shoulders and delivery of the body and legs. The second stage of labour begins when the cervix is fully dilated and delivery will occur when the presenting part reaches the pelvic floor.


The normal duration of this stage in the absence of regional anaesthesia ranges from 20 to 60 min in the primiparous, down to 10–30 min in the multiparous patient. Prolongation of the second stage may be defined as 2 h or more in the primiparous patient, and 1 h or more in the multiparous patient. Preparations for delivery, including cleansing, are made as described earlier. Drape the patient in such a manner that there is a clear view of the perineum.



Maternal position


Either a dorsal lithotomy or lateral Sims’ position may be used for the actual delivery. The dorsal lithotomy position is recommended for inexperienced operators, as it is easier to visualize and manually control the delivery process, and perform an episiotomy. In the dorsal lithotomy position the mother should be tilted slightly over to the left side using a pillow or soft wedge, to avoid compression of the inferior vena cava by the gravid uterus and possible maternal hypotension and fetal hypoxia.



Episiotomy


When the presenting part distends the perineum delivery is imminent. Consider an episiotomy at this time, but one should not be performed routinely. Episiotomy refers to a surgical incision of the female perineum performed by the accoucheur at the time of parturition. The primary reason to perform an episiotomy is to prevent a large spontaneous, irregular laceration of the perineum. It is usually performed with scissors when the perineum is stretched and distended, just prior to crowning of the fetal head, following infiltration of a posterior area of the peritoneum with 5–10 mL of 1% lignocaine (lidocaine) between contractions.


Commonly a mediolateral perineal incision is made beginning at the fourchette and is extended towards the ischiorectal fossa. A midline episiotomy is no longer recommended due to an increased risk of tears extending through to the rectum. The patient should be encouraged to bear down during contractions and to rest in between.



Delivery of the head


Delivery of the head must be controlled by the accoucheur so that it extends slowly after crowning, and does not ‘pop out’ of the vagina. Placing the palm of one hand over the head to control its extension most easily achieves this. At this point the patient should cease actively pushing and may need to be instructed to pant or breathe through her nose, in order to overcome her desire to push. The accoucheur’s second hand covered with a sterile gauze pad or towel may be used to gently lift the baby’s chin, which can be felt in the space between the anus and the coccyx.


As the occiput descends under the symphysis pubis, extension of the head occurs and progressively the forehead, nose, mouth and finally chin emerge. If there is evidence of meconium staining of the liquor, gently suction the baby’s nose and mouth, although there is no evidence that this intervention reduces the risk of meconium aspiration or improves perinatal outcome.3


In 25–30% of patients the umbilical cord is looped around the neck, which should be checked for. Generally it is only loosely looped and can be drawn over the head. If there is tension, place two clamps on the cord 2–3 cm apart and cut the cord in between them. Release of additional loops is now straightforward by unwinding the clamped ends around the neck. The baby’s head, having been delivered face down in the most common occipito-anterior position, is allowed to ‘restitute’ (or correct) to one or the other lateral position.



Restitution and delivery of the shoulders


Once the head has restituted, the shoulders will lie in an antero-posterior plane within the pelvis, and delivery of the shoulders is now effected taking great care not to allow the perineum to tear. Usually the anterior shoulder slips under the symphysis pubis with the next contraction by exerting gentle downward and backward traction on the head to facilitate this. Do not use excessive force as this may result in a brachial plexus injury.


On delivery of the anterior shoulder, lifting the baby up will result in delivery of the posterior shoulder followed by the body and lower limbs. Grasp the baby firmly with one hand, securing the infant behind the neck and the other encircling both ankles and place on the mother’s abdomen. The baby is slippery as a result of being covered with vernix and should never be held with one hand alone. Dry the baby and wrap in a warm, dry blanket to minimize heat loss, and record the time of birth.



Clamping the cord and Apgar score


There is no need to immediately cut the cord if the baby is breathing spontaneously and is close to term. There appears to be a benefit in delaying cord clamping in preterm and possibly term infants, as more blood is transferred from the placenta to the infant when clamping is delayed.4,5 Perform an assessment of the baby with Apgar scoring to determine the need for resuscitation.


If the baby is preterm or requires resuscitation, quickly clamp the cord following delivery and transfer the baby for further assessment and resuscitation to a resuscitation trolley that has a radiant heat source. Apply an umbilical clamp 1–2 cm from the baby’s abdomen to cut the umbilical cord and trim the cord approximately 0.5 cm above the plastic clamp.



Use of oxytocics


Following the birth of the baby, palpate the woman’s abdomen to exclude the possibility of a second fetus, where no antenatal ultrasound result is available, and if none, administer an oxytocic agent. The commonest is oxytocin at a dose of 10 units given intramuscularly, or 5 units intravenously as a slow bolus. An alternative is ergometrine in a dose of 250 μg intramuscularly, or slowly intravenously, but as this agent is associated with nausea, vomiting and hypertension it is unsuitable for use in pre-eclampsia, eclampsia or hypertension. Ergometrine is also associated with an increased risk of retained placenta.



Third stage


After administration of the oxytocic agent, look for signs of separation of the placenta from the uterine wall. The three classic signs of placental separation are: (1) lengthening of the umbilical cord, (2) a gush of blood from the vagina signifying separation of the placenta from the uterine wall and (3) change in the shape of the uterine fundus from discoid to globular, with elevation of the fundal height. Following separation, and once the uterus is firmly contracted, apply traction on the cord in a backward and downward direction with one hand, whilst the other is placed suprapubically to support the uterus. Cease traction if the cord feels as though it is tearing.



Placental inspection


As the placenta appears at the introitus, traction is then applied in an upward direction and the placenta is grasped and gently rotated to ensure that the membranes are delivered without tearing. Inspect the placenta and membranes to look for any missing segments or cotyledons, or evidence of a missing succenturiate lobe, which may prevent the uterus from contracting properly if they remain within the uterus.



Procedure post delivery



Uterine tone


Rub over the uterus to facilitate contraction and expulsion of clots. A common cause of post-partum haemorrhage is incomplete uterine contraction, as a result of clots or tissue remaining within the cavity, which may be expelled by massaging the fundus or by manual removal under anaesthesia. Further oxytocics may be necessary.


Bleeding may also occur from other sites so always perform a careful examination of the cervix, vagina, episiotomy wound and perineum following delivery. Full examination of the cervix for ongoing bleeding will require anaesthesia. The episiotomy wound and any other lacerations may be repaired with a synthetic absorbable suture.



Vitamin K


Keep the baby warm and dry and measure and record both mother and baby’s vital signs. Also make regular observations of the maternal fundal height, uterine tone and vaginal loss. If vitamin K is available, administer it to the baby as a deep intramuscular 1 mg injection.



Disposition


Disposition of mother and baby to an obstetric unit either within the hospital or at a distant hospital should then be made when both are stable. The important information that must be provided includes the time of birth, drugs given to either mother or baby and the Apgar scores of the baby. Include the results of any blood tests and a copy of the observations. If either mother or baby is unstable then early consultation with the appropriate referral service is mandatory regarding the optimum timing and nature of the transfer.



Complications of delivery



Breech delivery


Breech presentation occurs in 3–4% of all deliveries, reducing in incidence with advancing gestation. Most breech presentations are delivered by caesarean section. Neonatal morbidity and mortality are worse in breech deliveries than in those fetuses delivering by cephalic presentation.2 The object is safe delivery of the fetus.



Management of the breech delivery


Minimal interference is best. Perform an episiotomy as the fetal anus is climbing the perineum. Allow maternal effort to deliver the baby spontaneously to the umbilicus, delivering the legs with knee flexion. A loop of umbilical cord may be pulled down and allowed to hang. The mother is encouraged to bear down until the trunk becomes visible up to the scapula. Then rotate the trunk until the anterior shoulder delivers. Subsequent rotation of the trunk in the opposite direction results in delivery of the posterior shoulder.


Once the shoulders are delivered the accoucheur delivers the head either with the application of forceps, or by placing the middle finger in the baby’s throat, and flexing the head with the other hand resulting in delivery (Mauriceau Smellie Veit manoeuvre).



Shoulder dystocia


Shoulder dystocia is one of the most frightening complications of vaginal delivery and is frequently unexpected. The rate is approx 1:300 deliveries. The important steps in management are recognizing the at-risk patient, getting assistance early and understanding the manoeuvres to deliver the fetus. The at-risk patient may have a large baby, gestational diabetes or have had a previous shoulder dystocia. In many cases of shoulder dystocia, however, there are no predisposing factors at all.



Recognizing shoulder dystocia


The problem encountered in shoulder dystocia is following delivery of the fetal head as the anterior shoulder does not deliver spontaneously, or with gentle traction by the accoucheur. The anterior shoulder becomes caught immediately above the symphysis. The first sign of shoulder dystocia is retraction of the fetal chin into the perineum, following the delivery of the head. Delivery in under 5 min is essential to prevent asphyxia.



Morbidity with shoulder dystocia


Fetal mortality and morbidity rates are significant. The effects of prolonged asphyxia include neuropsychiatric dysfunction. Brachial plexus injuries result from lateral traction on the fetal head during delivery. The Erb’s palsy arises from damage to the C5 and C6 nerve roots, with paralysis of the deltoid and short muscles of the shoulder, and of brachialis and biceps, which flex and supinate the elbow. The arm hangs limply by the side with the forearm pronated and the palm facing backwards (‘waiter’s tip position’). About 90% of these lesions recover fully or almost fully.



Treatment of shoulder dystocia:



• McRoberts manoeuvre: exaggerated flexion of maternal legs resulting in widening of the pelvic diameter.

• Suprapubic pressure (these two usually result in delivery of the fetus).

• Woods corkscrew manoeuvre: the shoulders are rotated to a transverse position freeing the obstruction.

• Delivery of the posterior shoulder (may result in clavicular or humeral fracture).

• Zavanelli’s procedure: replacing the head in the uterus and performing a caesarean section.


Post-partum haemorrhage


The average blood loss at vaginal delivery is generally estimated to be 500 mL. A post-partum haemorrhage (PPH) is best defined and diagnosed clinically as excessive bleeding that makes the patient symptomatic with lightheadedness, vertigo and syncope and/or results in signs of maternal hypovolaemia with hypotension, tachycardia or oliguria. It is also commonly defined as blood loss of 500 mL or greater after delivery of the fetus.


The causes of PPH may be broadly classified as those relating to retained products, uterine hypotonia or atony, trauma or coagulation abnormalities. Effective management relies on an accurate assessment and identification of the cause.



Causes of PPH



• Retained placenta or products of conception

• Uterine atony

• Soft-tissue laceration

• Coagulopathy

• Uterine rupture

• Uterine inversion


Risk factors for PPH



• Retained placenta

• Grand multiparity (reduced muscular tissue in uterus)

• Antepartum haemorrhage

• Over distension of the uterus from polyhydramnios, macrosomia or multiple pregnancy

• Large placental site associated with multiple pregnancy

• Past history of PPH or haemorrhagic disorders

• Fibroid uterus

• Precipitate labour

• Induced labour

• Prolonged labour

• Chorioamnionitis

• Tocolytic agents, inhalational anaesthetics.

No risk factors are found in up to 20% of cases.



Management of PPH


Prevention is the mainstay of treatment by identifying the at-risk patient, and the aggressive use of oxytocin, along with active management of the third stage of labour. These measures reduce the incidence of PPH by 40%. Resuscitate the patient with intravenous fluids and cross-match blood. Remember to rub up the fundus and deliver the placenta if undelivered. Examine the lower genital tract for tears.



Uterine rupture


Suspect uterine rupture in patients with severe abdominal pain. If a coagulation or platelet defect is present then correct with either fresh frozen plasma (FFP) or platelets. Manage uterine atony by the initial administration of oxytocics such as oxytocin 5 units i.v., which may be followed by an infusion of 20–40 units of oxytocin in 1 L of 0.9% saline. Use an initial rate of 250 mL/h with the infusion rate slowed as uterine contraction occurs. Other agents that are effective in the management of uterine atony include misoprostol 800–1000 μg per rectum (PR) and/or ergometrine 250 μg by the intravenous or intramuscular route.



Further medical treatment of PPH


Further medical treatment includes intramyometrial PG F2a 250–500 μg in aliquots up to a maximum of 2 mg. It is successful in 60–85% cases of refractory uterine atony. Side effects include nausea, vomiting, diarrhoea, pyrexia, hypertension and bronchoconstriction. Its use is therefore contraindicated in women with asthma and hypertension.


Should uterine atony persist, further measures may be required. Exploration of the uterine cavity may be required to identify and remove retained products and bimanual uterine compression may be employed as a temporizing measure.



Surgical management of PPH


Surgical management of continuing PPH will require laparotomy.


• Uterine tamponade. The Bakri tamponade balloon was specifically designed for uterine tamponade to control post-partum bleeding. It is a silicone balloon with a capacity of 500 mL of saline, and strength to withstand a maximum internal and external pressure of 300 mmHg. A Sengstaken–Blakemore tube can be used to tamponade the uterus if the Bakri device is not available.

• Uterine artery ligation has minimal complications and reduces the pulse pressure by 60–70% to allow endogenous haemostatic mechanisms to control bleeding. Failing this, internal iliac artery ligation may be performed usually bilaterally.

• Uterine compression sutures. Uterine compression sutures are an effective method for reducing PPH and avoiding hysterectomy. The B-Lynch suture (or its modifications) envelops and compresses the uterus, similar to the result achieved with manual uterine compression.

• Hysterectomy is the operation of last resort. It may be necessary in uterine atony or rupture, as well as in placenta praevia, or be the procedure of choice in women of high parity.


Resuscitation of the neonate


Approximately 5% of infants require some resuscitation at birth such as stimulation to breathe, and between 1 and 10% of those born in hospital are reported to require assisted ventilation. Most newborn infants do not need any assistance establishing effective respiration at birth. Of those who do, the majority only need minimal help to start breathing. Few require intubation and ventilation, and the need for external cardiac massage with chest compressions is most unusual.6



Neonates who may need resuscitation


The need for resuscitation in the newborn should be anticipated in some groups such as the preterm birth, absent or minimal antenatal care, maternal illness, complicated or prolonged delivery, antepartum haemorrhage, multiple births and a previous neonatal death. Additionally there are occasions when the requirement for newborn resuscitation is unexpected, thus EDs must make available a suitable place, appropriate equipment and trained personnel to perform newborn resuscitation at short notice following an emergency delivery.


A structured and sequential approach to assessment and intervention in the newborn is required. This includes the initial steps in stabilization, including airway clearance, positioning and stimulation, ventilation, chest compressions and administration of drugs or i.v. volume expansion.6 The initial assessment addresses the key elements of response to stimulation, breathing, heart rate, tone and colour. Ongoing assessment is focused on the breathing, heart rate, colour and tone.


The Australian Resuscitation Council has published a Neonatal Resuscitation Flowchart illustrating the assessment and resuscitation of a newborn baby (Fig. 19.1.1).


image

Fig. 19.1.1 Neonatal Resuscitation Flowchart. Reproduced with permission from the Australian Resuscitation Council.



Positive pressure ventilation and chest compressions


Positive pressure ventilation alone is generally effective in raising the heart rate >100/min and establishing spontaneous respirations. Chest compressions are indicated if the newborn’s heart rate fails to rise above 60/min following ventilation. These are achieved by using an encircling thumbs technique at the lower half of the sternum, or by a two-finger technique, if only one healthcare worker is available. Inflations and chest compressions should be synchronized with a 3:1 ratio of 90 compressions and 30 inflations to achieve approximately 120 ‘events’ per minute.7



Use of adrenaline


Adrenaline is recommended if the heart rate remains <60 beats/min, after 1 min of effective ventilation and chest compressions. The recommended intravenous dose is 10–30 μg/kg or 0.1–0.3 mL/kg of a 1:10000 adrenaline solution by a quick push followed by a small saline flush. This dose of adrenaline is repeated if the heart rate remains below 60 beats/min despite effective ventilation and cardiac compressions. Higher doses of adrenaline are not recommended.



Route of administration of adrenaline


The preferred route of administration of adrenaline is via the umbilical vein. Other routes include those through an intraosseous catheter or peripheral vein catheter, although these are more technically challenging. Adrenaline can also be administered via the endotracheal tube, but there is insufficient evidence to support its routine use via this route. If the endotracheal route is used doses of 30–100 μg/kg are recommended, although again the efficacy and safety of these higher doses has not been studied.8



Use of intravenous fluids


Consider intravenous fluids when there is suspected blood loss and/or the infant appears shocked, i.e. pale, with poor perfusion and a weak pulse, and has not responded adequately to the other resuscitative measures above. In the absence of suitable blood for neonatal transfusion, use isotonic crystalloid normal saline at an initial intravenous dose of 10 mL/kg given by bolus push. This dose may be repeated after observing the response.8



Use of naloxone


Naloxone should not be used routinely as part of the initial resuscitation of newborns with respiratory depression in the delivery room. It may be considered in situations of continuing respiratory depression following restoration of heart rate and colour by standard resuscitation methods as outlined above. The currently recommended naloxone dose is 0.1 mg/kg intravenously, or intramuscularly, though evidence to support this recommendation is lacking.8



Neonatal transfer


Neonates requiring resuscitation following emergency delivery will need to be referred to a regional or tertiary neonatal unit for ongoing care. Transfer of these babies requires careful communication and coordination between the two centres, and transport is usually undertaken by a specialized neonatal transport team.



Acknowledgements


The author wishes to acknowledge the assistance of Dr Ian Barabash, Senior Obstetric Registrar at Sunshine Hospital, Melbourne, and Dr Michael Gregora, Director of Obstetrics and Gynaecology, Sunshine Coast and Cooloola Health Service District, Queensland.



References



1 Weir PE, Beischer NA. Birth before arrival in hospital. Medical Journal of Australia. 1980;2:31-33.


2 Brenner WE. Breech presentation. Clinical Obstetrics and Gynecology. 1978;21:511-531.


3 Vain NE, Szyld EG, Prudent LM, et al. Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet. 2004;364:597-602.


4 Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database of Systematic Reviews. 4, 2004. CD003248


5 Ceriani Cernadas JM, Carroli G, Pellegrini L, et al. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial. Pediatrics. 2006;117(4):e779-786. Epub 2006 Mar 27


6 Australian Resuscitation Council Guideline 13.1. Introduction to resuscitation of the newborn infant, February 2006. http://www.resus.org.au. (accessed Jan 2008)


7 Australian Resuscitation Council Guideline 13.6. Chest compression during resuscitation of the newborn infant, February 2006. http://www.resus.org.au. (accessed Jan 2008)


8 Australian Resuscitation Council Guideline 13.7. Medication or fluids for the resuscitation of the newborn infant, February 2006. http://www.resus.org.au. (accessed Jan 2008)



Further reading



Advanced Life Support Group. Advanced paediatric life support: the practical approach, 4th edn, Oxford: Blackwell British Medical Journal Books, 2005.


Beischer NA, Mackay EV, Colditz P, editors. Obstetrics and the newborn: an illustrated textbook, 3rd edn, Philadelphia, PA: W B Saunders, 1997.


Bobak IM, Jensen MD, editors. Essentials of maternity nursing, 3rd edn, St Louis: Mosby, 1991.


DeCherney AH, Nathan L, editors. Current obstetric and gynaecologic diagnosis and treatment, 9th edn, New Jersey: Lange: McGraw Hill Professional, 2002.


Funai EF, Norwitz ER. Management of normal labor and delivery. In: Rose BD, editor. Up to date. Waltham, MA, 2007.


Gianopoulos JG. Emergency complications of labour and delivery. Emergency Medical Clinics of North America. 1994;12(1):201-217.


International Liaison Committee on Resuscitation. International consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Part 7: Neonatal Resuscitation. Resuscitation. 2005;67:293-303.


James DK, Steer PJ, Weiner CP, et al. High risk pregnancy: management options, 3rd edn, Philadelphia, PA: WB Saunders, 2006.


Oates JK, Abraham S. Llewellyn-Jones fundamentals of obstetrics and gynaecology, 8th edn, St Louis: Mosby, 2004.


Tintinalli JE, Kelen GD, Stapczynski S. Emergency medicine: a comprehensive study guide, 6th edn, New York: McGraw-Hill Inc, 2003.



19.2 Ectopic pregnancy and bleeding in early pregnancy



Sheila Bryan




Essentials



1 Approximately 25% of all clinically diagnosed pregnancies are associated with bleeding in the first 12 weeks, of which approximately 50% of cases will be due to a failed pregnancy.

2 Ectopic pregnancy occurs at a rate of about 11:1000 diagnosed pregnancies.

3 The management of ectopic pregnancy and failed pregnancy may be surgical, medical or conservative.


Introduction


Bleeding in early pregnancy is a common problem affecting approximately 25% of all clinically diagnosed pregnancies, and of these approximately 50% will have bleeding due to a failed pregnancy.1 Other causes of bleeding include incidental or physiological, which have no bearing on the outcome of the pregnancy, molar pregnancy and ectopic pregnancy.



Failed pregnancy


Failed pregnancies are defined on ultrasound criteria. Embryonic death is defined as an embryo greater than 6 mm with no cardiac activity. Fetal death is a fetus greater than 8 weeks with no cardiac activity. An anembryonic pregnancy (‘blighted ovum’) is a gestational sac equal to or greater than 20 mm with no embryo.


A failed pregnancy may then remain in the uterus (previously termed as a missed abortion), or may progress to either an incomplete or complete miscarriage, as defined by the presence or absence of pregnancy-related tissue in the uterus.



Ectopic pregnancy


An ectopic pregnancy is a pregnancy that is implanted outside of the normal uterine cavity. The most common location of an ectopic pregnancy is in the fallopian tube. Other sites include cervix (∼1%), ovary (1–3%), interstitial (1–3%), abdomen (1%) and rarely in a uterine scar.


The natural history of an ectopic pregnancy may be one of resorption, spontaneous miscarriage (vaginal or tubal) or it may continue to grow and disrupt the surrounding structures (rupture).



History


History should include the date of the last normal menstrual period and a complete obstetric and gynaecological history including the use of assisted reproductive techniques. Risk factors for ectopic pregnancy include a past history of tubal damage, a previous ectopic pregnancy, pelvic infection, tubal surgery, assisted reproductive techniques, increased age, smoking and progesterone-only contraception. Intrauterine contraceptive devices (IUD) not only decrease the chance of intrauterine pregnancies, but also increase the likelihood of an ectopic pregnancy.2


When estimating the amount of vaginal bleeding it is useful to quantify the blood loss compared to the woman’s normal menstrual loss. Ectopic pregnancy is rarely associated with heavy bleeding. Heavy bleeding and the passage of clots are more common with failed intrauterine pregnancy. However, the history of passage of fetal products should not be used as the basis for a diagnosis. Blood clots or a decidual cast may be misinterpreted as the products of conception. In addition, the correct identification of the products of conception does not exclude the possibility of a live twin or of a coexistent ectopic pregnancy (heterotopic pregnancy).



Examination


Determination of the patient’s haemodynamic status and the rate of ongoing bleeding are a priority. Hypotension, tachycardia and signs of peritoneal irritation suggest a ruptured ectopic pregnancy or bleeding from a corpus luteal cyst.


Bimanual examination can localize tenderness and identify adnexal masses and can also give an estimate of the size of the uterus. However, bimanual examination lacks sensitivity and specificity in identification of small, unruptured ectopic pregnancies3 and gives no information about the viability of the pregnancy. Speculum examination allows visualization of the vaginal walls and the cervix, and allows identification of the source of bleeding.


A complete physical examination should be performed including an assessment of the woman’s mental state, as pregnancy loss may have a profound psychological impact on some women.



Investigations



Biochemistry



Beta subunit of human chorionic gonadotrophin


The beta subunit of human chorionic gonadotrophin (β-hCG) is produced by the outer layer of cells of the gestational sac (the syncytiotrophoblast) and may be detected as early as 9 days after fertilization.4 The β-hCG level increases by approximately 1.66 times every 48 h, then plateaus, before falling at around 12 weeks to a lower level. At any stage of the pregnancy there is always a large range of normal values.


The half life of β-hCG is approximately 48 h, which results in the β-hCG level remaining elevated for a number of weeks post-termination or miscarriage. A positive pregnancy test or a single β-hCG level is therefore unreliable to confirm ongoing pregnancy, and cannot be used to identify retained products of conception. High levels of β-hCG may be associated with multiple or molar pregnancies.



Urine pregnancy test


Urine pregnancy tests are sensitive to a β-hCG level of 25–60 IU/L. Thus false negatives may occur in the setting of early pregnancy or dilute urine.



Haematology


A full blood count and cross-match should be arranged for haemodynamically unstable patients. Blood group and Rhesus factor should be determined on all patients.



Ultrasound


Ultrasound should be performed in every patient to identify the anatomical location of the pregnancy, and to look for a fetal heart beat. The introduction of emergency department (ED) ultrasound provides a cost-effective method for the assessment of patients presenting with bleeding in early pregnancy.5



Transvaginal ultrasound


A gestational sac can be identified as early as 31 days gestation using transvaginal ultrasound. The differential diagnosis of an early gestational sac is a pseudo-sac or an endometrial cyst. A pseudo-sac is a small collection of fluid seen in the uterine cavity, often in association with an ectopic pregnancy. A yolk sac can be identified within the gestational sac at 5–6 weeks when the β-hCG is around 1500 IU/L (except in the case of anembryonic pregnancies). Embryonic cardiac activity should be identified by approximately 39 days (5.5 weeks) gestation, at which stage the crown rump length of the embryo is approximately 5 mm.6



Transabdominal ultrasound


A developing pregnancy may be expected to be reliably identified by about 6 weeks using transabdominal ultrasound, when the β-hCG is approximately 6500 IU/L.


An ultrasound is still valuable when the β-hCG level is less then 1000 IU/L, while not expecting to identify an intrauterine gestational sac.7 Ultrasound can assist in the diagnosis of a ruptured ectopic, if free fluid is identified in the pouch of Douglas and no pregnancy is identified in the uterus.



Heterotopic pregnancy


The identification of an interuterine pregnancy does not exclude an ectopic pregnancy. Ectopic pregnancy may coexist with an intrauterine pregnancy, which is known as a heterotopic pregnancy. The incidence of heterotopic pregnancy in the general population is around 1:3889, but in patients who have undergone assisted reproduction it increases significantly to up to 1:100–1:500.8



Management



Rh(D) immunoglobulin


All patients should have their blood group and Rhesus (Rh) factor determined. As little as 0.1 mL of Rh(D) positive fetal blood will cause maternal Rh iso-immunization. A dose of 250 IU of Rh(D) immunoglobulin should be given in early pregnancy bleeding with a singleton pregnancy to an Rh-negative woman as soon as possible, certainly within 72 h of onset of the bleeding. This dose will prevent immunization from a feto–maternal haemorrhage of up to 2.5 mL of fetal cells. Further doses may be required in the case of repeat or prolonged bleeding.9


A dose of 625 IU of Rh(D) is recommended in multiple pregnancies or with a gestation of greater than 13 weeks. The Kleihauer test is used in later pregnancy to quantify the amount of fetal cells in the maternal circulation, but is unreliable in early pregnancy.



Ectopic pregnancy



Haemodynamically unstable patients


Haemodynamically unstable patients with suspected ectopic pregnancy should be resuscitated and transferred to theatre for surgical intervention as soon as possible. A ruptured corpus luteal cyst may rarely cause similar haemodynamic compromise and is often diagnosed laparoscopically.



Haemodynamically stable patients


The management options for haemodynamically stable patients with an ectopic pregnancy include observation, medical treatment or surgical intervention.


Factors considered in reaching a management choice include the location of the ectopic pregnancy, the β-hCG level, the size of the ectopic pregnancy, the presence of fetal cardiac activity and patient factors.


Observation is sometimes considered in stable patients with a low β-hCG (<1000 IU/L), which is falling. Medical management using intramuscular methotrexate is an option in some patients.10 Selection criteria include non-tubal ectopic pregnancy, or a small tubal ectopic pregnancy (<3 cm) with no cardiac activity, and a β-hCG level less than 5000 IU/L.



Failed pregnancy (miscarriage)



Haemodynamically unstable patients


Patients with heavy bleeding, hypotension and bradycardia should have a speculum examination. Occasionally the products of conception cause dilatation of the cervix, which leads to neurocardiogenic shock, or cervical shock. Removal of the clot and products of conception from the cervix usually results in reversal of the shock.


Haemodynamic compromise may also be secondary to significant blood loss related to the miscarriage. Fluid resuscitation should be instituted simultaneously with attempts to control the bleeding, by removal of blood clot and the products of conception from the cervix and vagina. Uterine contraction may be induced by administering ergometrine 200 μg i.m., if removal of clot and tissue fail to control the bleeding, while emergency surgical evacuation of the uterus is being arranged.



Haemodynamically stable patients


Haemodynamically stable patients have traditionally been treated by surgical evacuation of uterine contents known as evacuation of retained products of conception (ERPC), following the diagnosis of a failed pregnancy (miscarriage).


Other options for emptying the uterus include waiting for spontaneous expulsion (conservative management), or using agents such as misoprostol to induce uterine contraction and miscarriage (medical management). Currently there is insufficient evidence to support the superiority of any of these three treatment options. A number of studies have assessed the time to achieve complete miscarriage and the frequency of complications. These studies have varied with respect to inclusion criteria and duration of conservative management.


The success of conservative treatment is variable but in one study, 78.6% of women studied had an empty uterus at 8 weeks.11 Conservative management is generally associated with slightly longer duration of bleeding and pain, and in some studies the need for transfusion. The incidence of infection was similar in some studies, but higher in the surgical group in others. Complications of surgery such as cervical trauma, uterine perforation and intrauterine adhesions were uncommon. The current view is that a woman’s preference should be a major consideration in recommending treatment options.12



Prognosis


Approximately 50% of patients with bleeding in early pregnancy will proceed to term. Only 60% of women with an ectopic pregnancy will conceive again naturally, and they will have an ectopic rate of 25–30% in subsequent pregnancies.



Disposition


There is an 85–90% chance of the pregnancy progressing to term in a patient with early pregnancy bleeding and an ultrasound confirming a live intrauterine gestation. Poor prognostic indicators include advanced maternal age, the ultrasound findings of an enlarged yolk sac and fetal bradycardia after 7 weeks’ gestation. Patients may be reassured and discharged for review by the treating obstetrician or antenatal clinic in the absence of the above findings. They should be advised to avoid sexual intercourse and not to use tampons until after the bleeding has settled. There is no evidence to support improved pregnancy outcomes from prescribing bed rest.13


The patient with an ultrasound finding of a gestational sac <20 mm with no yolk sac should be followed up with either serial β-hCG levels or repeat ultrasound to ensure the exclusion of a pseudo-sac. Patients with a failed pregnancy or an ectopic pregnancy should be referred to a gynaecology service for ongoing management.


Referral for counselling or psychological support may be indicated in some women.


Investigation for an underlying cause is generally not indicated until after the third consecutive miscarriage due to the high frequency of first trimester miscarriage.




Controversies



1 The role of emergency physician ultrasound within the ED.

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on 19: Obstetrics and Gynaecology

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