Category: Obs & Gynae

Major Haemorrhage Protocol

In the case of patient with Massive Haemorrhage weather that be from Trauma, Surgical, O&G, UGIB, you can activate the MHP

Remember:

  • Do the Basics – don’t forget ABCD
  • Inform Transfusion and get someone to run a G&S sample down
  • FFP can take up to 45min and platelets come from Leeds
  • If you no longer need the MTP – inform transfusion and return products ASAP
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Early Pregnancy: Pain and Bleeding

This pathway for patients in early pregnancy (<16/40) with pain and/or bleeding, extends from Triage to Admission, enabling the triage nurse to:

  • Decide which patients require ED assessment and treatment
  • Discharge or admit suitable patients without the need formal ED assessment

***Pregnancy MUST be confirmed with a positive pregnancy test.***

There are 3 decision trees you could follow

  1. Haemodynamically Unstable
  2. Haemodynamically Stable – Bleeding without pain
  3. Haemodynamically Stable – Pain

1. Haemodynamically UNSTABLE

Haemodynamically UNSTABLE

  1. Consider need for RESUS!
  2. Requires Assessment by ED clinicians
  3. IV access – consider need for 2 cannulae green or bigger
  4. Bloods:
    • Group and Save – Consider Crossmatch
    • FBC
    • U&E, LFT, β-HCG
  5. Treatment (not exaustive):
    • High flow oxygen
    • IV Fluid/Blood
    • Analgesia
  6. Contact Gynae SpR/MG
2. Haemodynamically STABLE – Bleeding without pain

3. Haemodynamically STABLE – Pain

Hyperemesis Gravidarum

Nausea and vomiting in pregnancy is common and at best an unpleasant experience for the patient, and at worst can be life threatening. It normal starts @ 4-7/40, peaks @ 9/40, and finishes @ 20/40.

We need to conduct a thorough history and examination looking for causes other than a high βHCG. these include:

  • Abdominal pathology
  • Urinary pathology
  • Infections
  • Drug History
  • Chronic H.Pylori

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Hypertensive Disorders in Pregnancy

  • New onset hypertension after 20 weeks of gestation (systolic blood pressure > 140 and/or diastolic blood pressure > 90)

And either

  • Proteinuria (urine protein:creatinine ratio ≥30mg/mmol)

Or

  • Other features of pre-eclampsia1:
    • AKI (creatinine ≥ 90)
    • Liver dysfunction (ALT>40)/epigastric/RUQ pain
    • New severe persistent headache without an alternative diagnosis
    • Persistent visual disturbance
    • Haematological complications (platelets <150/DIC/haemolysis)
    • Neurological complications (clonus/stroke/seizures(eclampsia))
    • Pulmonary oedema
    • Uteroplacental dysfunction (fetal growth restriction/placental abruption/intrauterine death)

Onset is usually after 20 weeks of gestation, but it can also occur up to a few weeks postpartum.

Eclampsia- This is pre-eclampsia that has progressed to seizures

Risk Factors:

Clinical features of pre-eclampsia:

  • Asymptomatic hypertension (picked up on screening or incidentally when presenting with another issue)
  • Headache (usually frontal)
  • RUQ or epigastric pain (also a symptom of HELLP syndrome)
  • Nausea and vomiting
  • Oedema (common but not specific). Especially if rapidly increasing and involving face and hands.
  • Visual disturbance (flashing lights in the visual fields or scotomata)
  • Shortness of breath (uncommon but can occur due to pulmonary oedema)
  • Hyper-reflexia and/or clonus

HELLP syndrome is a variant of severe pre-eclampsia characterised by haemolysis, elevated liver enzymes and low platelets.4

Symptoms and signs are similar to those of pre-eclampsia but also include jaundice and bleeding.

Management of Pre-eclampsia:

 

  • Contact obstetrics early
  • Manage the patient in an area with close monitoring if pre-eclampsia with severe features
  • BP management:
    • Labetalol first line unless unsuitable or contraindicated3 (e.g. asthma)
    • Nifedipine MR second line
    • Methyldopa third line (not used postpartum due to risk of depression)
  • Careful fluid balance monitoring
    • Fluid restriction to reduce the risk of pulmonary oedema
    • Monitor urine output if severe
  • Consider IV magnesium sulphate for eclampsia prophylaxis if severe features of pre-eclampsia

Definitive management:

Definitive management of pre-eclampsia is ultimately delivery of the fetus.   Timing of delivery will be decided by senior members of the obstetric team according to the severity of pre-eclampsia, the current gestation and in consultation with the patient. Following diagnosis of pre-eclampsia, the majority of women are managed as inpatients until delivery.

 

ED Management of Eclampsia:

  • Ask for help early from ITU and obstetric teams
  • ABC approach, manage in left lateral position
  • Airway and breathing assessment with high flow oxygen
  • If inadequate ventilation, consider early intubation (laryngeal oedema in pre-eclampsia and increased risk of aspiration in pregnancy)
  • Magnesium sulphate IV is treatment of choice for seizures – 4g loading dose over 5-10 mins then 1g/hr infusion for 24 hours
  • Further 2g boluses of magnesium sulphate can be given if further seizures occur after initial loading.3
  • Patients will need to be managed in HDU/ITU to stabilise blood pressure prior to delivery

Full NICE guidance is available here

Anti-D immunoglobulin

Rhesus (Rh)-D negative women, pregnant with Rh-D positive foetus are at risk of developing antibodies against future pregnancies if/when they suffer a sensitising event. (Remember, this should be considered a standard treatment for all Rh-D negative women, as we are never certain of the fathers Rh-D status) Read more

Rape & Sexual Assault

Don’t

Preform intimate examinations on Sexual assault/Rape patients

  • Unless life-threatening injuries are suspected e.g Haemorrhage.
  • As our examination will inevitably destroy evidence that may aid this patient’s case

Do’s

  • Consider contamination injury (HIV, HepB, HepC) – Guide
  • Consider emergency contraception
  • Children must have police referral for safeguarding and discussion with social care. The paediatricians in CHT may be able to offer support in navigation of services but the responsibility for non-urgent medical assessment lies with specialists at SARC.
  • Refer to The Sexual Assault Referral Centre, either via Police or Self referral

Read more

Early Pregnancy Bleed <16>

Bleeding in early pregnancy is a relatively common problem and in the many cases (esp. with spotting) the pregnancy remains viable. However, bleeding in early pregnancy should never be thought of as normal, and it is vital that we investigate this appropriately.

 

Communication is also vital at a very stressful time

  • Who you are discussing this pregnancy in front of? – Does the patient want them to know
  • Manage expectations – There is nothing we or mum can do to change the out come of the pregnancy apart from ensuring mum is well
  • Ensure the patient has all the details they need – Return advice, clinic time, where to go, what is happening
  • Be sensitive to the patients feelings – Patients respond very differently, be careful not to impose your emotions/assumptions on the situation

Think Anti-D!

Anti-D immunoglobulin guide

 

Search: ectopic pregnancy, Ectopic Pregancy, pv bleed, MISCARRIAGE, vaginal bleed, EPAU

Pulmonary Embolism in Pregnancy

Unfortunately the the normal pathway for investigation of PE performs poorly in pregnancy RCOG have the following pathway

1. Investigation – of suspected PE

  • Clinical assessment – its all on the history and exam scoring doesn’t work
  • Perform the following tests:
    • CXR – sheilding can protect the baby and may avoid further radiation
    • ECG
    • Bloods: FBC, U&E, LFTs, Clotting
  • Commence Tinzaparin (unless treatment is contraindicated – use booking weight to calculate dose) –[BNF]