Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

OK, so, hi everyone. Thank you for coming on a Thursday evening. So we have Doctor Trisha Valencia with us today giving us a electron obstetric emergencies. So we hope you enjoy and if you have any questions, pop them into the chart. So hand over to her, if you guys gonna unmute, I'm very happy to be interrupted as well if you guys have any sort of questions or clarifications. Um otherwise, we can always discuss more at the end of the presentation. Um So, yeah, my name is Trisha. I'm one of, I'm an F two now at uh Northwest London. Um My first job was actually in obs. Um It feels like a few years now since I've done my year five syne placement, but I really enjoyed it. Um So this presentation is sort of geared towards a junior doctor. So I think that in a few years' time you guys will be in my place and in terms of obstetric emergencies, like what you need to know is to identify an acute, acutely unwell patient, you need to identify when you need to escalate really urgently and you need to sort of know what the next steps are so that when you need to escalate to other members of the MTT, you'll be able to refer quite efficiently and you need to be able to document quite competently as well. Um So that's my goals for this teaching session. Um Hopefully it will be useful for both your paces and your sort of written exam. Uh Just read some few tips that I found helpful when I was revising for S and I ID. So, you know, the RCO G greens have guidelines in I CT S. Most of the stuff you need to learn are there. But during your placements, uh depending on which hospital you are. And if you have access, the trust guidelines are also really helpful. So it condenses all of the guidelines available and makes it more digestible and more practical and when the exams are getting near, it's practice, practice, practice. Um I've left my email here. So if anyone has any questions or anyone wants to practice, I'm very happy to sort of support with that and then just do your questions regularly for active recall and you guys, you guys would do well, right. So this session, I've organized it in sort of like a chronological order in terms of the um in the pregnancy period. Um I'm only gonna cover sort of obstetric emergencies would be um from 24 weeks of this gestation onwards. I'm not gonna cover any sort of gynecological emergencies. So I've split them into three parts. So, emergencies that you encounter in the antenatal period. So you have intrapartum emergencies. So things that in labor, what you need to just press the emergency buzzer and sort of the postnasal period emergency is most likely to be a postpartum hemorrhage. Um So antepartum hemorrhage. So it's any sort of um vagina bleeding um from 24 weeks and after um it could range from anything from like small spotting to a massive hemorrhage. Um So spotting can, can also be like sort of a small stain, sort of a pink bleed or a fresh bleed, but that's anything that less than 50 MS. Um I've classified them into sort of previously associated with abdominal pain and previously associated without abdominal pain. Um if it's painful. So your differentials are placental abruption. Uh We'll go through that in more detail in a bit or uh T PTL preterm labor. Um If it's non painful, it could be placenta previa or other genital tract causes. So these could be your cervical ectropions, um external genital abnormalities like um tears, cervical polyps, um majority of antepartum hemorrhage, especially if they're minor or spotting are actually unexplained. Um So I think it's really important in these cases to have a really good history and examination, to exclude these sort of dangerous differentials. Um And in terms of so painful PV bleeds, if the pain is intermittent. So it's most likely to be labor cause labor is sort of like so regular uncomfortable tightenings. Um That's usually what contractions sound like from the history. But if the pain is constant and examination, the uterus is exquisitely tender and sort of hard on palpation described as a w the uterus that points more to a placental abruption. Ok. And if these signs are not present on history of the examination, then you can go through the other pathway. So we'll start with placenta previa. So, placenta Previa, um historically, it's anything that's um on ultrasound shows a low line placenta which is like 20 millimeters from the internal os. Um I'm not gonna go through this category issue. So you can go through that on your own time. But strictly speaking, I think in the guidelines nowadays, placenta Previa is the placenta covering sort of the cervix completely. Yeah. So the placenta is a really um vascular organ, so it's very prone to bleeding. Um And no, that that's why it's kind of like a high risk um sort of condition in at the the antenatal period. So you have risk factors here. So when in the exams, when in your cases, when they ask you about risk factors, it's always good to categorize of maternal fetal or pregnancy or labor uh related risk factors in terms of Placentia. The most common risk factor is previous cesarean sections. So this is actually something that you probably heard in your placement. So VBAC um sort of advise and management So VAC is vaginal birth after Cesarean section. So it's one of the things that you'll counsel uh people about, um that, you know, the more sort of Cesarean sections you have in the future, the risk of complications like placenta Pviia or a abruption sort of increases. Um Another sort of significant risk factor when you're taking your upset history is a previous placenta previa or any other sort of procedures in the past that concerns the endometrium. Um because this is a very high risk, sort of the placenta is obstructing the cervix. Um We there's a high risk of bleed during delivery. So, ideally, you'd, once this is diagnosed, you do a follow up scan in the antenatal period and in about 36 weeks, the placenta is still obstructing the o you to for delivery before the of labor. So, otherwise, uh once the baby is delivered, it would sort of lead to sort of a massive bleed if it's vaginal. So next part is placenta abruption. So if you can refer to the picture here, uh placenta abruption is basically when the placenta comes away from the walls of the endometrium. Um And then that's really dangerous because the placenta needs sort of nutrients from the, from the mom. And then when it comes away, it, there's a lot of bleeding because it's very vascular and usually the bleeding comes from sort of the maternal blood supply. Um So what on history and examination, you'd see some si most likely to be, have some signs of hemodynamic instability. So mother would be sort of tachycardic, low BP. Um I've listed down some sort of risk factors here. Um There's quite a lot of information on these slides. Um But we have a lot of information to cover, so I'm happy to just circulate the, the slides to you guys after. Um But I've highlighted sort of the most common risk factors. A previous abs abruption is one of the most common risk factors, but other things that sort of once again, um kind of compromises the endometrium. So the the placenta doesn't stick to it as efficiently. So, like previous um sort of abdominal trauma, smoking and drug misuse because smoking and drug misuse, um compromises your vascular supply. Um and sort of um because the rosa is compromised, it doesn't, it's not like a, is a healthy sort of placental development. Um So to diagnose this, usually, if a examination is clinically suspected, you'll do an ultrasound and usually what you see on the ultrasound findings is a retroplacental clot. Um And I've mentioned before on the abdominal examination, the uterus would be very tense and hard on palpation and usually because there's blood loss, still be sort of fetal compromised. Um I also want you to be aware that sometimes in, even though it's, it's like a cause of massive bleeding, the history might sometimes say that the vaginal bleed is very minimal, just because you could have something called a concealed bleed. The bleeding stays like in this picture in the sort of endometrial but doesn't sort of come off because the head is in the way. So this is a very high risk situation. So if you encounter this in real life, you encounter this in cases. The first thing you must say is I would escalate urgently from a senior for a review. Um And then you'll put the patient on monitoring, they'd likely to be admitted. And if the bleeding is massive, there's a la large retroplacental clot, there's evidence of fetal compromise or maternal compromise. The management would be urgent delivery. I don't know if I'm going really quickly. Um But um if you guys want to interrupt me, just, just let me know um another cause of.