PGY1 Education Program
Wednesday 26 th September and 3 rd October 2012
Dr Wendy Carseldine
Teaching Fellow, Maternity and Gynaecology

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Hypertension in Pregnancy
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Post-partum haemorrhage
Shoulder dystocia
Maternal collapse

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Pre-existing hypertension
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Hypertension prior to 20 weeks gestation
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Must be investigated before labelled essential
Pregnancy induced hypertension
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After 20 weeks gestation
Pre-eclampsia
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Multi-system disorder unique to pregnancy
Hypertension + involvement
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Renal
Haematological
Liver
Neurological
Pulmonary oedema
IUGR
Placental abruption

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Crises in pre-eclampsia
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HELLP: Complicate up to 20% of pre-eclampsia
Pulmonary oedema
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Placental abruption
Cerebral haemorrhage
Cortical blindness
DIC
Renal failure
Hepatic rupture
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Unusual causes of HT in pregnancy
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Phaeochromocytoma
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Renal artery stenosis
Coarctation of the aorta

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Symptoms
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Headache, visual disturbance
RUQ/epigastric pain
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Nausea and vomiting
Severe oedema
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Signs
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Hypertension
Proteinuria
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RUQ tenderness
Hyper-reflexia, clonus
IUGR +/- FDIU
Placental abruption

HYPERTENSION IN PREGNANCY:
INVESTIGATIONS
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Bloods
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FBC
EUC
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LFT
Uric acid
Co-ags
Urine
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Protein creatinine ratio
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24 hour protein collection
Ultrasound
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Fetal growth
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AFI
Fetal dopplers

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Prevention
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Aspirin
Clexane
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Antihypertensive treatment
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Oral agents
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Labetalol
Methyldopa
Clonidine
Nifedipine
IV agents
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Hydralazine
Labetalol
Diazoxide

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Seizure prevention
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MgSO
4
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Loading dose
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Infusion for 24 hours
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Delivery
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Risk of prematurity
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Risk of disease development

Every minute, at least one woman dies from complications related to pregnancy or childbirth, 529 000 women a year.
Five direct complications account for more than 70% of maternal deaths: haemorrhage (25%), infection (15%), unsafe abortion (13%), eclampsia (12%), and obstructed labour (8%).

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Incidence: 5-15%
Definitions
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>500 mL blood loss during or after childbirth or enough to cause haemodynamic compromise
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Severe >1000 mL
Primary: first 24 hours
Secondary: from 24 hours to 6 weeks postpartum

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Tone (70%)
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Prolonged 3 rd stage
Over distended uterus (polyhydramnious, twins, macrosomia)
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Exhausted uterus (rapid labour, prolonged 1 st or 2 nd stage, high parity, dystocia/augmentation with Syntocinon)
Infection
Drug induced
Uterine anomalies (fibroids, structural)
Trauma (20%)
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Episiotomy, perineal tear
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Caesarean section
Uterine rupture
Uterine inversion
Tissue (10%)
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Retained placenta/cotyledon
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Abnormal placenta (accreta or increta)
Coagulopathy (1%)
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Pre-existing
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Pregnancy acquired (pre-eclampsia, infection, DIC secondary to FDIU)

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Identification of risk factors
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Appropriate antenatal and intrapartum management
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Delivery in a unit with rapid access to blood and blood products
Abnormal placentation
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All women should have an antenatal ultrasound for placental location
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Recognition of placenta praevia or abnormally adherent placentation
Active management of the 3 rd stage of labour
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Prophylactic oxytocin (reduce risk by 50%)
Early cord clamping, controlled cord traction
Provide appropriate information to women requesting physiological 3 rd stage

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Communication
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Team: midwives, obstetric staff, anaesthetist,
Haematology lab, blood bank, haematologist
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Porters for patient transport and delivery of blood/specimens
Nominate a team member to record events
Use of Massive Transfusion Protocol
JHH: x7700

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ABC
Assess Airway
Assess breathing
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Oxygen by mask (10-15 l/min)
Evaluate circulation
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2 x large IV access (at least 16g cannula), consider arterial line
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Rapid IVF initial resuscitation (Normal saline, gelofusine)
Keep patient warm (also warmed IVF)
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Transfuse blood ASAP (Packed RBC, FFP,
Platelets, Cryoprecipitate)
Consider Recombinant fVIIa

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Monitoring and Investigation
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Venepuncture
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X-match, FBC, Coagulation profile, EUC, LFT
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Observations
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BP, HR, RR, O2 Sat, Temp
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Insert IDC to monitor urine output and contract uterus
Thromboembolic prophylaxis once bleeding controlled
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Estimate blood loss
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Weigh if large volume

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Transfer to theatre
Examination under anaesthetic (GA/regional)
Atony
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Mechanical (bimanual compression, empty bladder)
Pharmacological (Syntocinon, Ergometrine, Misoprostol/Cervagem,
Prostin F2  )
Balloon tamponade (Bakri)
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Laparotomy: B-Lynch Suture, uterine artery/internal iliac artery ligation, hysterectomy
Artery embolisation (radiology)
Trauma
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Examine uterus (rupture), cervix, vagina, vulva, perineum
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Apply pressure and surgical repair
Correct inversion
Tissue
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Examination of placenta
Manual removal (digital or curettage) of retained products
Coagulopathy
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Correction directed by laboratory testing

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Once bleeding is controlled
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Consider ICU/HDU care
Ongoing review and laboratory testing
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Debriefing and counselling to woman, family and staff
Remember next pregnancy prevention/active management

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Incidence: 2%
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Risk Factors
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Maternal obesity
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Macrosomia
Post-dates pregnancy
Diabetes
Assisted delivery

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Get help
Consider episiotomy
McRoberts manoeuvre
Suprapubic pressure
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Constant
Rocking
Delivery of the posterior arm
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Consider use of infant feeding tube
Internal manoeuvres
Last resort
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Zavanelli
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Fracture the fetal clavicle
Symphysiotomy

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PPH
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Cardiac arrest
Amniotic fluid embolism
Thromboembolic disease
Puerperal sepsis