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OB40 Obstetrics
Abnormalities and Complications of Labour and Delivery Toronto Notes 2019 Uterine Rupture
Definition
• associatedwithpreviousuterinescar(in40%ofcases),hyperstimulationwithoxytocin,grand multiparity, and previous intrauterine manipulation
• generallyoccursduringlabour,butcanoccurearlierwithaclassicalincision
• 0.5-0.8%incidence,upto12%withclassicalincision
Presentation
• prolongedfetalbradycardia–mostcommonpresentation
• acuteonsetofconstantlowerabdominalpain,maynothavepainifreceivingepiduralanalgesia • hyper/hypotonicuterinecontractions
• abnormalprogressinlabour
• vaginalbleeding
• intra-abdominalhemorrhage
• lossofstationofthepresentingfetalpart
• maternaltachycardia,hypotensionorshock
Risk Factors
• uterinescarring(i.e.previousuterinesurgeriesincludingCesarean(especiallyclassicalincision), perforation with D&C, myomectomy)
• excessive uterine stimulation (i.e. protracted labour, oxytocin, prostaglandins) • uterine trauma (i.e. operative equipment, ECV)
• multiparity
• uterineabnormalities
• malpresentation • placentaaccreta
Treatment
• ruleoutplacentalabruption
• maternalstabilization(mayrequirehysterectomy),treathypovolemia • immediatedeliveryforfetalsurvival
Complications
• maternalmortality1-10%
• maternal hemorrhage, shock, DIC
• amnioticfluidembolus
• hysterectomyifuncontrollablehemorrhage
• fetaldistress,associatedwithinfantmortalityashighas15%
Amniotic Fluid Embolus
Definition
• amnioticfluiddebrisinmaternalcirculationtriggeringananaphylactoidimmunologicresponse
Etiology/Epidemiology
• rareintrapartumorimmediatepostpartumcomplication
• 13-30%maternalmortalityrate
• leadingcauseofmaternaldeathininducedabortionsandmiscarriages • 1/8,000-1/80,000births
Risk Factors
• placentalabruption • rapidlabour
• multiparity
• uterinerupture
• uterinemanipulation
• induction medication and procedures
Differential Diagnosis
• pulmonaryembolus,drug-inducedanaphylaxis,septicshock,eclampsia,HELLPsyndrome,abruption, chronic coagulopathy
Presentation
• suddenonsetofrespiratorydistress,cardiovascularcollapse(hypotension,hypoxia),andcoagulopathy • seizurein10%
• ARDSandleftventriculardysfunctionseeninsurvivors
Maternal Mortality Causes
• Thromboembolism • Cardiac event
• Suicide
• Sepsis
• Ectopic pregnancy
• HTN
• Amniotic fluid embolism • Hemorrhage
* In Canada (2013), lifetime risk of maternal death is 1 in 5,200