Gynekologicko - porodnická klinika Lékařské fakulty MU a FN Brno přednosta: Prof. MUDr. Pavel Ventruba, DrSc., MBA n Emergency Conditions nin Obstetrics and Gynecology n P. Janků, L. Hruban VEN fnb nove logo General Medicine Obstetrics and Gynecology Seminary 2015 – Autumn semester Some of acute conditions in obstetrics nbleeding in pregnancy npostpartal haemorrhagy neclampsia nfetal hypoxia nembolism –amniotic fluid –trombosis –air embolism Bleeding in pregnancy nMost important condition in pregnancy nIst trimester –ectopic pregnancy –abortion nIInd trimester –abortion nIIIrd trimester –placenta praevia –vasa praevia –placental abruption nPostpartal haemorrhagy Ectopic pregnancy nmost common cause of maternal death in Ist trimester nincidence 10-20/1000 pregnancies nincidence is increased 3 times due to a sexually tranmitted agent n whe568726 Types of ectopic pregnancy Risk factors Symptoms of ectopic pregnancy nammenorrhoea – 5-8 weeks nabdominal pain 97% nvaginal bleeding 79% nabdominal tenderness 54% nhistory of infertility 15% nIUD 14% nprevious ectopic pregnancy 11% Ectopic pregnancy - Examinations methods nhCG ngynaecological examination nultrasound n ectopicuterus13 OB_1_Abnormal_Ectopic_Pregnancy Ectopic pregnancy - Examinations methods nDiagnostic laparoscopy dx-lap-FIG15 ectopic1 1268138728_laparoscopy Ectopic pregnancy - treatment nSurgical nlaparoscopy – 99% –salpingectomy - 95 % in CR –salpingostomy – rare – high risk of recurrence –resection of ectopic pregnancy – nlaparotomy – 1% –with life – treatening – heavy blood loss nMedical nmethotrexate image006 Abortion n25 % of women lose a pregnancy at some time in their reproductive lives nup to 24 weeks of gestation nreccurent abortion or miscarriage – loss of 3 or more early gestations n12 – 15 % of all clinically recognised pregnancies fail spontaneously n40% of all pregnancy n95% in Ist trimester Abortion - etiology ngenetic factors 50% –chromosomal abnormalities ninfection nanatomical abnormality of uterus ncervical incompetence nsocial end enviromental factors –alcohol, toxic agents, smoking n nalloimmune factors nendocrine dysfunction –luteal phase defect nautoimmune factors –antiphospholipid syndrom ninherited thrombophilia n Diagnosis of abortion nGynecological examination nbleeding nopen cervix n nUltrasound – transvaginal nno FHR nwiped and irregular shape of gestational sac n nhCG ndecrease level n Treatment of abortion ncurretage gesu_01_img0073 unbornChild5 Placenta praevia nPlacenta is partly or wholly implanted in nthe lower uterine segment. nplacenta in lower uterine segment nplacenta praevia marginalis nplacenta praevia partialis nplacenta praevia centralis, totalis previa incidence 0,4 – 0,8% Placenta praevia - diagnosis nUltrasonography –ultrasound 30 – 32 week 03_-placenta-previa-copia figure5 Placenta praevia - diagnosis nSymptoms nbleeding in the 3rd trimester nabnormaly located and inserted placenta separates from the decidua nbleeding results from the exposed uterine vessels from the lower uterine segment which is thin nlower segment has poor contractility and the bleeding can be sever Placenta praevia – clinical management nexpectant management nhospitalisation 32 – 37 week ncaesarean section 38 week – placenta praevia ncaesarean section for heavy bleeding ntocolytics are contraindicated nvaginal delivery – low uterine segment placenta, placenta praevia marginalis Placenta accreta nplacenta is abnormally adherent to the uterine wall nplacenta adherens - grows into the decidua basalis nplacenta acreta – grows on the uterine muscles nplacenta increta – invade uterine muscles nplacenta percreta – penetrate through uterus n1:2500 deliveries nplacenta praevia 10% Placenta accreta Placenta_accreta placenta-accreta Placenta accreta - diagnosis nUltrasound nMRI gr2-midi figure10 image043 Placenta accreta - management n90% women with placenta percreta will lose more than 3000 ml of blood during operation nthe diagnosis is made mostly during the caesarean section or labour nhysterectomy may be necessary by increta and percreta npelvic arterial embolisation could be an alternative n Placental abruption nincidence 1 % nplacental attachment to the uterus is disrupted by haemorrhage netiology –abdominal trauma –uterine decompression –prolonged rupture of the membranes –unkonwn Placenta abruption - diagnosis nbleeding npain – hypertonus nultrasound si55550961 ml40vet_Feline_abd_amniotic_sac Placental abruption - management nexpectant management –abruption very minor –gestation very preterm ncaesarean section –immediately by heavy bleeding –immediately 32 week above Postpartum haemorrhage nuterine atony or hypotony nretained placenta nlower genital tract trauma nuterine rupture Uterine atony nuterus contractions and retraction fails to occur nuterus remains soft , boggy and relaxed ncauses – unknown or retained placenta n80% of PPH Uterine atony - management nuterotonics –oxytocin, PGE, MEM, carbetocin ncompression of uterus ncurretage ntamponade – Bakri baloon cathetr nB - lynch compressive suture nembolisation of pelvic vessels nligation of internal iliac vessels nhysterectomy n n Bimanual compression Bakri baloon tamponade PPH-Fig-28-03 B-Lynch compressive suture PPH-Fig-31-02a,b,c PPH-Fig-31-03a,b Internal iliac artery ligation PPH-Fig-32-01a,b Retained placenta nCause nconstriction of lower part – cervix nplacenta adherens nManagement nmanual removal + curretage ngeneral anesthesia After the placenta is mostly separated, curl your palm around the bulk of it. fig68withdrawdb