Emergency medicine, resuscitation and perioperative care
Introduction
Emergency medicine and perioperative care tests resuscitation of the pregnant and gynaecological patient, recognition of shock and sepsis, anaphylaxis, massive haemorrhage and thromboprophylaxis.
Maternal collapse
- Start standard BLS and ALS: compressions 100–120/min with manual left uterine displacement rather than tilting the whole body.
- Perimortem caesarean section within 4 minutes of arrest when the uterine fundus is at or above the umbilicus (roughly 20 weeks), performed where the patient lies, without moving her.
- Reversible causes: haemorrhage, sepsis, eclampsia, embolism, local anaesthetic toxicity and magnesium toxicity (give calcium gluconate).
Sepsis and anaphylaxis
- Sepsis: cultures and lactate, broad-spectrum antibiotics within one hour, fluid resuscitation; group A streptococcus is a classic culprit in obstetric sepsis.
- Anaphylaxis: adrenaline 0.5 mg IM (1 mg/mL) into the thigh, repeated every 5 minutes; oxygen and fluids, with corticosteroids and antihistamines only as adjuncts.
- Local anaesthetic toxicity: stop injection, secure the airway, give 20% lipid emulsion 1.5 mL/kg bolus followed by infusion.
Haemorrhage
- Massive obstetric haemorrhage: two large-bore cannulae, cross-match, tranexamic acid 1 g within 3 hours, balanced transfusion of red cells, plasma and platelets, fibrinogen replacement, then escalation to balloon tamponade, uterine artery embolisation or hysterectomy.
Perioperative care
- VTE risk assessment for all admissions: LMWH for major gynaecological surgery, extended for four weeks after cancer surgery; mechanical prophylaxis plus early mobilisation.
- Antibiotic prophylaxis for hysterectomy and caesarean section; normothermia and goal-directed fluids within enhanced recovery pathways.
Worked example
A 33-year-old collapses 20 minutes after a spinal anaesthetic for caesarean section. She is unresponsive and pulseless, having had a rash and hypotension before the arrest. This is anaphylaxis: give adrenaline 0.5 mg IM, fluids and airway support, and because she is beyond 20 weeks, perform perimortem caesarean section within 4 minutes if circulation does not return.
Traps
- Tilting the whole body during maternal CPR, which degrades compression quality.
- Delaying antibiotics in sepsis while waiting for culture results.
- Giving antihistamines instead of adrenaline in anaphylaxis.
- Missing magnesium toxicity in a woman on magnesium sulphate (loss of reflexes, respiratory depression, oliguria).