Obstetric and Gynecologic Emergencies
What the board tests
Ectopic pregnancy, hypertensive disorders of pregnancy, postpartum haemorrhage and the intrapartum emergencies where minutes decide fetal and maternal outcome.
Early pregnancy and hypertension
- Ectopic: risk factors, beta-hCG with transvaginal ultrasound. An unstable patient with a positive pregnancy test and free fluid goes to theatre; do not wait for a definitive scan. Methotrexate only if stable, unruptured, beta-hCG below the local threshold and no cardiac activity.
- Preeclampsia: BP 140/90 or more after 20 weeks plus proteinuria or end-organ dysfunction. Severe features include BP 160/110, platelets under 100, transaminases doubled, creatinine rise, pulmonary oedema and neurological symptoms.
- Magnesium sulphate: 4-6 g loading over 20 min then 1-2 g/h for eclampsia prophylaxis in severe disease; monitor reflexes, respiratory rate and urine output; antidote is calcium gluconate 1 g IV.
- Antihypertensives: labetalol, hydralazine or nifedipine. Never give ACE inhibitors or ARBs.
Obstetric emergencies
- Postpartum haemorrhage: uterine atony is commonest. Rub up a contraction, give oxytocin, then misoprostol or carboprost, tranexamic acid 1 g, balloon tamponade, then surgery. Remember the four Ts.
- Shoulder dystocia: McRoberts manoeuvre then suprapubic pressure, then internal rotational manoeuvres; never apply fundal pressure.
- Cord prolapse: elevate the presenting part, knee-chest or Trendelenburg position, immediate delivery.
- Perimortem caesarean delivery within 4 min of maternal arrest when the uterus is at or above the umbilicus.
Worked example
A woman at 28 weeks has BP 168/112, headache and platelets 90. This is preeclampsia with severe features. Give magnesium sulphate, treat BP with labetalol to below 160/110, take bloods for haemolysis and liver enzymes, and involve obstetrics for delivery. Reasoning: severe features mandate magnesium and delivery, not expectant management.
Traps
Giving ACE inhibitors in pregnancy; missing ectopic pregnancy when a scan is non-diagnostic; fundal pressure in shoulder dystocia; forgetting calcium gluconate for magnesium toxicity; attributing abdominal pain in early pregnancy to gastroenteritis.