Oxford Handbook of Midwifery (92 page)

Any suspected or proven case of amniotic fluid embolism should be reported to the UK register.

1. Arulkumaran S, Symonds IM, Fowlie A (2004).
   Oxford Handbook of Obstetrics and Gynaecology.
   

   Oxford: Oxford University Press.
   

2. The Practice Development Team (2010).
   Jessop Wing, Labour Ward Guidelines 2010.
   Sheffield: Sheffield Teaching Hospitals NHS Trust.
   

   

   CHAPTER 19
   Emergencies
   

   408‌‌
   

   HELLP syndrome
   

   (
   H
   , haemolysis;
   EL
   , elevated liver enzymes;
   LP
   , low platelets)
   

   • This is an uncommon but severe complication of pre-eclampsia, although it is sometimes seen when hypertension is not present. It is a manifestation of impaired liver function.
     
   • It may occur during the later stages of pregnancy, during or up to 48h after delivery. Diagnosis is confirmed by laboratory assessment of the blood coagulation pattern. There is a risk of maternal/fetal morbidity/ mortality due to:
     
     • Impaired clotting, or bleeding
       
     • Severe liver damage, leading to failure or rupture
       
     • Severe kidney damage, leading to failure
       
     • Respiratory difficulties
       
     • Cerebral haemorrhage/convulsions
       
     • IUGR: premature delivery may be needed and intrauterine death may occur.
       
   • Be aware of, and assess for:
     
     • Epigastric pain (severe, not relieved by antacid; liver tenderness)
       
     • Nausea and vomiting, headaches
       
     • Haematuria, jaundice
       
     • Blood slow to clot.
       
   • Discuss management plans with a consultant obstetrician.
     

     Diagnosis
     

   • Blood samples to send for laboratory assessment include:
     
     • FBC/platelets
       
     • U/E
       
     • Clotting and DIC screen
       
     • LFTs
       
     • G&S and cross-match.
       
   • Laboratory reports demonstrate the altered blood pattern:
     
     • Haemolysis
       (the breakdown of red blood cells). This process begins to occur faster than it would naturally. Severe pre-eclampsia causes damage to the vascular system. Changes occur in the liver. Platelets collect as the initial step of repair and fibrin networks form. Haemolysis results from damage that occurs as the circulating red cells are pushed through the fibrin networks. A reduction
       

       in red cell numbers occurs. Haematocrit (a measure of red cell concentration) may therefore decrease; bilirubin (a by-product of red cell breakdown) may increase.
       

     • Elevated liver enzymes
       . Intravascular fibrin deposits obstruct the flow of blood in the liver. The liver is under stress, therefore the liver enzyme levels become raised. Liver damage is indicated by raised alkaline phosphatase (APT), alanine transaminase (ALT), and AST.
       
     • Low platelets
       (<100×10
       ⁹
       /L). Platelets initiate and are essential to blood coagulation. In HELLP syndrome, clotting factors are mopped up and platelet levels in the blood decrease (thrombocytopenia). This is only treated if bleeding occurs.
       

HELLP SYNDROME

409

Treatment

• Transfusion of platelets or blood may be necessary if the woman is bleeding.
  
• Caesarean may be performed under general anaesthesia since regional anaesthesia may be contraindicated because of low platelets; however, intubation may increase blood pressure further.
  

• IV glucose may be needed (10% glucose/500mL in 6h) to maintain blood glucose at 5+ mmol/L.
  
• Accurate assessment of intake and output of fluids is paramount.
  
• A CVP or arterial line will facilitate accuracy.
  

  Be aware that the woman may have haemorrhage during and/or post caesarean. Ensure an adequate local supply of suitable cross-matched blood.
  

  

  CHAPTER 19
  Emergencies
  

  410‌‌
  

  Disseminated intravascular coagulation
  

  • DIC may occur as a secondary to severe pre-eclampsia and HELLP syndrome.
    
  • Because of injury to vessel walls, blood clotting activity is abnormally increased. Fibrin is formed, resulting in a large number of small thrombi in the capillary circulation.
    
  • As a normal reaction to clot formation, to maintain equilibrium, the body initiates a process of clot breakdown (fibrinolysis).
    
  • In DIC, because clot formation is widespread a large number of fibrin degradation products (FDPs) are produced. These are also anticoagulants. Clotting factors and platelets are mopped up as the large number of microthrombi form.
    
  • As a result, uncontrolled bleeding may occur, without clot formation.
    

    Diagnosis
    

  • Report:
    
    • Any unexpected bleeding from the nose or mucous membrane and oozing from a venepuncture site
      
    • Cyanosis of the extremities (fingers/toes).
      
  • Laboratory tests of venous blood samples should demonstrate when a case of severe pre-eclampsia is beginning to be affected by DIC. Discuss the required frequency of testing with the obstetrician. It is usually daily.
    
    • The
      D-dimer test
      detects fibrin derivatives and therefore breakdown. FDPs should normally be 200ng/mL but in DIC can be
      

      >2000ng/mL. This is the most specific test for DIC.
      

    • FBC and platelets
      . Platelets are essential factors for coagulation of the blood and will be decreased in DIC (<100×10
      ⁹
      /L).
      
    • Prothrombin time
      (PT) measures the coagulation time of plasma (extrinsic clotting pathway). The normal range is 11–15s. In DIC this time may be increased.
      
    • Activated partial thromboplastin time
      (APTT) measures plasma coagulation (intrinsic clotting pathway). The normal range is 29–37s. This time may also be increased in DIC.
      
    • Fibrinogen levels
      detect the coagulation capacity of the blood. Fibrinogen is a protein formed in the liver. Thrombin activates fibrinogen to form fibrin. The normal range is 0–40g/L. It may be decreased in DIC.
      

      Treatment
      

      This is aimed at prevention and correcting the underlying problem, and therefore removing the trigger mechanism for DIC. If the blood pattern demonstrates rising FDPs, this would form part of the rationale for a speedy delivery.
      

  • Unless FDP levels are very high, the presence of some clotting factors should stop bleeding.
    
  • If treatment is considered necessary, for instance to prepare a woman for caesarean, a senior haematologist should be consulted.
    
  • Treatment involves replacement of clotting factors in order to restore equilibrium.
    

    This page intentionally left blank
    

    

    CHAPTER 19
    Emergencies
    

    412‌‌
    

    Acute uterine inversion
    

    Definition
    

    This is a rare complication of labour. The uterus turns inside out and pro- lapses into the vagina. It happens suddenly during the third stage of labour. It can be a cause of maternal death because of shock and haemorrhage.
    

    Factors associated with acute uterine inversion
    

  • Adherent placenta
    
  • Fundal placenta
    
  • Short umbilical cord
    
  • More common in primiparae
    
  • Macrosomic fetus
    
  • Atonic uterus (sometimes with sudden cough or sneeze)
    
  • Distended uterus suddenly emptied.
    

    Types of acute inversion
    

  • Incomplete inversion when the body of the uterus does not extend beyond the cervical rim.
    
  • Complete inversion when the body of the uterus extends as far as the introitus.
    
  • Prolapse of the uterus through the introitus.
    

    Prevention
    

  • The reason why inversion happens is not fully understood. However, acute inversion may sometimes be aggravated by mismanagement of the third stage of labour.
    ¹
    
  • The midwife should
    never
    :
    
    • Use fundal pressure to expel the placenta (Crede’s manoeuvre)
      
    • Use excessive controlled cord traction (CCT)
      
    • Attempt to deliver the placenta without signs of separation
      
    • Use CCT when the uterus is relaxed
      
    • Use CCT omitting to guard the uterus with the left hand above the symphysis pubis.
      

      Signs and symptoms
      

  • The placenta may/may not be separated.
    
  • Haemorrhage is usually present whether or not the placenta is separated.
    
  • Shock due to:
    
    • Blood loss
      
    • Pain.
      
  • On abdominal palpation the fundus of the uterus cannot be located or if inversion is incomplete a concave shape may be felt.
    
  • A bluish, bleeding mass may be present in the vagina or at the introitus. It is the interior of the fundus of the uterus.
    
  • Incomplete inversion is more difficult to identify. Extreme shock and pain (possibly caused by tension on the peritoneum, ovaries, and nerves of the broad ligament) may be out of proportion to the amount of haemorrhage and may be a clue to diagnosis.
    

    

    ACUTE UTERINE INVERSION
    

    413
    

    Management