TEALE FENNING

Nick Raine-Fenning

Obstetrics 2: March 2008

What are the clinical features of AFE (5 marks)

What steps would you take to optimise outcome in the case of an AFE (5 marks)

What is the differential diagnosis of seizures in labour (10 marks)

Xerxes I · Posted: Sat Apr 19, 2008 3:22 pm Post subject:

What are the clinical features of AFE (5 marks)

Amniotic fluid embolism remains a significant cause of maternal mortality. Despite the advances in critical care, the mortality rate from the condition remains very high and the number of maternal mortality in the latest report of Confidential enquiry into maternal death showed a considerable increase compared to the previous report.

It is typically presented as sudden maternal collapse in peripartum period. It may have little or no warning signs but if any, panic attack, air hunger, nausea and vomitting and feeling of impending doom can be present just before the collapse.

It has been associated with uterine stimulation in labour, however, this association has been challenged as a significant proportion of cases happen in the absence of uterine stimulation.

ran out of bubbles now!, let's cheat Wink

should have mentioned these,

Central cyanosis, respiratory distress.
If survived the initial attack, half will have DIC
Probably should have been more specific in mortality rate (80%)
and also peripartum is too conservative a word I think, should have said during or shortly after labour,
Any other comments? Doesn't it seem too short for 5 marks?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

it's not too short for 5 marks,

mortality, collapse, and comment about ut stimulation will be 3 marks together and the rest 2 marks easily.

i would include

Hypotensio
Dyspnea
Seizure
Cough
Cyanosis
Fetal bradycardia, in response to the hypoxic insult, if not already delivered
Pulmonary edema
Cardiac arrest
Uterine atony, is a ppt factor
Coagulopathy
Altered mental status/confusion/agitation
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Xerxes I · Posted: Sat Apr 19, 2008 3:45 pm Post subject:

What steps would you take to optimise outcome in the case of an AFE (5 marks)

Immediate resuscitation and basic life support is the core (I need a better word, mainstay?) in the management of amniotic fluid embolism. Help should be summoned immediately usually by dialing 2222 to summon obstetricians, anaesthetist and the hospital resuscitation team. Consultant obstetrician and anaesthetist on duty should be asked to attend immediately.

Airway should be secured in an appropriate way, usually by intubation if a skilled person is in attendance, otherwise, any forein body or vomitus should be cleared and chin lift and jaw thrust performed to secure a patent airway. resuscitation should be commenced immediately and continued until resus team arrive(should I say how I'd resuscitate?). If undelivered, a perimortem caesarean section may be necessary depending on the circumstances to help with maternal venous return and also to save the baby.

effective training of labour ward staff for dealing with maternal collapse is pramount. This shold be in the form of drills and skills sessions and resuscitation courses. This should be kept up to date and reviewed regularly. Familiarity of the staff with the place emergency equipments are kept is an example of how simple things can save lives. (stop it now, ur running out of proper stuff and are BSing!)

Not happy with it, doesn't have a proper structure to it. didn't know where to start and what to include.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

core / mainstay / back bone / foundation ??
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

actually this is very good,

i'd start by saying something like, early diagnosis and effective resuscitation will help optimize the outcome.

i would give 30 to 2 ratio where u say resuscitation.

also add, foetal monitoring if undelivered.

further management in ITU with dopamine for BP stabilisation.
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Xerxes I · Posted: Sat Apr 19, 2008 4:14 pm Post subject:

Thanks Raj, that was extra quick, quicker than 2222

What is the differential diagnosis of seizures in labour (10 marks)

why can't we use bullet points, this is shouting "bullet point me" Ok

Seizure during labour can be due to a range of causes related or unrelated to pregnancy. Labour stress and pain can trigger a seizure in a person with preexisting epilepsy. The compliance with treatment of epilepsy and taking antiepileptic drugs is usually reduced in pregnancy women because of fear of fetal toxicity and this can contribute to the higher incidence of non obstetric seizures. Furthermore, increased maternal serum volume and reduced albumin during pregnancy may reduce the levels of the drugs in the blood.

Rarely, a space occupying brain lesion can cause seizure. This can be a benign or malignant tumor or an intracranial bleeding.

Substance related conditions including alcohol withdrawal or drug overdoses should be considered. More commonly, severe hypoglycemia, especially in diabetic women can cause seizures (I should have said this earlier.)

metabolic disturbances (hypocalcemia, but why?, I would mention it somewhere)

Pregnancy related causes of seizure in a labouring woman include eclampsia and amniotic fluid embolism. Eclampsia usually occurs in women with severe preeclampsia, but this is not always the case and care should be taken not to exclude this based on the abscence of previously known preeclampsia.

Amniotic fluid embolism can present with seizures and usually will be followed by maternal collapse.

The list goes on, infection, meningitis, encephalitis, etc,

Xerxes I · Posted: Sat Apr 19, 2008 4:20 pm Post subject:

Other causes of increase frequency of seizures during pregnancy and specially labour:

-Enhanced metabolism & increased drug clearance associated with
pregnancy can result in decreased serum drug concentration.
-Increased volume of distribution of the AED.
-Increased serum binding proteins.
-Decreased or non-compliance with medication.
-Sleep deprivation, hormonal changes of pregnancy , and
associated psychological and emotional stress of pregnancy: all lower
threshold for seizures. sleep deprivation is particularly relevant to labour.
-Nausea and vomiting, This one too is relevant to labour, and of course early pregnancy.

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

hi, surely not quicker than 2222. Embarassed

u have mostly covered all DDs.

i would set them in an essay using Abi's technique. i.e

common cause of seizures in pregnancy are epilepsy and ecclampsia. pre existing severe preecclampsia, stage of prodrome with twitching will point to ecclampsia where as preexisting epilepsy with history of previous non preg related seizures and followup history from neuro clinic, may worsen during pregnancy and lead to epileptic seizure.

didn't do that well at all, did i? well the point is give a few diagnostic points about each condition with the diagnosis. also mention amniotic fluid embolism here.

u have included all the DDs but i'll summarize them again if that's ok.

head injury
stroke
metabolic -- electrolyte imbalance, diabetes, hypoxia, hepatic, diab insipides
toxic - drug and alcohol withdrawal, barbiturates, amphetamine, heroin, cocaine and occlogyric crisis with metoclopramide
brain tumors, hydrocephalus
neuro-degenerative disorders - tay sachs, PKU,
febrile
psychiatric causes

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 962

just read the next bit of the answer, sounds good.

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region