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Y4 reproductive health > Complicated pregnancy > Flashcards

Complicated pregnancy Flashcards

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1
Q

VTE in pregnancy risk factors

A

Smoking

Parity > 3

Age > 35 years

BMI > 30

Reduced mobility, multiple pregnancy

Pre-eclampsia

Gross varicose veins

FHx of VTE, thrombophilia, IVF pregnancy

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2
Q

VTE in pregnancy prophylaxis

A

Start from:

  • 28 weeks if 3 risk factors
  • first trimester if there are four or more of these risk factors

All pregnant women should have a risk assessment for their risk of VTE at booking; performed again at birth

LMWH unless contraindicated, continued throughout the antenatal period & for six weeks postnatally (temporarily stopped if woman goes into labour)

Mechanical prophylaxis → intermittent pneumatic compression, anti-embolic compression stockings

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3
Q

VTE in pregnancy diagnosis

A

Doppler USS - repeat if negative on days 3 & 7 in patients with a high index of suspicion of DVT

Suspected PE - CXR, ECG

CTPA/VQ scan

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4
Q

VTE in pregnancy mx

A

LMWH - enoxaparin, dalteparin & tinzaparin

  • should be started immediately before confirming the diagnosis in patients with DVT/PE
  • continued for remainder of pregnancy & six weeks postnatally/three months in total
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5
Q

Maternal sepsis aetiology

A

Chorioamnionitis

Urinary tract infections

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6
Q

Chorioamnionitis

A

Infection of the chorioamniotic membranes & amniotic fluid

Usually occurs in later pregnancy & during labour

Can be caused by a large variety of bacteria → gram-positive bacteria, gram-negative bacteria & anaerobes

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7
Q

Chorioamnionitis clinical features

A

Abdominal pain

Uterine tenderness

Vaginal discharge

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8
Q

Maternal sepsis presentation

A

MEOWS - monitors physical observations to identify signs of sepsis

Non-specific signs - fever, tachycardia, raised RR, reduced oxygen sats, low BP, altered consciousness, reduced urine output, raised white cells on FBC, fetal compromise on CTG

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9
Q

Maternal sepsis ix

A

FBC, U&Es, LFTs, CRP, clotting, blood cultures, blood gas

Additional ix for suspected source → urine dipstick & culture, high vaginal swab, throat swab, sputum culture, wound swab after procedures, LP

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10
Q

Maternal sepsis mx

A

Senior obstetricians and midwives should be involved early in the care of the women with suspected chorioamnionitis/sepsis

Sepsis 6

Continuous maternal & fetal monitoring is required

Abx from local guidelines

  • tazocin + gentamicin
  • amoxicillin + clindamycin + gentamicin
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11
Q

Placental abruption

A

A part/all of the placenta separates from the wall of the uterus prematurely

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12
Q

Placental abruption pathophysiology

A

Thought to occur following a rupture of maternal vessels within the basal layer of the endometrium

Blood accumulates & splits the placental attachment from the basal layer

Detached portion of the placenta is unable to function → rapid fetal compromise

Two types:

  • revealed - bleeding tracks down from the site of placental separation and drains through the cervix, results in vaginal bleeding
  • concealed - bleeding remains within the uterus & typically forms a clot retroplacentally; bleeding is not visible but can be severe enough to cause systemic shock
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13
Q

Placental abruption risk factors

A

Placental abruption in previous pregnancy

Pre-eclampsia & other HTN disorders

Abnormal lie of the baby

Polyhydramnios

Abdominal trauma

Smoking/drug use

Bleeding in first trimester

Underlying thrombophilias

Multiple pregnancies

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14
Q

Placental abruption clinical features

A

Painful vaginal bleeding

O/E - woody uterus (tense all of the time) & painful on palpation

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15
Q

Placental abruption ix

A

Bloods - FBC, clotting profile, Kleihauer, group and save, cross-match, U&Es, LFTs

CTG if > 26 weeks

Transvaginal scan

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16
Q

Placental abruption mx

A

ABCDE

Emergency delivery - maternal +/- fetal compromise

Induction of delivery - haemorrhage at term without maternal or fetal compromise

Conservative mx - for partial/marginal abruptions not associated with maternal or fetal compromise

Give anti-D within 72 hours of the onset of bleeding if the woman is Rh D-

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17
Q

Placenta praevia

A

Placenta is fully or partially attached to the lower uterine segment

Important cause of antepartum haemorrhage - vaginal bleeding from week 24 of gestation until delivery

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18
Q

Placenta praevia pathophysiology

A

Minor placenta praevia - placenta is low but does not cover the internal cervical os

Major placenta praevia - placenta lies over the internal cervical os

Low-lying placenta is more susceptible to haemorrhage

  • can be spontaneous or provoked by mild trauma (vaginal examination)
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19
Q

Placenta praevia risk factors

A

Previous CS - main

High parity

Maternal age > 40 years

Multiple pregnancy

Previous placenta praevia

History of uterine infection

Curettage to the endometrium after miscarriage/termination

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20
Q

Placenta praevia clinical features

A

Painless vaginal bleeding

Can be pain if woman is in labour

O/E - CS scar, multiple pregnancy, uterus is not tender on palpation

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21
Q

Placenta praevia ix

A

Bloods - FBC, clotting profile, Kleihauer test (if woman if Rh-, determine amount of haemorrhage & dose of anti-D), group and save, cross-match, U&Es, LFTs

Woman > 26 weeks, CTG performed

Digital vaginal examination should not be performed → may provoke severe haemorrhage

Transvaginal USS

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22
Q

Placenta praevia mx

A

ABCDE

May be identified in an asymptomatic patient at their 20 weeks USS:

  • placenta praevia minor → repeat scan at 36 weeks
  • placenta praevia major → repeat scan at 32 weeks

CS safest mode of delivery (elective at 38 weeks)

All cases of antepartum haemorrhage → give anti-D within 72 hours of the onset of bleeding if woman if Rh D-

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23
Q

Vasa praevia

A

Condition where the fetal vessels are within the fetal membranes & travel across the internal cervical os

The vessels are placed over internal cervical os, before the fetus

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24
Q

Vasa praevia pathophysiology

A

Fetal vessels are exposed, outside the protection of the umbilical cord/placenta

Travel through the chorioamniotic membranes & pass across the internal cervical os

Exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour & at birth

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25
Vasa praevia types
Type I - fetal vessels are exposed as a velamentous umbilical cord Type II - fetal vessels are exposed as they travel to an accessory placental lobe
26
Vasa praevia risk factors
Low lying placenta IVF pregnancy Multiple pregnancy
27
Vasa praevia clinical features
Triad - painless vaginal bleeding, rupture of membranes & fetal bradycardia May be diagnosed by ultrasound during pregnancy → planned CS APH, with bleeding during the second/third trimester of pregnancy May be detected during labour → when fetal distress & dark red bleeding occur following rupture of the membranes O/E - pulsating fetal vessels seen in membranes through the dilated cervix
28
Vasa praevia mx
Asymptomatic women with vasa praevia: - corticosteroids from 32 weeks - elective CS planned for 34-36 weeks Emergency CS for APH
29
Uterine sources of APH
Circumvallate placenta Placental sinuses
30
Lower genital tract sources of APH
Cervical polyps Cervical erosions & carcinoma Cervicitis Vaginitis Vulval varicosities
31
Primary post-partum haemorrhage
Loss of >500 ml of blood PV within 24 hours of delivery Minor - 500-1000ml of blood loss Major - > 1000ml of blood loss
32
Primary post-partum haemorrhage aetiology & risk factors
Tone - uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle - maternal profile: age > 40, BMI > 35, Asian ethnicity - uterine over-distension: multiple pregnancy, polyhydramnios, fetal macrosomia - labour - induction, prolonged - placental problems - praevia, abruption, previous PPH Tissue - retention of placenta tissue Trauma - refers to damage sustained to the reproductive tract during delivery - instrumental vaginal deliveries - episiotomy - CS Thrombin - coagulopathies and vascular abnormalities which increase of primary PPH: - vascular - placental abruption, HTN, pre-eclampsia - coagulopathies - VWD, haemophilia A/B, ITP or acquired eg. DIC, HELLP
33
Primary post-partum haemorrhage clinical features
PV bleeding Dizziness, palpitations, SoB O/E - haemodynamic instability, signs of uterine rupture, reveal sites of local trauma, examination of placenta
34
Primary post-partum haemorrhage ix
Bloods - FBC, cross match 4-6 units of blood, coagulation profile, U&Es, LFTs
35
Primary post-partum haemorrhage definitive mx
Uterine atony - bimanual compression to stimulate uterine contraction, pharmacological measures, surgical measures (intrauterine balloon tamponade) Trauma - primary repair of laceration if uterine rupture Tissue - IV oxytocin, manual removal of placenta & prophylactic abx in theatres Thrombin - correct any coagulation abnormalities with blood products under the advice of the haematology team
36
Syntocinon
Synthetic oxytocin, act on oxytocin receptors in the myometrium SEs: N&V, headache Contraindications: hypertonic uterus, severe CVS disease
37
Ergometrine
Multiple receptor sites action SEs: HTN, nausea, bradycardia Contraindications: HTN, eclampsia, vascular disease
38
Carboprost
Prostaglandin analogue SEs: bronchospasm, pulmonary oedema, HTN, CVS collapse Contraindications: cardiac disease, pulmonary disease, untreated PID
39
Misoprostol
Prostaglandin analogue SEs: diarrhoea
40
Primary post-partum haemorrhage prevention
Active management of the 3rd stage of labour routinely reduces PPH risk by 60%: - women delivering vaginally should be administered 5-10 units of IM oxytocin prophylactically - women delivery via SC should be administered of IV oxytocin
41
Secondary post-partum haemorrhage
Excessive vaginal bleeding in the period from 24 hours after delivery to twelve weeks postpartum
42
Secondary post-partum haemorrhage aetiology & risk factors
Uterine infection - CS, premature rupture of membranes, long labour Retained placental fragments or tissue Abnormal involution of the placental site Trophoblastic disease
43
Secondary post-partum haemorrhage clinical features
Excessive vaginal bleeding - spotting on and off for days, with an occasional gush of fresh blood - 10% have massive haemorrhage Endometritis - fevers/rigors, lower abdominal pain or foul smelling lochia O/E: lower abdominal tenderness, uterus may be high, speculum to see amount of bleeding + high vaginal swab
44
Secondary post-partum haemorrhage ix
Bloods - FBC, U&Es, CRP, coagulation profile, group and save, blood cultures Pelvic USS
45
Secondary post-partum haemorrhage
Abx - ampicillin & metronidazole (gentamicin added in cases of endomyometritis or overt sepsis) Uterotonics - syntocinon, syntometrine, carboprost, misoprostol Surgical measures - excessive/continuing bleeding
46
Breech presentation
Fetus presents buttocks or feet first
47
Breech presentation types
Complete (flexed breech) - both legs are flexed at the hips and knees Frank (extended breech) - both legs are flexed at the hip and extended at the knee → most common type Footling breech - one or both legs extended at the hip, so foot is the presenting part
48
Breech presentation risk factors
Uterine - multiparity, uterine malformations, fibroids, placenta praevia Fetal - prematurity, macrosomia, polyhydramnios, twin pregnancy, abnormality
49
Breech presentation clinical features
Identified on clinical examination - round fetal head can be felt in the upper part of the uterus & irregular mass in the pelvis 20% → not diagnosed until labour → signs of fetal distress eg. meconium stained liquor
50
Breech presentation external cephalic version
Manipulation of the fetus to a cephalic presentation through the maternal abdomen 50% success rate Offered from 37 weeks gestation Complications - fetal heart abnormalities, placental abruption
51
Breech presentation CS
Elective CS offered if ECV not possible
52
Vaginal breech birth
Contraindication - footling breech Specific manoeuvres: - flexing the fetal knees - Lovsett’s manoeuvre - rotate the body and deliver the shoulders - MSV manoeuvre - deliver the head by flexion
53
Breech presentation complications
Cord prolapse Fetal head entrapment Premature rupture of membranes Birth asphyxia Intracranial haemorrhage
54
VBAC mx
Women should deliver in a hospital setting Continuous CTG monitoring Beware of additional analgesic requirements → may indicate impeding uterine rupture Avoid induction Caution augmentation After 39 weeks, an elective repeat CS is recommended
55
VBAC benefits
If successful, shorter hospital stay and recovery Lower risk of maternal death Good chance of successful future VBACs if successful
56
VBAC risks
Uterine rupture Anal sphincter injury HIE to neonate Risk of stillbirth beyond 39 weeks whilst awaiting spontaneous labour
57
VBAC contraindications
Absolute - classical CS scar, previous uterine rupture Relative - complex uterine scars or >2 prior lower segment CS
58
SGA
An infant with a birth weight < 10th centile for its gestational age
59
SGA aetiology
Normal small Placental mediated growth restriction - growth is usually normal initially but slows in utero Non-placenta mediated growth restriction - growth is affected by fetal factors eg. chromosomal/structural anomaly, error in metabolism or fetal infection
60
SGA risk factors
Minor - maternal age > 35, smoker 1-10/day, nulliparity, IVF singleton Major - previous SGA baby, maternal/paternal SGA, previous stillbirth, smoker > 11 day
61
SGA prevention
Modifiable risk factors management High risk of PE → 75mg aspirin 16 weeks gestation until delivery
62
SGA surveillance
UAD should be primary surveillance tool Normal → repeat every 14 days; abnormal → repeat more frequently/consider delivery
63
SGA delivery
Delivery is being considered between 24 & 35+6 weeks gestation → single course of antenatal steroids < 37 weeks - absent/reverse end-diastolic flow on Doppler → CS By 37 weeks - abnormal UAD/MCA doppler → can offer induction At 37 weeks - normal UAD → can offer induction
64
SGA neonatal complications
Birth asphyxia Meconium aspiration Hypothermia Hypo-/hyperglycaemia Polycythaemia NEC
65
SGA long-term complications
CP Type 2 diabetes Obesity HTN Precocious puberty Behavioural problems
66
LGA aetiology
Constitutional Maternal diabetes Previous macrosomia Maternal obesity/rapid weight gain Overdue Male baby
67
LGA risks
Mother → shoulder dystocia, failure to progress, perineal tears, instrumental delivery/caesarean, PPH, uterine rupture Baby → birth injury (Erb’s palsy, clavicular fracture), neonatal hypoglycaemia, obesity in later life, T2DM in adulthood
68
LGA mx
USS to exclude polyhydramnios OGTT for GDM Main risk = shoulder dystocia - risk reduced by having access to obstetrician, paediatrician & active management of third stage of labour
69
Oligohydramnios
Low level of amniotic fluid during pregnancy
70
Oligohydramnios aetiology
PPROM Placental insufficiency Renal agenesis Non-functional fetal kidneys Obstructive uropathy Genetic/chromosomal anomalies Viral infections
71
Oligohydramnios ix
H&E - symptoms of leaking fluids & feeling damp all the time USS Karyotyping (if appropriate)
72
Oligohydramnios mx
Largely dependent on the underlying cause Ruptured membranes - labour likely to commence within 24-48 hours in most; course of steroids & abx given; IoL considered around 34-36 weeks if no spontaneous labour Placental insufficiency - babies are likely to be delivered before 36-37 weeks
73
Polyhydramnios
Abnormally large level of amniotic fluid during pregnancy
74
Polyhydramnios aetiology
Idiopathic Any condition that prevents fetus from swallowing - oesophageal atresia, CNS abnormalities, muscular dystrophies Duodenal atresia ‘double bubble’ Anaemia Fetal hydrops Twin to twin transfusion syndrome
75
Polyhydramnios clinical assessment
Examination - tense uterus? USS - diagnosis Maternal glucose tolerance test Karyotyping TORCH screen Maternal red cell antibodies should be checked
76
Polyhydramnios mx
No medical intervention required in majority Maternal sx severe → aminoreduction; not performed routinely due to association with infection & placental abruption Indomethacin can be used to enhance water retention → associated with premature closure of DA → not used beyond 32 weeks
77
Multiple pregnancy types
Monozygotic - identical twins Dizygotic - non-identical twins Monoamniotic - single amniotic sac Diamniotic - two separate amniotic sacs Monochorionic - share a single placenta Dichorionic - two separate placentas
78
Multiple pregnancy diagnosis
Usually diagnosed on the booking ultrasound scan Dichorionic diamniotic - lambda sign/twin peak sign Monochorionic diamniotic - T sign Monochorionic monoamniotic - no membrane separating the twins
79
Multiple pregnancy maternal complications
Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery/CS PPH
80
Multiple pregnancy fetal complications
Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities
81
Multiple pregnancy antenatal care
Specialist multiple pregnancy obstetric team Additional monitoring for anaemia - FBC at booking, 20 weeks gestation + 28 weeks gestation Additional USS scans - 2 weekly scans from 16 weeks for monochorionic twins - 4 weekly scans from 20 weeks for dichorionic twins Planned birth offered
82
Stillbirth
Birth of a dead fetus after 24 weeks gestation
83
Stillbirth aetiology
Unexplained Pre-eclampsia Placental abruption Vasa praevia Cord prolapse/wrapped around the fetus neck Obstetric cholestasis Diabetes Thyroid disease Infections eg. rubella, parvovirus Genetic abnormalities/congenital malformations
84
Stillbirth risk factors
Fetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on the back
85
Stillbirth prevention
Risk assessment for SGA/FGR Modifiable risk factors treated - stopping smoking, avoiding alcohol & effective control of diabetes Ask about three key symptoms - reduced fetal movements, abdominal pain, vaginal bleeding
86
Stillbirth mx
USS confirms diagnosis Rhesus-D negative women require anti-D prophylaxis when IUFD is diagnosed Vaginal birth 1st line → IoL or expectant management choice Dopamine agonists can be used to suppress lactation after stillbirth Testing can be carried out after stillbirth to determine the cause → genetic testing of the fetus & placenta, postmortem examination, testing maternal & fetal infection
87
Prematurity
Infants born < 37 weeks gestation
88
Prematurity neonatal risks
Neonatal death Respiratory distress syndrome Chronic lung disease Intraventricular haemorrhage NEC Sepsis Retinopathy of prematurity
89
Umbilical cord prolapse
Umbilical cord descends through the cervix, with (or before) the presenting part of the fetus
90
Umbilical cord prolapse pathophysiology
Fetal hypoxia occurs via two main mechanisms: - occlusion - presenting part of the fetus presses onto the umbilical cord, occluding the blood flow to the fetus - arterial vasospasm - exposure of the umbilical cord to the cold results in vasospasm
91
Umbilical cord prolapse risk factors
Breech presentation Unstable lie Artificial rupture of membranes Polyhydramnios Prematurity
92
Umbilical cord prolapse clinical features
Always be considered in the presence of a non-reassuring fetal heart rate pattern & absent membranes Can be confirmed by external inspection/digital vaginal examination
93
Umbilical cord prolapse mx
Call for help - obstetric emergency Avoid handling the cord Manually elevate the presenting part by lifting the presenting part off the cord by vaginal digital examination Encourage into left lateral position Consider tocolysis - relax uterus & stop contractions Delivery via emergency CS
94
Shoulder dystocia
Refers to a situation where, after the delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis OR less commonly the posterior shoulder becomes impacted on the sacral promontory Obstetric emergency
95
Shoulder dystocia pre-labour risk factors
Previous shoulder dystocia Macrosomia Diabetes Maternal BMI > 30 Induction of labour
96
Shoulder dystocia intrapartum risk factors
Prolonged 1st stage of labour Secondary arrest Prolonged second stage of labour Augmentation of labour with oxytocin Assisted vaginal delivery
97
Shoulder dystocia immediate mx
Call for help Advise mother to stop pushing Avoid downwards traction on the fetal head Consider episiotomy - make access for manoeuvres easier
98
Shoulder dystocia manoeuvres
First line - McRoberts, suprapubic pressure applied in a sustained/rocking fashion Second line - posterior arm, internal rotation (’corkscrew manoeuvre’)
99
Shoulder dystocia post-delivery
Active mx of 3rd stage of labour PR to exclude a 3rd degree tear Debrief the mother & birth partner PT r/v before discharge Paediatric r/v
100
Shoulder dystocia complications
Maternal - 3rd/4th degree tears, PPH Fetal - humerus/clavicle fracture, brachial plexus injury, hypoxia brain injury

Y4 reproductive health (11 decks)

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