Complications of pregnancy, labour and twins Flashcards
(264 cards)
1
Q
How can you clinically assess fatal growth?
A
Symphysiofundal height (in cms) - Measuring from symphysis pubis to the top of the fundus of the uterus – may not be central
note - turn the measuring tape upside down to reduce bias
2
Q
How can you interpret symphysiofundal height?
A
Should be usually + or - 3cms of gestational age in weeks
e.g. At 32 weeks, a normal measurement would be 29 to 35 cms
3
Q
What investigation would you do if you suspect the baby is large or small for dates?
A
Ultrasound scan
4
Q
What measurements would you do on an ultrasound scan?
A
> Abdominal circumference
Femur length
Head circumference
5
Q
What can cause a foetus to be small for date?
A
> Low BMI, maternal build > Age > Ethnicity, familial/ genetic > Social class > Smoking > Substance misuse > Alcohol use – fetal alcohol syndrome
> Maternal disease:
- Preeclampsia
- Chronic hypertension
- Severe asthma
- Autoimmune disorders eg SLE, antiphospholid syndrome
- Repeated antepartum haemorrhages
> Infections – Toxoplasma, CMV etc
> Fetal abnormality (eg gastroschisis), chromosomal abnormality like triploidy, Turners XO
6
Q
What can cause a foetus to be large for date?
A
> Parity (multiparity)
> Ethinicity / familial / Genetic / social class
> Maternal diabetes
> Polyhydramnios:
- Maternal diabetes
- Fetal abnormality eg duodenal atresia, tracheo esophageal fistula
- Unexplained
> Multiple pregnancy
7
Q
What tests would do to confirm fetal well being?
A
> Confirm good fetal movement
> Fetal Cardiotocograph (CTG)
> Good Doppler blood flow in umbilical artery on scan
8
Q
What happens to mortality rates as there is an increase in number of babies in a multiple pregnancy e.g. twins, triplets etc?
A
Increases
9
Q
What happens to cerebral palsy rates as there is an increase in number of babies in a multiple pregnancy e.g. twins, triplets etc?
A
Increases
10
Q
What happens to average pregnancy length as there is an increase in number of babies in a multiple pregnancy e.g. twins, triplets etc?
A
Decreases
11
Q
What happens to average birth weights as there is an increase in number of babies in a multiple pregnancy e.g. twins, triplets etc?
A
Decreases
12
Q
What is chorionicity?
A
In a twin or multifetal pregnancy, the number of chorions in the placenta that supply blood and nourishment to the developing fetuses.
Twins sharing a common placenta may experience twin-twin transfusion syndrome; those with separate blood supplies have, on average, fewer perinatal health problems.
13
Q
What is zygosity?
A
In the case of twins, whether developing from one zygote (monozygotic twins) or two zygotes (dizygotic twins).
14
Q
What can lead to Twin to Twin Transfusion syndrome?
A
When there is chorionicity
Twins sharing a common placenta may experience twin-twin transfusion syndrome. There is an arteriovenous shunt in place.
Those with separate blood supplies have, on average, fewer perinatal health problems.
15
Q
What is Dichorionic Diamniotic twins?
A
Two separate placenta and two sacs
16
Q
What is Monochorionic Monoamniotic twins?
A
One sac and one placenta
17
Q
Two sacs with one fused looking placenta - what is this called?
A
Either:
- Dichorionic diamniotic
- Monochorionic diamniotic
18
Q
On an ultrasound what does a T sign indicate?
A
Monochorionic
19
Q
On an ultrasound what does a Lamda sign indicate?
A
Dichorionic
20
Q
What is the natural rate of twinning?
A
1:90
21
Q
What is the incidence of monozygotic twins?
A
4:1000 pregnancies
22
Q
What can cause an increase in the incidence of dizygotic twins?
A
> Increase of age > Parity > Weight > Height > Familial
23
Q
What can cause an increase in the incidence of monozygotic twins?
A
There is a constant rate of 4:1000 pregnancies
24
Q
When is multiple pregnancy suspected?
A
- Large for date uterine size
- Multiple fetal heart rates are detected
- Multiple fetal parts are felt
- HCG & maternal serum alpha-fetoprotein is elevated for gestational age
- Pregnancy with ART (Assisted reproduction technique)
25
How is multiple pregnancy confirmed?
Ultrasound
26
Monozygotic versus Dizygotic?
Monozygotic = One egg leads to twins (identical)
Dizygotic = Two eggs (ova) lead to twins (Non-identical)
27
Which type of twins are more common?
Dizygotic = 70-80% of all twins
Two eggs (ova) lead to twins (Non-identical)
28
What is the rate of monozygotic twins in all twins?
20-30% of all twins
29
What is the rate of monozygotic twins in all twins?
70-80% of all twins
30
How does monozygotic twins occur?
The cleavage of a single fertilised ova
31
What determines placentation of monozygotic twins?
The timing of the cleavage of the single fertilised ova determines plancentation
32
Which type of monozygotic twins has the lowest mortality rate?
Dichorionic/diamniotic monozygotic twins <10% mortality rate
33
When does cleavage occur to allow production of Dichorionic/diamniotic monozygotic twins?
Cleavage of the fertilised ova must occur within the first 3 days after fertilisation
34
What does it mean for monozygotic twins to be Dichorionic/diamniotic?
Each fetus will be surrounded by amnion & chorion (each fetus has its own placenta), much like dizygotic twins
35
What does it mean for monozygotic twins to be monochorionic/diamniotic?
Share single placenta but separate amniotic sac
36
What does it mean for monozygotic twins to be monochorionic/monoamniotic?
Share single placenta & single sac
37
Which type of monozygotic twins has the highest rate of mortality?
Monochorionic/monoamniotic
= Share single placenta & single sac
A mortality of 50-60%
38
What is the rate of Monochorionic/monoamniotic monozygotic twins?
<1%
39
When does cleavage occur to allow production of monochorionic/diamniotic monozygotic twins?
Cleavage occurs between days 4 and 8 after fertilisation
40
When does cleavage occur to allow production of monochorionic/monoamniotic monozygotic twins?
Cleavage occurs after the 8th day, usually between days 9-12
41
What is the mortality rate of monochorionic/diamniotic monozygotic twins?
Mortality of 25% in monochorionic/diamniotic monozygotic twins
42
If cleavage of monozygotic twins does not occur until after 12 days what is likely to occur?
Cleavage after 12 days
43
What is the incidence of conjoined twins?
1:70,000 deliveries
44
What is the most common types of fusion in conjoined twins?
Chest and/or abdomen
45
Which type of monozygotic twins can lead to twin-twin transfusion?
They need to be monochorionic so therefore:
1) Monochorionic / diamoniotic
2) Monochorionic / monoamniotic
46
Complications of multiple pregnancy?
- High perinatal mortality & morbidity (3-4 times higher than singleton pregnancy)
- Abortion(<50% of twins diagnosed in the first trimester result in live birth(vanishing twin))
- Nausea & vomiting
- Preterm labour (50%)(twins delver at 37 weeks, triples at 33 weeks, Quadruplets at 29 weeks)
- IUGR
- PET (3 times higher than singleton)
- Polyhydramnios ( in 10%)
- Congenital anomalies
- Postpartum hemorrhage
- Placental abruption, placenta previa
- Discordant twin growth ( more than 20%discrepacy in fetal weights)
- Malpresentation, cord prolapse, Operative delivery
47
Causes of perinatal mortality & morbidity?
- Prematurity (Respiratory distress syndrome)
- Birth trauma
- Cerebral hemorrhage
- Birth asphyxia
- Congenital anomalies
- Still birth
48
What is the rate of twin-twin transfusion syndrome in monochorionic twins?
20-25%
49
Within twin-twin transfusion syndrome what happens to the recipient?
The recipient fetus will have heart failure, polyhydramnios, and hydrops
50
Within twin-twin transfusion syndrome what happens to the donor?
The donor will have IUGR & oligohydramnios
51
How would you manage twin-twin transfusion syndrome?
Management includes:
1) Amnio-reduction of the receipient twin
2) Intra-uterine blood transfusion for the donor twin
3) Selective fetal reduction
4) Fetoscopic laser ablation of placental anastomosis
52
How should you antenatally manage a multiple pregnancy?
> Adequate nutrition (300 additional calories per day per fetus)
> Prevent anemia
> More frequent antenatal visits
> Ultrasound:
- Assess chorionicity at 9-10 weeks
- Nuchal translucency at 12-13+ weeks
- Assessment of fetal growth & fetal wellbeing every 3-4 weeks from 23 weeks onward
> Multifetal reduction may offered for high order multiple gestation in the first trimester
> Preterm labour risk:
- Serial cervical length assessment
- Steroids for fetal lung maturation
53
What can be assessed in chronionicity by ultrasound in multiple pregnancy?
```
> Multiple gestational sacs
> Conjoined twins
> 2 yolk sacs
> 2 gestational sacs
> Twin peak sign (Lambda) Dichorionic twins
> T sign monochorionic twins
```
54
What does twin peak sign indicate?
Twin peak sign = Lambda
Indicates Dichorionic twins
55
Management of labour in multiple pregnancy - lie of first foetus is cephalic?
Usually normal delivery
56
Management of labour in multiple pregnancy - lie of first foetus is non vertex?
Cesarean section
57
Management of labour in multiple pregnancy - lie of foetus locked (Breech-vertix)?
Cesarean section
58
What dictates the management of labour in multiple pregnancy?
Depends on presentation, gestational age, presence of fetal complications, experience of the obstetrician
59
What is shoulder dystocia?
Shoulder dystocia is when the baby’s head has been born but one of the shoulders becomes stuck behind the mother’s pubic symphysis
60
What is the dangers of shoulder dystocia?
> Damage to the brachial plexus
> Umbilical cord entrapment
> Severe brain damage or death due to hypoxia or acidosis if delay in delivery
61
Management of Shoulder Dystocia?
HELPERR:
1) H – Call for Help
2) E – Evaluate for Episiotomy
3) L – Legs (McRoberts Position)
4) P – Suprapubic Pressure
5) E – Enter Manouvers (Internal Rotation)
6) R – Remove the Posterior Arm
7) R – Roll the Patient (Onto all Fours)
62
What causes postpartum haemorrhage?
1) Thrombin causes
2) Tissue causes
3) Tone causes
4) Trauma causes
5) Other causes
63
What causes postpartum haemorrhage - Thrombin?
> Pre-eclampsia
> Placental abruption
> Pyrexia in labour
> Bleeding disorders
64
What causes postpartum haemorrhage - Tissue?
> Retained placenta
> Placenta accreta
> Retained products of conception
65
What causes postpartum haemorrhage - Tone?
> Placenta praevia
> Over distention of the uterus, multiple pregnancy, polyhydramnios, macrosomia
> Uterine relaxants
> PPH
66
What causes postpartum haemorrhage - Trauma?
> Caesarean section
> Episiotomy
> Macrosomia (>4kg baby)
67
What causes postpartum haemorrhage - Others?
```
> Asian ethnicity
> Anaemia
> Induction
> BMI >35
> Prolonged labour
> Age
```
68
What is primary postpartum haemorrhage?
In the first 24 hours after delivery >500ml blood loss
- >500 is common 1/20
- Severe haemorrhage, >2000ml, is rare 6/1000
69
What is secondary postpartum haemorrhage?
>24 hours to up to 6 weeks post delivery (Often caused by RPOC)
70
What is more common primary or secondary postpartum haemorrhage?
Primary which is 99% of all PPH
71
Management of primary postpartum haemorrhage?
```
> Call for help!
> ABCDE...
> Empty Bladder
> Rub up fundus
> Drugs
> Surgical
> Manage on clinical signs not just EBL
> Fluid Replacement +/- Blood Products.
```
72
Management of primary postpartum haemorrhage - drugs?
1) Oxytocin 5iu slow iv injection
2) Ergometrine 0.5mg slow iv injection (not in HTN)
3) Oxytocin infusion
4) Carboprost 0.25mg im (max 8 doses
5) Misoprostol 800 micrograms
73
Management of primary postpartum haemorrhage - Surgical?
> Surgical:
1) Intrauterine Balloon tamponade
2) Interventional Radiology
3) B-Lynch Suture
4) Hysterectomy
74
What is cord prolapse?
Cord prolapse - the descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membrane.
75
What is the overall incidence of cord prolapse?
0.1-0.6%
76
Risk factors of cord prolapse - general?
```
> Multiparity
> Low birthweight (<2.5 kg)
> Preterm labour <37 weeks
> Fetal congenital anomalies
> Breech presentation
> Transverse, oblique and unstable lie
> Second twin
> Polyhydramnios
> Unenganged presenting part
> Low-lying placenta
```
77
Risk factors of cord prolapse - procedure related?
> Artificial rupture of membranes with high presenting part
> Vaginal manipulation of the foetus with ruptured membranes
> External cephalic version (during procedure)
> Internal podalic version
> Stabilising induction of labour
> Insertion of intrauterine pressure transducer
> Large balloon Cather induction of labour
78
Management of cord prolapse?
> Call for Help!
> Replace cord into vagina (not uterus)
> Perform digital elevation of the presenting part
> Catheterise and fill bladder to elevate presenting part.
> Encourage mother to adopt Knee-Chest or left lateral position with raised hips
> Consider tocolysis
> Arrange for a Category 1 C-Section
> Use a gloved hand in the vagina to push the foetus up and off the cord
> Knee-chest (90o angle) position uses gravity to shift the foetus out of the pelvis
> Elevate the woman hips using two pillows and Trendelenburg (head down) position
79
How often is there failure to start abut?
Approx 1 in 5 pregnancies
80
What is the risks of use of prostaglandin/oxytocin to induce labour?
Risk of uterine hyperstimulation
81
What indications are there for induction of labour?
1) Diabetes (usually before due date)
2) Post dates – Term + 7 days
3) Maternal health problem that necessitates planning of delivery e.g. on treatment for DVT
4) Fetal reasons e.g. growth concerns, oligohydramnios
5) You may also see IOL for :
- social
- maternal request
- pelvic pain
- “big” babies
82
What is induction of labour?
Induction of labour is when an attempt is made to instigate labour artificially using medications and/or devices to “ripen cervix” followed usually by artificial rupture of membranes (performing an amniotomy)
83
What is the Bishops's score?
The Bishop’s score is used to clinically assess the cervix.
The higher the score, the more progressive change there is in the cervix and indicates that induction of labour is likely to be successful.
84
What does the Bishops's score use to asses the cervix?
1) Dilatation (in cm)
2) Length of cervix (in cm) (Effacement)
3) Position
4) Consistency
5) Station (in cm)
85
If cervix is not dilated and effaced (Low Bishop's score) what can be done to induce labour?
Vaginal prostaglandin pessaries / Cook Balloon can be used to ripen (open) the cervix
86
Once cervix has dilated and effaced what is done next to induce labour?
An amniotomy can be performed
87
What is amniotomy?
Amniotomy is the artificial rupture of the fetal membranes (“waters”) usually using a sharp device e.g. amniohook
88
Once amniotomy has been performed what is used next to allow induction of labour?
Once amniotomy performed, IV oxytocin can be used to achieve adequate contractions – aim for 4-5 contractions in 10 minutes
89
What are causes of inadequate progress in labour?
```
> Cephalopelvic
disproportion (CPD)
> Malposition
> Malpresentation
> Inadequate uterine activity
> Other reasons for obstruction (e.g. ovarian cyst or fibroid)
```
90
How is progress of labour evaluated?
Progress in labour is evaluated by a combination or abdominal and vaginal examinations to determine:
> Cervical effacement
> Cervical dilatation
> Descent of the fetal head through the maternal pelvis
91
What is inadequate uterine activity?
If contractions are inadequate the fetal head will not descend and exert force on the cervix and the cervix will not dilate.
92
How can the strength and duration of contractions be increased?
Giving a synthetic IV oxytocin to the mother
93
What is cephalopelvic disproportion (CPD)?
It means that the fetal head is in the correct position for labour but is too large to negotiate the maternal pelvis and be born!
94
Types of passage and passenger issues in labour?
> Cephalopelvic diproportion (CPD)
> Malpresentation
> Malposition
95
Which types of lie are there?
1) Longitudinal
2) Oblique
3) Transverse
They can then be:
1) Cephalic/vertex
2) Breeched
3) Shoulder presentation
96
What does cephalic or vertex presentation mean?
Head first
97
What does breech labour mean?
Feet first
98
What is malposition?
> Involves the fetal head being in an incorrect position for labour and ‘relative’ CPD occurs
> Occipito-posterior & Occipito-transverse
99
What can cause fatal distress?
Too many contractions (Uterine Hyper-stimulation) can result in fetal distress due to insufficient placental blood flow.
100
How is fatal well being determined?
Intermittent auscultation of the fetal heart:
> Cardiotocography
> Fetal blood sampling
> Fetal ECG
101
When is fatal blood sampling used?
When there is an abnormal CTG
102
What is being measured when using fatal blood sampling?
> We can measure pH and base excess
> pH gives a measure of likely hypoxaemia
103
Which situation are there in which labour is not advised?
1) Obstruction to birth canal
- Major placenta praevia, masses
2) Malpresentations
- Transverse, shoulder, hand, ??breech
3) Medical conditions where labour would not be safe for woman
4) Specific previous labour complications
- previous uterine rupture
5) Fetal conditions
104
What is the rate of assisted/ instrumental delivery?
Around 15% of births
105
What are the risks of caesarean section compared to vaginal birth?
1) Infection
2) Bleeding
3) Visceral injury
4) VTE
106
What are the benefits of Caesarean section?
Reduced risk of perineal injury compared with vaginal birth
107
What s the average rate of caesarian section in the UK?
Around 25%
108
What are the 3rd stage complications of labour?
> Retained placenta
> Post partum haemorrhage
> Tears
109
What is the puerperium?
The postpartum period
110
Post partum problems?
1) Bleeding
2) Infection (wound, endometritis, breast)
3) Problems with infant feeding
4) Problems with bonding
5) Social issues (partner, other children and financial issues)
6) Psychiatric issues
111
Postnatal problems?
Post partum haemorrhage
Venous thromboembolism
Sepsis
Psychiatric disorders of the puerperium
Don’t forget pre-eclampsia
112
How many times more likely is a pregnant woman to develop a thromboembolism (DVT or PE)?
6-10 times more likely
Immediately post part period there is still a state of hyper-coagulability
113
What is the leading cause of maternal death in UK?
Sepsis
114
If you suspect sepsis in any pregnancy woman what should you do?
1) Prompt IV antibiotic administration
2) Perform full septic screen = Blood cultures, LVS, MSSU, wound swabs
3) Antipyretic measures
4) IV fluids
5) Referral to hospital
115
Almost a quarter of women who died between six weeks and one year after pregnancy died from what?
Mental-health related causes
116
How to treat baby blues?
> Affects most women due to hormonal changes around the time of birth – usually 1-3 days PN
> Does not affect functioning and requires no specific treatment
117
What is postnatal depression?
Postnatal Depression
> Can continue on from baby blues or start sometime later
> Has classical ‘depressive’ symptoms
> Affects functioning, bonding and often requires treatment
> Increased risk in women with personal or family history of affective disorder
118
What is puerperal psychosis?
Puerperal psychosis:
> Rare but serious psychotic illness of the postnatal period
> Women can be a danger to themselves and their babies
> Requires inpatient psychiatric care
> Much more common in women with personal or family history of affective disorder, bipolar disorder or psychosis
119
When do eclamptic seizures most commonly occur?
Most eclamptic seizures occur in the postnatal period
120
What is spontaneous abortion or miscarriage?
The spontaneous termination of a pregnancy before 24 completed weeks gestation with no evidence of life
121
What are the types of spontaneous miscarriage?
```
> Threatened
> Inevitable
> Incomplete
> Complete
> Septic
> Missed
```
122
What is the rate of spontaneous miscarriage?
Around 15% or higher
123
What is a threatened miscarriage?
A threatened miscarriage refers to bleeding from the gravid uterus before 24 weeks gestation when there is a viable fetus and no evidence of cervical dilatation
124
What is an inevitable miscarriage?
Abortion becomes inevitable if the cervix has already begun to dilate
125
What is an incomplete miscarriage?
When there is only partial expulsion of the products of conception
126
What is an complete miscarriage?
Complete expulsion of the products of conception is referred to as a complete abortion
127
What is an septic miscarriage?
Following an incomplete abortion there is always a risk of ascending infection into the uterus which can spread throughout the pelvis and this is known as a septic abortion
128
What is a missed miscarriage?
Missed abortion describes a pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception.
129
Signs/Symptoms of a threatened miscarriage?
Is this viable?
> Vaginal bleeding
> +/- Pain
> Closed cervix on speculum examination
This pregnancy is viable
130
Signs/symptoms of a inevitable miscarriage?
Is this viable?
> Open cervix with bleeding, that could be heavy (+/- clots)
This pregnancy is viable
131
Signs/symptoms of a missed miscarriage?
Is this viable?
> No symptoms
> Could have bleeding/ brown loss vaginally
> Gestational sac seen on scan
> No clear fetus (empty gestational sac) or a fetal pole with no fetal heart seen in the gestational sac
132
Signs/symptoms of a incomplete miscarriage?
Is this viable?
> Open cervix, vaginal bleeding (may be heavy)
> Products of pregnancy may be seen within the uterus on US
133
What type of miscarriage puts a woman at high risk of sepsis?
Incomplete miscarriage
134
Aetiology of spontaneous miscarriage?
> Abnormal conceptus:
- Chromosomal
- Genetic, structural
> Uterine abnormality:
- Congenital
- Fibroids
> Cervical incompetence:
- Primary
- Secondary
> Maternal:
- Increasing age
- Diabetes
> Unknown
135
What percentage of the population have a failure of normal fusion of the Mullerian ducts?
Approx 1%
Of these around 30% are likely to have spontaneous miscarriage
136
How do you manage a threatened miscarriage?
Conservatively
137
How do you manage a Inevitable miscarriage?
If bleeding heavy may require evacuation
138
How do you manage a missed miscarriage?
> Conservatively
> Medical - Prostaglandins (misoprostol)
> Surgical - SMM (Surgical management of miscarriage)
139
How do you manage a septic miscarriage?
Antibiotics and evacuate uterus
140
What is an ectopic pregnancy?
Pregnancy implanted outside of the uterine cavity
141
Where is the most common site of an ectopic pregnancy?
Tubal (95-97%):
1) Ampullary = Most common
2) Isthmus = Second most common
142
What is the incidence of ectopic pregnancy?
1:90 pregnancies
143
What are the risk factors of ectopic pregnancy?
> Pelvic inflammatory disease
> Previous tubal surgery
> Previous ectopic
> Assisted conception
144
How would someone present with an ectopic pregnancy?
> Period of ammenorhoea (with +ve urine pregnancy test)
> +/- Vaginal bleeding
> +/- Pain abdomen
> +/- GI or urinary symptoms
145
Which investigations would you perform for ectopic pregnancy?
Scan – no intrauterine gestational sac, may see adnexal mass, fluid in Pouch of Douglas
Serum BHCG levels – may need to serially track levels over 48 hour intervals- if a normal early intrauterine pregnancy HCG levels will increase by at least 66%ish
Serum Progesterone levels – with viable IU pregnancy high levels > 25ng/ml
146
Which investigations would you perform for ectopic pregnancy - Scan?
Scan:
> No intrauterine
> Gestational sac
> May see adnexal mass, fluid in Pouch of Douglas
147
Which investigations would you perform for ectopic pregnancy - Serum BHCG levels?
Serum BHCG levels – may need to serially track levels over 48 hour intervals- if a normal early intrauterine pregnancy HCG levels will increase by at least 66%ish
148
Which investigations would you perform for ectopic pregnancy - Serum progesterone levels?
Serum Progesterone levels – with viable IU pregnancy high levels > 25ng/ml
149
Management of ectopic pregnancy?
> Medical - Methotrexate
> Surgical (Mostly laparosciopical):
- Salpingectomy
- Salpingotomy for few indications
> Conservative
150
Management of ectopic pregnancy - Medical?
Medical - Methotrexate
151
Management of ectopic pregnancy - Surgical?
> Surgical (Mostly laparosciopical):
- Salpingectomy
- Salpingotomy for few indications
152
What is antepartum haemorrhage?
APH - haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby.
APH is one of the gravest obstetric emergencies and is associated with significant maternal and neonatal morbidity and mortality.
153
Causes of Antepartum Haemorrhage?
Placenta praevia
Placental abruption
APH of unknown origin
Local lesions of the genital tract
Vasa praevia (very rare)
154
What is placenta praevia?
Placenta praevia is
| where the placenta is attached to the lower segment of the uterus
155
What is placental abruption?
Placental abruption is where the placenta has started to separate from the uterine wall before the birth of the baby and is associated with a retroplacental clot.
156
What are some of the causes for APH?
> APH of unknown aetiology includes haemorrhage where other causes have been completely excluded.
> APH may be from local lesions within the genital tract including the cervix and the vaginal. For example cervical erosions and polps may cause an APH and occasionally cervical Ca may present with an APH whilst trichomonas or thrush infections within the vaginal can occasionallyt cause a blood stained discharge.
157
What is Vasa praevia?
>All or part of the placenta implants in the lower uterine segment
> Vasa praeviua is a rare but serious cause of APH.
158
What does Vasa praevia put someone at risk of?
> Usually the blood loss is small and is due to rupture of a fetal vessel within the fetal membranes. The blood loss is fetal and not maternal and the effect on the fetus can be catastrophic.
159
What is the incidence of placenta praevia?
1/200 pregnancies
160
What is the most common aetiology of placenta praevia?
> Multiparous women
> Multiple pregnancies
> Previous caesaren section
161
How is placenta praevia graded?
Grade I = Placenta encroaching on the lower segment but not the internal cervical os
Grade II = Placenta reaches the internal os
Grade III = Placenta eccentrically covers the os
Grade IV = Central placenta praevia
162
What is Grade I placenta praevia?
Grade I = Placenta encroaching on the lower segment but not the internal cervical os
163
What is Grade II placenta praevia?
Grade II = Placenta reaches the internal os
164
What is Grade III placenta praevia?
Grade III = Placenta eccentrically covers the os
165
What is Grade IV placenta praevia?
Grade IV = Central placenta praevia
166
How does placenta praevia present?
> Painless PV bleeding
> Malpresentation of the fetus
> Incidental
167
Why does bleeding occur in placenta praevia?
With placenta preavia the bleeding is due to separation of the placenta as the lower uterine segment forms and the cervix effaces.
The blood loss occurs from the venous sinuses in the lower segment.
Usually the blood loss is painless and tends to be recurrent.
168
How is placenta praevia diagnosed?
> Ultrasound is the first choice
> MRI scanning is more accurate method as it allows identification of the internal cervical os but is not widely available. Probably relevant if the USS is inconclusive.
169
How is placenta praevia managed?
1) Patient is admitted to hospital
2) Vaginal examination is contraindicated
3) Diagnosis confirmed by US
4) Blood is cross matched and blood transfused depending on the maternal condition.
5) A conservative approach is adopted to prolong the pregnancy toi gain fetal maturity and then deliver by Caesareanb section.
There is a risk of PPH with PP.
170
What must not be done in placenta praevia?
Vaginal examination should not be performed in placenta praevia
171
Management of PPH?
1) Medical management – oxytocin, ergometrine, carbaprost, tranexemic acid
2) Balloon tamponade
3) Surgical:
- B Lynch cutre
- Ligation of uterine
- Iliac vessels
- Hystrectomy
172
What is placental abruption?
Haemorrhage resulting from premature separation of the placenta before the birth of the baby and is associated with a retroplacental clot
173
What is the incidence of placental abruption?
The incidence of placental abrution will depend on maternal age, parity and social status but it iu estimated to occur in approx 3% of all pregnancies
174
Which factors are associated with placental abruption?
> Pre-eclampsia/ chronic hypertension
> Multiple pregnancy
> Polyhydramnios
> Smoking
> Increasing age
> Parity
> Previous abruption
> Cocaine use
175
Types of placental abruption?
Placental abruption:
- Revealed
- Concealed
- Mixed (concealed and revealed)
176
Types of placental abruption - Revealed?
In revealed placental abruption the major haemorrhage is apparent externally because the blood released from the placenta escapes through the cervical os.
177
Types of placental abruption - Concealed?
In concealed haemorrhage the haemorrhage occurs between the placenta and the uterine wall.
The uterine contents increase in volume and the fundal height is larger than would be consistent for gestation.
In some situations the blood penetrates the uterine wall and the uterus appears bruised and this is know as a Couvelaire uterus.
178
Presentation of placental abruption?
> Pain
> Vaginal bleeding (may be minimal bleeding)
> Increased uterine activity (tone may be having contractions)
179
General management of APH?
Management will vary from expectant treatment to attempting a vaginal delivery to immediate Caesarean section depending on:
1) Amount of bleeding
2) General condition of
mother and baby
3) Gestation
180
Complications of placental abruption?
> Maternal shock, collapse (may be disproportionate to the amount of bleeding seen)
> Fetal death
> Maternal DIC, renal failure
> Postpartum haemorrhage - ‘couvelaire uterus’
181
Preterm labour?
Onset of labour before 37 completed weeks gestation (259 days)
> 32-36 wks mildly preterm
> 28-32 wks very preterm
> 24-28 wks extremely preterm
It can be spontaneous or induced
182
How common is preterm labour?
> Around 5-7% of singletons
> 30-40% within multiple pregnancies
183
Predisposing factors for preterm labour?
> Multiple pregnancy
> Polyhydramnios
> APH
> Pre-eclampsia
> Infection eg UTI
> Prelabour premature rupture of membranes
> Majority no cause (idiopathic)
184
How is preterm delivery diagnosed?
Contractions with evidence of cervical change on VE
185
What should be consider within preterm labour?
The possible cause, e.g. abruption, infection etc
186
Management Preterm Delivery - <24-26 weeks?
Generally regarded as very poor prognosis
| decisions made in discussion with parents and neonatologists
187
When are preterm deliveries considered viable?
After 26 weeks
188
If a preterm labour is consider viable (>26 weeks) how should it be managed?
> Consider tocolysis to allow steroids/ transfer
> Steroids unless contraindicated
> Transfer to unit with NICU facilities
> Aim for vaginal delivery
189
What is the major risk of preterm delivery?
Major cause of perinatal mortality and morbidity
This is gestation dependent
190
What are the survival rates of preterm labours - <24 weeks?
6%
191
What are the survival rates of preterm labours - 24 weeks?
26%
192
What are the survival rates of preterm labours - 25 weeks?
43%
193
What are the survival rates of preterm labours - 26 weeks?
48%
194
What are the survival rates of preterm labours - 27 weeks?
73%
195
What are the survival rates of preterm labours - 24 weeks?
84%
196
What are the severe disability rates of preterm labours - <24 weeks?
65%
197
What are the severe disability rates of preterm labours - 24 weeks?
38%
198
What are the severe disability rates of preterm labours - 25 weeks?
31%
199
What are the severe disability rates of preterm labours - 26 weeks?
26%
200
Causes of neonatal morbidity in pretsrmurity?
1) Respiratory distress syndrome
2) Intraventricular haemorrhage
3) Cerebral palsy
nutrition
4) Temperature control
5) Jaundice
6) Infections
7) Visual impairment
8) Hearing loss
201
Trophoblast cells of the fertilised egg (chorion) produce which hormone?
Trophoblast produces B-hCG or Beta-human Chorionic Gonadotrophi
202
What is the target of B-hCG?
B-hCG – target is corpus luteum in ovary
203
What is the function of B-hCG?
B-hCG – function is to stimulate corpus luteum to produce progestogen, which stops decidua from shedding
204
Which hormone is used for the basis of pregnancy tests?
B-hCG
205
What does the egg burrow into?
The decidua
206
> Woman, 26 yrs
> Misses period
> Pregnancy test positive
> Vaginal bleeding 7 weeks after missed period
What has probably happened? How is this confirmed
Miscarriage confirmed by US = No fetus present but membranes and decidua lining uterus still there
Decidual cast confirmed with removal of remaining tissue by obstetrician
207
> Woman, 32 years old
> Misses period.
> 8 weeks pregnant
> Small amount of bleeding per vagina
Which tests should be performed?
> BhCG raised
> Ultrasound: Thickened lining of endometrial cavity. Expanded fallopian tube
Diagnosis = Ectopic pregnancy
Treatment = Considered using methotrexate – but opted for operative removal of fallopian tube tissue sent to pathology
208
Within ectopic pregnancy what predisposes to haemorrhage and rupture?
Lack of proper decidual layer and small size of tube predispose to haemorrhage and rupture
209
> 32 year old woman
+ve pregnancy test
> 7 weeks pregnant – minor bleed
> Ultrasound: uterine cavity shows some placental tissue but no fetus. Fallopian tubes normal.
> B-hCG raised
Diagnosis?
Miscarriage
Endometrial tissue removed by obstetrician and sent to pathology
Microscopy = enlarged abnormal chorionic villi with abundant trophoblast = molar pregnancy
210
> Minor bleed
> Ultrasound: uterine cavity shows some placental tissue but no fetus. Fallopian tubes normal.
> B-hCG raised
> Microscopy = enlarged abnormal chorionic villi with abundant trophoblast
What is this?
A molar pregnancy
211
How can a normal adult female switch off of certain genes in ova?
Mum to be switches off certain genes in ova (eggs) by methylating them
212
How can a normal adult male switch off of certain genes in testes (sperm)?
Dad to be switches off different genes in sperm by methylating them
213
What does the switching off of of certain genes in ova promote?
Promotes early baby growth
214
What does the switching off of of certain genes in testes promote?
Dad’s changes promote early placenta growth via trophoblast proliferation
215
What is the common cause of a molar pregnancy?
Various causes but often caused by 2 sperm fertilising one egg with no chromosomes
216
In terms of genes what happens as a result of a molar pregnancy?
Empty ovum and 2 lots of dad’s genes with dads changes (methylation)
This results is imbalance in methylated (switched off) genes leading to trophoblast cells proliferate and therefore:
1) Overgrowth of placenta
2) All but no or all but non-existent fetal growth
because they have too many of dad’s methylated genes
217
What can a molar pregnancy lead to?
A form of precancer of trophoblast cells
If it persists can (rarely) give rise to a malignant tumour called choriocarcinoma
218
How to treat molar pregnancy?
1) Remove
| 2) If BhCG stays high (persistent disease) cure by methotrexate
219
What is considered chronic hypertension in pregnancy?
Hypertension (>140/90 BP) either pre-pregnancy or at booking (≤ 20 weeks gestation)
220
What is considered mild chronic hypertension in pregnancy?
Mild HT:
> Diastolic BP 90-99,
> Systolic BP 140-49
221
What is considered moderate chronic hypertension in pregnancy?
Moderate HT:
> Diastolic BP 100-109
> Systolic BP 150-159
222
What is considered severe chronic hypertension in pregnancy?
Severe HT:
> Diastolic BP ≥110
> Systolic BP ≥ 160
223
What is gestational hypertension?
New hypertension (BP >140/90) after 20 weeks gestation
224
What is pre-eclampsia?
New hypertension (BP >140/90) after 20 weeks gestation in association with significant proteinuria:
> Mild HT on two occasions more than 4 hours apart
> Moderate to severe HT
+
> Proteinuria of more than 300 mgms/ 24 hours (protein urine
> Protein:creatinine ratio > 30mgms/mmol)
225
How can we test for significant proteinuria?
> Automated reagent strip urine protein estimation > 1+
Automated reagent strip urine protein estimation > 1+
> Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
> 24 hours urine protein collection > 300mg/ day
226
What BP should be targeted for chronic hypertension in pregnancy?
<150/100 BP
227
What is the pathophysiology of pre-eclampsia?
1) Immunological
2) Genetic predisposition:
- Secondary invasion of maternal spiral arterioles by trophoblasts impaired --> reduced placental perfusion
- Imbalance between vasodilators / vasoconstrictors in pregnancy (prostocyclin / thromboxane)
228
What are the risk factors for pre-eclampsia?
> First pregnancy
> Extremes of maternal age
> Pre-eclampsia in a previous pregnancy (esp. severe PET, delivery <34 weeks, IUGR baby, IUD, abruption)
> Pregnancy interval >10 years
> BMI > 35
> Family history of PET
> Multiple pregnancy
```
> Underlying medical disorders
- chronic hypertension
- pre-existing renal disease
- pre-existing diabetes
- autoimmune disorders
– eg. antiphospholipid antibodies, SLE
```
229
Maternal complications of pre-eclampsia?
Maternal:
- eclampsia - seizures
- severe hypertension – cerebral haemorrhage, stroke
- HELLP (hemolysis, elevated liver enzymes, low platelets)
- DIC (disseminated intravascular coagulation)
- renal failure
- pulmonary odema, cardiac failure
230
Fetal complications of pre-eclampsia?
Impaired placental perfusion → IUGR, fetal distress, prematurity, increased PN mortality
231
What are the symptoms/signs of severe PET?
> Headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands face legs
> Severe Hypertension; > 3+ of urine proteinuria
> Clonus / brisk reflexes; papillodema, epigastric tenderness
> Reducing urine output
> Convulsions (Eclampsia)
232
What are the biochemical abnormalities of severe PET?
> Raised liver enzymes
> Bilirubin if HELLP present
> Raised urea and urate
> Creatinine
233
What are the haematological abnormalities of severe PET?
> Low platelets
> Low haemoglobin, signs of haemolysis
> Features of DIC
234
How do you monitor severe PET?
> Frequent BP checks, Urine protein
> Check symptomatology – headaches, epigastric pain, visual disturbances
> Check for hyper-reflexia (clonus), tenderness over the liver
> Blood investigations:
- Full Blood Count (for hemolysis, platelets)
- Liver Function Tests
- Renal Function Tests – serum urea, creatinine, urate
- Coagulation tests if indicated
> Fetal investigations:
- Scan for growth
- Cardiotocography (CTG)
235
What does PET stand for?
Pre-eclampsia toxaemia
236
How is PET (Pre-eclampsia toxaemia) managed?
> Only ‘cure’ for PET is delivery of the baby and placenta
> Consider induction of labour / CS if maternal or fetal condition deteriorates, irrespective of gestation
> Conservative (aim for fetal maturity)
- close observation of clinical signs & investigations
- anti-hypertensives (labetolol, methyldopa, nifedipine)
- steroids for fetal lung maturity if gestation < 36wks
> Risks of PET may persist into the puerperium therefore monitoring must be continued post delivery
237
How many pregnant woman suffer from PET?
5-8%
238
How many pregnant woman suffer from severe PET?
0.5%
239
How many pregnant woman suffer from eclampsia seizures?
0.05%
240
What is the general ratio of eclampsia seizures in terms of being antepartum, intrapartum, postpartum?
1) Postpartum = 44%
2) Antepartum = 38%
3) Intrapartum = 18%
241
What is the treatment for eclampsia seizures?
1) Magnesium sulphate bolus + IV infusion
2) Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
3) Avoid fluid overload – aim for 80mls/hour fluid intake
242
Which prophylaxis is available for PET in subsequent pregnancies?
Low does Aspirin from 12 weeks till delivery
243
What are women with PET at higher risk of developing in later life?
Hypertension
244
What is gestational diabetes?
> Carbohydrate intolerance with onset (or first recognised) in pregnancy
> Abnormal glucose tolerance that reverts to normal after delivery
> However, more at risk of developing type II diabetes later in life
245
If a woman has gestational diabetes what is she at higher risk of developing in the future?
Type II diabetes
246
What happens to insulin requirements during pregnancy and why?
> Insulin requirements of the mother increase
> Because human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol from the placenta have anti-insulin action
247
Why does hyper-insulinemia occur?
If the mother is diabetic this leads to an increased glucose crossing the placenta and induces higher the normal production in the foetus leading to macrosomia.
Post-delivery this puts the neonate at higher risk of hypoglycaemia due to excess insulin production. Also increased risk of respiratory distress
248
What does the effect of diabetes have on the foetus?
1) Fetal congenital abnormalities e.g – cardiac abnormalities, sacral agenesis (especially if blood sugars high peri-conception
2) Miscarriage
3) Fetal macrosomia, polyhydramnios
4) Operative delivery, shoulder dystocia
5) Stillbirth, increased perinatal mortality
249
What does the effect of diabetes have on the mother?
1) Increased risk of pre-eclampsia
2) Worsening of maternal nephropathy, retinopathy, hypoglycaemia,
3) Reduced awareness of hypoglycaemia
4) Infections
250
What does the effect of diabetes have on the neonates?
1) Impaired lung maturity
2) Neonatal hypoglycaemia
3) Jaundice
251
Management of maternal diabetes preconception?
1) Better glycemic control, ideally blood sugars should be round 4 – 7 mmol/l pre-conception and HbA1c < 6.5% ( < 48 mmol/mol)
2) Folic acid 5mg
3) Dietary advice
4) Retinal and renal assessment
252
Management of maternal diabetes during pregnancy?
1) Optimise glucose control – insulin requirements will increase:
< 5.3 mmol/l - Fasting
< 7.8 mmol/l - 1 hour postprandial
< 6.4 mmol/l - 2 hours postprandial
< 6 mmol/l – before bedtime
2) Could continue oral anti-diabetic agents (metformin) but may need to change to insulin for tighter glucose control
3) Should be aware of the risk of hypoglycaemia – provide glucagon injections/ conc. glucose solution
4) Watch for ketonuria/ infections
5) Repeat retinal assessments 28 and 34 weeks
6) Watch fetal growth
7) Observe for PET labour usually induced 38-40 weeks, earlier if fetal or maternal concerns
8) Consider elective caesarean section if significant fetal macrosomia
9) Maintain blood sugar in labour with insulin – dextrose insulin infusion
10 ) Continuous CTG fetal monitoring in labour
11) Early feeding of baby to reduce neonatal hypoglycemia
12) Can go back to pre-pregnancy regimen of insulin post delivery
253
Risk factors for Gestational Diabetes Mellitus / consider screening for GDM?
1) Increased BMI >30
2) Previous macrosomic baby > 4.5kg
3) Previous GDM
4) Family history of diabetes
5) Women from high risk groups for developing diabetes – eg. Asian origin
6) Polyhydramnios or big baby in current pregnancy
7) Recurrent glycosuria in current pregnancy
254
How do you screen for gestational diabetes mellitus?
> HbA1C:
1) if > 6% (43 mmol/mol), 75gms OGTT to be done.
2) If OGTT normal, repeat OGTT at 24 -28 weeks
Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (eg. Previous GDM) present
255
Management of gestational diabetes mellitus?
1) Control blood sugars – diet
2) Metformin/ insulin if sugars remain high
3) Post delivery – check OGTT 6 to 8 weeks PN
4) Yearly check on HbA1C/ blood sugars as at a higher risk of developing overt diabetes
256
What is Virchow's triad?
There element that lead to an increased risk of venous thromboembolism:
1) Stasis
2) Vessel wall injury
3) Hyper-coagulability
257
What happens to the risk of throb-embolism during pregnancy and why?
> Risk of thrombo-embolism increased in pregnancy, due to being in a hyper coagulable state:
1) Increase in fibrinogen, factor VIII, VW factor, platelets
2) Decrease in natural anticoagulants – antithrombin III
3) Increase in fibrinolysis
>Increased stasis – progesterone, effects of enlarging uterus
> May be vascular damage at delivery/ caesearean section
Covering every aspect of Virchow's triad
258
What increases the risk even further of a thromboembolic-embolism during pregnancy?
> Older mothers, increasing parity
> Increased BMI, smokers
> IV drug users
> PET
> Dehydration – hyperemesis
> Decreased mobility
> Infections
> Operative delivery, prolonged labour
> Haemorrhage, blood loss > 2 l
> Previous VTE (not explained by other predisposing eg. fractures, injury), those with thrombophilia (protein C, protein S, Anti thrombin III deficiencies, etc), strong family history of VTE
> Sickle cell disease
259
What prophylaxis is available for venous thrombosis-embolsim?
> TED stockings
> Advice increased mobility, hydration
> Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk factor if significant risk), may need to continue 6 weeks postpartum
260
Signs/ symptoms of VTE (Venous thrombosis-embolism)?
1) Pain in calf
2) Increased girth of affected leg
3) Calf muscle tenderness
breathlessness
4) Pain on breathing
5) Cough
6) Tachycardia
7) Hypoxic
8) Pleural rub, etc
261
How should you investigate VTE (Venous thrombo-embolism)?
```
> ECG
> Blood gases
> Doppler
> V/Q (ventilation perfusion) lung scan
> CTPA computed tomography pulmonary angiogram)
```
Appropriate treatment with anticoagulation
if VTE confirmed
262
How should VTE be treated?
Venous thrombo-embolsim is treated with anticoagulation
263
Do opiates cross the placenta? What occurs as a result? How would you manage?
1) Yes opiates cross the placenta
2) Pregnancy often proceeds well if mother eating properly
3) Immediate withdrawal from heroin when baby is born replace with methadone
4) Later withdrawal from methadone
264
What is separation of placenta from the uterine wall?
Abruption, this leads to hypoxia in baby and often antepartum haemorrhage
If viable, emergency caesarian section should be performed
