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Obs 5 Flashcards

1
Q

What are the RFs for a multiple pregnancy?

A
  • Advanced maternal age
  • IVF
  • Previous multiple pregnancy
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2
Q

Define chorion and amnion

A

Chorion = number of placentae
Amnion = number of amniotic sacs

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3
Q

Describe monozygous twins

A

Division of fertilised egg = IDENTICAL (20% of twins)

Dichorionic diamniotic:

  • Cleavage days 1-3
  • 2 placenta and 2 amniotic sacs
  • S/S: λ sign

Monochorionic diamniotic:

  • Cleavage days 4-8
  • 1 placenta (share), 2 amniotic sacs
  • S/S: T-sign

Monochorionic monoamniotic:

  • Cleavage days 8-12
  • 1 placenta (share), 1 amniotic sac (share)
  • S/S: T-sign, ‘entangled cords’

Conjoined twins:

  • Cleavage days 13-15
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4
Q

Describe dizygous twins

A

Fertilisation of 2 ovum by 2 different sperm = NON-IDENTICAL (80% of twins)

  • DCDA – separate placentae, amnions, chorions
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5
Q

How is GA estimated for multiple pregnancies?

A

Offer 1st trimester USS when CRL 45-84 mm (11-13+6 weeks) to determine: EGA, chorionicity, and to screen for Down syndrome (use largest baby to estimate GA)

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6
Q

How is chronionicity detected for multiple pregnancies?

A

> Refers to the type of placentation (this is the most important feature to an obstetrician)

  • Detect at time of detecting twin/triplet pregnancy by USS using number of placental masses, lambda (dichorionic) or T-sign (monochorionic) and membrane thickness
  • Examine junction between the inter-fetal membrane and the placenta
  • In DC pregnancies = triangular placental tissue projection (λ sign) into base of the membrane
  • In MC pregnancies = no placental tissue projection (T-sign) into the base of the membrane
  • If presenting after 14 weeks, determine chorionicity using all of membrane thickness, lambda sign, number of placental masses and disconcordant foetal sex
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7
Q

What are the S/S of multiple pregnancies?

A

(Asymptomatic):

1st trimester = incidental on USS, hyperemesis (increased βHCG)

2nd trimester = large for dates, multiple parts on abdominal exam

Abdominal exam = increased SFH, multiple parts, >1 FH

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8
Q

What is the antenatal management of a multiple pregnancy?

A
  • FBC at 20-24w (query extra supplementation of iron or folic acid, repeat at 28w)
  • BP (increased chance of eclampsia)
  • GTT (increased likelihood of diabetes) - 16w (every 2w) for MC, 20w (every 4w) for DC
  • TTTS screening = every 2 weeks from 16-24 weeks – if MC
  • General growth scans = after 24w (every 2 or 4 weeks)

Serial USS for foetal growths:

  • MC twins = scan at 12, 16 and then every 2 weeks until delivery
  • DC twins = scan at 12, 20 and then every 4 weeks until delivery
  • MC/ DC triplets = scan at 12, 16 and every 2 weeks until delivery
  • TC triplets = scan at 12, 20 and every 4 weeks until delivery
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9
Q

Describe the specialist care for multiple pregnancies

A
  • Uncomplicated monochorionic diamniotic twin pregnancy should be offered at least 9 appointments with a healthcare professional, at least 2 should be with a specialist obstetrician
  • Uncomplicated dichorionic twin pregnancy should be offered at least 8 appointments and at least 2 with a specialist obstetrician
  • Uncomplicated monochorionic triamniotic or dichorionic triamniotic pregnancy should be offered at least 11 appointments and at least 2 with a specialist obstetrician
  • Uncomplicated trichorionic triamniotic triplet pregnancy should be offered at least 7 scans and at least 2 with a specialist obstetrician
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10
Q

How is pre-term birth in multiple pregnancies prevented?

A

Do NOT use the following routinely to prevent spontaneous preterm birth:

  • Bed rest at home or in hospital
  • IM or vaginal progesterone
  • Cervical cerclage
  • Oral tocolytics
  • Corticosteroids will be useful if preterm birth is likely (should be targeted)
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11
Q

Describe the birth of multiple pregnancies

A
  • 60% of twin pregnancies result in spontaneous birth before 37 weeks
  • Offer continuous foetal monitoring (CTG); if needed: scalp electrode and foetal blood monitoring
  • Offer elective birth if (if declined > weekly obstetrician appointments):
  • Uncomplicated monochorionic twin – from 36 weeks (after course of steroids)
  • Uncomplicated dichorionic twin – from 37 weeks
  • Uncomplicated triplet – from 35 weeks (after a course of steroids)

Vaginal delivery (first twin is in the cephalic position; 2nd may be breech but this is ok)

  • Second breech baby can be turned using Internal Pedalic Version (IPV)
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12
Q

Describe the foetal complications of multiple pregnancies

A

IUGR:
(and discordant IUGR: when one baby is SGA and the other normal or LGA)

  • Monitored with EFW discordance (not SFH)
  • Difference in size >20% is an indicator of IUGR

Intra-uterine death (IUD):

  • For dizygotic twins, the other twin will be fine
  • In monochorionic, this can be bad as the BP will drop in the surviving twins’ placenta > neurological damage in the surviving twin in 25%

Down Syndrome:
(greater absolute risk as same risk PER baby so increased TOTAL risk)

Also:

  • Structural Abnormalities (2x in monozygotic babies)
  • Twin-to-Twin Transfusion Syndrome (TTTS)
  • Malpresentation
  • Premature
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13
Q

What are the maternal complications of multiple pregnancies?

A
  • Pre-eclampsia (more risk of abnormal vasculature development)
  • Hyperemesis gravidarum (more bHCG)
  • GDM (more placental lactogen and placental steroids so more likely to tip into diabetes)
  • APH, PPH (stretched uterus)
  • Anaemia and thrombocytopaenia (more required to sustain the two children)
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14
Q

What is TTTS?

A

Results from an unbalanced blood supply through placental anastomoses in monochorionic twins

Donor twin = growth restriction, renal tubular dysgenesis, and oliguria

Recipient twin = visceromegaly and polyuria

Mother = sudden abdomen size increase, SOB

  • Start diagnostic monitoring with USS from 16-24 weeks on a 2-weekly basis
  • Delivered by 34-37 weeks
  • New treatment (<26w) = foetoscopic laser ablation of vascular anastomoses
  • New treatment (>26w) = delivery
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15
Q

What are RFs for high-risk pregnancies?

A
  • Any previous complicated pregnancies (biggest risk for another abnormal pregnancy)
  • Age <15yo or >35yo
  • Pre-pregnancy weight under 45kg or obese
  • Height under 5 ft (1.5m)
  • Incompetent cervix
  • Uterine malformations
  • Small pelvis
  • Being single, smoker, alcohol, illicit drugs
  • No access to early prenatal care
  • Low socioeconomic status
  • Hx of recurrent miscarriages
  • Hypothyroid / Hyperthyroid
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16
Q

What is the management of high-risk pregnancies?

A
  1. Continued surveillance for high risk patients – more frequent scans
  2. Offer high dose folate 5mg – also given to…
  • Previous child with NTD
  • Diabetes mellitus
  • Woman on an anti-epileptic
  • Obesity
  • HIV positive taking co-trimoxazole
  • Sickle cell disease
  1. Offer low dose aspirin (75mg, OD) as prophylaxis for pre-eclampsia
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17
Q

Define obesity in pregnancy

A

Obesity = BMI >30kg/m2

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18
Q

What is the aetiology of obesity in pregnancy?

A

Pre-existing obesity – poor diet, lack of exercise
Fluid retention – polyhydramnios, heart, kidney, liver failure

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19
Q

What are the S/S of obesity in pregnancy?

A

Obesity

+Associated conditions may be present:

  • GDM
  • Pre-eclampsia
  • Infections
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20
Q

What are the investigations for obesity in pregnancy?

A
  • BMI monitoring
  • Bloods – FBC, LFT, UE, cholesterol, OGTT
  • USS – liquor volume, foetal growth scans
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21
Q

What is the management of obesity in pregnancy?

A

Conservative:

  • More exercise, better diet, vitamin D supplementation

Labour planning:

  • Assess risk of giving birth via vaginal delivery and whether there needs to be induction/CS

Post-natal follow up:

  • T2DM testing
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22
Q

What are the complications of obesity in pregnancy?

A
  • GDM
  • Pre-eclampsia
  • Infections
  • Overdue pregnancy, labour difficulties, CS or miscarriage

Prognosis – almost 1/3 maternal deaths are in obese mothers

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23
Q

What is oligohydramnios?

A

Decreased volume of amniotic fluid, <5th centile, deepest pool <2cm

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24
Q

What are the causes of oligohydramnios?

A

Reduced input fluid:

  • Placental insufficiency
  • Pre-eclampsia

Reduced output fluid:

  • Structural pathology (renal agenesis, atresia of ureter / urethra)
  • Medications (ACEi, NSAIDs)

Lost fluid:

  • Amniotic rupture
25
Q

What are the S/S of oligohydramnios?

A

Commonly asymptomatic

  • History of fluid leak PV, rupture of membranes
  • Abdominal exam – decreased fundal height, foetal parts easily palpable
  • Speculum – assess for membrane rupture if appropriate
26
Q

What are the investigations for oligohydramnios?

A
  • Speculum - assess for membrane rupture
  • USS – liquor volume, foetal anomalies
  • CTG– foetal wellbeing
27
Q

What is the management of oligohydramnios?

A

Planned birth in an obstetric unit is recommended

Pre-Term:

  • Expectant management
  • Ongoing antepartum surveillance
  • Continuous fetal heart rate monitoring during labour
  • Delivery if further abnormalities arise

Term:

  • Delivery is often the most appropriate management
28
Q

What are the complications of olighydramnios?

A

Labour:

  • Increased incidence of CTG abnormalities
  • Meconium liquor
  • Emergency CS

Neonate: can cause POTTER SEQUENCE

  • Pulmonary hypoplasia
  • Twisted faces
  • Twisted skin
  • Extremity deformities
  • Renal agenesis

Prognosis – increased perinatal mortality rates with early onset oligohydramnios

29
Q

What is polyhydramnios?

A

Increased volume of amniotic fluid, above 95th centile, or deepest pool greater than 8 cm.

30
Q

What are the causes of polyhydramnios?

A

Failure of foetal swallowing:

  • Neurological / chromosomal abnormalities
  • GIT (duodenal atresia, oesophageal atresia, TOF)

Foetal polyuria:

  • Maternal diabetes
  • TTTS

Also:

  • Congenital infections
31
Q

What are the S/S of polyhydramnios?

A
  • Symptoms of underlying cause
  • Abdomen – increased fundal height, impalpable foetal parts, tense abdo
32
Q

What are the investigations for polyhydramnios?

A
  • USS - liquor volume, foetal growth
  • Umbilical artery dopplers - exclude foetal anomalies
  • Other – exclude maternal diabetes
33
Q

What is the management of polyhydramnios?

A
  • Antenatal monitoring of foetus, ensure diabetes control, paediatrician present at delivery
  • Amnioreduction (if gross polyhydramnios / discomfort)
  • COX inhibitors to decrease foetal urine output
34
Q

What are the complications of polyhydramnios?

A
  • PTL
  • Malpresentation
  • Placental abruption
  • Cord prolapse
  • PPH
  • Increased risk CS

Prognosis – increased perinatal morbidity and mortality, related to PTL/congenital

35
Q

Define a low-lying placenta

A

Placental edge is <2cm from internal os on TVUSS

36
Q

What is placenta praevia?

A

Placenta lies over the internal os (diagnosed at ≥32 weeks)

37
Q

What are the types of placenta praevia?

A

Classical grading:

  • I = placenta does not cover internal cervical os but is low lying
  • II = placenta reaches internal os but doesn’t cover it (lower edge reaching internal os)
  • III = placenta covers the internal os before dilation but not when dilated / lower edge partially covering the internal os
  • IV (‘major’) = placenta completely covers the internal os
38
Q

What are the RFs for placenta praevia?

A
  • Multiple pregnancy
  • Increased maternal age
  • Previous uterine surgery (i.e. CS)
  • Previous praevia history
  • Smoking
  • IVF (6x increased risk)
39
Q

What are the S/S of placenta praevia?

A
  • Painless bright red PV bleeding in 2nd or 3rd trimester
  • Can have small bleeds before large
  • Potential signs of shock (shock in proportion to visible loss)
  • Uterus not tender
  • Lie and presentation may be abnormal
  • Fetal heart usually normal
  • Coagulation problems rare
40
Q

What are the investigations for placenta praevia?

A

Digital vaginal examination should not be performed before an USS as it may provoke a severe haemorrhage (speculum ok to assess bleeding)

  • 1st line diagnosis: TVUSS
  • Bloods – FBC, clotting studies, G&S, U&E, LFT
  • If mother RhD -ve: Kleihauer test (check level of foetal blood in maternal circulation) +/- administer anti-D
  • CTG

Placenta praevia often picked up on routine 20w abdominal USS

41
Q

What is the management of placenta praevia?

A

1. Picked up on 20w anomaly scan:

  • Only 10% go on to have a low-lying placenta later in pregnancy
  • Rescan at 32 weeks

2. USS at 32 weeks:

  • Still present and grade I/II: Rescan at 36 weeks
  • Still present and grade III/IV: Admit at 34 weeks with CS at 37 weeks

3. USS at 36 weeks:

  • Grade I = vaginal delivery
  • Grade III/IV = CS

Also:

  • Antenatal corticosteroids from 34-36 weeks (can be earlier if at risk of PTL)
  • Tocolysis (facilitate antenatal corticosteroids)
  • General advice: NOT to have sex if low-lying placenta or placenta praevia

If a woman with known placenta praevia goes into labour prior to the elective C section, an emergency C section should be performed due to the risk of PPH

42
Q

What is the management of placenta praevia with bleeding?

A
  • Admit and ABC approach (IV access and fluids)
  • Bloods: FBC, G&S, consider crossmatch, Kleihauer test
  • Anti-D if Rh-D -ve and Kleihauer test
  • Admit at least until bleeding has stopped (and keep them in for 48 hours to observe)
  • If not able to stabilise = emergency C section
  • If in labour or term reached = emergency C section

Scans:

  • CTG (if >27 weeks)
  • Umbilical artery dopplers (every 2 weeks)
  • Growth scan
43
Q

What are the complications of placenta praevia?

A

Maternal:

  • Haemorrhage – antepartum and postpartum
  • DIC
  • Hysterectomy
  • Maternal mortality is 1 in 300

Foetal:

  • IUGR
  • Death
44
Q

What is vasa praevia?

A

Foetal blood vessels connecting the umbilical cord to the placenta travel across the internal cervical os and below the foetal presenting part, unprotected by placental tissue or umbilical cord

> When baby descends, they can rupture the vessels

45
Q

What are the 2 types of vasa praevia?

A

Type 1 VP = vessels connect a velamentous umbilical cord to the placenta (single or bilobed placenta)

Type 2 VP = vessels connect the lobes of the placenta (single or bilobed) to 1 or more succenturiate lobes (accessory lobes)

46
Q

What is Benckaiser’s haemorrhage?

A

The haemorrhage of blood when the vessels are ruptured

47
Q

What are the RFs for vasa praevia?

A
  • Foetal anomaly (bilobed placenta or succenturiate lobes)
  • History of low-lying placenta in 2nd trimester
  • Multiple pregnancies
  • IVF
48
Q

What are the S/S of vasa praevia?

A

Typical picture = ROM > fresh PV bleeding + foetal bradycardia

  • After the membranes rupture, the veins alone can’t hold the weight of the baby > bleeding
  • Foetal HR abnormalities – decelerations, bradycardia, sinusoidal trace, foetal demise
  • O/E > you can palpate the vessels in the membranes, amnioscope can directly visualise this
49
Q

What are the investigations for vasa praevia?

A

Can be clinical based on sx

  • Usually diagnosed via TVUSS with Doppler
  • VE - may be able to detect pulsating foetal vessels inside internal os
  • Kleihauer test (measures amount of foetal Hb in a mother’s bloodstream)
  • Haemoglobin electrophoresis – identify if foetal or maternal blood (takes a long time)
  • Doppler USS
50
Q

What is the management of vasa praevia?

A

C-section

> Rapid delivery + aggressive resuscitation including use of blood transfusion if required are essential

51
Q

What are the complications of vasa praevia?

A

Foetal mortality if presenting with haemorrhage is 60% but if identified antenatally its 3%

  • No major maternal risk
  • Foetus: Loss of relatively small amounts of blood can have major implications for the foetus
52
Q

What is placental abruption?

A

Separation of the placenta from the uterine wall before delivery (>24 weeks; if <24w, miscarriage)

Haemorrhage may be concealed (20%) or revealed (80%)

53
Q

What are the RFs for placental abruption?

A
  • Previous placental abruption
  • HTN
  • Previous APH
  • PPROM
  • Abdominal trauma
  • Smoking, cocaine
  • Polyhydramnios
  • Idiopathic

Although most cases occur in low-risk pregnancies

54
Q

What are the S/S of placental abruption?

A

Constant abdominal pain ± PV bleeding (if revealed – 80%), SUSTAINED contractions

On examination:

  • General – shock out of keeping with visible loss
  • Abdomen – hypertonic “woody” tender uterus
  • Speculum – assess bleeding
  • Vaginal exam (NOT in praevia) – cervical dilatation
  • Normal lie and presentation
  • Fetal heart: absent/distressed
  • Coagulation problems
  • Beware pre-eclampsia, DIC, anuria
55
Q

What is a key difference between placenta praevia and placental abruption?

A

Praevia = bleed, no pain

Abruption = bleed, pain

56
Q

What are the investigations for placental abruption?

A
  • Basic obs
  • Abdominal exam
  • Bloods – FBC, clotting, U&E, crossmatch
  • CTG for baby
  • TVUSS – exclude praevia – abruption unlikely to be present unless very large, may show retroplacental collection of blood

If unsure if praevia, DO NOT BIMANUAL

57
Q

What is the management of placental abruption?

A

Mild:

  • If preterm and stable: conservative management with close monitoring > IOL at term
  • Admit for at least 48 hours or until bleeding stops
  • Anti-D Ig followed by Kleihauer test
  • Foetus alive and >36 weeks without distress = vaginal delivery

Severe:

  • ABC > 2x wide bore cannulae, fluids, blood transfusions, correct coagulopathies
  • Foetus alive and >36 weeks and distress = Emergency CS
  • Corticosteroids for foetal lung development (between 24-34+6w)
  • Consider IOL if foetal compromise
  • Foetus dead = induce vaginal delivery
58
Q

What are the complications of placental abruption?

A

Maternal:

  • Haemorrhage (APH, PPH)
  • DIC
  • Renal failure
  • “Couvelaire uterus” (extravasation of blood into myometrium and beneath the peritoneum > very hard uterus)
  • Sheehan syndrome

Foetal:

  • Birth asphyxia
  • Death
59
Q

What antenatal Down Syndrome screening is offered?

A

Combined test is now standard:

  • Should be done between 11 - 13+6 weeks
  • High HCG, low pregnancy-associated plasma protein A (PAPP-A), thickened nuchal translucency

Quadruple test:

  • If women book later in pregnancy the quadruple test should be offered between 15 - 20 weeks
  • Low Alpha-fetoprotein, low unconjugated oestriol, high HCG and high inhibin A

O&G (17 decks)

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