obstetric complications Flashcards
(49 cards)
1
Q
Vaginal hematoma
A
Risk
- operative vaginal delivery
- infant over 4000 g
- nulliparity
- prolonged 2nd stage of labor
Clinical features
- potentially life threatening
- protruding vaginal mass (purple)
- injury to uterine artery
- rectal or vaginal pressure
- hypovolemic shock due to occult bleeding
- minimal vaginal bleeding
Treatment
- nonexpanding: observation
- expanding: embolization, surgery
2
Q
risk of preterm labor
A
prior preterm labor (number one association)
multiple gestations
history of cervical surgery –> cold knife conization
first step in evaluating risk is transvaginal US to measure cervical length in second semester (shorter is predictor)
labor can be prevented with progesterone or cerclage
screen with cervical length measurement by TVUS
3
Q
placental abruption
A
risk
- maternal HTN or preeclampsia/eclampsia
- abdominal trauma
- prior placental abruption
- cocaine and tobacco use
Clinical
- sudden onset vaginal bleeding
- abdominal or back pain
- high frequency, low intensity contractions
- hypertonic, tender uterus
- distended uterus can be sign of concealed abruption
diagnosis
- primarily clinical presentation
- US can rule out placenta previa and may show retroplacental hematoma
management:
- in case of hypovolemic shock: aggressive fluid resuscitation with crystalloids
- left lateral decubitus positioning to maximize cardiac output
complications
- hypovolemic shock
- DIC
4
Q
Septic abortion
A
Risk factors
- retained products of conception from
- elective abortion with nonsterile technique
- missed or incomplete abortion
Clinical
- fever, chills, abdominal pain
- sanguinopurulent vaginal discharge
- boggy, tender uterus
- dilated cervix
- pelvic US: retained ROC, thick endometrial stripe
Management
- IV fluids
- broad spectrum antibiotics
- suction curettage
5
Q
Placenta previa
A
Risk
- prior placenta previa
- prior c section
- multiple gestation
- smoking
Clinical
- painless vaginal bleeding >20 weeks gestation
- can see effacement
Diagnosis
-transabdominal followed by transvaginal sonogram
mangagement
- no intercourse
- no digital cervical exam
- inpatient admission for bleeding episodes
6
Q
intrauterine fetal demise
A
definition
-fetal death over 20 weeks prior to expulsion from mother
risk
- nulliparity
- HTN
- obesity
- DM
diagnosis
- absence of fetal cardiac activity on US
- if no sounds on doppler, needs to be confirmed with US
management
- 20-23 weeks: dilation and evac or vaginal delivery
- over 24 weeks: vaginal delivery
complication
-coagulopathy after several weeks of fetal retention
7
Q
evaluation of fetal demise
A
Fetal
- autopsy
- gross and microscopic examination of placenta, membranes, and cords
- karyotype/genetic studies
Maternal
- Kleihauer-Betke test for fetomaternal hemorrhage
- antiphospholipid antibodies
- coag studies
8
Q
Breech presentation
A
TYPES
- frank: hips flexed and knees extended (butt first)
- Complete: hips and knees flexed
- incomplete: 1 or both hips not flexed (feet first)
RISK
- advanced maternal age
- mulitparity
- uterine didelphys
- septate uterus
- uterine leiomyomas
- fetal anomalies
- preterm
- oliogo/polyhydramnios
- placenta previa
Management
- external cephalic version
- cesarean delivery
9
Q
Illicit drug abuse in pregnancy
A
RISK
- adolescent pregnancy
- late/noncompliant prenatal care
- inadequate pregnancy weight gain
COMPLICATIONS
- spontaneous abortion
- preterm birth
- preeclampsia
- abruptio placentae
- fetal growth restriction
- intrauterine fetal demise
10
Q
Chorioamnionitis
A
RISK
- premature rupture of membranes
- prolonged rupture of membranes
- prolonged labor
- internal monitoring
- repetitive vaginal exams
- genital tract pathogens
CLINICAL
- nausea
- vomiting
- uterine focal tenderness
- maternal fever plus fetal tachy, maternal leukocytosis, maternal tachy, or purulent amniotic fluid
- may have abnormal contraction pattern
MANAGE
- broad spectrum antibiotics
- delivery (augementation of labor)
COMPLICATIONS
- maternal: postpartum hemorrhage, endometritis
- fetal: preterm birth, pneumonia, encephalopathy
11
Q
septic pelvic thrombophlebitis
A
RISK
- C section
- pelvic surgery
- endometritis
- PID
- pregnancy
- malignancy
PATHOPHYS
- hypercoagulability
- pelvic venous dilation
- vascular trauma
- infection
CLINICAL
- fever unresponsive to antibiotics
- no localizing symptoms
- negative infectious evaluation
- diagnosis of exclusion
TREATMENT
- anticoagulation
- broad spectrum antibiotics
12
Q
External cephalic version
A
PROCEDURE
- manual rotation of fetus to cephalic presentation
- decreases cesarean delivery rate
INDICATIONS
- breech/transverse presentation
- over 37 weeks gestation
ABSOLUTE CONTRAINDICATIONS
- same as contraindications to vaginal delivery
- prior classical (vertical incision) cesarean delivery
- prior extensive uterine myomectomy
- placenta previa
COMPLICATIONS
- placental abruption
- intrauterine fetal demise
13
Q
Uterine rupture
A
RISK
-scar from prior C section and then trying to deliver vaginally
CLINICAL
- intense, focal, abdominal pain that is relieved by rupture and then resumes
- bleeding
- loss of fetal station
- abnormal heart readings –> decelerations
- palpable fetal parts on abdominal exam
- loss of intrauterine pressure
MANAGEMENT
-emergency laparotomy to confirm diagnosis and expedite delivery
14
Q
HELLP syndrome
A
PATHO
- abnormal placentation
- triggers systemic inflammation and activation of clotting cascade that consumes platelets
- MAHA leads to liver damage as well as increased bilirubin production
- hepato necrosis and thrombi
CLINICAL
- preeclampsia
- nausea/vomiting
- right upper quadrant abdominal pain – stretching of hepatic capsule
LAB
- microangiopathic hemolytic anemia – indirect hyperbili
- elevated liver enzymes
- low platelet coutn
TREATMENT
- delivery
- Mg for seizure prophylaxis
- Antihypertensive drugs
15
Q
pulmonary edema in preeclampsia
A
PATHOPHYS
- generalized arterial vasospasm leading to increased SVR and high cardiac afterload
- decreased renal function
- decreased serum albumin
- increased capillary permeability due to endothelial damage
CLINICAL
- increased BP
- tachycardia
- tachypnea
- hypoxia
- pitting edema
MANAGE
- oxygen
- fluid resus
- diuresis
16
Q
Shoulder dystocia
A
Definition
-failure of usual obstetric maneuvers to deliver fetal shoulders
RISK
- fetal macrosomnia
- maternal obesity
- excessive pregnancy weight gain
- gestational diabetes
- post term pregnancy
WARNING SIGNS
- protracted labor
- prolonged first or second stage of labor
- retraction of fetal head into the perineum after delivery (turtle sign)
17
Q
Late and post term pregnancy
A
Definition
- late term is over 41 weeks
- post term is over 42 weeks
RISK
- prior
- nulliparity
- obesity
- AMA
- fetal anomalies
COMPLICATIONS Fetal -macrosomnia -dysmaturity syndrome -oligohydramnios -demise
maternal
- severe obstetric lac
- c section
- postpartum hemorrhage
MANAGE
- frequent fetal monitoring
- delivery prior to 43 weeks
18
Q
pregnancy related risks due to hypertension
A
MATERNAL
- superimposed preeclampsia
- post partum hemorrhage
- gestational diabetes
- placental abruption
- c section
FETAL
- fetal growth restriction
- perinatal mortality
- preterm delivery
- oligohydramnios
19
Q
Preterm prelabor ROM
A
- less than 34 weeks
- RISK: multiple gest, previous, genital tract infection, antepartum bleeding
IF otherwise UNCOMPLICATED
- expectant management
- latency antibiotics
- corticosteroids
- fetal surveillance
20
Q
Placenta accreta
A
DEF
-uterine villi attach directly to myometrium
RISK
- prior c section
- hx of d and c
- AMA
DIAGNOSIS
-antenatal US showing absent placental-myometrial interface and intraplacental villous lakes
MANAGEMENT
-c section if known
COMPLICATIONS
- abnormal placenta delivery
- cord avulsion requiring manual extraction
- placental adherence
- severe hemorrhage
21
Q
Hyperemesis gravidarum
A
RISK
- mole
- multigestation
- history of hyperemisis
CLINICAL
- severe, persistent vomiting
- over 5 percent prepregnancy weight loss
- dehydration
- orthostatic hypertension
LAB
- ketonuria
- hypochloremic metabolic alkalosis
- hypokalemia
- hemoconcentration
TREAT
- admission to hospital
- antiemtics
- IVF
22
Q
Low back pain during pregnancy
A
ETI
- enlarged uterus
- exaggerated lordosis
- joint/ligament laxity from increased progesterone/relaxin
- weak abdominal muscles leading to decreased lumbar support
RISK
- excessive weight gain
- chronic back pain
- back pain in priory pregnancy
- multi parity
IMAGING
-not indicated
MANAGE
- behavioral modifications
- heating pads
- analgesics
23
Q
Preterm labor 34 to 36 6/7 management
A
betamethasone
penicillin if GBS positive or unknown
24
Q
preterm management 32 to 33 6/7
A
betamethasone
tocolytics
penicillin
25
preterm management less than 32 weeks
betamethasone
tocolytics
mg sulfate
penicillin
26
Missed abortion
no vaginal bleeding
closed cervical os
no fetal cardiac activity or empty sac
27
threatened abortion
vaginal bleeding
closed cervical os
fetal cardiac activity
28
inevitable abortion
vaginal bleeding
dilated cervical os
products of conception may be seen or felt at or above cervical os
29
incomplete abortion
vaginal bleeding
dilated cervical os
some products of conception expelled and some remain
30
complete abortion
vaginal bleeding
closed cervical os
products of conception completely expelled
31
Fetal hydrops
PATHOGEN
- increased CO demand causing heart failure
- increased fluid movement into interstitial spaces
CLINICAL
- pericardial effusion
- pleural effusion
- ascites
- skin edema -- peeling skin
- placenta edema-- thickening
- polyhydramnios
- edematous scalp
```
ETIOLOGY
-immune: Rh(D) alloimmunization
-non immune
Parvo
Fetal aneuploidy
CV abnormalities
Thalassemia
```
32
pubic symphysis diastasis
RISK
- fetal macrosomia
- multiparity
- preciptious labor
- operative vaginal delivery
PRESENTATION
- difficulty ambulating
- radiating suprapubic pain
- pubic symphysis tenderness
- intact neurologic exam
MANAGEMENT
- conservative
- NSAIDs
- physical therapy
- pelvic support
33
degenerating uterine leiomyoma
- abdominal pain
- fundal fullness
- firm, tender mass
- grow rapidly during pregnancy
- can outgrow blood supply leading to infarction and necrosis
- uterine contractions
- leukocytosis
- manage conservatively
34
post partum endometritis
RISK
- C section
- chorioamnionitis
- GBS
- prolonged ROM
- operative vaginal delivery
CLINICAL
- fever over 24 hours post partum
- uterine fundal tenderness
- purulent lochia
ETIOLOGY
-polymicrobial infection
TREAT
-Clindamycin and gentamicin
35
Post partum hemorrhage
DEF
>500 cc after vaginal
>1000 cc after C
RISK
- prolonged or induced labor
- chorioamnionitis
- multiple gestation
- polyhydramnios
- grand multiparity
- operative delivery
CAUSES
- uterine atony (most common)
- retained placenta
- genital tract laceration
- uterine rupture
- coagulopathy
TREAT
- bimanual uterine massage, oxytocin
- IVF, O2
- uterotonics
- intrauterine balloon tamponade
- uterine artery embolism
- hysterectomy
36
Congenital CMV
U/S
- periventricular calcifications
- ventriculomegaly
- microcephaly
- intrahepatic calcifications
- fetal grwoth restriction
- hydrops
Neonatal features
- petechiae
- HSM
- chorioretinitis
- microcephaly
long term sequelae
- sensorineural hearing loss
- seizures
- developmental delay
37
Spontaneous abortion
DEF
-pregnancy loss less than 20 weeks
RISK
- AMA
- previous SAB
- Substance use
TREATMENT
- expectant
- medication induction
- suction currettage if infection or hemodynamically unstabel
ADDITIONAL
- Rho(D) immunoglobulin
- pathology examination
COMPLICATIONS
- hemorrhage
- retained products of conception
- septic abortion
- uterine perforation
- intrauterine adhesions
38
cervical insufficiency
RISK
- cervical conization or LEEP
- mechanical cervical dilation
- obstetric cervical laceration
- uterine anomalies
CLINICAL
- vaginal discharge in the absence of labor
- painless dilation of cervix
- can lead to second trimester pregnancy loss
DIAGNOSIS
- prior or current painless cervical dilation
- history of preterm birth with current cervical length < 25mm on u/s
MANAGE
- serial u/s of cervical length
- cerclage placement
39
rectovaginal fistula
- may present within first 2 weeks postpartum
- can occur after 3rd or 4th degree laceration, inadequate wound repair, or wound breakdown, and infection
- can occur due to prolonged second stage labor --> ischemic pressure necrosis of rectovaginal septum from fetal head compression
CLINICAL
- incontinence of flatus
- fecal material through vagina
- malodorous brown/tan discharge
DIAGNOSIS
- dark red, velvety rectal mucosa on posterior vaginal wall
- anoscopy may help visualize opening
TREAT
-surgical repair of fistulous tract
40
Antihypertensives during pregnancy
FIRST LINE
- beta blockers (labetalol)
- Ca channel blockers (nifedipine)
- hydralazine
- methyldopa
SECOND LINE
- clonidine
- thiazide diruretics
CONTRAINDICATED
- ACE inhibitors
- Ang II rec blockers
- direct renin inhibitors
- nitroprusside
- mineralocorticoid receptor antagonists.
41
fetal tachycardia causes
- maternal fever
- medication side effect
- fetal hyperthyroidism
- fetal tachyarrhythmia
42
fetal bradycardia causes
- maternal hypothermia
- medication side effect
- fetal hypothyroidism
- fetal heart block
43
Sheehan syndrome
PATHOGEN
- obstetric hemorrhage complicated by hypotension
- post partum pituitary infarction
CLINICAL
- lactation failure (low prolactin)
- amenorrhea, hot flashes, vaginal atrophy (low FSH, LH)
- fatigue, brady (low TSH)
- anorexia, weight loss, hypotension (low ACTH)
- decreased lean body mass (low growth hormone)
44
Acute fatty liver of pregnancy
PATHOPHYS
-microvesicular fatty infiltration of hepatocytes secondary to abnormal maternal-fetal fatty acid metabolism
CLINICAL
- nausea, vomiting
- RUQ or epigastric pain
- fulminant liver failure
LAB
- profound hypoglycemia
- increased aminotransferases (2 or 3x normal)
- increased bilirubin
- thrombocytopenia
- DIC
MANAGE
-immediate delivery
45
Esophageal perforation
ETI
- instrumentation, trauma
- effort rupture
- esophagitis
CLINICAL
- chest/back or epigastric pain, systemic signs
- crepitus, Hamman sign (crunching sound on auscultation)
- pleural effusion with atypical fluid
DIAGNOSIS
- CXR or CT scan showing widened mediastinum, pneumomediastinum, pneumothorax, pleural effusions
- CT scan: esophageal wall thickening, mediastinal fluid collection
- esophagography with water soluble contrast: leak from perforation
MANAGE
- NPO, IV antibiotics and PPIs
- emergency surgical consultation
46
Symmetric fetal growth restriction
ONSET
-first trimester
ETI
- chromosomal abnormalities
- congenital infection
CLINICAL
-global growth lag
MANAGE
- weeking BPP
- serial Dopplers
- serial growth US
47
asymetric fetal growth restriction
ONSET
-second or third trimester
ETI
- utero-placental insufficiency
- maternal malnutrition
CLINICAL
-head sparing growth lag
MANAGE
- weekly BPPs
- serial dopplers
- serial growth US
48
Postpartum urinary retention
DEF
- inability to void over 6 hours after SVD
- overflow incontinence
RISK
- primiparity
- regional neuraxial anesthesia
- operative vaginal delivery
- perineal injury
- C section
CLINICAL
- small volume voids or inability to void
- incomplete bladder emptying
- dribbling urine
MANAGE
- self-limited condition
- intermittent catheritization
49
amniotic fluid embolism
RISK
- advanced maternal age
- gravida over 5
- cesarean or instrumental delivery
- placenta previa or abruption
- preeclampsia
CLINICAL
- cardiogenic shock
- hypoxemic resp failure
- DIC
- coma or seizures
TREATMENT
- respiratory and hemodynamic support
- transfusion
