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Placenta Abnormalities Flashcards

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1
Q

What is placenta praevia?

A

Placenta is fully or partially attached to lower uterine segment

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2
Q

What is a common symptom of placenta praevia?

A

Vaginal bleeding after 20 weeks of gestation

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3
Q

What is minor placenta praevia?

A

placenta is low but does not cover the internal cervical os.

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4
Q

What is major placenta praevia?

A

placenta lies over the internal cervical os

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5
Q

What is placenta praevia associated with?

A

*multiparity
*multiple pregnancy
*increased maternal age
*embryos are more likely to implant on a lower segment scar from previous caesarean section or uterine surgery
*smsoking

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6
Q

What is the first line investigation for placenta praevia?t

A

Transvaginal ultrasound and is gold standard

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7
Q

When to re-scan in placenta praevia?

A

Rescan at 32 weeks of

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8
Q

What to do if placenta praevia is still present at 32 weeks?

A

If it is grade I/II, rescan at 36 weeks

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9
Q

When to advise C-section in placenta praevia?

A

Placenta praevia present at 36 weeks, advise c-section at 37 weeks
Grade III/IV placenta praevia should have admission at 34 ekes for C-section at 37 weeks maximum

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10
Q

When to plan for c-section in placenta praevia?

A

Plan for c-section delivery in all cases of placenta praevia that have been confirmed at 32 weeks or later (see Investigations

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11
Q

What are the clinical features of placenta praevia?

A

*shock in proportion to visible loss
*no pain
*uterus not tender
*lie and presentation may be abnormal
*fetal heart usually normal
*coagulation problems rare
*small bleeds before large

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12
Q

What investigation must not be done in placenta praevia?

A

digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage

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13
Q

What is grade I placenta praevia?

A

placenta reaches lower segment but not the internal os

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14
Q

What is grade I placenta praevia?

A

placenta reaches internal os but doesn’t cover it

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15
Q

What is grade III placenta praevia?

A

placenta covers the internal os before dilation but not when dilated

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16
Q

What is grade IV placenta praevia?

A

Major- placenta completely covers the internal os

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17
Q

What is offered to women with major placenta praevia?

A

elective delivery should be offered between 36+0 and 37+6 weeks of gestation for women with a major placenta praevia to reduce the risk of emergency caesarean section due to bleeding

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18
Q

What should be done if elective C-section is planned and patient goes into labour with placenta praevia?

A

an emergency caesarean section should be performed due to the risk of post-partum haemorrhage

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19
Q

How to manage placenta praevia with bleeding?

A

*admit
*ABC approach to stabilise the woman
*if not able to stabilise → emergency caesarean section
*if in labour or term reached → emergency caesarean section

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20
Q

What is a major cause of death in placenta praevia?

A

Post-partum haemorrhage

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21
Q

How to manage minimal bleeding with placenta praevia?

A

Confirm that source is local vaginal bleeding (due to placenta praevia) and manage symptomatically
Admit for at least 48h of observation

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22
Q

How to manage moderate to severe bleeding with placenta praevia?

A

ABC approach, resuscitation and stabilisation. If stabilisation is not achieved, send for emergency caesarean Section.
Corticosteroids should be considered if between 24-34 weeks gestation and there is risk of preterm labour
Anti-D if RhD negative and Kleihauer test
C-section if evidence of foetal compromise

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23
Q

What is vasa praevia?

A

the foetal vessels, unprotected by the umbilical cord or placental tissue, run dangerously close to or across the internal cervical os. These vessels are prone to rupture during the rupture of membranes, which can result in foetal haemorrhage and potentially foetal death.

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24
Q

What is the classic triad for vasa praevia?

A

*Painless vaginal bleeding
*Rupture of membranes
*Foetal bradycardia (or resulting foetal death

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25
What are the risk factors for vasa praevia?
*Velamentous cord insertion: *Placenta previa or low-lying placenta: The placenta is located close to or covering the cervix, increasing the likelihood of exposed vessels crossing the os. *Bilobed or succenturiate-lobed placenta: Accessory lobes of the placenta are connected by foetal vessels that can lie over the cervix. *Multiple pregnancy: increase the risk of abnormal placental development, including velamentous cord insertion or accessory placental lobes. *Assisted reproductive technologies (ART): In vitro fertilisation (IVF) and other ART are associated with an increased risk of abnormal placental implantation and cord insertion. *Previous uterine surgery Maternal factors: *Advanced maternal age: Older mothers may have a higher risk of placental implantation abnormalities. *History of vasa praevia in a previous pregnancy. *Abnormal presentation: Malpresentation (e.g. transverse or breech position) may be associated with placental abnormalities that increase the risk of vasa praevia.
26
What is velamentous cord insertion?
umbilical cord inserts into the membranes instead of the placental disk, leaving fetal vessels exposed.
27
What is the diagnosis for vasa praevia?
Trnasabdominal or transvainal ultrasound
28
What is the key complication of vasa praevia?
Foetal distress from blood loss
29
What is the diagnosis of vasa praevia?
Transabdominal or transvaginal ultrasound
30
Whatt is the primaryy management of vasa praevia?
elective caesarean section prior to the rupture of membranes, typically arranged for 35-36 weeks gestation. However, if the mother goes into labour or her membranes rupture, an emergency caesarean section should be carried out immediately to prevent foetal death.
31
What is placental abruption?
premature separation of the placenta from the uterine wall during pregnancy, resulting maternal haemorrhage.
32
What is the aetiology of placental abrutpion?
*proteinuric hypertension *cocaine use and smoking *multiparity *maternal trauma *increasing maternal age *polyhydroamniosis
33
What are the clinical symptoms of placental abrutpion?
*Acute severe disproportionate Abdominal pain ( undefined “Woody” hard uterus on examination Contractions *Vaginal bleeding (However in some cases haemorrhage may be confined to the uterus and thus concealed) *Reduced foetal movements and abnormal CTG *Hypovolaemic shock which is often disproportionate to the amount of vaginal bleeding visible
34
What is the diagnosis for placenta abrutpion?
Physical examination but bloods may show anaemia, clotting disorders like DIC
35
What to do if foetus is alive, distressed and less than 36 weeks gestation?
Immediate C-section
36
What to do if foetus is alive, not distressed and less than 36 weeks gestation?
observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
37
What to do if foetus is alive, distressed and over than 36 weeks gestation?
Immediate C-section
38
What to do if foetus is alive, not distressed and over than 36 weeks gestation?
Deliver vaginally
39
What to do in placental abruption with dead foetus?
induce vaginal delivery
40
When is emergency c-section indicated?
indicated in the presence of maternal and/or foetal compromise unless spontaneous delivery is imminent or operative vaginal birth is achievable. Even if an in-utero foetal death has been diagnosed, a caesarean section may still be indicated if there is maternal compromise.
41
What is a complication of placental abruption?
Haemorrhage (antepartum and post-partum); this may lead to hysterectomy needing to be performed and infertility in future DIC Renal failure undefinedCouvelaire uterus” (extravasation of blood into myometrium and beneath the peritoneum leading to a very hard uterus
42
What is premature rupture of membranes?
refers to the rupture of membranes and release of amniotic fluid at least one hour before the onset of contractions. The pregnancy is at term.
43
What are the key aspects of pre-term rupture of membrane?
Speculum examiantion while sterile will show pooling of amniotic fluid
44
What is the most characteristic symptom of preterm rupture of membranes?
gush or slow trickle of clear or pale yellow fluid from the vagina (i.e. the amniotic fluid). The woman may feel a sudden burst of fluid or notice a continual leaking over time. No (or very minimal) contractions are felt
45
Which investigation should be performed for PPROM?
sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infectio
46
What confirms membrane rupture?
Insulin-like growth factor binding protein-1 (IGFBP-1) test OR alpha-microglobulin-1 test: Performed if pooling identified on speculum, to help confirmed membrane rupture
47
What investigation can be done in mothers without pooling of amniotic fluid?
Foetal fibronectin test: Performed for those without pooling of amniotic fluid (intact membranes); if raised, suggests high risk of pre-term labour.
48
What does clear amniotic fluid indicate?
Normal
49
What does dark yellow amniotic fluid indicate?
Foetal Haemolysis, indicating foetal distress
50
What to do if amniotic fluid is clear and membranes are ruptured within 24h?
expectant management can be followed (for up to 96h). Approximately 60% of women will begin labour within 24h.
51
What to do if amniotic fluid is clear and membranes are ruptured over 24h?
Induce labour
52
What to do if amniotic fluid has traces of meconium with membrane rupture?
Immediate labour induction
53
What are the complications of membrane rupture?
Chorioamnionitis and neonatal sepsis are serious complications of PROM due to the increased risk of ascending infection from the lower genital tract. The prolonged exposure of the amniotic sac to vaginal flora allows bacterial invasion, most commonly involving Group B Streptococcus (GBS), or Escherichia coli.
54
How will chorioamnionitis present?
presents in the mother with fever, uterine tenderness, tachycardia (maternal and foetal), foul-smelling amniotic fluid, and leukocytosis
55
What is preterm prelabour rupture of membranes?
Rupture of sac before 37 weeks gestation, associated with prematurity
56
What are the complications of preterm prelabur rupture of membranes and release?
Pulmonary hypoplasia Foetal infection and prematurity Maternal chorioamnionitis
57
What determines amniotic fluid levels?
Produced at 16 weeks gestation by foetal urine production
58
How is pre-term prelabour rupture of membranes confirmed?
sterile speculum examination should be performed (to look for pooling of amniotic fluid in the posterior vaginal vault) but digital examination should be avoided due to the risk of infection
59
What investigation should be done if amniotic fluid pooling is not observed?
NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure) or insulin-like growth factor binding protein-1 (IGFBP-1) ultrasound may also be useful to show oligohydramnios
60
What are the risk factors for rupture of membranes?
*Ascending vaginal infection causing chorioamnionitis *History of previous PROM *Multiple gestation/multle gestation *Short cervical length *Smoking
61
What to do in preterm premature rupture of membranes?
admission for observation, particularly to monitor for signs of infection or labour regular observations (e.g. temperature, pulse) to ensure chorioamnionitis is not developing
62
What medication to givee in preterm premature rupture of membranes?
oral erythromycin should be given for 10 days (or until labour is established, whichever is sooner) antenatal corticosteroids (typically dexamethasone) should be administered to reduce the risk of respiratory distress syndrome (especially before 34 weeks, and consider between 34–36 weeks)
63
What to give for foetal neuro protection in premature preterm membrane rupture?
V magnesium sulphate
64
When is delivery reccomended in pre term premature membrane rupture?
Delivery at 37 weeks gestation
65
What is placenta accreta?
the attachment of the placenta to the myometrium, due to a defective decidua basalis. This puts risk of post partum haemorrhage
66
What are the risk factors for placenta accreta?
previous caesarean section placenta praevia
67
What is placenta increta?
chorionic villi invade into the myometrium
68
What is placenta pacreta?
chorionic villi invade through the perimetrium
69
What is placenta praevia associated with?
Abnormal lie/ presentation
70
What must be avoided in suspected antepartum haemorrhage?
Vaginal examination as women with placenta praevia may haemorrhage
71
On ultrasound what causes uterine myometrial thinning?
Placenta accreta which will also have , the presence of abnormal lacunae, and neovascularisation between the uterus and placent
72
What is the intial investigation for premature rupture of pregnancy?
Sterile speculum examination should be performed to assess for pooling of amniotic fluid in the posterior vaginal vault.
73
What investigation to do if speculum confirms no pooling of amniotic fluid in the posterior vaginal vault?
Ultrasound
74
What to do for testing if there is pooling of fluid?
NICE recommend testing the fluid for placental alpha microglobulin-1 protein (PAMG-1) (e.g. AmniSure) or insulin-like growth factor binding protein-1 (IGFBP-1) which is high in amniotic fluid
75
How is dexamethasone adminstered in pre term premature rupture?
IM dexamethasone
76
What is placenta percreta?
chorionic villi that invade the perimetrium, the outermost layer of the uterus. Placenta increta is the most severe disorder on the 'placenta accreta' spectrum.
77
What increases the risk of placenta accreta?
Previous c section
78
How to manage placental abruption if foetus is not distressed?
the fetus is alive, <36 weeks and not showing signs of distress, admit and administer steroids and then observe
79
When to avoid speculum examination?
no access to the patient's maternity notes. If this patient had placenta praevia, a speculum examination could cause or exacerbate haemorrhage
80
What causes attachment of placenta to the bladder?
Placenta percreta from implantation of placenta past myometrium
81
Does nulliparity or Multiparity increase risk of placental abruption?
Multiparity
82
What causes low-grade fever, pain and vomiting in pregnancy with history of fibroids?
Fibroid degeneration; If growth outstrips their blood supply, they can undergo red or 'carneous' degeneration
83
How to manage preterm prelabour rupture of membranes (PPROM) without signs of infection or fetal compromise?
Administer oral erythromycin to prevent infection and corticosteroids to promote lung maturity ; continue monitoring until 37 weeks
84
When to do conservative management of placental abruption?
Management of placental abruption when the fetus is alive, <36 weeks and not showing signs of distress is to admit and administer steroids. Pelvic ultrasound can be done after to visualise extremity of abrutpion.
85
What is first line and gold standard investigation for placenta praevia?
Transvaginal ultrasound
86
What causes rupture of membranes followed by painless vaginal bleeding and fetal bradycardia?
Vasa praevia, where fetal blood vessels cross or run near the internal orifice of the uterus
87
How to differentiate presentation of placenta praevia and abrutpion?
Placenta praevia is painless vaginal bleeding Placental aburotion will have lower abdominal pain
88
What causes abdominal pain with raised WBC and normal urine dipstick?
Appendicitis
89
Why is the uterus hard on palpation in abruption?
retroplacental blood tracks into the myometrium
90
What is reccoemnded for placenta praevia with birth planning?
Elective delivery should be offered between 36+0 and 37+6 weeks of gestation for women with a major placenta praevia to reduce the risk of emergency caesarean section due to bleeding
91
What to do if a woman with placenta praevia goes into spontaneous lanour.
Arrange for emergency c section
92
What to give for pre-term prelabour rupture of membranes?
10 days of oral erythromycin
93
What treatment is contraindicated for preterm labour?
Oxytocin which can accelerate labor, cause fetal distress due to reduced oxygen flow, and potentially lead to uterine rupture.
94
How to differentiate vasa and placenta praevia?
painless vaginal bleeding, rupture of membranes and fetal bradycardia (fetal heart rate. Placenta praevia will have painless vaginal bleeding
95
What causes the uterine fundus to no longer palpable in the abdomen post birth?
Uterine inversion, severe obstetric complication in which the fundus of the uterus collapses downwards, passing through the uterine cavity and the cervix, essentially turning the uterus inside out. The primary symptom is large post partum haemorrhag
96
How does uterine inversion occur?
excessive traction applied to the umbilical cord before placental separation
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98
Which factors cause uterine inversion?
relaxed or atonic uterus short umbilical cord previous uterine inversion.
99
How is uterine inversion diagnosed?
primarily clinical, based on the characteristic presentation. However, ultrasound imaging can be useful in confirming the diagnosis
100
How to manage uterine inversion?
Johnson manoeuvre Hydrostatic methods
101
What is the Johnson manoeuvre
This involves using the hand to push the fundus back into the abdomen.
102
What is a hydrostatic method for uterine inversion?
This method involves filling the vagina with fluid to inflate the uterus back to the normal position
103
What method should be used when conservative options fail for uterine inversion?
Laparotomy
104
What causes sudden gush of fluid and foetal heart rate decelerations during labour?
Umbilical cord prolapse
105
What is the term for low lying placenta?
Placenta praevia
106
What is the follow up for placenta praevia?
follow up scan at 32 weeks. Advise against intercouse due to risk of placental abruption and bleeding. If unresolved at term, advise C-sectiom
107
Which placenta praevia is clinically significant?
Type 3 and 4 placenta praevia covers the cervical is
108
What is a Couvelaire uterus?
rare, life-threatening emergency caused by severe placental abruption, where blood infiltrates the uterine wall, resulting in a bluish-purple discoloration and a rigid "woody" uterus. It is often diagnosed during a cesarean section and managed conservatively
109
What to do for stable rupture of membranes?
If stable foetus between 24-32 weeks do expectant management and do repeat USS every 2 weeks to monitor for infection
110
How to manage pre term labour without membrane rupture?
administering corticosteroids to promote foetal lung maturity (in case the baby needs to be delivered) and tocolytics to inhibit uterine contractions
111
What causes sudden onset of abdominal pain and loss of contractions during labour, especially in the context of previous caesarean section?
Uterine rupture -> manage with emergency laparotomy
112
When is vaginal examiantion contraindicated?
Preterm prelsbour rupture of membranes Active genital infection History of placenta praevia any PV bleeding
113
Which abnormality is vaginal examination appropriate during lanour?
Cord prolapse
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