Week 12- OBG Flashcards
(39 cards)
Pregnancy-related pelvic girdle pain (PGP) or symphysis pubis dysfunction (SPD)
PGP is a collection of uncomfortable symptoms caused by a stiffness of your pelvic joints or the joints moving unevenly at either the back or front of your pelvis.
Women with PGP may feel pain:
over the pubic bone at the front in the centre, roughly level with your hips
across 1 or both sides of your lower back
in the area between your vagina and anus (perineum)
spreading to your thighs
Some women may feel or hear a clicking or grinding in the pelvic area.
The pain can be worse when:
walking
going up or down stairs
standing on 1 leg (for example, when you’re getting dressed)
turning over in bed
moving your legs apart (for example, when you get out of a car)
Most women with PGP can have a vaginal birth.
Molar Pregnancy
Molar pregnancy is an abnormality of the placenta, caused by a problem when the egg and sperm join together at fertilization.
There are two types of molar pregnancy, complete and partial. Complete molar pregnancies have only placental parts (there is no baby), and form when the sperm fertilizes an empty egg. Because the egg is empty, no baby is formed. The placenta grows and produces the pregnancy hormone, called HCG, so the patient thinks she is pregnant. Unfortunately, an ultrasound (sometimes called a sonogram) will show that there is no baby, only placenta. A partial mole occurs when 2 sperm fertilize an egg. Instead of forming twins, something goes wrong, leading to a pregnancy with an abnormal foetus and an abnormal placenta. The baby has too many chromosomes and almost always dies in the uterus.
Most molar pregnancies occur after a miscarriage, some occur after an ectopic (tubal) pregnancy or even a normal delivery.
Women with a molar pregnancy usually feel pregnant and complain of vaginal spotting or bleeding. Many women with molar pregnancies develop nausea and vomiting. Some even develop rare complications like thyroid disease or very early preeclampsia (toxemia). Preeclampsia occurring earlier than 20 weeks is very worrisome for a molar pregnancy.
Treatment for molar pregnancy
Treatment consists of a D&C (dilation and curettage) of the uterus, where a small vacuum device is inserted into the uterus, under anaesthesia, to remove the molar pregnancy. This must be done very carefully or excessive bleeding and blood clots to the lungs can occur. The placental tissue is sent to the pathologist, who looks under the microscope to make the final diagnosis. An HCG level, and sometimes a thyroid level, are also obtained. In unusual cases, where the patient has completed her childbearing, a hysterectomy may be preferable. Although most cases of molar pregnancy occur after a miscarriage, some occur after ectopic pregnancies or a normal pregnancy. Therefore, women with abnormal bleeding or a persistent cough (especially if it produces blood) should see their doctor for an HCG level to make sure they do not have a molar pregnancy.
When the HCG levels drop then increase again it means that the molar pregnancy has grown from microscopic cells in the wall of the uterus to larger cells. These cells can act like a cancer, and metastasize (spread) to other organs, like the lungs, brain, bones, and vagina. Treatment for recurrent molar pregnancy, called gestational trophoblastic neoplasia, or GTN, in medical terms, usually consists of methotrexate.
Preeclampsia
Preeclampsia is defined as the presence of (1) a systolic blood pressure (SBP) greater than or equal to 140 mm Hg or a diastolic blood pressure (DBP) greater than or equal to 90 mm Hg or higher, on two occasions at least 4 hours apart in a previously normotensive patient, OR (2) an SBP greater than or equal to 160 mm Hg or a DBP greater than or equal to 110 mm Hg or higher.
Preeclampsia is a disorder of widespread vascular endothelial malfunction and vasospasm that occurs after 20 weeks’ gestation and can present as late as 4-6 weeks post partum. It is clinically defined by hypertension and proteinuria, with or without pathologic oedema.
The most effective treatment for preeclampsia is delivery. You’re at increased risk of seizures, placental abruption, stroke . Labetalol, hydralazine.
Preterm labour and premature rupture of membranes
Preterm birth is significantly more common in young women, those with low body weight (body mass index <19), those of lower social class, unmarried or unsupported mothers, smokers, previous preterm delivery, persistent vaginal bleeding in early pregnancy, and heart disease. Can be caused by: Iatrogenic (induction for medical reasons) Infection Premature rupture of the membranes Multiple pregnancy Polyhydramnios Intrauterine death Foetal abnormalities Uterine abnormalities Cervical incompetence
Risks: Death Respiratory distress syndrome Hypothermia Hypoglycaemia Necrotising enterocolitis Jaundice Infection Retinopathy of prematurity
Management of preterm labour
Suppression of uterine contractions to postpone delivery, or to allow the administration of corticosteroids to the mother and so to her foetus to promote surfactant release in the foetal lung and reduce the incidence of the neonatal respiratory distress syndrome by up to 50%. This effect is only significant at gestations up to 34 weeks; after this it is usual to allow preterm labour to progress.
Tocolytics
Currently used
β sympathomimetics, such as ritodrine, terbutaline, salbutamol
Magnesium sulphate (used particularly in the United States)
Prostaglandin synthase inhibitors, such as unselective (indomethacin) and selective (cyclo-oxygenase type 2—nimesulide)
Nitric oxide donors, such as glyceryl trinitrate
Calcium channel blockers, such as nifedipine
When the membranes have ruptured, the use of tocolytics is controversial. The concern is that contractions may result from occult chorioamnionitis, and suppressing labour could allow infection to spread. If tocolytics are used in this situation intravenous broad spectrum antibiotics should probably also be given.
Primary Postpartum Haemorrhage
Primary postpartum haemorrhage (PPH) is loss of blood estimated to be >500 ml, from the genital tract, within 24 hours of delivery (the most common obstetric haemorrhage):
Minor PPH is estimated blood loss of up to 1000 mls.
Major PPH is any estimated blood loss over 1000 mls.
Secondary PPH is defined as abnormal bleeding from the genital tract, from 24 hours after delivery until six weeks postpartum.
The causes of PPH have been described as the “four T’s”:
Tone: uterine atony, distended bladder.
Trauma: lacerations of the uterus, cervix or vagina.
Tissue: retained placenta or clots.
Thrombin: pre-existing or acquired coagulopathy.
The most common cause of PPH is uterine atony, followed by retained placenta.
For major PPH:
Assess airway, breathing, circulation.
Oxygen by mask at 10-15 litres per minute.
IV access with 2 x 14-gauge cannulae.
Keep the woman lying flat and warm.
Transfuse blood as soon as available. Until available, transfuse up to 2 litres of warmed crystalloid Hartmann’s solution and/or 1-2 litres of colloid. Infusions should be warmed and a blood filter not used. In the absence of cross-matched blood, components may be required in line with local hospital guidelines and haematological advice.
Recombinant factor VIIa (rFVIIa) is increasingly frequently used for arresting bleeding in severe haemorrhage.
Examination to establish cause, and exclude other causes than uterine atony (the most common cause).
If the cause is established to be uterine atony, the following measures are taken in turn:
Bimanual uterine compression to stimulate contraction.
Ensure the bladder is empty.
Oxytocin 5 units by slow IV infusion. May require repeat. The latest Cochrane review supports the use of oxytocin as first-line treatment.
Ergometrine 0.5 mg slow IV or IM unless there is a history of hypertension.
Oxytocin infusion unless fluid restriction is necessary.
Carboprost 0.25 mg IM repeated to a maximum of 8 doses unless there is a history of asthma. It is licensed only for bleeding after a caesarean section in Europe. It is also sometimes used off licence as an intramyometrial injection.
Misoprostol 1000 micrograms rectally. The Cochrane review determined misoprostol is not as effective as oxytocin, but may be helpful in low resource settings, as it does not need refrigeration or infusion.
Heat-stable carbetocin has been shown to be as effective as oxytocin for the prevention of blood loss of at least 500 ml or the use of additional uterotonic agents[11].
If these physical and pharmacological methods are not succeeding, surgical options as follows:
Balloon tamponade.
Haemostatic brace suturing - eg, the B-Lynch compression suture.
Bilateral ligation of the uterine arteries.
Bilateral ligation of the internal iliac arteries.
Selective arterial embolization.
Hysterectomy should be considered early, especially in cases of placenta accreta or uterine rupture. If possible, a second consultant should be involved in this decision.
Complications: Hypovolaemic shock. Disseminated intravascular coagulation. Acute kidney injury. Liver failure. Acute (adult) respiratory distress syndrome. Death.
Managing a home birth
Community midwives usually provide the care for home births. A midwife will come out to you when you are in labour to see how you’re getting along. She’ll talk to you and your birth partner, and watch you having a few contractions. She may carry out an internal examination to see how far dilated your cervix is.
Plastic sheeting or bin liners to protect your floor, bed or sofa.
Old towels or sheets to cover the plastic sheeting.
A couple of containers, in case you’re sick during labour.
A warm blanket or throw, in case you get cold.
Bin liners for dirty linen and rubbish.
Newspapers and old sheets or towels can create a covered path between where you labour and give birth, and the toilet.
A desk light or head torch, so your midwife can check your vagina for tears or to check your baby after the birth.
Clean warm towels, a baby blanket
Once the placenta is delivered, your midwife will check to see if you have a tear that needs stitching. Most tears can be stitched up by your midwife. If the placenta doesn’t come away, or if you have a very bad tear, you’ll need to go to hospital.
A physical exam of the baby is required from a physician within three days.
Home vs hospital births
During delivery the home birth group needed significantly less medication and fewer interventions whereas no differences were found in durations of labour, occurrence of severe perineal lesions, and maternal blood loss. There was no difference between home and hospital delivered babies in birth weight, gestational age, or clinical condition. Apgar scores were slightly higher and umbilical cord pH lower in home births, but these differences may have been due to differences in clamping and the time of transportation.
Amniocentesis and Chorionic Villus Sampling
prenatal diagnosis for a variety of reasons including a higher chance aneuploidy screening result, fetal structural anomaly, or a known risk of inherited genetic disease.
CVS is usually performed between 11+0 and 13+6 weeks of gestation. If required, CVS can be performed between 14+0 and 14+6 weeks’ gestation. Individualised counselling of the merits of CVS versus amniocentesis should be provided for women considering CVS during this time period. Amniocentesis, performed to obtain amniotic fluid for analysis, is usually offered from 15+0 weeks.
Gestational Trophoblastic Disease
Gestational trophoblastic disease (GTD) is a term used for a group of pregnancy-related tumours. These tumours are rare, and they appear when cells in the womb start to proliferate uncontrollably. The cells that form gestational trophoblastic tumours are called trophoblasts and come from tissue that grows to form the placenta during pregnancy.
There are two subtypes of hydatidiform mole: complete hydatidiform mole, and partial hydatidiform mole.
The four malignant tumours Invasive mole Choriocarcinoma Placental site trophoblastic tumour Epithelioid trophoblastic tumour
Hydatidiform moles are abnormal conceptions with excessive placental development. Conception takes place, but placental tissue grows very fast, rather than supporting the growth of a foetus.
Vaginal bleeding, enlarged uterus, pelvic pain or discomfort, and vomiting too much (hyperemesis) are the most common symptoms of GTD. But GTD also leads to elevated serum hCG (human chorionic gonadotropin hormone). Since pregnancy is by far the most common cause of elevated serum hCG, clinicians generally first suspect a pregnancy with a complication. However, in GTD, the beta subunit of hCG (beta hCG) is also always elevated. Therefore, if GTD is clinically suspected, serum beta hCG is also measured. There might be some signs and symptoms of hyperthyroidism .
Suction curettage is the preferred method of evacuation. Hysterectomy is an alternative if no further pregnancies are wished for by the female patient. Hydatidiform mole also has successfully been treated with systemic (intravenous) methotrexate
Vasa praevia
Vasa praevia occurs when the foetal vessels run through the free placental membranes. Unprotected by placental tissue or Wharton’s jelly of the umbilical cord, a vasa praevia is likely to rupture in active labour, or when amniotomy is performed to induce or augment labour, in particular when located near or over the cervix, under the foetal presenting part. Vasa praevia is classified as type I when the vessel is connected to a velamentous umbilical cord, and type II when it connects the placenta with a succenturiate or accessory lobe.
Vasa praevia may be diagnosed during early labour by vaginal examination, detecting the pulsating foetal vessels inside the internal os, or by the presence of dark-red vaginal bleeding and acute foetal compromise after spontaneous or artificial rupture of the placental membranes. The foetal mortality rate in this situation is at least 60% despite urgent caesarean delivery. However, improved survival rates of over 95% have been reported where the diagnosis has been made antenatally by ultrasound followed by planned caesarean section.
Secondary postpartum haemorrhage
This commonly presents in primary care as prolonged or excessive bleeding once the woman has returned home after delivery.
Aetiology
The two most common causes are:
Infection - endometritis. This occurs in 1-3% after spontaneous vaginal delivery. It is the most common cause of postnatal morbidity between day 2 and day 10. Risk factors are:
Caesarean section, prolonged rupture of membranes, severe meconium staining in liquor, long labour with multiple examinations, manual removal of placenta, mother’s age at extremes of the reproductive span, low socio-economic status, maternal anaemia, prolonged surgery, internal fetal monitoring and general anaesthetic.
Symptoms vary but may include:
Fever. Abdominal pain. Offensive smelling lochia. Abnormal vaginal bleeding - postpartum haemorrhage. Abnormal vaginal discharge. Dyspareunia. Dysuria. General malaise. Look for history of extended labour, difficult third stage, ragged placenta, PPH.
Examination
There may be:
Fever.
Rigors.
Tachycardia.
Tenderness of the suprapubic area and adnexae.
Elevated fundus which feels boggy in RPOC.
If sepsis is suspected in the community, urgent referral to hospital is indicated where ‘red flag’ signs and symptoms are present. If the woman appears seriously unwell, by emergency ambulance:
Pyrexia >38°C.
Sustained tachycardia (more than 90 bpm).
Breathlessness (respiratory rate >20 breaths per minute - a serious symptom).
Abdominal or chest pain.
Diarrhoea and/or vomiting.
Uterine or renal angle pain and tenderness.
Woman is generally unwell or seems unduly anxious/distressed.
Speculum examination will allow visualisation of the cervix and lower genital tract to exclude lacerations. If a clot is visible within the cervical os, it may be removed with tissue forceps (although few GPs regularly carry these), allowing the cervix to close.
For endometritis: IV antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. Antibiotic choice should be guided by type and likely source of infection, as well as by local prescribing guidelines. The RCOG guideline for sepsis following pregnancy recommends IV piperacillin/tazobactam. For severe sepsis, carbapenem plus clindamycin. Other options, for less severe infections include co-amoxiclav, metronidazole and gentamicin. However, it stresses guidelines based on local resistance should be followed
If RPOC are suspected, elective curettage with antibiotic cover may be required. Surgical measures should be undertaken if there is excessive or continuing bleeding, irrespective of ultrasound findings. A senior obstetrician should be involved in decisions and performance of any evacuation of RCOP, as these women are carrying a high risk of uterine perforation.
The patient may require iron supplementation if Hb has fallen. Warn of the risk of constipation.
Caesarean section
Reasons for the operation include obstructed labour, twin pregnancy, high blood pressure in the mother, breech birth, and problems with the placenta or umbilical cord.
Endometriosis
Endometriosis risk factors include: an early menarche, late menopause, late first sexual encounter, delayed childbearing and nulliparity.
Obstruction to vaginal outflow - eg, hydrocolpos, female genital mutilation or defects in the uterus or Fallopian tubes.
Genetic factors:
Risk for first-degree relatives of women with severe endometriosis is six times higher than that for relatives of unaffected women.
Other risk factors include white ethnicity, low body mass index (BMI) and smoking.
Lymphatic or retrograde flow - main theories of spread.
Dysmenorrhoea. Dyspareunia. Cyclical or chronic pelvic pain. Subfertility. Other symptoms may include bloating, lethargy, constipation and low back pain. Less common symptoms include cyclical rectal bleeding, menorrhagia, diarrhoea and haematuria.
However, there may be:
Posterior fornix or adnexal tenderness.
Palpable nodules in the posterior fornix or adnexal masses (endometriosis can cause cystic lesions on the ovaries, known as ‘chocolate cysts’).
Bluish haemorrhagic nodules visible in the posterior fornix.
Ectopic Pregnancy
One third of women with ectopic pregnancies do not have risk factors. However, the following increase risk of ectopic pregnancy:
Assisted reproductive treatments such as in vitro fertilisation (IVF).
History of pelvic infection. Pelvic inflammatory disease may cause complete tubal occlusion or delay the transport of the embryo so that implantation occurs in the tube.
Adhesions from infection and inflammation from endometriosis may play a part.
Previous tubal surgery. Ectopic pregnancy has been reported in tubes that have been divided in a sterilisation operation and where they have been reconstructed to reverse one. A past history of ectopic pregnancy increases the risk.
IUCD use. IUCDs reduce the risk of ectopic pregnancy compared to using no contraception. The risk of ectopic pregnancy with an IUCD or intrauterine system (IUS) in situ is around 1 in 1,000 over five years. However, where an IUCD fails, the risk of a pregnancy being ectopic is very high, with some studies showing half of pregnancies in this situation being ectopic.
Women becoming pregnant whilst using progestogen-only contraceptive methods may also have an increased risk of ectopic pregnancy
The most common symptoms are:
Abdominal pain.
Pelvic pain.
Amenorrhoea or missed period.
Vaginal bleeding (with or without clots).
Other symptoms may include:
Dizziness, fainting or syncope.
Breast tenderness.
Shoulder tip pain.
Urinary symptoms.
Passage of tissue.
Rectal pain or pressure on defecation.
Gastrointestinal symptoms such as diarrhoea and/or vomiting.
There may be a history of a previous ectopic pregnancy. After one ectopic pregnancy the chance of another is much increased.
If the ectopic pregnancy has ruptured, bleeding is profuse and there may be features of hypovolaemic shock, including feeling dizzy on standing. Most bleeding will be into the pelvis and so vaginal bleeding may be minimal and misleading.
Common signs:
Pelvic or abdominal tenderness.
Adnexal tenderness.
Other possible signs:
Rebound tenderness. Cervical tenderness. Pallor. Abdominal distension. Enlarged uterus. Tachycardia and/or hypotension. Shock or collapse.
Pain and abdominal tenderness.
Pelvic tenderness.
Cervical motion tenderness.
Vaginal bleeding.
Benign Ovarian Tumours
Ovarian tumours can be divided into three main groups:
Functional
Benign
Malignant
Serous cystadenoma :
Develop papillary growths which may be so prolific that the cyst appears solid.
They occur in adults of all ages, with mean ages differing from 40-60 years.
They are bilateral in 10-20% of cases.
Mucinous cystadenoma:
The most common large ovarian tumours and which may become enormous.
They are filled with mucinous material and rupture may cause pseudomyxoma peritonei. They may be multilocular.
Mucinous cystadenomas of the ovary occur mainly in women aged 20-50, but may occur in younger women.
Benign cystic teratoma; rarely malignant.
They arise from primitive germ cells.
A benign mature teratoma (dermoid cyst) may contain well-differentiated tissue - eg, hair, and teeth.
May be bilateral.
They are most common in young women.
Poorly differentiated, malignant teratomas are rare.
Fibroma (very few are malignant); small, solid benign fibrous tissue tumours. They are associated with Meigs’ syndrome and ascites.
Thecoma (very few are malignant).
Adenofibroma.
Brenner’s tumour:
Rare ovarian tumours displaying benign, borderline or proliferative, and malignant variants.
Usually benign and mostly unilateral.
They may be associated with mucinous cystadenoma and cystic teratoma.
Risk factors Obesity. Tamoxifen therapy has been associated with an increase in persistent ovarian cysts. Early menarche. Infertility. Dermoid cysts can run in families.
Presentation
Asymptomatic - chance finding (eg, on bimanual examination or ultrasound).
Dull ache or pain in the lower abdomen, low back pain.
Torsion or rupture may lead to severe abdominal pain and fever.
Dyspareunia.
Swollen abdomen, with palpable mass arising out of the pelvis, which is dull to percussion and does not disappear if the bladder is emptied.
Pressure effects - eg, on the bladder, causing urinary frequency, or on venous return, causing varicose veins and leg oedema.
Torsion, infarction or haemorrhage:
Causes severe pain.
Torsion may be intermittent, presenting with intermittent episodes of severe pain.
Ovarian torsion is a complication for persistent masses in pregnancy.
Rupture:
Rupture of a large cyst may cause peritonitis and shock.
Rupture of mucinous cystadenomas may disseminate cells which continue to secrete mucin and cause death by binding up the viscera (pseudomyxoma peritonei).
Ascites - suggests malignancy or Meigs’ syndrome.
Endocrine - hormone-secreting tumours may cause virilisation, menstrual irregularities or postmenopausal bleeding. This is uncommon though.
Differential diagnosis
Fibroids
Fibroids are extremely common benign monoclonal tumours of the smooth muscle cells of the uterine myometrium, containing a large amount of extracellular matrix with disordered collagen. They start as multiple, single-cell seedlings distributed throughout the uterine wall. These then increase in size very slowly over many years, stimulated by oestrogens and progestogens. As the fibroid grows, the central areas may not receive an adequate blood supply and then undergo benign degeneration often followed by calcification.
Intramural (the majority).
Submucosal: growing into the uterine cavity. They may be pedunculated and may protrude through the cervical os.
Subserosal: growing outwards from the uterus - can be:
Uterine
Cervical
Intraligamentous
Pedunculated subserous (abdominal)
Most uterine fibroids are asymptomatic but in perimenopause or menopause, they typically manifest as abnormal uterine bleeding, which represents up to 70% of all gynecological consultations
Nearly 70% of white women and more than 80% of black women have had at least one fibroid by the age of 50 years.
Approximately 40% of white women and 60% of black women have had fibroids by the age of 35 years.
Antifibrinolytic agents (eg, tranexamic acid) may also also reduce menorrhagia. Combined hormonal contraception (CHC): despite the 'pill' previously being considered a risk factor for fibroid growth, CHC is helpful if the patient requires contraception, although it is not as effective as a levonorgestrel-releasing intrauterine system (LNG-IUS) Mirena coil.
Induced labour
Pharmacological methods of induction can cause hyperstimulation – this is when the uterus contracts too frequently or contractions last too long, which can lead to changes in foetal heart rate and result in foetal compromise. Might be more painful.
explain to women that some risks associated with a pregnancy continuing beyond 41+0 weeks may increase over time and these include:
increased likelihood of caesarean birth, of the baby needing admission to a neonatal intensive care unit or stillbirth and neonatal death.
If a woman has preterm prelabour rupture of membranes, do not carry out induction of labour before 34+0 weeks unless there are additional obstetric indications (for example, infection or foetal compromise). Offer expectant management until 37+0 weeks.
If a woman has preterm prelabour rupture of membranes after 34+0 weeks, but before 37+0 weeks, discuss the options of expectant management until 37+0 weeks or induction of labour with her. Induce if GBS+.
If there’s prelabour rupture at term, offer induction of labour if labour has not started naturally after approximately 24 hours. If has had a positive group B streptococcus test at any time in their current pregnancy, offer immediate induction of labour or caesarean birth.
Advise women who have had a previous caesarean birth that induction of labour could lead to an increased risk of emergency caesarean birth and an increased risk of uterine rupture. Induction of labour is not generally recommended if a woman’s baby is in the breech position. Do not induce labour if there is foetal growth restriction with confirmed foetal compromise. Offer caesarean birth instead.
Intrauterine foetal death
In the event of an intrauterine fetal death, if there is evidence of ruptured membranes, infection or bleeding, offer immediate induction of labour or caesarean birth.
Use oral mifepristone 200 mg followed by vaginal dinoprostone or oral or vaginal misoprostol. Base the choice and dosage of drug used on clinical circumstances and national protocols, or a mechanical method of induction.
Women who have intrauterine foetal death, and who have had a previous lower segment caesarean birth, that induction of labour could lead to an increased risk of uterine rupture. Both dinoprostone and misoprostol are contraindicated in women with a uterine scar. Membrane sweeps can induce also.
Placenta Praevia
placenta praevia should be used when the placenta lies directly over the internal os.
For pregnancies at more than 16 weeks of gestation the term low-lying placenta should be
used when the placental edge is less than 20 mm from the internal os on transabdominal or
transvaginal scanning. Follow up tvs at 32 weeks to see if it continues. Then another at 36 weeks to decide method of delivery.
Women with asymptomatic placenta praevia or a low-lying placenta in the third trimester
should be counselled about the risks of preterm delivery and obstetric haemorrhage and hysterectomy.
Might deliver with tocolysis or late preterm induction. Delivery should be by caesarean.
Placenta accreta
Placenta accreta is a serious pregnancy condition that occurs when the placenta grows too deeply into the uterine wall. Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after delivery.
You will deliver by a scheduled cesarean section. This usually takes place around week 35-36 of pregnancy.
The risks of placenta accreta spectrum are
massive obstetric haemorrhage, increased risk of lower urinary tract damage, the need for
blood transfusion and the risk of hysterectomy.
Sometimes the placenta is removed, sometimes left in situ.
Vasa Praevia
Vasa praevia is where one or more of the baby’s placental or umbilical blood vessels cross the entrance to the birth canal under the baby. Having vasa praevia increases the chance that if the membranes tear during labour (naturally or by a health professional), the blood vessels might also tear.
In the presence of confirmed vasa praevia in the third trimester, elective caesarean section should ideally be carried out prior to the onset of labour. A decision for prophylactic hospitalisation from 30–32 weeks of gestation in women with confirmed vasa praevia should be individualised.
The ultimate management goal of confirmed vasa praevia should be to deliver before rupture of membranes while minimising the impact of iatrogenic prematurity. Caesarean delivery for a prenatal diagnosis of vasa praevia at 34–36 weeks of gestation is reasonable in asymptomatic women.
Administration of corticosteroids for foetal lung maturity should be recommended from32 weeks of gestation due to the increased risk of preterm delivery.
Assisted birth preferences
Inform women that epidural analgesia may increase the need for assisted vaginal birth although
this is less likely with newer analgesic techniques.
Inform women that administering epidural analgesia in the latent phase of labour compared to
the active phase of labour does not increase the risk of assisted vaginal birth.
Encourage women not using epidural analgesia to adopt upright or lateral positions in the
second stage of labour as this reduces the need for assisted vaginal birth.
Encourage women using epidural analgesia to adopt lying down lateral positions rather than
upright positions in the second stage of labour as this increases the rate of spontaneous vaginal
birth.
Recommend delayed pushing for 1–2 hours in nulliparous women with epidural analgesia as
this may reduce the need for rotational and midpelvic assisted vaginal birth.
Rotational births should be performed by experienced operators; the choice of instrument
depending on the clinical circumstances and expertise of the individual. The options include
Kielland’s rotational forceps, manual rotation followed by direct traction forceps (more likely tear) or vacuum, and rotational vacuum extraction. (more likely haematoma).
A single prophylactic dose of intravenous amoxicillin and clavulanic acid should be
recommended following assisted vaginal birth. Reassess women after assisted vaginal birth for venous thromboembolism risk and the need for
thromboprophylaxis. Women should be educated about the risk of urinary retention so that they are aware of the
importance of bladder emptying in the postpartum period. Might have a catheter to prevent.
Laxatives avoid constipation risks of stitch breaks or tears.
