3- Abnormal Pregnancy III & IV Flashcards
Preterm labor is the most common cause of perinatal morbidity/ mortality, and can lead to long-term neuro impairment. How is preterm labor defined?
Regular contractions between 20 - 37 weeks resulting in cervical changes
Pt presents with menstrual-like cramps, low/ dull backache, abd/ pelvic pressure, abd cramping, vaginal discharge, and painless uterine contractions. What are you concerned for?
Preterm labor
What is included as part of preterm labor eval aside from digital cervical exam, UA C+S +/- NST?
R/o ROM
US for cervical length
GBS culture
What diagnostic test is used as a predictive value for preterm labor?
Fetal fibronectin (fFN) = “glue like” glycoprotein
Present @ term, but NOT @ 22-35 wks
(none = (-) predictive value, (+) = (+) predictive value)
What criteria must be met for a diagnosis of preterm labor?
Uterine contractions ≥ 4 q 20 min or ≥ 8 in 60 min PLUS
- cervical dilation ≥ 3cm or
- cervical length < 20mm on TVUS or
- cervical length 20-30mm on TVUS + (+) fFN
What is the management for preterm labor?
Hospitalize if < 34 weeks
+ betamethasone, tocolytic drugs, GBS abx, mg sulfate (neuroprotection)
What tocolytic agents are used in the management of preterm labor?
In-pt: Terbutaline, Mg Sulfate
Out-pt: Nifepidine, Indomethacin
What is defined as placental location close to or over the internal cervical os and is the leading cause of 3rd trimester bleeding?
Placenta previa
What is a specific RF for placenta previa?
Hx of prior c-section or uterine surgery
What are the 4 degrees of placenta previa?
Complete- internal os completely covered
Partial- internal os partially covered
Marginal- edge of placenta at margin of internal os
Low-lying- placenta < 2cm from internal os
Pt presents with mod-severe acute painless vaginal bleeding in the late 2nd or 3rd trimester. What are you concerned for?
Placenta previa
How is placenta previa diagnosed?
Start w/ transabdominal US
Confirm w/ TVUS
If placenta previa is detected in the 2nd trimester, what pt education can be provided?
Most resolve by 32-35 wks due to placental migration
(unless complete placenta previa)
What should you NEVER do on a known placenta previa pt?
Bimanual/ cervix exam
What is the management for placenta previa if presenting w/ spontaneous labor or hemorrhage?
Immediation c-section
What is the management for placenta previa if preterm w/o active bleeding?
Observe (home > hospital) until c-section @ 37-38 wks
Corticosteroids if < 37 wks, RhoGAM if Rh (-)
What complications are a/w placenta previa? (4)
Increased risk of:
- preterm delivery/ perinatal death
- placenta accreta (too deep/ firm into uterine wall)
- placenta increta (into uterine muscle)
- placenta percreta (through uterine muscle layers, most dangerous)
What is defined as abnormal premature separation of an otherwise normally implanted placenta that can cause 2nd/ 3rd trimester bleeding or hemorrhage?
Abruptio placentae
What are the types of placental abruption?
Marginal, partial, complete
(complete a/w increased risk of fetal death)
What is the greatest RF for placental abruption?
Abdominal trauma
(displaces uterus → detaches placenta)
What is the most common presentation of placental abruption?
Hemorrhage and abd pain
(others: fetal distress, rigid abd, irritable uterus, DIC)
What is included in the management of a placental abruption? (4)
Expectant if marginal
Tx shock/ stabilize hemodynamically
C-section if fetal distress
Corticosteroids if < 37 wks
What is defined as fetal blood vessels running unsupported through the membranes over the cervix and under the presenting fetal part and what is the problem w/ this condition?
Vasa previa
Membranes rupture → fetal blood supply vessels rupture → rapid fetal blood loss/ death
Multiple gestation pregnancies, 2nd trimester/ low-lying placentas, bi-lobed/ accessory lobed placentas, and IVF pregnancies are RF for what condition?
Vasa previa
Pt presents w/ vaginal bleeding w/ ROM and changes in fetal heart rate. What are you concerned for and what is used for confirmation of dx?
Vasa previa
Dx w/ color doppler US
What is the management for vasa previa?
Hospitalize if 3rd trimester
Corticosteroids b/w 28-32 wks
Pelvic rest
C-section @ 35 wks
How is premature rupture of membranes (PROM) defined?
Spontaneous rupture of membranes before the onset of labor
90% of women at term will go into spontaneous labor w/i 24 hrs of PROM. If spontaneous labor does not ensue, there is increased risk of what?
Chorioamnionitis
(infection of chorion/ amnion/ both)
What complications are a/w PROM? (4)
Preterm labor
Cord prolapse
Placental abruption
Intrauterine infection
Preterm premature rupture of membranes (PPROM) is defined as PROM that occurs when?
Before 37 wks gestation
Neonatal infection, necrotizing enterocoloitis, RDS (respiratory distress), neuro/ neuromuscular dysfunction are complications a/w what?
PROM (before 37 wks)
If PPROM occurs < 26 weeks gestation, what are associated risks? (2)
Fetal pulmonary hyperplasia
Limb positioning defects
What RFs are a/w PPROM? (3)
Smoking (x2), prior PROM, polyhydraminos
What tests are used to confirm membrane rupture?
Nitrazine paper (pH)
FERN test
What should be avoided if suspicion for PROM?
Vaginal exams
(limit risk of infection)
What is included in the management for PROM if chorioamnionitis is present?
Prompt delivery, regardless of gestational age
What is included in the management for PROM if chorioamnionitis is NOT present?
Hospitalization for induction of labor
What is included in the management for PPROM if chorioamnionitis is NOT present?
> 34 weeks → induce labor
24-34 weeks → hospitalize, steroids, abx, Mg
What is the outcome for PROM?
Typical labor and delivery course
What is the typical outcome for PPROM?
Spontaneous labor w/i 1 week
↑ risk of neuro- developmental impairment
Continue pregnancy @ home w/ close f/u (rare)
How is postterm pregnancy defined?
Pregnancy lasting ≥ 42 weeks gestation
What problems are a/w postterm pregnancy?
Stillbirth (≥ 41 weeks = increased risk)
Fetal dysmaturity syndrome- malnutrition
What is the #1 cause of postterm pregnancy?
Inaccurate estimation of gestational age
(must accurately date pregnancy- 1st trimester US most accurate)
Stillbirth, shoulder dystocia, fetal injury, oligohydraminos, and meconium aspiration are fetal complications of what?
Postterm pregnancy
Trauma, hemorrhage, and labor abnormalities are maternal complications a/w what?
Postterm pregnancy
What is included in management for postterm pregnancy?
Induction of labor @ 41 completed weeks
Expectant management if refuse induction (serial NST/ BPP)
What abnormal labor patterns can be the cause of intrapartum complications?
Protraction disorder- labor is progressing at a slower pace than expected
Arrest disorder- complete cessation in progress of labor
What is the management for abnormal labor patterns?
Observation, augmentation, operative vaginal delivery, c-section
What are the types of breech presentations?
Frank- feet near head
Complete- legs crossed
Incomplete- one/ both feet extended
How is a breech presentation detected/ confirmed?
Cervical exam → US
What are the preferred methods of management for breech presentation?
External cephalic version (ECV) @ 36 weeks
C-section b/w 39-41 weeks
(vaginal delivery not preferred/ rarely performed)
Transverse lie occurs when the head and butt of the baby are horizontal. What is the management?
ECV or C-section
(no possibility for vaginal delivery because no presenting part)
Cephalopelvic disproportion arises from what 2 factors?
Diminished pelvic size or excessive fetal size
(or both)
What is the most common cause of cephalopelvic disproportion?
Contraction of mid-pelvis during 2nd stage of labor
What is defined as descension of the umbilical cord alongside or beyond the fetal presenting part?
Cord prolapse- rare obstetric emergency
In addition to visualization or palpation of umbilical cord adhead of presenting, how is umbilical cord prolapse diagnosed?
Abrupt onset of:
- severe, prolonged fetal bradycardia
- mod-severe variable decelerations
What is the management for umbilical cord prolapse?
Trendelenburg, immediate C-section
What is defined as the inability to deliver the shoulders after the head of the baby has delivered?
Shoulder dystocia
Why is shoulder dystocia considered to be an acute obstretric emergency?
May cause fetal damage (brachial plexus injury)/ death
What is the management for shoulder dystocia?
McRoberts maneuver
What is defined as an adverse response of the fetus to the stress of labor contractions and is usually reflected in the interpretation of the fetal heart rate (reassuring vs nonreassuring)?
Fetal intolerance to labor
What is the goal in management of fetal intolerance to labor?
Recognize changes in fetal oxygenation that could result in serious complications
What fetal HR parameteres for decelerations are followed for consideration of fetal intolerance to labor?
(N = 110-160 +/- 6-25 bpm, accelerations N)
Early: top of contraction, due to head compression
Variable: before end of contraction, due to cord compression
Late: after full contraction, due to uteroplacental insufficiency
What is included in the management for fetal intolerance to labor? (7)
Repositioning of pt
D/c pitocin
Correct maternal hypotension
Admin O2 to mother
Tocolysis
Amnioinfusion
Prepare for C-section
What does VBAC stand for?
Vaginal birth after cesarean
What does TOLAC stand for?
Trial of labor after cesarean
What does PRCD stand for?
Planned repeat cesarean delivery
What is the greatest maternal risk a/w VBAC?
Uterine rupture
What is the greatest fetal risk a/w TOLAC?
Perinatal/ neonatal mortality
How much delivery-associated blood loss is considered postpartum hemorrhage (PPH) for vaginal and C-section?
Vaginal > 500mL
C-section > 1000mL
What is the most common cause of PPH?
Uterine atony
What complications are a/w PPH? (5)
RDS
Coagulopathy
Shock
Loss of fertility
Pituitary necrosis (Sheehan syndrome)
What criteria are used for diagnosis of PPH?
Cumulative blood loss ≥ 1000mL
Bleeding a/w s+s of hypovolemia w/i 24 hrs of birth regardless of delivery route
S+s of blood loss
How do you differentiate between primary vs secondary PPH?
Primary (early): w/i 24 hrs after delivery
Secondary (late, delayed): 24 hrs - 12 weeks after delivery
What are the tx goals of PPH? (4)
Prevent hypoperfusion of vital organs w/ adequate circulation
Adequate tissue oxygenation
Reverse/ prevent coagulopathy
Eliminate obstetric cause of PPH
