8- Complicated pregnancy (life threatening problems) Flashcards
what makes a women at high risk of having complicationd in pregnancy
- Certain physical characteristics, such as age and weight
- Problems in a previous pregnancy, including the need to have a cesarean delivery
- Certain disorders present before pregnancy
- Exposures that can harm the fetus
older women and pregnancy
Women aged 35 and older are at increased risk of having the following:
- A preexisting disorder that increases risk during pregnancy, such as high blood pressure or diabetes
- Problems related to the pregnancy, such as preeclampsia, gestational diabetes (diabetes that develops during pregnancy), chromosomal abnormalities in the fetus, and stillbirth
- Complications during labor, such as difficult labor or a placenta that detaches too soon (placental abruption) or is mislocated (placenta previa)
underweight women and pregnancy
Small, underweight babies
overweight women and pregnancy
- Very large babies (large-for-gestational age), which may be difficult to deliver
- Babies who are born underweight (small-for-gestational age)
- Babies with birth defects
- Miscarriages and stillbirth
- Gestational diabetes
- Gestational hypertension (high blood pressure that first develops after 20 weeks of pregnancy)
- Preeclampsia (gestational hypertension accompanied by protein in the urine)
- A pregnancy that lasts 42 weeks or longer (postterm pregnancy)
- Need for a cesarean delivery
problems with previous pregnancy
- A premature baby
- An underweight baby (small-for-gestational age)
- A baby that weighed more than 10 pounds (large-for-gestational age)
- A baby with birth defects
- A previous miscarriage
- A history of several pregnancy losses
- A late (postterm) delivery (after 42 weeks of pregnancy)
- Rh incompatibility that required a blood transfusion to the fetus
- Labor that required a cesarean delivery
- Too much amniotic fluid in the uterus (polyhydramnios)
- Too little amniotic fluid in the uterus (oligohydramnios)
- An abnormally located pregnancy (ectopic pregnancy)
- A fetus in an abnormal position, such as buttocks first (breech)
- A baby whose shoulder gets caught in the birth canal (shoulder dystocia)
disorders which women have before pregnancy which can increase risk of current pregnancy
- High blood pressure
- Diabetes
- Kidney disorders
- Kidney infections
- Heart failure
- Sickle cell disease
- Sexually transmitted infections
- Problems with the fallopian tubes
- short cervix due to LLETZ
exposure during pregnancy
- Certain infections
- Certain drugs (such lithium, azithromycin, erythromycin, and antidepressants called selective serotonin reuptake inhibitors)
- Radiation and certain chemicals (such as carbon monoxide, lead, gasoline, and mercury)
Life threatening problems of pregnancy
o Obstetric haemorrhage
o Venous thromboembolism
o Sepsis
o Maternal collapse
o Retained placenta
Obstetric haemorrhage
refers to any kind of excessive bleeding (usually related to pregnancy) in a parturient. This could be during pregnancy, child birth, or in the postpartum period.
classification of PPH
- MINOR 500-1000MLS
- MODERATE (>1000MLS)
- MAJOR (1000-2000MLS)
- MASSIVE (>2000MLS OR 150MLS/MIN)
what is the most common cause of obstetric haemorrhage
post partum haemorhage
- >500mls
causes of obstetric haemorrhage
- placenta praevia
- placental abruption
- placeta accreta
- PPH e.g. uterine atony
placenta praevia
where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus
Definitions:
- Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
- Placenta praevia is used only when the placenta is over the internal cervical os
placenta praevia is a cause of
antepartum haemorrhage
risks of having placenta praevia
- Antepartum haemorrhage
- Emergency caesarean section
- Emergency hysterectomy
- Maternal anaemia and transfusions
- Preterm birth and low birth weight
- Stillbirth
risk factors for placenta praevia
- Previous caesarean sections
- Previous placenta praevia
- Older maternal age
- Maternal smoking
- Structural uterine abnormalities (e.g. fibroids)
- Assisted reproduction (e.g. IVF)
diagnosing placenta praevia
- 20 week anomoly USS
presentation of placenta praevia
many asymptomatic
- painless (bright red) vaginal bleeding in pregnancy (antepartum haemorrhage).
- Bleeding usually occurs later in pregnancy (around or after 36 weeks)
management of placenta praevia
- repeat transvaginal US at 32 and 36 weeks to guide delivery decision
- corticosteroid given between 34 and 35+6 weeks to mature fetal lungs
- planned delivery between 36 and 37 weeks (to prevent spontaneous labour and bleeding)
- Caesarean section if complete placenta praevia or low-lying placenta
- Emergency c-section if premature labour or antenatal bleeding
management of haemorrhage cause by placenta praevia
- Emergency caesarean section
- Blood transfusions
- Intrauterine balloon tamponade
- Uterine artery occlusion
- Emergency hysterectomy
placenta accreta
Placenta accreta refers to when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby. It is referred to as placenta accreta spectrum, as there is a spectrum of severity in how deep and broad the abnormal implantation extends.
Pathophysiology of placenta accreta
There are three layers to the uterine wall:
- Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels
- Myometrium, the middle layer that contains smooth muscle
- Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa)
Usually the placenta attaches to the endometrium. This allows the placenta to separate cleanly during the third stage of labour, after delivery of the baby.
With placenta accreta, the placenta embeds past the endometrium, into the myometrium and beyond. This may happen due to a defect in the endometrium. Imperfections may occur due to previous uterine surgery, such as a caesarean section or curettage procedure. The deep implantation makes it very difficult for the placenta to separate during delivery, leading to extensive bleeding (postpartum haemorrhage).
define superficial placenta accreta
is where the placenta implants in the surface of the myometrium, but not beyond
define placenta increta
is where the placenta attaches deeply into the myometrium
define placenta percreta
is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
RF for placenta accreta
Risk Factors
- Previous placenta accreta
- Previous endometrial curettage procedures (e.g. for miscarriage or abortion)
- Previous caesarean section
- Multigravida
- Increased maternal age
- Low-lying placenta or placenta praevia
presentation of placenta accreta
typically asymptomatic during pregnancy
- may be picked up on US scan
- diagnosed at birth when its difficult to deliver placenta
placenta accreta is a significant cause of
postpartum haemorrhage
if placenta accreta is diagnosed antenatally by US what should happen
MRI scans may be used to assess the depth and width of the invasion.
management of placenta accreta at birth to prevent haemorrhage
- delivery between 35 to 36+6 weeks gestation to prevent spontaneous labour
- antenatal steroids
- caesearan
option during caesarean in a women with placenta accreta
- Hysterectomy with the placenta remaining in the uterus (recommended)
- Uterus preserving surgery, with resection of part of the myometrium along with the placenta
- Expectant management, leaving the placenta in place to be reabsorbed over time
placental abruption
refers to when the placenta separates from the wall of the uterus during pregnancy.
- significant cause of antepartum hameorrhage
The risk factors for placental abruption are:
- Previous placental abruption
- Pre-eclampsia
- Bleeding early in pregnancy
- Trauma (consider domestic violence)
- Multiple pregnancy
- Fetal growth restriction
- Multigravida
- Increased maternal age
- Smoking
- Cocaine or amphetamine use
The typical presentation of placental abruption is with:
- Sudden onset severe abdominal pain that is continuous
- Vaginal bleeding (antepartum haemorrhage)- darker in colour
- Shock (hypotension and tachycardia)
- Abnormalities on the CTG indicating fetal distress
- Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage
severity of antepartum haemorrhage
- Spotting: spots of blood noticed on underwear
- Minor haemorrhage: less than 50ml blood loss
- Major haemorrhage: 50 – 1000ml blood loss
- Massive haemorrhage: more than 1000 ml blood loss, or signs of shock
Concealed abruption
is where the cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage.
Concealed abruption is opposed to revealed abruption, where the blood loss is observed via the vagina
causes of PPH
4 Ts
- tone
- trauma
- tissue
- thrombin
To be classified as postpartum haemorrhage, there needs to be a loss of:
- 500ml after a vaginal delivery
- 1000ml after a caesarean section
It can be classified as:
- Minor PPH – under 1000ml blood loss
- Major PPH – over 1000ml blood loss
Major PPH can be further sub-classified as:
- Moderate PPH – 1000 – 2000ml blood loss
- Severe PPH – over 2000ml blood loss
It can also be categorised as:
Primary PPH: bleeding within 24 hours of birth
Secondary PPH: from 24 hours to 12 weeks after birth
prevention of PPH and risks associated
- Treating anaemia during the antenatal period
- Giving birth with an empty bladder (a full bladder reduces uterine contraction)
- Active management of the third stage (with intramuscular oxytocin in the third stage)
- Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
The initial steps with major or massive haemorrhage are:
- Urgent involvement of a senior obstetrician, midwife and anaesthetist
- 2 x grey cannula
- Bloods include FBC, UE, LFT and coagulation studies
- Crossmatch 4 units of blood
- Fluid and blood resuscitation as required
- CTG monitoring of the fetus
- Close monitoring of the mother
management of placental abruption
- Management of major haemorrhage
- USS to exclude placenta praevia
- antenatal steroids betwen 24 adn 34+6 weekd
- anti-D propylaxis for rhesus-D negative women (kleihauer test to quanitfy how much fetal blood is mixdd with matrnal bllod)
- emergency caesaean if mother unstable or fetal distress
- active management of third stage
blood vessels in the umbilical cord
The umbilical cord usually contains two arteries and one vein. The vein carries the oxygenated blood from the placenta to the fetus. The arteries carry the deoxygenated blood and the waste products from the fetus to the placenta.
mechanical treatment to stop bleeding during PPH
- Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
- Catheterisation (bladder distention prevents uterus contractions)
There is a long list of risk factors for VTE in pregnancy:
Smoking
Parity ≥ 3
Age > 35 years
BMI > 30
Reduced mobility
Multiple pregnancy
Pre-eclampsia
Gross varicose veins
Immobility
Family history of VTE
Thrombophilia
IVF pregnancy
surgical treatment to stop PPH
- Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
- B-Lynch suture – putting a suture around the uterus to compress it
- Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
- Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life
medical treatment to stop PPH
Medical treatment options involve:
- Oxytocin (slow injection followed by continuous infusion)
- Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
- Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
- Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
- Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding
management of postpartum haemorrhage
1) Stabilise the patient
2) Stop the bleeding
- mechanical
- medical
- surgical
prevention of VTE in pregnancy
Prophylactic LMWH
* 28 weeks if there are three risk factors
* First trimester if there are four or more of these risk factors
There are additional scenarios where prophylaxis is considered, even in the absence of other risk factors:
- Hospital admission
- Surgical procedures
- Previous VTE
- Medical conditions such as cancer or arthritis
- High-risk thrombophilias
- Ovarian hyperstimulation syndrome
stabilising a patient after PPH
- Resuscitation with an ABCDE approach
- Lie the woman flat, keep her warm and communicate with her and the partner
- Insert two large-bore cannulas
- Bloods for FBC, U&E and clotting screen
- Group and cross match 4 units
- Warmed IV fluid and blood resuscitation as required
- Oxygen (regardless of saturations)
- Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion
management of women with a massive PE or haemodynamic compromise
This is a life-threatening scenario. Treatment options are:
- Unfractionated heparin
- Thrombolysis
- Surgical embolectomy
maternal sepsis
Sepsis in pregnancy is a medical emergency that requires prompt recognition and management to reduce the risk of maternal and fetal morbidity and mortality.
- during pregnancy and shortly after birth
most common causes of maternal sepsis
Chorioamnionitis
Urinary tract infections
Sepsis can develop as the result of many complications. Here are just a few:
- Miscarriages (spontaneous abortions) or induced abortions:Infections are a risk after any miscarriage or abortion. Non-sterile abortions, those that may be done outside of a healthcare facility, are a particular risk. Anyone who has had one should watch for signs and symptoms of an infection (lasting or increasing pain, discolored or odorous (smelly) discharge, abdominal tenderness, high temperature, fatigue, feeling unwell).
- Cesarean sections: Sepsis can develop after any type of surgery. Cesarean sections are major abdominal surgeries with all the associated risks.
-
Prolonged or obstructed labor: An unusually long time of labor or labor that stops progressing.
Ruptured membranes: The longer the period between the “water breaking” and the baby’s birth, the higher the chance of an infection. - Infection following vaginal delivery: Although not common in the developed world among those who give birth in healthcare facilities, infections are very common in the developing world.
- Mastitis: Infection in the breasts can trigger sepsis.
- Viral or bacterial illnesses: Any illness that raises the risk of sepsis in the general population will do so during pregnancy as well.
Chorioamnionitis
Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid. Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). It usually occurs in later pregnancy and during labour.
Chorioamnionitis can be caused by a large variety of bacteria, including gram-positive bacteria, gram-negative bacteria and anaerobes.
presentations of maternal sepsis
The non-specific signs of sepsis include:
Fever
Tachycardia
Raised respiratory rate (often an early sign)
Reduced oxygen saturations
Low blood pressure
Altered consciousness
Reduced urine output
Raised white blood cells on a full blood count
Evidence of fetal compromise on a CTG
Additional signs and symptoms related to chorioamnionitis include:
Abdominal pain
Uterine tenderness
Vaginal discharge
Additional signs and symptoms related to a urinary tract infection include:
Dysuria
Urinary frequency
Suprapubic pain or discomfort
Renal angle pain (with pyelonephritis)
Vomiting (with pyelonephritis)
what is used to monitor for signs of sepsis
MEOWS chart.
MEOWS stands for maternity early obstetric warning system. This includes monitoring their physical observations to identify signs of sepsis.
Investigations
Arrange blood tests for patients with suspected sepsis:
- Full blood count to assess cell count including white cells and neutrophils
- U&Es to assess kidney function and for acute kidney injury
- LFTs to assess liver function and as a possible source of infection (e.g. acute cholecystitis)
- CRP to assess inflammation
- Clotting to assess for disseminated intravascular coagulopathy (DIC)
- Blood cultures to assess for bacteraemia
- Blood gas to assess lactate, pH and glucose
Additional investigations can be helpful based on the suspected source of infection:
- Urine dipstick and culture
- High vaginal swab
- Throat swab
- Sputum culture
- Wound swab after procedures
- Lumbar puncture for meningitis or encephalitis
management of maternal sepsis
- SEPSIS six
- continous maternal and fetal monitoring
- if fetal distress= emergency caesaran (general anaesthesia)
- broad spectrum antibiotics : Example regimes include piperacillin and tazobactam (tazocin) plus gentamicin, or amoxicillin, clindamycin and gentamicin.
Septic Six
Septic Six
Three tests:
- Blood lactate level
- Blood cultures
- Urine output
Three treatments:
- Oxygen to maintain oxygen saturations 94-98%
- Empirical broad-spectrum antibiotics
- IV fluids
maternal collapse
an acute event involving the cardiorespiraotry system and/or central nervous system, rsuslting ina. reduced or abscent consicous level, at nay stage of pregnancy and up to 6 weeks after birth
causes of maternal collapse
Many causes which may or may not be pregnancy related. Use ABCDE to indentify cause of collapse.
- Haemorrhage
- Thromboembolism
- Cardiac disease
- Sepsis
- Drug toxicity and overdose
- Eclampsia
- Intracranial haemorrhage
- Anaphylaxis
4
Amniotic fluid embolisation
is a rare (2 per 100,000 deliveries) but severe condition where the amniotic fluid passes into the mother’s blood. This usually occurs around labour and delivery. The amniotic fluid contains fetal tissue, causing an immune reaction from the mother.
pathophysiology of amniotic fluid embolisation
The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism
RF for amniotic fluid embolism
The main risk factors for amniotic fluid embolus are:
- Increasing maternal age
- Induction of labour
- Caesarean section
- Multiple pregnancy
presentation of amniotic fluid embolism
- Shortness of breath
- Hypoxia
- Hypotension
- Coagulopathy
- Haemorrhage
- Tachycardia
- Confusion
- Seizures
- Cardiac arrest
*
management of amniotic fluid embolism
The overall management of amniotic fluid embolism is supportive. There are no specific treatments.
Amniotic fluid embolism is a medical emergency – get help immediately. It requires the input of experienced obstetricians, medics, anaesthetics, intensive care teams and haematologists. They are likely to need transfer to the intensive care unit.
The initial management of any acutely unwell patient is with an ABCDE approach, assessing and treating:
A – Airway: Secure the airway
B – Breathing: Provide oxygen for hypoxia
C – Circulation: IV fluids to treat hypotension and blood transfusion in haemorrhage
D – Disability: Treat seizures and consider other neurological deficits
E – Exposure
Causes of cardiac arrest in pregnancy
The Resuscitation Council UK list the reversible causes of adult cardiac arrest as the 4 Ts and 4 Hs:
4 Ts:
Thrombosis (i.e. PE or MI)
Tension pneumothorax
Toxins
Tamponade (cardiac)
4 Hs:
Hypoxia
Hypovolaemia
Hypothermia
Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities
The RCOG guideline advises adding to the list:
Eclampsia
Intracranial haemorrhage
The three major causes of cardiac arrest in pregnancy to remember are:
- Obstetric haemorrhage
- Pulmonary embolism
- Sepsis leading to metabolic acidosis and septic shock
causes of massive obstetric haemorrhage
- Ectopic pregnancy (early pregnancy)
- Placental abruption (including concealed haemorrhage)
- Placenta praevia
- Placenta accreta
- Uterine rupture
aortocaval compression
After 20 weeks gestation, the uterus is a significant size. When a pregnant woman lies on her back (supine), the mass of the uterus can compress the inferior vena cava and aorta. The compression on the vena cava is most significant, as it reduces the blood returning to the heart (venous return). This reduces the cardiac output, leading to hypotension. In some instances, this can be enough to lead to the loss of cardiac output and cardiac arrest.
manageemnt of aortocaval compression
The vena cava is slightly to the right side of the body. The solution to aortocaval compression is to place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava. This should relieve the compression on the inferior vena cava and improve venous return and cardiac output.
Resuscitation in pregnancy follows the same principles as standard adult life support, except for:
- A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta
- Early intubation to protect the airway
- Early supplementary oxygen
- Aggressive fluid resuscitation (caution in pre-eclampsia)
- Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR
maternal cardiac arrest and delivery of baby
Immediate caesarean section is performed in a pregnant woman when:
- There is no response after 4 minutes to CPR performed correctly
- CPR continues for more than 4 minutes in a woman more than 20 weeks gestation
The aim is to deliver the baby and placenta within 5 minutes of CPR commencing. The operation is performed at the site of the arrest, for example,** in A&E resus or on the ward.**
The primary reason for the immediate delivery is to improve the survival of the mother. Delivery improves the venous return to the heart, improves cardiac output and reduces oxygen consumption. It also helps with ventilation and chest compressions. Delivery increases the chances of the baby surviving, although this is secondary to the survival of the mother.
maternal cardiac arrest and delivery of baby
Immediate caesarean section is performed in a pregnant woman when:
- There is no response after 4 minutes to CPR performed correctly
- CPR continues for more than 4 minutes in a woman more than 20 weeks gestation
The aim is to deliver the baby and placenta within 5 minutes of CPR commencing. The operation is performed at the site of the arrest, for example,** in A&E resus or on the ward.**
The primary reason for the immediate delivery is to improve the survival of the mother. Delivery improves the venous return to the heart, improves cardiac output and reduces oxygen consumption. It also helps with ventilation and chest compressions. Delivery increases the chances of the baby surviving, although this is secondary to the survival of the mother.
cord prolapse
Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.
cord prolapse diagnosis
Diagnosis
Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG. A prolapsed umbilical cord can be diagnosed by vaginal examination. Speculum examination can be used to confirm the diagnosis.
management of cord prolapse
Emergency caesarean section is indicated where cord prolapse occurs. A normal vaginal delivery has a high risk of cord compression and significant hypoxia to the baby. Pushing the cord back in is not recommended. The cord should be kept warm and wet and have minimal handling whilst waiting for delivery (handling causes vasospasm).
When the baby is compressing a prolapsed cord, the presenting part can be pushed upwards to prevent it compressing the cord. The woman can lie in the left lateral position (with a pillow under the hip) or the knee-chest position (on all fours), using gravity to draw the fetus away from the pelvis and reduce compression on the cord. Tocolytic medication (e.g. terbutaline) can be used to minimise contractions whilst waiting for delivery by caesarean section.
when is umbilical cord gases implicated
in all high risk deliveries to look for hypoxia and acidosis
why is cord gases done
To determine if there was a complication shortly before or during delivery that deprived the baby of oxygen. Oxygen deprivation (birth asphyxia) can cause brain damage, hypoxic-ischemic encephalopathy (HIE), periventricular leukomalacia (PVL – usually seen in premature babies), intraventricular hemorrhages (brain bleeds) and lifelong conditions such as cerebral palsy (CP), seizure disorders, intellectual disabilities, and developmental delays.
A 27-year-old nulliparous woman is undergoing investigations for infertility. Her doctor wishes to perform a blood test to confirm ovulation.
LEAD IN:
Please select the most appropriate HORMONE TEST from the option list.
Physiology of menstruation
OPTIONS:
A. Progesterone
B. Oestradiol
C. Follicle stimulating hormone
D. Sex-Hormone-Binding-Globulin E. Luteinising hormone
A Progesterone
If ovulation occurs, the corpus luteum begins to secrete Progesterone; a rise in plasma Progesterone levels in the midluteal phase is therefore suggestive of an ovulatory cycle. In longer cycles the best timing for the test is one week before expected menstruation.
Normal cord gases
normal scalp sampling gases
