Antenatal issues Flashcards
Placental abruption
Painful, hypertonic uterus
Couvelaire uterus @ CS
Recurrence 15%
RF: hx, PET/HTN, AMA/IVF, smoke/cocaine use, multiple preg, trauma/DV, PPROM/PTB, APLS
Prevention:
Modify RF, aspirin clexane, BP optimise
Praevia
Painless APH+/- malpresentation
20% LLP @ morph, 85% resolves
1 CS 5 fold, >5 CS 50% risk
Risk of PTB
Delivery 38-39, high risk 37-38
Accreta
w/ praevia
- 1 cs 3%, 2 cs 10%, 4 CS 60%
Accreta - absent decidua between placenta & myometrium
Percreta - into myometrium
Increta - full thickness, involve serosa/local organs
MRI+US ~ 100% sensitive
Delivery 36-37, or 34-36 if high risk
MDT +/- IR balloon
US + MRI assess degree of invasion
Intraop cell saver, MTP, midline laparotomy
Surgical options:
Attempt delivery
En bloc hysterectomy
Conservative - 2/3 avoid, 1/3 haemorrhage 30% recurrence
Delay hysterectomy 7 days
Surgical risk:
20-30% take back
Organ injury/fistula 6-7^
ICU admission
Mortality 7%
Praevia US
Thinning of myometrium
Loss of hypoechoic space between placenta myometrial
Interruption of bladder line, exophytic mass
Turbulent flow in lacunae
Placenta invade to myometrium
Vasa praevia
60% mortality with rupture of vessel
RFS: LLP, velamentous insertion, bilobe succenturiate lobe, multiple pregnancy
T1 velamentous cord w/ LLP
USS:
- Grey scale tubular structure over int os
- vascularity on color flow
- fetal vessel waveform on pulse doppler
T2 succenturiate lobe
Delivery:
34-35+6/40 prior to ROM/labour
Admit from 30/40
- consider steroids
- tertiary centre with neonatal transfusion
- allow expedite delivery if ruptures/labour
PPROM
50% labour in 1 week, 75% in 2 weeks
Maternal risk: sepsis, abruption
Fetal risk: PTB, pulm hypoplasia, limb/face deformities, cord prolapse
RFs: prev hx, low BMI, smoker/drug use, CT disease, cervical incompetence, amnio, APH, poly, multiple pregn
Chorioamnionitis histopath
- neurophil infiltration & inflammatory changes @ chorioamnion
- funisitis & chorionic vasculitis
Evidence PPROM
ORACLE 1
- erythromycin less adverse outcomes
- prolong pregnancy, reduce surfactant tx, neonatal bacteraemia, major cerebral anomalies
- augmentin/both asso high NEC
- 7 year follow up
no diff in functiona/behavioural/health outcomes
ORACLE II
TPL and antibiotics
No diff in composite outcome
Lower rate of maternal infection
PPROMTT
34-36+6/40 IOL vs expectant
Fetal - no diff in neonatal sepsis, morbidity or mortality
Increase RDS, prolonged stay
Matenral - no diff in APH/PPH, infection
lower CS rate in expectant group
Prematurity
RDS - surfactent deficiency -> widespread atelectasis -> hypoventilation
TTN - incomplete fluid removal -> diminished resp effort
IVH 20% <32/40
PVL - hypoxic lesion @ immature white matter asso. spasticity/cog impair
NEC- 40% mortalitu, ulcerative inflammation due to infection & ischaemia of bowel
Jaundice/hypothermia/hypoBSL/infection
Long term:
- Neurodevelopmental delay
impaired development of frontaltempora/hippocampus
- cognitive impairment
- behavioural/MH issue
- SNLH
CP 5% if <34/40
CLD - O2 dependent at 36/40 corrected GA -> barotrauma, obstructed airway disease
ROP
Cardio - HTN, pullm HTN, cardiac failure, PDA
Renal - higher risk of CKD
Higher metabolic risk - DM/obesity
Anetanatal screening
If symptomatic
FFN - poor PPV, good NPV 98%
fetal glycoprotein @ decide/fetal chorioamnion interface
CI: semen, blood, cervical manipulation, lubricants
Combine with CL -> QUIPP
Actim partus - detect if decidual cells damaged, less sensitive and 80% specific
Asymptomatic
TV US - <25mm commence progesterone
<10mm consider cerclage
can be useful in symptomatic women between 24-34/40
Cervical cerclage
McDonalds Purse string suture @ cervicovaginal junction with Mersilene tape
Shirodka - bladder mobilise, insert above cardinal lig
Trans Abdominal - lap insertion @ cervicoisthmic junction
Compare to prog:
Same effective if LR women with short cervix
Indication:
preventing PTB in
- singleton with short cervix
- progressive shortening despite prog
- poor obstetrics hx >3 PTB/midtrimester loss
- painless cervical dilatation <24/40
Complications: bladder damage, PPROM, cervical trauma, pyrexia
Progesterone
200mg till 34/40
Reduce PTB in short cervix by 50%
Reduce PTB in prev PTB
Evidence for PTB
EPPPIC meta- analysis
PV prog in asymptomatic women with prev PTB or short cervix
- reduce PTB, better performance in short cervix women
- favourable neonatal outcome
- no evidence in twins
PROGRESS trial
Asymptomatic short cervix
PTB reduce by 40%
Both showed favourable neonatal outcome but insign
TPL - steroids
promote lung maturation
- alveoli growth & diff -> gas exchange
- T2 pneumocyte dev + surfactant improve lung compliance
- increase No2 -> blood flow
Cochrane steroids
<37/40 1 coourse
Reduce perinatal death, RDS
Probable reduce in IVH, dev delay
No diff in maternal death/infection
ALPS late preterm
- reduce resp treatment
- more neonatal hypoglycaemia
- no diff in chorio/neonatal sepsis
ACTORDS repeat steroids
until 32/40
- reduce RDS, serious morbidity
- 2 year f/u no diff in survival free of mod/severe disability, body size of geenral health
- more seek help for attention problems
TPL - MgSO4
Improve cerebral flow
Reduce excitatory stimuli
S/E peripheral vasodilation
- flush/sweat/sense of warth
COCHRANE:
Reduce CP & death
Reduce CP @ 2 years
Probable reduction of IVH
No diff in death/major dev disability
Fetal growth restriction
Uteroplacental insufficiency
(PET - poor placentation/APLS/DM - vasculopathy)
- asymmetrical IUGR
- inadequate trophoblastic invasion, poor vascular remodelling-> high resistance placenta
- brain sparing, reduce flow to kidney, reduce liver glycogen to meet demand
Maternal nutrition supply
- weight/drugs/medical conditions
Fetal growth potential
- genetics, multiple Pregnancy, infection
