case based obstetrics Flashcards
You are a registrar working in the maternity hospital.
Gabrielle is a very distressed primiparous 26-year-old who has presented with heavy vaginal bleeding at 31 weeks gestation.
Gabrielle is not in pain.
What is the most likely cause?
placenta praevia
what are other causes of antepartum haemorrage
Placental abruption (painful!), placenta accreta, vasa praevia, local lesions of genital tract
How is placenta praevia diagnosed?
Ultrasound scan – transvaginal may be required to provide accurate measurement of how placenta is related to the cervix
This is safe to do, but please note vaginal exam is not safe as may exacerbate haemorrhage
How does low lying placenta differ from placenta praevia?
RCOG guideline 2018:
The American Institute of Ultrasound in Medicine (AIUM)8 has recommended that the term ‘placenta praevia’ is used when the placenta lies directly over the internal os. For pregnancies greater than 16 weeks of gestation, the placenta should be reported as ‘low lying’ when the placental edge is less than 20 mm from the internal os, and as normal when the placental edge is 20 mm or more from the internal os on TAS or TVS. This new classification could better define the risks of perinatal complications, such as antepartum haemorrhage and major postpartum haemorrhage (PPH),9, 10 and has the potential of improving the obstetric management of placenta praevia. Recent articles reviewed in this guideline refer to the AIUM classification.
Once admitted, how would you manage Gabrielle?
ABCDE approach
IV access, cross match and transfusion if shocked
Foetal monitoring CTG
Ultrasound if diagnosis in doubt and patient stable
Maternal monitoring HR, BP, temp.
Steroids if preterm delivery likely - IM betamethasone/dexamethasone
Magnesium sulphate if preterm delivery imminent
Anti-D if rhesus negative
38-year-old G2P1 has rupture of membranes at 33 weeks gestation
What do we mean by G2P1?
Gravida 2, Para 1
Gravida = total number of confirmed pregnancies that a woman has had (including current pregnancies), regardless of the outcome
Parity (x+y) common interpretation – no absolute authority and many interpretations exist
X = number of deliveries alive or dead after 24 weeks gestation
Y = number of deliveries alive or dead before 24 weeks gestation (nearly always dead, any ectopic, miscarriages etc.)
i.e. this lady has one child, and is expecting another!
You are a registrar working in O&G.
Tracy, a 38-year-old with gestational diabetes, presents with a clear gush of liquid from the vagina.
Tracy reports no contractions.
Has labour started?
What is the name of this condition?
No; labour is defined as the onset of contractions with progressive cervical change
Prelabour premature rupture of membranes (PPROM)
Onset of labour before how many weeks is defined as ‘preterm’?
Onset of labour before 37 completed weeks gestation
32-36 weeks mildly preterm
28-32 weeks very preterm
24-28 weeks extremely preterm
What are some complications of PPROM?
Pre-term delivery – resulting in neonatal morbidity (e.g. low birth weight, respiratory hypoplasia, sepsis)
Chorioamnionitis (inflammation foetal membranes due bacterial infection) leading to sepsis in baby and/or mother
Abruption
You perform a sterile speculum examination. The cervix is closed, and a foetal fibrinonectin (fFN) test is negative. A high vaginal swab is taken to check for infection.
What does a negative fFN test tell us?
Negative - labour unlikely in the next 2 weeks
If positive, likely in next 2 weeks => therefore steroids, tocolysis, analgesia and hospital observation may be indicated
Tracy receives prophylactic antibiotics to reduce risk of chorioamnionitis, and corticosteroids (IM betamethasone). The recommendation is to observe then discharge, with the aim to induce birth after 36 weeks gestation.
Why were corticosteroids administered?
Induce foetal lung maturation. 2 IM injections (dexamethasone or betamethasone) 24 hrs apart (effect is maximal 24hrs after the second dose) are given.
Sometimes tocolytics are administered too, why not here?
Tocolytics aim to stop contractions to allow time for steroids to work before birth or to allow transfer to an appropriate facility for birth. As Tracy has no contractions here, tocolytics are not indicated.
What are some signs of respiratory distress syndrome?
STERNAL and SUBCOSTAL RECESSION
Increased RESP RATE
Expiratory Grunting
Diminished Breath Sounds
Cyanosis
Nasal Flaring
How is respiratory distress syndrome managed?
Oxygen. Early treatment with surfactant if required. Continuous positive airway pressure (CPAP) and minimal intervention.
