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Y4 reproductive health > Complicated pregnancy > Flashcards

Complicated pregnancy Flashcards

1
Q

VTE in pregnancy risk factors

A

Smoking

Parity > 3

Age > 35 years

BMI > 30

Reduced mobility, multiple pregnancy

Pre-eclampsia

Gross varicose veins

FHx of VTE, thrombophilia, IVF pregnancy

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2
Q

VTE in pregnancy prophylaxis

A

Start from:

  • 28 weeks if 3 risk factors
  • first trimester if there are four or more of these risk factors

All pregnant women should have a risk assessment for their risk of VTE at booking; performed again at birth

LMWH unless contraindicated, continued throughout the antenatal period & for six weeks postnatally (temporarily stopped if woman goes into labour)

Mechanical prophylaxis → intermittent pneumatic compression, anti-embolic compression stockings

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3
Q

VTE in pregnancy diagnosis

A

Doppler USS - repeat if negative on days 3 & 7 in patients with a high index of suspicion of DVT

Suspected PE - CXR, ECG

CTPA/VQ scan

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4
Q

VTE in pregnancy mx

A

LMWH - enoxaparin, dalteparin & tinzaparin

  • should be started immediately before confirming the diagnosis in patients with DVT/PE
  • continued for remainder of pregnancy & six weeks postnatally/three months in total
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5
Q

Maternal sepsis aetiology

A

Chorioamnionitis

Urinary tract infections

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6
Q

Chorioamnionitis

A

Infection of the chorioamniotic membranes & amniotic fluid

Usually occurs in later pregnancy & during labour

Can be caused by a large variety of bacteria → gram-positive bacteria, gram-negative bacteria & anaerobes

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7
Q

Chorioamnionitis clinical features

A

Abdominal pain

Uterine tenderness

Vaginal discharge

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8
Q

Maternal sepsis presentation

A

MEOWS - monitors physical observations to identify signs of sepsis

Non-specific signs - fever, tachycardia, raised RR, reduced oxygen sats, low BP, altered consciousness, reduced urine output, raised white cells on FBC, fetal compromise on CTG

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9
Q

Maternal sepsis ix

A

FBC, U&Es, LFTs, CRP, clotting, blood cultures, blood gas

Additional ix for suspected source → urine dipstick & culture, high vaginal swab, throat swab, sputum culture, wound swab after procedures, LP

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10
Q

Maternal sepsis mx

A

Senior obstetricians and midwives should be involved early in the care of the women with suspected chorioamnionitis/sepsis

Sepsis 6

Continuous maternal & fetal monitoring is required

Abx from local guidelines

  • tazocin + gentamicin
  • amoxicillin + clindamycin + gentamicin
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11
Q

Placental abruption

A

A part/all of the placenta separates from the wall of the uterus prematurely

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12
Q

Placental abruption pathophysiology

A

Thought to occur following a rupture of maternal vessels within the basal layer of the endometrium

Blood accumulates & splits the placental attachment from the basal layer

Detached portion of the placenta is unable to function → rapid fetal compromise

Two types:

  • revealed - bleeding tracks down from the site of placental separation and drains through the cervix, results in vaginal bleeding
  • concealed - bleeding remains within the uterus & typically forms a clot retroplacentally; bleeding is not visible but can be severe enough to cause systemic shock
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13
Q

Placental abruption risk factors

A

Placental abruption in previous pregnancy

Pre-eclampsia & other HTN disorders

Abnormal lie of the baby

Polyhydramnios

Abdominal trauma

Smoking/drug use

Bleeding in first trimester

Underlying thrombophilias

Multiple pregnancies

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14
Q

Placental abruption clinical features

A

Painful vaginal bleeding

O/E - woody uterus (tense all of the time) & painful on palpation

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15
Q

Placental abruption ix

A

Bloods - FBC, clotting profile, Kleihauer, group and save, cross-match, U&Es, LFTs

CTG if > 26 weeks

Transvaginal scan

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16
Q

Placental abruption mx

A

ABCDE

Emergency delivery - maternal +/- fetal compromise

Induction of delivery - haemorrhage at term without maternal or fetal compromise

Conservative mx - for partial/marginal abruptions not associated with maternal or fetal compromise

Give anti-D within 72 hours of the onset of bleeding if the woman is Rh D-

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17
Q

Placenta praevia

A

Placenta is fully or partially attached to the lower uterine segment

Important cause of antepartum haemorrhage - vaginal bleeding from week 24 of gestation until delivery

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18
Q

Placenta praevia pathophysiology

A

Minor placenta praevia - placenta is low but does not cover the internal cervical os

Major placenta praevia - placenta lies over the internal cervical os

Low-lying placenta is more susceptible to haemorrhage

  • can be spontaneous or provoked by mild trauma (vaginal examination)
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19
Q

Placenta praevia risk factors

A

Previous CS - main

High parity

Maternal age > 40 years

Multiple pregnancy

Previous placenta praevia

History of uterine infection

Curettage to the endometrium after miscarriage/termination

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20
Q

Placenta praevia clinical features

A

Painless vaginal bleeding

Can be pain if woman is in labour

O/E - CS scar, multiple pregnancy, uterus is not tender on palpation

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21
Q

Placenta praevia ix

A

Bloods - FBC, clotting profile, Kleihauer test (if woman if Rh-, determine amount of haemorrhage & dose of anti-D), group and save, cross-match, U&Es, LFTs

Woman > 26 weeks, CTG performed

Digital vaginal examination should not be performed → may provoke severe haemorrhage

Transvaginal USS

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22
Q

Placenta praevia mx

A

ABCDE

May be identified in an asymptomatic patient at their 20 weeks USS:

  • placenta praevia minor → repeat scan at 36 weeks
  • placenta praevia major → repeat scan at 32 weeks

CS safest mode of delivery (elective at 38 weeks)

All cases of antepartum haemorrhage → give anti-D within 72 hours of the onset of bleeding if woman if Rh D-

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23
Q

Vasa praevia

A

Condition where the fetal vessels are within the fetal membranes & travel across the internal cervical os

The vessels are placed over internal cervical os, before the fetus

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24
Q

Vasa praevia pathophysiology

A

Fetal vessels are exposed, outside the protection of the umbilical cord/placenta

Travel through the chorioamniotic membranes & pass across the internal cervical os

Exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour & at birth

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25
Q

Vasa praevia types

A

Type I - fetal vessels are exposed as a velamentous umbilical cord

Type II - fetal vessels are exposed as they travel to an accessory placental lobe

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26
Q

Vasa praevia risk factors

A

Low lying placenta

IVF pregnancy

Multiple pregnancy

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27
Q

Vasa praevia clinical features

A

Triad - painless vaginal bleeding, rupture of membranes & fetal bradycardia

May be diagnosed by ultrasound during pregnancy → planned CS

APH, with bleeding during the second/third trimester of pregnancy

May be detected during labour → when fetal distress & dark red bleeding occur following rupture of the membranes

O/E - pulsating fetal vessels seen in membranes through the dilated cervix

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28
Q

Vasa praevia mx

A

Asymptomatic women with vasa praevia:

  • corticosteroids from 32 weeks
  • elective CS planned for 34-36 weeks

Emergency CS for APH

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29
Q

Uterine sources of APH

A

Circumvallate placenta

Placental sinuses

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30
Q

Lower genital tract sources of APH

A

Cervical polyps

Cervical erosions & carcinoma

Cervicitis

Vaginitis

Vulval varicosities

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31
Q

Primary post-partum haemorrhage

A

Loss of >500 ml of blood PV within 24 hours of delivery

Minor - 500-1000ml of blood loss

Major - > 1000ml of blood loss

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32
Q

Primary post-partum haemorrhage aetiology & risk factors

A

Tone - uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle

  • maternal profile: age > 40, BMI > 35, Asian ethnicity
  • uterine over-distension: multiple pregnancy, polyhydramnios, fetal macrosomia
  • labour - induction, prolonged
  • placental problems - praevia, abruption, previous PPH

Tissue - retention of placenta tissue

Trauma - refers to damage sustained to the reproductive tract during delivery

  • instrumental vaginal deliveries
  • episiotomy
  • CS

Thrombin - coagulopathies and vascular abnormalities which increase of primary PPH:

  • vascular - placental abruption, HTN, pre-eclampsia
  • coagulopathies - VWD, haemophilia A/B, ITP or acquired eg. DIC, HELLP
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33
Q

Primary post-partum haemorrhage clinical features

A

PV bleeding

Dizziness, palpitations, SoB

O/E - haemodynamic instability, signs of uterine rupture, reveal sites of local trauma, examination of placenta

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34
Q

Primary post-partum haemorrhage ix

A

Bloods - FBC, cross match 4-6 units of blood, coagulation profile, U&Es, LFTs

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35
Q

Primary post-partum haemorrhage definitive mx

A

Uterine atony - bimanual compression to stimulate uterine contraction, pharmacological measures, surgical measures (intrauterine balloon tamponade)

Trauma - primary repair of laceration if uterine rupture

Tissue - IV oxytocin, manual removal of placenta & prophylactic abx in theatres

Thrombin - correct any coagulation abnormalities with blood products under the advice of the haematology team

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36
Q

Syntocinon

A

Synthetic oxytocin, act on oxytocin receptors in the myometrium

SEs: N&V, headache

Contraindications: hypertonic uterus, severe CVS disease

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37
Q

Ergometrine

A

Multiple receptor sites action

SEs: HTN, nausea, bradycardia

Contraindications: HTN, eclampsia, vascular disease

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38
Q

Carboprost

A

Prostaglandin analogue

SEs: bronchospasm, pulmonary oedema, HTN, CVS collapse

Contraindications: cardiac disease, pulmonary disease, untreated PID

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39
Q

Misoprostol

A

Prostaglandin analogue

SEs: diarrhoea

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40
Q

Primary post-partum haemorrhage prevention

A

Active management of the 3rd stage of labour routinely reduces PPH risk by 60%:

  • women delivering vaginally should be administered 5-10 units of IM oxytocin prophylactically
  • women delivery via SC should be administered of IV oxytocin
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41
Q

Secondary post-partum haemorrhage

A

Excessive vaginal bleeding in the period from 24 hours after delivery to twelve weeks postpartum

42
Q

Secondary post-partum haemorrhage aetiology & risk factors

A

Uterine infection - CS, premature rupture of membranes, long labour

Retained placental fragments or tissue

Abnormal involution of the placental site

Trophoblastic disease

43
Q

Secondary post-partum haemorrhage clinical features

A

Excessive vaginal bleeding

  • spotting on and off for days, with an occasional gush of fresh blood
  • 10% have massive haemorrhage

Endometritis - fevers/rigors, lower abdominal pain or foul smelling lochia

O/E: lower abdominal tenderness, uterus may be high, speculum to see amount of bleeding + high vaginal swab

44
Q

Secondary post-partum haemorrhage ix

A

Bloods - FBC, U&Es, CRP, coagulation profile, group and save, blood cultures

Pelvic USS

45
Q

Secondary post-partum haemorrhage

A

Abx - ampicillin & metronidazole (gentamicin added in cases of endomyometritis or overt sepsis)

Uterotonics - syntocinon, syntometrine, carboprost, misoprostol

Surgical measures - excessive/continuing bleeding

46
Q

Breech presentation

A

Fetus presents buttocks or feet first

47
Q

Breech presentation types

A

Complete (flexed breech) - both legs are flexed at the hips and knees

Frank (extended breech) - both legs are flexed at the hip and extended at the knee → most common type

Footling breech - one or both legs extended at the hip, so foot is the presenting part

48
Q

Breech presentation risk factors

A

Uterine - multiparity, uterine malformations, fibroids, placenta praevia

Fetal - prematurity, macrosomia, polyhydramnios, twin pregnancy, abnormality

49
Q

Breech presentation clinical features

A

Identified on clinical examination - round fetal head can be felt in the upper part of the uterus & irregular mass in the pelvis

20% → not diagnosed until labour → signs of fetal distress eg. meconium stained liquor

50
Q

Breech presentation external cephalic version

A

Manipulation of the fetus to a cephalic presentation through the maternal abdomen

50% success rate

Offered from 37 weeks gestation

Complications - fetal heart abnormalities, placental abruption

51
Q

Breech presentation CS

A

Elective CS offered if ECV not possible

52
Q

Vaginal breech birth

A

Contraindication - footling breech

Specific manoeuvres:

  • flexing the fetal knees
  • Lovsett’s manoeuvre - rotate the body and deliver the shoulders
  • MSV manoeuvre - deliver the head by flexion
53
Q

Breech presentation complications

A

Cord prolapse

Fetal head entrapment

Premature rupture of membranes

Birth asphyxia

Intracranial haemorrhage

54
Q

VBAC mx

A

Women should deliver in a hospital setting

Continuous CTG monitoring

Beware of additional analgesic requirements → may indicate impeding uterine rupture

Avoid induction

Caution augmentation

After 39 weeks, an elective repeat CS is recommended

55
Q

VBAC benefits

A

If successful, shorter hospital stay and recovery

Lower risk of maternal death

Good chance of successful future VBACs if successful

56
Q

VBAC risks

A

Uterine rupture

Anal sphincter injury

HIE to neonate

Risk of stillbirth beyond 39 weeks whilst awaiting spontaneous labour

57
Q

VBAC contraindications

A

Absolute - classical CS scar, previous uterine rupture

Relative - complex uterine scars or >2 prior lower segment CS

58
Q

SGA

A

An infant with a birth weight < 10th centile for its gestational age

59
Q

SGA aetiology

A

Normal small

Placental mediated growth restriction - growth is usually normal initially but slows in utero

Non-placenta mediated growth restriction - growth is affected by fetal factors eg. chromosomal/structural anomaly, error in metabolism or fetal infection

60
Q

SGA risk factors

A

Minor - maternal age > 35, smoker 1-10/day, nulliparity, IVF singleton

Major - previous SGA baby, maternal/paternal SGA, previous stillbirth, smoker > 11 day

61
Q

SGA prevention

A

Modifiable risk factors management

High risk of PE → 75mg aspirin 16 weeks gestation until delivery

62
Q

SGA surveillance

A

UAD should be primary surveillance tool

Normal → repeat every 14 days; abnormal → repeat more frequently/consider delivery

63
Q

SGA delivery

A

Delivery is being considered between 24 & 35+6 weeks gestation → single course of antenatal steroids

< 37 weeks - absent/reverse end-diastolic flow on Doppler → CS

By 37 weeks - abnormal UAD/MCA doppler → can offer induction

At 37 weeks - normal UAD → can offer induction

64
Q

SGA neonatal complications

A

Birth asphyxia

Meconium aspiration

Hypothermia

Hypo-/hyperglycaemia

Polycythaemia

NEC

65
Q

SGA long-term complications

A

CP

Type 2 diabetes

Obesity

HTN

Precocious puberty

Behavioural problems

66
Q

LGA aetiology

A

Constitutional

Maternal diabetes

Previous macrosomia

Maternal obesity/rapid weight gain

Overdue

Male baby

67
Q

LGA risks

A

Mother → shoulder dystocia, failure to progress, perineal tears, instrumental delivery/caesarean, PPH, uterine rupture

Baby → birth injury (Erb’s palsy, clavicular fracture), neonatal hypoglycaemia, obesity in later life, T2DM in adulthood

68
Q

LGA mx

A

USS to exclude polyhydramnios

OGTT for GDM

Main risk = shoulder dystocia

  • risk reduced by having access to obstetrician, paediatrician & active management of third stage of labour
69
Q

Oligohydramnios

A

Low level of amniotic fluid during pregnancy

70
Q

Oligohydramnios aetiology

A

PPROM

Placental insufficiency

Renal agenesis

Non-functional fetal kidneys

Obstructive uropathy

Genetic/chromosomal anomalies

Viral infections

71
Q

Oligohydramnios ix

A

H&E - symptoms of leaking fluids & feeling damp all the time

USS

Karyotyping (if appropriate)

72
Q

Oligohydramnios mx

A

Largely dependent on the underlying cause

Ruptured membranes - labour likely to commence within 24-48 hours in most; course of steroids & abx given; IoL considered around 34-36 weeks if no spontaneous labour

Placental insufficiency - babies are likely to be delivered before 36-37 weeks

73
Q

Polyhydramnios

A

Abnormally large level of amniotic fluid during pregnancy

74
Q

Polyhydramnios aetiology

A

Idiopathic

Any condition that prevents fetus from swallowing - oesophageal atresia, CNS abnormalities, muscular dystrophies

Duodenal atresia ‘double bubble’

Anaemia

Fetal hydrops

Twin to twin transfusion syndrome

75
Q

Polyhydramnios clinical assessment

A

Examination - tense uterus?

USS - diagnosis

Maternal glucose tolerance test

Karyotyping

TORCH screen

Maternal red cell antibodies should be checked

76
Q

Polyhydramnios mx

A

No medical intervention required in majority

Maternal sx severe → aminoreduction; not performed routinely due to association with infection & placental abruption

Indomethacin can be used to enhance water retention → associated with premature closure of DA → not used beyond 32 weeks

77
Q

Multiple pregnancy types

A

Monozygotic - identical twins

Dizygotic - non-identical twins

Monoamniotic - single amniotic sac

Diamniotic - two separate amniotic sacs

Monochorionic - share a single placenta

Dichorionic - two separate placentas

78
Q

Multiple pregnancy diagnosis

A

Usually diagnosed on the booking ultrasound scan

Dichorionic diamniotic - lambda sign/twin peak sign

Monochorionic diamniotic - T sign

Monochorionic monoamniotic - no membrane separating the twins

79
Q

Multiple pregnancy maternal complications

A

Anaemia

Polyhydramnios

Hypertension

Malpresentation

Spontaneous preterm birth

Instrumental delivery/CS

PPH

80
Q

Multiple pregnancy fetal complications

A

Miscarriage

Stillbirth

Fetal growth restriction

Prematurity

Twin-twin transfusion syndrome

Twin anaemia polycythaemia sequence

Congenital abnormalities

81
Q

Multiple pregnancy antenatal care

A

Specialist multiple pregnancy obstetric team

Additional monitoring for anaemia - FBC at booking, 20 weeks gestation + 28 weeks gestation

Additional USS scans

  • 2 weekly scans from 16 weeks for monochorionic twins
  • 4 weekly scans from 20 weeks for dichorionic twins

Planned birth offered

82
Q

Stillbirth

A

Birth of a dead fetus after 24 weeks gestation

83
Q

Stillbirth aetiology

A

Unexplained

Pre-eclampsia

Placental abruption

Vasa praevia

Cord prolapse/wrapped around the fetus neck

Obstetric cholestasis

Diabetes

Thyroid disease

Infections eg. rubella, parvovirus

Genetic abnormalities/congenital malformations

84
Q

Stillbirth risk factors

A

Fetal growth restriction

Smoking

Alcohol

Increased maternal age

Maternal obesity

Twins

Sleeping on the back

85
Q

Stillbirth prevention

A

Risk assessment for SGA/FGR

Modifiable risk factors treated - stopping smoking, avoiding alcohol & effective control of diabetes

Ask about three key symptoms - reduced fetal movements, abdominal pain, vaginal bleeding

86
Q

Stillbirth mx

A

USS confirms diagnosis

Rhesus-D negative women require anti-D prophylaxis when IUFD is diagnosed

Vaginal birth 1st line → IoL or expectant management choice

Dopamine agonists can be used to suppress lactation after stillbirth

Testing can be carried out after stillbirth to determine the cause → genetic testing of the fetus & placenta, postmortem examination, testing maternal & fetal infection

87
Q

Prematurity

A

Infants born < 37 weeks gestation

88
Q

Prematurity neonatal risks

A

Neonatal death

Respiratory distress syndrome

Chronic lung disease

Intraventricular haemorrhage

NEC

Sepsis

Retinopathy of prematurity

89
Q

Umbilical cord prolapse

A

Umbilical cord descends through the cervix, with (or before) the presenting part of the fetus

90
Q

Umbilical cord prolapse pathophysiology

A

Fetal hypoxia occurs via two main mechanisms:

  • occlusion - presenting part of the fetus presses onto the umbilical cord, occluding the blood flow to the fetus
  • arterial vasospasm - exposure of the umbilical cord to the cold results in vasospasm
91
Q

Umbilical cord prolapse risk factors

A

Breech presentation

Unstable lie

Artificial rupture of membranes

Polyhydramnios

Prematurity

92
Q

Umbilical cord prolapse clinical features

A

Always be considered in the presence of a non-reassuring fetal heart rate pattern & absent membranes

Can be confirmed by external inspection/digital vaginal examination

93
Q

Umbilical cord prolapse mx

A

Call for help - obstetric emergency

Avoid handling the cord

Manually elevate the presenting part by lifting the presenting part off the cord by vaginal digital examination

Encourage into left lateral position

Consider tocolysis - relax uterus & stop contractions

Delivery via emergency CS

94
Q

Shoulder dystocia

A

Refers to a situation where, after the delivery of the head, the anterior shoulder of the fetus becomes impacted on the maternal pubic symphysis OR less commonly the posterior shoulder becomes impacted on the sacral promontory

Obstetric emergency

95
Q

Shoulder dystocia pre-labour risk factors

A

Previous shoulder dystocia

Macrosomia

Diabetes

Maternal BMI > 30

Induction of labour

96
Q

Shoulder dystocia intrapartum risk factors

A

Prolonged 1st stage of labour

Secondary arrest

Prolonged second stage of labour

Augmentation of labour with oxytocin

Assisted vaginal delivery

97
Q

Shoulder dystocia immediate mx

A

Call for help

Advise mother to stop pushing

Avoid downwards traction on the fetal head

Consider episiotomy - make access for manoeuvres easier

98
Q

Shoulder dystocia manoeuvres

A

First line - McRoberts, suprapubic pressure applied in a sustained/rocking fashion

Second line - posterior arm, internal rotation (’corkscrew manoeuvre’)

99
Q

Shoulder dystocia post-delivery

A

Active mx of 3rd stage of labour

PR to exclude a 3rd degree tear

Debrief the mother & birth partner

PT r/v before discharge

Paediatric r/v

100
Q

Shoulder dystocia complications

A

Maternal - 3rd/4th degree tears, PPH

Fetal - humerus/clavicle fracture, brachial plexus injury, hypoxia brain injury

Y4 reproductive health (11 decks)

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