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Y4 Obs & Gyn > Complicated Pregnancy - labour > Flashcards

Complicated Pregnancy - labour Flashcards

1
Q

what could cause an ante-partum haemorrhage?

A

placenta praevia
placental abruption
vasa praevia
polyps, infections etc

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2
Q

what is placental praevia?

A

placenta lies in lower uterine segment, can lead to covering internal cervical os

graded 1 to 4 –> not reaching os to completely covering os

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3
Q

what are risk factors for placental praevia?

A

previous caesarean
previous TOP
multiparity
advanced maternal age
multiple pregnancy
deficient endometrium with manual placenta removal
smoking

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4
Q

how might placenta praevia present?

A

hx: painless vaginal bleeding, light contractions

examinations: non-tender uterus, vaginal bleeding, lie and presentation abnormal, low lying placenta on 20w anomaly scan

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5
Q

how is ante-partum haemorrhages investigated?

A

bedside: vitals
lab: FBC, U&E, LFT, clotting, G&S, crossmatch, Kleihauer test
imaging: CTG, USS

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6
Q

how is placenta praevia managed?

A
  • 16-20w → if identified rescan at 32w, and again at 36w
  • in still at 36w, delivery via C-section
    • risk of spontaneous labour, associated haemorrhage
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7
Q

what is placental abruption?

A

complete or partial detachment of placenta before delivery, causing rupture of maternal vessels and hence reduced blood flow and oxygenation to foetus

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8
Q

what are some risk factors for placental abruption?

A
  • maternal age 35+
  • multiparity
  • current pre-eclampsia
  • previous abruptions
  • smoking or cocaine use in pregnancy
  • trauma
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9
Q

how might placental abruption present?

A
  • abdominal pain
  • vaginal bleeding
  • uterine contractions
  • dizziness and LOC

O/E tense uterus, absent or distressed foetal heart

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10
Q

what is your understanding of revealed vs concealed placental abruption?

A

if amount of blood does not correlate with the degree of abruption or shock
- blood may be accumulating instead of tracking down out of vagina and maybe concealed

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11
Q

what are some investigations carried out in suspected placental abruption?

A
  • bedside - vitals
  • labs - FBC, U&E, LFT, clotting, G&S, crossmatch, Kleihauer
  • imaging - transvaginal USS, CTG
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12
Q

how is placental abruption managed?

A
  • if foetus alive with no distress closely observe if <36w and if over deliver vaginally
  • if signs of distress immediate C-section
  • no signs of life then induce vaginal or C section if haemodynamically compromised
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13
Q

what are some complications of placental abruption to mother and baby?

A
  • mother: major haemorrhage, shock, DIC, PPH
  • baby: placental insufficiency, prem birth, stillbirth
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14
Q

what is vasa praevia?

A

fetal blood vessels (the two umbilical arteries and single umbilical vein) arewithin the fetal membranesand run across theinternal cervical os and not protected within umbilical cord or placenta

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15
Q

how is vasa praevia managed?

A
  • elective C- section at 34-36 w
  • corticosteroids from 32w to promote foetal lung maturity
  • APH → C-section required
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16
Q

what are some other causes of APH?

A
  • polyps
  • carcinoma
  • infection
  • placental accreta where placenta embedded into myometrium abnormally
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17
Q

how would you classify a PPH?

A

*blood loss of over 500ml after childbirth
minor: 500-1000ml
major: >1000ml

primary: within 24h
secondary: 24h to upto 12w postnatal

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18
Q

what are the primary and secondary causes of PPH?

A

primary - 4T
tone, trauma, tissue, thrombin

secondary
endometriosis, retained products of conception

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19
Q

what are some RF for PPH?

A

previous PPH
overdistension of uterus: polyhydramnios
clotting disorders
multiparity
prolonged labour
placental praevia

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20
Q

what investigations would you do as a result of a PPH or before?

A
  • labs: FBC, clotting, G&S, crossmatch, baselines
  • sepsis screen
  • pelvic USS
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21
Q

how do you manage PPH?

A
  • A to E
  • tone: oxytocin, bimanual compression, balloon tamponade
  • trauma: repair
  • tissue: manual removal of placenta
  • thrombin: tranexemic acid, blood products, vitamin K
  • secondary: infection mx, USS, transfusion
22
Q

what are some complications of a PPH?

A
  • anaemia
  • hypovolaemic shock
  • PTSD
  • hysterectomy
  • DIC
  • Sheehans
  • death
23
Q

what is a cause of thromboembolism during labour?

A

amniotic fluid embolism

*rupture of membranes, at CS, during delivery, rarely even with termination, manual removal of placenta and amniocentesis

24
Q

what are some risk factors for an amniotic fluid embolism?

A
  • multiple pregnancy
  • maternal age >35
  • CS
  • instrumental delivery
  • eclampsia
  • polyhydramnios
  • placental abruption
  • uterine rupture
  • induction of labour
25
Q

how might an amniotic fluid embolism present?

A

maternal collapse
dyspnoea, chest pain, hypoxia, ARDS
hypotension
reduced consciousness

*anaphylaxis like picture

26
Q

how is an amniotic fluid embolism managed?

A
  • high flow oxygen and anaesthetics for intubation
  • cardiopulmonary resus
  • fluids if hypotensive
  • catheterise pulmonary artery
  • treat DIC with whole blood of packed cells
  • delivery baby by cs IF ARREST
  • *POSTMORTEM - examine lungs for amniotic squames and lanugo hair
27
Q

what is the pathophysiology of maternal sepsis?

A
  • naturally occurring immunological changes with pregnancy
  • need for procedures and surgery
  • wounds
  • risks such as PROM or GD
  • bacterial infection of uterus, UTI or pneumonia
  • chronic disease
28
Q

how might maternal sepsis present?

A
  • tachycardia
  • tachypnoea
  • oliguria
  • rigours and pyrexia
  • abdo pain
  • offensive vaginal discharge
  • altered consciousness
29
Q

how might you investigate sepsis?

A
  • Full blood count, CRP, U&E’s, lactate, glucose, clotting screen incl. fibrinogen
  • Blood cultures (even if the woman is on antibiotics)
  • Midstream urine
  • Any other relevant swabs of wound, pus, vagina, placenta, sputum
  • Throats swabs
  • Chest X-ray and USS
30
Q

how do you manage maternal sepsis?

A

SEPSIS 6 PLUS 1
- plus 1 is foetal monitoring with CTG

  • thrombosis-prophylaxis
  • continuous obs every 15min until stabilised
  • catheterise
31
Q

what could cause maternal collapse?

A

haemorrhage
thromboembolism
cardiac disease like aortic dissection
sepsis
drug toxicity
eclampsia
anaphylaxis
hypoglycaemia

32
Q

what are some resus difficulties in pregnancy?

A
  • aortocaval compression and reduced CO from 20 weeks gestation onwards and affects compression efficacy
  • resp changes with lung function, increased O2 consumption etc
  • intubations difficult as weight gain, laryngeal oedema etc
  • aspiration where pregnant women are at higher risk
  • circulation increased to blood can be lost rapidly
33
Q

how do you manage maternal collapse?

A

A TO E

34
Q

what are some risk factors associated with prematurity?

A
  • Social deprivation
  • Smoking, Alcohol, Drugs
  • Overweight or underweight mother
  • Maternal co-morbidities
  • Twins - multiple pregnancy
  • Personal or family history of prematurity
  • early pregnancy - within 6m of previous
  • infection, diabetes, hypertension
  • trauma
35
Q

how might you manage prematurity?

A
  • delay birth: vaginal progesterone, cervical cerclage
  • when in labour: tacolysis with nifedipine, IV magnesium, steroids
  • supportive care post delivery
36
Q

what are some early complications of prematurity?

A
  • Respiratory distress syndrome
  • Hypothermia
  • Hypoglycaemia
  • Poor feeding
  • Apnoea and bradycardia
  • Neonatal jaundice
  • Intraventricular haemorrhage
  • Retinopathy of prematurity
  • Necrotising enterocolitis
  • Immature immune system and infection
37
Q

what are some later complications of prematurity?

A
  • Chronic lung disease of prematurity (CLDP)
  • Learning and behavioural difficulties
    • gross motor, fine motor, speech and language
  • Susceptibility to infections, particularly respiratory tract infections
  • Hearing and visual impairment
  • Cerebral palsy
38
Q

what counts as prolonged labour?

A

prolonged when combine duration of the first and second stage is more than 18h

39
Q

what might prolong labour?

A
  • fault in power: abnormal contractions, incoordinate contractions
  • fault in passage: contacted pelvis, cervical dystocia, pelvic tumour, full bladder, spasms, old scarring
  • fault in passenger: malposition (OP), malpresentation (face, brow), anomalies of foetus (hydrocephalus), macrosomia
40
Q

what are the risks of prolonged labour?

A

foetal: hypoxia, infection, intracranial stress and haemorrhage
maternal: distress, PPH, trauma, puerperal sepsis

41
Q

how do you manage a prolonged labour?

A
  • prevention with early detection, use of partograph, change in posture
  • careful evaluation in mother and foetus
  • correct dehydration
  • if uterine activity suboptimal - amniotomy, oxytocin infusion, effective pain relief
  • secondary arrest - C-section and careful oxytocin
  • if FHR reassuring vaginal delivery, otherwise assisted
42
Q

what could cause foetal compromise?

A

can be due to placental insufficiency, uterine hyperstimulation, maternal hypotension, cord compression, placental abruption, uterine rupture, foetal sepsis

*vaginal exams, topping up epidurals, foetal blood obtaining may affect FHR

43
Q

how might you investigate for suspected foetal compromise?

A
  • CTG for HR 110-160 and variability of 6-25 normal
  • scalp electrode
44
Q

what is suggestive of significant foetal compromise?

A
  • bradycardia (below 100bpm for over 5 minutes)
  • absent baseline variability <3bpm
  • sinusoidal foetal heart rate pattern
  • complicated variable decelerations with reduced or absent baseline variability
  • late decelerations with reduced or absent baseline variability
45
Q

how do you manage suspected foetal compromise?

A
  • reposition to lateral
  • administer fluid bolus
  • discontinue oxytocin
  • assess tone
  • catheterisation to empty bladder
  • theatre prep!
  • abx might be needed
46
Q

what is reduced foetal movement suggestive of?

A

foetal compensation to reduce oxygen consumption as a response to chronic hypoxia in utero

  • risk of stillbirth and foetal growth restriction
47
Q

what is the physiology of FM?

A
  • quickening - first recognised foetal movements
    • between 18-20 weeks gestation and increases until 21w and plateaus
    • multiparous experience movements before at 16-18w
    • movements don reduce with pregnancy
48
Q

what are some RF for RFM?

A

posture
distraction
placental position
medication
foetal position
body habits
amniotic fluid
foetal size

49
Q

how is RFM investigated?

A

handheld doppler
USS
CGT
*if movement not felt by 24w referral

50
Q

when would you suspect a retained placenta?

A

Lack of expulsion of placenta within 30 mins of delivery

  • common cause of secondary post-partum haemorrhage
  • excessive vaginal bleeding after 24h from delivery
51
Q

what is the pathophysiology of a retained placenta?

A
  • can be trapped as cervix begun to close, adherent to uterine wall. pathologically invaded myometrium
  • uterus still high on examination if placenta retained
  • Pelvic USS can diagnose retained placenta
52
Q

how do you manage a retained placenta?

A
  • controlled cord traction
  • manual removal of placenta
  • instrumental extraction
  • managing unexpected placenta accreta
  • PPH mx
  • manage underlying

Y4 Obs & Gyn (16 decks)

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