Complications in pregnancy Flashcards
complications/risks of intrahepatic cholestasis of pregnancy (ICP)/obstetric cholestasis (OS)?
- increased rate of stillbirth/intrauterine death-fetal death before or during birth, at 24 weeks or later gestation, and fetal distress-partly due to increased likelihood of meconium passage (baby opens bowels before being born causing green/brown discolouration of fluid)
- increased risk of premature birth (spontaneous and iatrogenic) (1 in 10 will deliver before 37wks).
- maternal morbidity due to intense pruritus and sleep lack
management of intrahepatic cholestasis of pregnancy?
- weekly monitoring of LFTs, if return to normal or soar then revise diagnosis, wait at least 10 days before re-checking after delivery as normal LFT fluctuations during this time in normal pregnancies
- ursodeoxycholic acid for symptomatic relief-GS dissolving agent which reduces cholesterol content in bile
- Vit K PO as may be vit K malabsorption, this will reduce haemorrhagic disease in both mother and baby
- induction from 37 weeks onwards to avoid late stillbirth, has been shown from this time that perinatal and maternal morbidity increases, offer continuous fetal monitoring during labour
definitive management of acute fatty liver of pregnancy?
delivery
RFs for obstetric cholestasis?
occurrence in previous pregnancy FH of condition multiple pregnancy gallstones Hep C
during what stage of pregnancy does obstetric cholestasis tend to present?
3rd trimester
presentation of obstetric cholestasis?
intense pruritus, particularly of palms of hands and soles of feet but can affect any part of body, may be excoriations, no rash
itching often worse at night, may affect sleep
itching can preceed raised LFTs by days or weeks, so important to rpt bloods poss. weekly
may be other symptoms of cholestasis e.g. pale stools, dark urine, jaundice
generalised malaise, fatigue
differentials important to rule out before diagnosing obstetric cholestasis?
other causes of liver disease and pruritus:
- viral hepatitis, including CMV, EBV
- AI hepatitis-anti-smooth muscle, ANA, anti-liver and kidney microsomal type 1 Abs
- drug induced hepatitis
- gallstones
must also exclude fatty liver of pregnancy, and pre-eclampsia-*HELLP-haemolysis, raised LFTs, low PLT-do FBC, BP+urine dip, ?clotting profile
also do liver USS
LFTs-ALT/AST, GGT raised, bilirubin usually raised
total bile acid level
outcome of obstetric cholestasis?
should settle spontaneously following delivery
f/u long enough to allow LFT normalisation, usually recheck at 6weeks
further specialist input needed if have not normalised by 6 months
a/v that significant risk of recurrence (45-90%)
causes of polyhydramnios?
anything which impairs amniotic fluid swallowing by the fetus, increases fetal urination, increases fetal production of fluid from lungs+oral+nasal cavities or interferes with intramembranous and transmembranous absorption-between fetal blood and placenta and across amnion and chorion:
-idiopathic
-congenital anomalies-upper GI atresia, CVS defects, micro or ancephaly, NTDs, renal defects e.g. bartters’s syndrome
-and genetic disorders-trisomy 21, 13, 18
maternal DM
-fetal anaemia-increases CO hence kidney perfusion and urination
-maternal diabetes
-multiple pregnancy
-congenital infections-toxoplasma, parvovirus, CMV, rubella
-hydrops fetalis-assoc. with rhesus haemolytic disease
-maternal substance abuse
-maternal metabolic abnormalities e.g. hypercalcaemia
the more severe the polyhydramnios, the more likely an underlying cause will be found
functions of amniotic fluid?
protect baby from trauma and infection
facilitate lung development
help with development and movement of limbs and other skeletal parts
presentation of polyhydramnios?
- large for dates uterus on antenatal examination-symphysis-fundal height, fetal parts may be difficult to palpate, may see on US examination
- mum-excessive breathlessness, early labour onset or PROM, cord prolapse, abnormal fetal presentation
- acute polyhydramnios-uterus enlarges rapidly, most commonly seen with twin pregnancies-twin to twin transfusion syndrome-unequal blood supply, 1 twin gets most (recipient) whereas other gets little (donor). recipient produces large amount of urine.
differentials for polyhydramnios?
multiple pregnancy
fetal macrosomia
placental abruption-uterine size may rapidly enlarge due to intrauterine haematoma development
chorioangioma-benign lesion of placenta due to excess capillary formation in absence of villus differentiation.
what methods are used via US to diagnose polyhydramnios?
amniotic fluid index-uterine cavity divided into 4 segments, total volume more than 24cm=polyhydramnios
single deepest pocket-deepest pocket measured vertically, more than 8cm.
lab tests that can help exclude associated diseases in polyhydramnios?
blood glucose and OGTT
maternal infection screen
if fetal anemia or hydrops fetalis suspected-maternal anitbodies,
genotyping
management of polyhydramnios?
secondary care
1st step-try to identify underlying cause, treat as appropriate e.g. intravascular transfusion for hydrops fetalis
aim to minimise preterm labour-regular antenatal checks, serial US
during labour require CTG-continuous monitoring
induce labour if fetal distress
corticosteroids if preterm labour suggested or iminent
PG synthetase inhibitors e.g. indometacin-reduce renal blood flow but risk of premature closure of DA, used for max 48hrs
amnioreduction-fluid drainage under US guidance, more commonly used in twin to twin transfusion syndrome, this may also benefit from connecting placental vessel ablation.
polyhydramnios complications?
prematurity, low birth weight, fetal death PROM placental abruption malpresentation PPH cord prolapse mother-UTIs, increased dyspnoea, HTN
what chromosomal abnormalities might be associated with a cystic hygroma?
also known as a macrocystic lymphatic malformation, this is a fluid filled sac, commonly found in neck, head, axilla or chest, that results from obstruction in the lymphatic system. assoc. with: downs syndrome turner's noonan
how is oligohydramnios defined from US?
amniotic fluid volume less than 500ml at 32-38wks
AFI less than 5 from late-mid trimester
max vertical pocket less than 2cm from late-mid trimester
why is oligohydramnios more common in pregnancies beyond term?
amniotic fluid volume normally decreases at term (to around 800ml)
also ?reduced placental function, and reduced fetal renal blood flow and urine production
fetal causes of oligohydramnios?
- congenital problems e.g. renal agenesis, ureteral atresia, obstructive uropathy
- chromosomal factors
- IUGR-chronic hypoxia causes blood shunting away from fetal kidneys towards the brain
- pre-labour rupture of membranes (PROM)
- post-term pregnancy
- fetal demise
placental causes of oligohydramnios?
- abruption
- twin to twin transfusion syndrome (monochorionic twins)
maternal causes of oligohydramnios?
- maternal dehydration
- uteroplacental insufficiency
- HTN, pre-eclampsia
- DM-villous oedema
- drugs-indometacin, ACEis
- chronic hypoxia
-may be idiopathic
3 main ways of amniotic fluid removal?
fetal swallowing-with GI tract absorption, then recirculating by the kidneys or transfer to mother via placental
fetal respiration
continuous bulk flow-hydrostatic and oncotic forces-at chorionic plate
causes of talipes equinovaris (clubfoot)?
idiopathic-most commonly spina bifida cerebral palsy oligohydramnios arthrogryposis edward's syndrome (trisomy 18)-overlapping of the fingers, rocker bottom feet, microcephaly and micrognathia, low set ears, cleft lip and plate, VSD, exomphalos (omphalocele).
who is most commonly affected by clubfoot?
males (twice as common)
usually bilateral
clubfoot features?
CAVE: cavus (high arched foot) forefoot adductiob varus heel hindfoot equinus (plantarflexed)
clubfoot management after birth?
early intervention: ponseti method of serial casting, usually corrected after 6-10 weeks, most also need achilles tenotomy-usually done under LA, and will need to wear night-time braces until 4 years of age.
investigations in cases of oligohydramnios?
- must assess for SLE-ANA, anti-dsDNA, as causes immune mediated placental infarcts and insufficiency, and also other maternal RFs-DM-?OGTT, HTN.
- US-can measure AFI (summation of largest vertical pocket depths in each quadrant) and maximum vertical pocket. look for IUGR-measurements of head+abdo circumference, and femur length. can look at kidneys and fetal bladder to rule out renal agenesis, cystic dysplasia and ureteral agenesis. can do fetal doppler if clinically indicated to look for placental insufficiency.
- sterile speculum examination to assess for PROM.
oligohydramnios management?
- if before term, usually expectant management. regular antepartum monitoring with US-assess fetal growth and f/u of AFV, ensure continuous fetal heart rate monitoring during labour.
- if at term, then deliver, may safely delay with reassuring fetal testing.
- post term-insufficient evidence to recommend induction.
if mum dehydrated, PO or IV rehydration can increase AFV by 30%.
oligohydramnios complications?
pulmonary hypoplasia
fetal compression syndrome
amniotic band syndrome
fetal infection
why are women at increased risk of renal stones in pregnancy?
increased renal excretion of calcium
why is there increased calcium absorption by mum in pregnancy?
increased production of calcitriol due to production of 1 alpha hydroxylase by the placenta which converts vit D into its active form
why is antepartum haemorrhage associated with cerebral palsy?
up to 1/5 of very preterm babies are born in associated with antepartum haemorrhage
define antepartum haemorrhgae
bleeding from or into the genital tract from 24+0 weeks gestation up until before birth of the baby.
causes of antepartum haemorrhage?
placenta praevia-abnormal placentation near or covering the internal cervical os
placental abruption-placenta separation from the uterus
local causes in gential tract-bleeding from the vulva, vagina or cervix
advice regarding induction of older patients in pregnancy?
women aged 40 or over advised induction on their due date if haven’t gone into spontaneous labour by this time to reduce the risk of stillbirth.
why is sensitisation in a pregnancy with a rhesus -ve mother and rhesus +ve fetus problematic for future pregnancies?
risk of sensitisation is greatest in the 1st pregnancy
usually no effect on pregnancy with which it occurs, but for future pregnancies there is a much greater and quicker immune response-production of anti-D Abs by mum which cross placenta and bind to RhD antigen on fetal rbc, causing their removal from the fetal circulation.
severe anaemia can result, which can cause fetal heart failure, fluid retention, fetal hydrops (fluid accumulation in compartments) and fetal death.
also unconjugated hyperbilirubinaemia after birth as bilirubin no longer cleared by placenta and neonatal liver not yet fully mature, which can cause brain damage (kernicterus)-can lead to cerebral palsy, deafness, motor and speech delay.
how can fetal hydrops be managed before birth?
intrauterine transfusions
but this carries a 2% risk of fetal loss
role of anti-D given after potentially sensitising events?
neutralise any RhD antigen on fetal rbc that have gone into the maternal circulation to stop maternal immune response
this is given in addition to routine antenatal anti-D prophylaxis at 28 wks (1500 IU)-may also be given as 2 doses at 28 and 34 weeks-both 500 or both 1000-1650.
usually given by community midwife or at routine antenatal clinic.
iron requirements in pregnancy?
3X that of a non-pregnant menstruating woman, and requirements increase as pregnancy advances
deficiency in pregnancy usually due to nutritional deficiency or low Fe stores from previous pregnancy or heavy menstrual blood loss.
RFs for group B strep infection in baby?
prematurity
prolonged rupture of membranes
maternal pyrexia e.g. secondary to chorioamnionitis
previous sibling GBS infection
management of normocytic or microcytic anaemia in pregnancy?
1st line-trial of oral iron tablets, further investigations only required if no improvement in Hb after 2 wks
indications for parenteral iron in treatment of anaemia in pregnancy?
if oral iron not tolerated, absorbed, patient not compliant, or patient near term and insufficient time for oral iron to be effective.
RFs for placental abruption?
- has happened in a previous pregnancy
- multiparity
- maternal HTN
- cocaine use
- trauma
- uterine overdistension
- smoking
- increasing maternal age
clinical features of placental abruption?
sudden onset severe abdo pain, constant tense, tender uterus shock out of keeping with visible loss PV bleeding normal lie and presentation fetal heart-distress/absent coagulation problems
RFs for placenta praevia?
- multiparity
- multiple gestation
- previous C sections-embryos more likely to implant on a lower segment scar
presentation of placenta praevia?
- painless PV bleeding after 24 weeks gestation
- shock in proportion to visible loss
- small bleeds before large
- uterus non-tender
- abnormal lie and presentation
- fetal heart usually normal
grading of placenta praevia?
1-placenta reaches lower segment but not internal cervical os
2-placenta reaches internal os but doesn’t cover it
3-placenta covers internal os before dilation but not when dilated
4-placenta completely covers internal os
what diagnosis is suggested by frank haematuria with a history of placenta praevia or prior C section?
placenta percreta-invasion of placenta through the myometrium
extension into the bladder can cause severe bleeding.
medical management of an incomplete or missed miscarriage?
vaginal misoprostol (PGE1 analogue) if woman's preference can give PO
800 micrograms single dose if missed miscarriage-pt asymptomatic, 600 if incomplete-retained products of conception on USS
if bleeding has not started after 24hrs post treatment should contact healthcare professional for ongoing management
analgesia and anti-emetics as needed
warn about treatment side effects-pain, D+V
urine pregnancy test 3 wks after treatment, if +ve return for further investigation in case of ectopic or molar pregnancy.
surgical options for miscarriage?
manual vacuum aspiration under LA in clinic or OP
surgical management in theatre under GA
when should systemic methotrexate be offered 1st line for treatment of an ectopic pregnancy?
in those who can return for f/u and have all of the following:
no significant pain
unruptured EP with adnexal mass smaller than 35mm with no visible heartbeat
serum hCG level less than 1500 IU/litre
no intrauterine pregnancy (as confirmed on USS)
when should surgery be offered as 1st line tment for ectopic pregnancy?
those who cannot return for f/u after MTX or have any 1 of the following:
EP with significant pain
EP with adnexal mass of 35mm or larger
EP with a fetal heartbeat visible on USS
EP and serum hCG level of 5000IU/L or more
f/u required for women who have had MTX for an ectopic pregnancy?
2 serum hCG measurements in the 1st week (days 4 and 7) after tment, then 1 per week until a negative result obtained
if hCG levels plateau or rise, reassess the woman’s condition for further treatment.
surgery offered for an ectopic pregnancy?
- salpingectomy, unless other RFs for infertility
- salpingotomy (hole made in FT to remove EP) if RFs for infertility e.g. CL tube damage, advise up to 1/5 will need further tment with MTX/salpingectomy.
- following salpingotomy 1 serum hCG at 7 days post surgery, then 1 per week until -ve.
- urine preg test after 3 wks post salpingectomy.
which patients should receive anti-D prophylaxis following a miscarriage or EP?
rhesus -ve women who’ve had surgical management of their miscarriage or EP
dose of 250IU
presentation of a molar pregnancy?
- irregular or heavy PV bleeding
- hyperemesis
- large for dates
- raised BP
- thyrotoxicosis
- abdo pain due to large ovarian cysts
how can serum hCG measurement be helpful in suspecting a molar pregnancy?
levels often much higher than would be expected in a normal pregnancy
what is a complete mole?
usually occur when a single sperm fertilises an ‘empty’ egg which has no genetic material inside, and then divides to give the fertilised egg a normal number of
chromosomes, all of which have come from the father. can also occur when two sperm fertilise an ‘empty’ egg.
what is a partial mole?
2 sperm fertilise a normal egg so developing pregnancy has 3 sets of chromosomes or more
usually some signs of early fetal development on US
in which patients is gestational trophoblastic disease more common?
Asian origin
teenagers
over 40 years of age
management of a molar pregnancy?
surgery-suction operation
if a partial mole, surgery also the preferred treatment, but fetus may be too large to be removed this way, and so may need to have a miscarriage induced with medication.
why is it necessary to know for sure if a patient has had a molar pregnancy?
as there is a small risk that some of the abnormal cells of a molar pregnancy may persist or develop into more severe forms of gestational trophoblastic disease e.g. choriocarcinoma, which will require further treatment.
f/u after a molar pregnancy?
f/u for at least 6mnths after registering with a specialist centre, with urine or blood hCGs to ensure falls back down to normal.
risk of having an IUD after a molar pregnancy?
increased risk of uterine perforation, so can only be given for contraception once hCG levels have returned to normal.
what can a molar pregnancy progress to?
gestational trophoblastic neoplasia (GTN) which includes invasive mole, choriocarcinoma, placental site trophoblastic tumour and epithelioid trophoblastic tumour.
type of cancer
gestational trophoblastic neoplasia management?
chemotherapy-usually methotrexate, continued until 6wks after hCG has returned to normal
hysterectomy may be required for placental site trophoblastic tumour or epithelioid trophoblastic tumour.
should not get pregnant again until 1 year after chemo complete
what is a threatened miscarriage?
PV bleeding at less than 24wks gestation with ongoing pregnancy
how is early or late miscarriage defined?
early-loss or pregnancy at 12 or less week of gestation
late-loss of pregnancy between 13 and 23+6 weeks gestation.
what is PV bleeding after 24wks of pregnancy defined as?
antepartum haemorrhage
what is recurrent miscarriage?
3 or more consecutive miscarriages
causes of miscarriage?
inherited thrombophilias antiphospholipid syndrome poorly controlled diabetes poorly controlled thyroid disease incompetent cervix/cervical insufficiency-cervix is effaced/dilated too early in pregnancy, cervical weakness genetically balanced parental translocation, fetla chromosomal abnormality multiple gestation placental failure uterine abnormality e.g. fibroids infections PCOS
RFs for miscarriage?
age over 30, even more so if over 35yrs, due to increased risk of random chromosomal abnormalities smoking alcohol paternal age over 45yrs uterine abnormality e.g. incompetent cervix uncontrolled diabetes SLE, antiphospholipid Abs low pre-preg BMI obesity fertility problems stress
miscarriage differentials?
- ectopic preg-more severe pain, precedes PV bleeding-less and darker, cervical motion tenderness on vaginal examination
- molar preg
- implantation bleed
- cervical ectropion
- cervicitis/vaginitis
- cervical polyp
- neoplasia
what happens in assessment of suspected miscarriage if gestational sac visible on US but no fetal heartbeat?
2nd scan to be performed, at either 7 or 14 days, depending on CRL or mean gestational sac measurements.
what hCG results suggest an ongoing preg when 2 taken 48hrs apart?
more than 63% increase
how should patients be f/u after medical management of a miscarriage with misoprostol?
preg test 3 weeks after receiving med management
unless develop worsening symptoms-should be r/v in case of ectopic or molar pregnancy
a/v bleeding can continue for up to 3wks
clinical indications for offering surgical evacuation of a miscarriage?
persistent excessive bleeding
haemodynamic compromise
infected retained tissue
gestational trophoblastic disease
how is hyperemesis gravidarum diagnosed?
protracted N+V with triad of more than 5% prepregnancy weight loss, dehydration and electrolyte imbalance.
antiemetics for hyperemesis gravidarum?
1st line: promethazine or cyclizine
2nd line: prochlorperazine, metoclopramide, ondansetron
PPIs, and H2 antagonists may be useful if also dyspepsia
vitamin supplements in hyperemesis gravidarum?
thiamine should be given routinely
fetal complications of hyperemesis gravidarum?
small for dates
prematurity
low birth weight
maternal complications of hyperemesis gravidarum?
dehydration
weight loss
acidosis
hyponatraemia, and risk of central pontine myelinolysis with correction
hyperkalaemia-muscle cramps, cardiac arrhythmias
wernicke’s encephalopathy-ophthlamoplegia, ataxia, confusion
mallory-weiss tear of oesophagus
retinal haemorrhages
postpartum gallbladder dysfunction, PTSD
what f/u is necessary if severe N+V/hyperemesis gravidarum continues into late 2nd or 3rd trimester?
serial growth scans
what biochemically is the cause of N+V and hyperemesis gravidarum in early preg?
rising levels of beta hCG, hence pregs with higher levels e.g. multiple gestation and molar preg, assoc. with increased disease severity.
why can a transient hyperthyroidism be assoc. with hyperemesis gravidarum?
rising beta hCG can act directly on TSH receptors to increase thyroid hormone production.
risks of GBS bacteriuria in pregnancy?
chorioamnionitis
neonatal infection
management of pt at term who has PROM and is known to be colonised with group B strep?
immediate induction of labour with intrapartum antibiotics
what were the findings of the ORACLE study in terms of antibiotic use for women in preterm labour?
was found that those in preterm labour but without PPROM, had no benefit from prophylactic antibiotics, and that there children were at higher risk of neurodevelopmental problems e.g. cerebral palsy.
how are mother’s with pyrexia greater than 38degrees managed in labour?
- CTG
- intrapartum antibiotics-broad spec including that to cover early onset group B strep disease.
management of pt who has had previous child with neonatal GBS disease?
intrapartum antibiotic prophylaxis
which antibiotic is used for mum to reduce risk of early onset group B strep infection of newborn?
IV benzylpenicillin 3g, given as soon as possible after labour onset, then 1.5g 4hourly until delivery.
clindamycin if pen allergic.
causes of late miscarriage (after 12 weeks gestation until 24wks)?
infection
cervical insufficiency, anatomical abnormality
what is a heterotopic pregnancy?
one in which there is both an intrauterine and ectopic pregnancy
how long might it take for a miscarriage to be completely resolved?
up to 6 weeks
what is thought to be the pathophysiology of obstetric cholestasis?
cause isn’t fully understood
influence of hormones, genetic and environmental factors
hormones-oestrogen-higher in pregnancy and may affect how your liver works
more common in women of certain ethnic groups
genetics-higher risk if it runs in your family, and if you’ve had it in a previous pregnancy.
advice for patient in pregnancy as to how she can cope with N+V?
- should try and eat small amount often-meals high in carbs, low in fat e.g. pasta, rice, potatoes, are easier to tolerate, can try plain biscuits and crackers
- avoid any foods or smells that trigger symptoms
- can take anti-sickness meds which are not risky to baby-may not be licensed for use in preg but no evidence that they cause any harm.
- ginger products might help, but can also irritate the stomach
- acupuncture may be helpful
tests of woman with severe N+V in pregnancy comes into the assessment unit?
-hx taken of if she can keep anything down, has she tried anti-sickness meds, has she lost weight, any other symptoms, abdo pain, bowel, bladder problems, has it happened in a prev pregnancy.
-obs, weight
-ix-blds-FBC, U+Es, LFTs, amylase, glucose, TFTs
urine dip-ketonuria
US-molar preg, multiple gestation
may need rapid rehydration with IV fluids
management of a pt admitted to hosp with hyperemesis gravidarum?
- IV fluids
- anti-emetic
- thiamine
- anti-embolic stockings
- LMWH injection
when might corticosteroids be considered in the tment of hyperemesis gravidarum?
not responded to any of the conventional anti-emetics
still suffering despite IV fluids
lost a lot of weight
what advice regarding contraception should be given to women who have had obstetric cholestasis in pregnancy?
should avoid the oestrogen-containing contraceptive pill (COCP)
maternal complications of obstetric cholestasis of pregnancy?
- intense pruritus-disturbs sleep, can cause excoriations due to itching
- jaundice, may feel unwell and lose appetite, may have dark urine and pale stools.
- malabsorption, leading to Vit K deficiency.
RFs for acute fatty liver of pregnancy (AFLP)?
- rare condition
- may be associated with a mutant gene producing defect in mitochondrial FA oxidation, infants born to mothers with this condition should be screened for defects in this system
- nulliparous, 1st pregnancy
- pre-eclampsia
- multiple gestation
- male fetuses
presentation of acute fatty liver of pregnancy?
N+V, abdo pain, fevers, jaundice, pruritus
usually starts about 35 wks gestation, but can be much earlier, and may occur after delivery
results of investigations in acute fatty liver of pregnancy?
- moderately raised liver transaminases
- raised serum bilirubin
- raised WCC, thrombocytopenia
- clotting profile-prolonged PT and APTT
BIOPSY=diagnostic
CT/MRI may show reduced attenuation in the liver
consider early delivery, condition usually resolves afterwards with complete recovery
supportive ITU care frequently required
acute fatty liver of pregnancy complications?
- maternal and fetal death
- DIC and GI bleeding
- AKI
- hepatic coma
- pancreatitis
- hypoglycaemia
what US scanning is required following the fetal anomaly scan at 20wks in the investigation of placenta praevia?
- asymptomatic women without a previous C section whose placenta has just reached the internal cervical os (grade 2) but not covered it at 20wks and in whom pregnancy is progressing normally can be managed expectantly, with further imaging at 36wks.
- when the placenta is completely covering the internal os at 20 weeks (making placenta praevia more likely), or placenta is anteriorly placed and reaching the os in a woman with a previous C section, making placenta accreta more likely, earlier f/u imaging advised at 32 weeks.
define placenta praevia?
placenta that is inserted wholly or in part into the lower segment of the uterus
if lies over the internal cervical os then is a major praevia
if leading edge of placenta is in the lower uterine segment but not covering the os, minor or partial praevia exists.
options for delivery in placenta praevia?
- if the placental edge is less than 2cm from the internal cervical os in the 3rd trimester, a C section is likely needed
- as lower uterine segment continues to develop beyond 36wks, there is a place for transvaginal US if fetal head is engaged prior to an otherwise planned C section
- elective delivery by C section in asymptomatic women is not recommended before 38wks for placenta praevia, or before 36-37wks for suspected placenta accreta.
define placenta accreta
placenta which has grown into the myometrium of the uterus
causes bleeding when attempt made to remove placenta. may be severe requiring a hysterectomy.
general advice for a woman in pregnancy with placenta praevia?
- avoid sex, part. if has been bleeding
- eat a healthy diet rich in iron to reduce risk of anaemia
- you may be offered a speculum examination to see where the bleeding is coming from and how much. this is completely safe in pregnancy.
most accurate method of diagnosing a tubal pregnancy?
transvaginal ultrasound
what imaging can supplement transvaginal US in diagnosing an interstitial pregnancy (rare type of tubal ectopic)?
MRI
investigations in suspected ectopic?
- serial beta-hCGs-48hrs apart, look for beta-hCG that only rises slightly, or stays the same
- transvaginal USS
- ?MRI
?LFTs before starting methotrexate (+FBC, U+Es)
RFs for cord prolapse?
- multiparity
- multiple gestation
- polyhydramnios
- abnormal presentation or lie-breech, transverse lie
- prematurity
- CPD
- placenta praevia
- long UC
- high fetal station
cord prolapse treatment?
- can push presenting part of fetus back into uterus to avoid compression
- use of tocolytics to reduce cord compression and allow C section delivery
- pt asked to go on all fours until an immediate C section can be performed.
define vasa praevia
complication of pregnancy where the fetal blood vessels cross or run near the internal cervical os, and are at risk of rupture when the membranes rupture.
