High risk pregnancy (breech, APH, placenta problems) Flashcards
What is placenta praevia?
It is an obstetric complication in which the placenta is inserted partially or wholly into the lower uterine segment. It is a leading cause of antepartum haemorrhage
NB - this is not formally diagnosed until 32 weeks
What are the main symptoms and signs of PP?
Painless, bright red vaginal bleeding (after 24 weeks)
Malpresentation of the foetus and normal uterine tone
Unstable foetal lie
NB - you must not undertake a digital vaginal exam as this may disrupt the placenta
How should PP be managed?
- Admit to hospital, insert IV line and resuscitate mother, monitor urine output with catheter
- Take FBC and blood group in case of haemorrhage
- Perform CTG to determine foetal status
- Perform USS to determine cause of bleeding
- Deliver child by C-section (38 wks or before if emergency) and give steroids
What is placental abruption?
Haemorrhage resulting from premature separation of the placenta (often spontaneously). It can be partial or complete.
This is often due to degeneration of the uterine arteries, causing separation of the uterine wall from the decade basalis
What causes placental abruption?
Trauma, folate deficiency, tobacco/drug use, HTN, maternal thrombophilia, foetal growth restriction
What are the main symptoms and signs of placental abruption?
Sudden onset painful vaginal bleeding (after 24 weeks)
Abdo pain that radiates to the back
Increased uterine activity (contractions)
Longitudinal foetal lie
HARD, TENDER UTERUS
How should placental abruption be managed?
- Admit to hospital, IV line insertion and maternal resuscitation
- Take FBC and blood group
- Blood transfusion
- Monitor urine output with catheter
- Perform CTG to determine foetal status
- Perform USS to determine cause of bleeding
- INDUCTION OF LABOUR OR C-SECTION IF FOETAL DISTRESS (give steroids)
What does meconium tell us?
It is a sign of foetal distress
What else can cause antepartum haemorrhage?
Vasa previa, unexplained, vaginal infections, cervical lesions
What are the different types of twin pregnancy?
Monozygotic multiple pregnancy (same ova) Dizygotic twins (different ovum fertilised by different sperm)
Having twins increases the likelihood of what?
Nausea and vomiting Anaemia Miscarriage Anterpartum haemorrhage Pre-eclampsia IUGR Preterm labour
How should twins be delivered?
Vaginally, unless they are preterm, breech, or there is malpresentation of the first twin
What is prolonged pregnancy?
Pregnancy that exceeds 294 days from the first day of the LMP (42 weeks)
What are the characteristic features of postmaturity in the foetus?
Oligohydramnios (decreased amniotic fluid)
Meconium in amniotic fluid
Inhalation of meconium into foetal lungs
These can lead to stillbirth, so the foetus is induced at 41 weeks
What are the three types of breech presentation
Frank/extended - legs touching head
Flexed - legs flexed at the hips
Knee/footling - lower limbs descend first through vagina
What are the risks of breech delivery, and what can be done to avoid this?
- Cord compression/prolapse
- Entrapment of the head behind the cervix
- Foetal intracranial haemorrhage
- Higher rate of neurological handicap (cerebral palsy)
To avoid this, an external cephalic version is performed to turn the baby round
What is an unstable lie?
One that is constantly changing, commonly associated with multiple parity, polyhydramnios, uterine anomalis, low-lying placenta
This should be managed with an ECV to prevent cord prolapse or shoulder presentation
What is the definition of antepartum haemorrhage?
Bleeding from or in the genital tract, occurring from 24 weeks gestation and prior to the birth
What are the DDs of antepartum haemorrhage?
Placental praevia
Placental abruption
Cervical bleeding
Vasa previa
What are the maternal complications of APH?
Anaemia, infection, maternal shock, renal tubular necrosis, PPH,
What are the foetal complications of APH?
Fetal hypoxia, IUGR, premature birth, death
What is the use of USS in APH?
It can confirm placental praevia but not placental abruption
What causes breech presentation?
- Idiopathic
- Previous breech baby
- Prematurity
- Conditions that prevent movement (foetal and uterine abnormalities/multiple pregnancy)
- Conditions that prevent head engagement (placenta previa, pelvic tumours/deformities)
What is Lovset’s manoeuvre?
Method of delivering the arms in breech presentation
What is the Mariceau-Smellie-Veit manoeuvre?
Method of delivering the head in breech presentation
What is external cephalic version?
Attempt to turn the baby to cephalic presentation, by manipulating the foetus through the maternal anterior abdominal wall, with USS guidance and a CTG monitoring straight after. It is done without anaesthetic
When does an ECV occur?
Nulliparous - after 36 weeks
Parous - after 37 weeks
Where is an ECV performed?
Hospital obstetric ward so that immediate c-section can occur if complications occur
What are the contraindications of ECV?
- Foetal compromise
- Pelvic mass
- Ruptured membrane
- Multiple pregnancy
- Placenta praevia
- Antepartum haemorrhage
What should happen with Rh negative woman after an ECV?
They need to have an Anti-D injection
What is obstetric cholestasis?
Cholestasis (inability of the bile to move from the liver to the duodenum) during pregnancy. It typically begins with itching in the third trimester, typically on the palms of the hands and soles of the feet
What is placenta accreta?
When the placenta abnormally attaches to they myometrium of the uterus
