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OBSTETRICS > LATE PREGNANCY PROBLEMS > Flashcards

LATE PREGNANCY PROBLEMS Flashcards

1
Q

Definition of stillbirth

A

A baby born dead after 24 completed weeks of pregnancy
The result of intrauterine death

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2
Q

How common is a stillbirth?

A

1 in every 200 pregnancies

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3
Q

Causes of stillbirth?

A

Unexplained (around 50%)
Pre-eclampsia
Placental abruption
Vasa praevia
Cord prolapse or wrapped around the fetal neck
Obstetric cholestasis
Diabetes
Thyroid disease
Infections, such as rubella, STI, parvovirus and listeria
Genetic abnormalities or congenital malformations

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4
Q

What can increase your risk of having a stillborn baby?

A

A multiple pregnancy
IUGR
Being over 35
Smoking, drinking alcohol, misusing drugs whilst pregnant
BMI >30
Pre-existing health conditions e.g. epilepsy
Sleeping on your back

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5
Q

How do we prevent stillbirths?

A

RSI assessment for having a baby with SGA or FGR is performed on all pregnant women. If at risk then they have foetal growth closely monitored with serial growth scans so women that need further help can be identified - may need planned early delivery when growth is static or other concerns
Treat modifiable risk factors e.g. stop smoking and drinking alcohol, effective control of diabetes, sleep on side
Give women at risk of pre-eclampsia aspirin

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6
Q

Investigation for intrauterine foetal death?

A

USS to visualise foetal heartbeat and confirm foetus being alive
(Note passive foetal movements may occur even after IUFD but another USS may be offered to the mother)

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7
Q

Managing a stillbirth

A

Rhesus-D negative women - anti-D prophylaxis
Vaginal birth with induction of labour or expectant management - this is safer than a C-section
Dopamine agonists can be used to suppress lactation after stillbirth

With parental consent, testing can be carried out after to determine the cause e.g. genetic testing of foetus and placenta, postmortem exam of foetus, testing for foetal and maternal infection, testing mother for conditions associated with stillbirth e.g. diabetes, thyroid disease, thrombophilia

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8
Q

Support group specific for stillbirth?

A

Sands - the Stillbirth And Neonatal Death charity

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9
Q

Registering a stillbirth

A

By law, stillborn babies have to be formally registered. In England and Wales, this must be done within 42 days of your baby’s birth

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10
Q

What is Antepartum haemorrhage?

A

Bleeding from the genital tract after 24+0 weeks of pregnancy, and prior to the birth of the baby

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11
Q

Epidemiology of Antepartum haemorrhage?

A

Complicates 3-5% of pregnancies
Leading cause of perinatal and maternal mortality worldwide

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12
Q

Cause of Antepartum haemorrhage?

A

1.placental abruption
2. Placenta praevia
3. Vasa praevia
Uterine rupture
Placenta acretia spectrum
Cervical polyps or ectropion
Infections - Vaginitis/cervicitis
Trauma
Abrasions e.g. from procedures or intercourse

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13
Q

Distinguishing placental abruption from placental praevia?

A

Placental abruption:
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems

Placenta praevia:
shock in proportion to visible loss
no pain
uterus not tender
lie and presentation may be abnormal
fetal heart usually normal
coagulation problems rare
small bleeds before large

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14
Q

What is placenta praevia?

A

A placenta lying wholly or partially in the lower uterine segment, lower than the presenting part of the foetus

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15
Q

Epidemiology of placenta praevia?

A

5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from the cervix as pregnancy goes on

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16
Q

What is the difference between a low-lying placenta and placenta praevia?

A

Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
Placenta praevia is used only when the placenta is over the internal cervical os

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17
Q

Risk factors for placenta praevia?

A

multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section
Previous placenta praevia
Advanced maternal age
Smoking
Assisted reproduction

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18
Q

Why does placenta praevia increase the likelihood of Antepartum haemorrhage?

A

Due to poor attachment of the placenta to the uterine wall

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19
Q

Grading of placenta praevia?

A

I “minor” - placenta reaches lower segment but not the internal os
II “marginal”- placenta reaches internal os but doesn’t cover it
III “partial” - placenta covers the internal os before dilation but not when dilated i.e. partially covers it
IV “major” - placenta completely covers the internal os

Although be aware that RCOG guidelines recommend against using this grading system - it is considered outdated
Instead they use low-lying placenta and placenta praevua

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20
Q

Clinical features of placenta praevia?

A

Painless vaginal bleeding - APH so later in pregnancy
shock in proportion to visible loss
lie and presentation may be abnormal

Note usually asymptomatic and diagnosed at the 20 week anomaly scan

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21
Q

Diagnosis of placenta praevia?

A

DO NOT PERFORM DIGITAL VAGINAL EXAMINATION BEFORE USS - may provoke severe haemorrhage
Often picked up on routine 20 week USS
Transvaginal USS - improved accuracy of placental localisation and considered safe

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22
Q

What do you do if you discover a low-lying placenta at the 20-week scan?

A

Rescan at 32 weeks. If still present and grade 1/2 then scan every 2 weeks. Do a final USS at 36 weeks to determine method of delivery:
- if grade 1 a trial of vaginal delivery may be offered
- if any higher grade then… elective c-section between 37-38 weeks

Corticosteroids considered at 34-36 weeks to mature foetal lungs due to risk of preterm delivery!

No need to limit I activity or intercourse unless they bleed

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23
Q

What should you do if a woman with known placenta praevia goes into labour prior to the elective caesarean section?

A

Emergency C-section due to risk of PPH

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24
Q

Management of placenta praevia with bleeding?

A

Admit
ABC approach to stabilise woman
If not able to stabilise -> emergency C-section
If in labour or term reached -> emergency C-section

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25
Q

Major cause of death in women with placenta praevia?

A

PPH

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26
Q

For women with placenta praevia why is an elective c-section booked foe between 36-37 weeks rather than later?

A

Due to the risk of spontaneous labour and bleeding!

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27
Q

What is a placental abruption?

A

Separation of a normally sited placenta from the uterine wall resulting in a maternal haemorrhage into the intervening space

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28
Q

How common is placental abruption?

A

1 in 200 pregnancies

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29
Q

Risk factors for placental abruption?

A

Previous placental abruption
Pre-eclampsia or HELLP
Cocaine use
Multiparity
Maternal trauma e.g. domestic violence
Increased maternal age
Smoking during pregnancy

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30
Q

Clinical features of placental abruption

A

Sudden onset severe continuous abdominal pain
APH - vaginal bleeding
Shock that is out of keeping with visible loss
“Woody” abdomen on palpation - tender and tense
Abnormalities on CTG indicating foetal distress

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31
Q

RCOG guidelines on severity of APH

A

Spotting: spots of blood noticed on underwear
Minor haemorrhage: less than 50ml blood loss
Major haemorrhage: 50 – 1000ml blood loss
Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

32
Q

Revealed vs concealed placental abruption?

A

Revealed: blood loss observed via the vagina
Concealed: cervical os remains closed so any bleeding remains inside uterine cavity. Severity of bleeding can be significantly underestimated!

33
Q

Investigtaions for placental abruption?

A

Observations
FBC, U&Es, LFTS - exclude pre-eclampsia and HELLP
Clotting profile
Kleihauer test
Group and save & crossmatch
USS - mostly to exclude placenta praevia as a cause of APH!
CTG to monitor foetus

34
Q

Management of placental abruption if foetus is alive and its <36 weeks?

A

If foetal or maternal distress: immediate Caesarian
If no foetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

(Note - active management of third stage is recommended!)

35
Q

Management of placental abruption if foetus is alive and it’s >36 weeks?

A

Foetal or maternal distress: immediate c-section
No foetal distress: deliver vaginally

(Note - active management of third stage is recommended!)

36
Q

Management of placental abruption if intrauterine death occurs?

A

Induce vaginal delivery
If mother is haemodynamically unstable or ongoing massive haemorrhage then c-section

(Note - active management of third stage is recommended!)

37
Q

Complications of placental abruption?

A

Maternal:
- major haemorrhage
- shock - can damage other organs too e.g. Sheehan syndrome
- DIC
- renal failure
- PPH

Foetal:
- IUGR - placental insufficiency
- hypoxia
- premature birth
- death

38
Q

What is Sheehan syndrome?

A

Postpartum Hypopituitarism caused by necrosis of the pituitary gland
Usually the result of severe massive haemorrhage during or after delivery

39
Q

Why can placental abruption cause DIC?

A

Placental haematoma can release thromboplastin (aka tissue factor)

40
Q

What is vasa praevia?

A

When foetus blood vessels (2 umbilical arteries and 1 umbilical vein) are within the foetal chorioamniotic membranes and run across the internal cervical os
I.e. vessels are placed over internal os before the foetus

41
Q

Aetiology of vasa praevia?

A

Normally foetal vessels are protected within the umbilical cord and this inserts directly into the placenta
In vasa praevia the vessels are exposed, outside the protection of the umbilical cord or placenta. There are 2 instances in which this can occur:
- velamentous umbilical cord - cord inserts into chorioamniotic membranes and foetal vessels travel unprotected through membranes before joining the placenta
- succenturiate (accessory) lobe of the placenta is connected by foetal vessels that travel through chorioamniotic membranes between placental lobes

Either way, foetal vessels are exposed outside the protection of the umbilical cord or placenta. Foetal vessels travel through chorioamniotic membranes and pass across the internal os. These vessels are prone to bleeding, especially when membranes rupture = can lead to dramatic foetal blood loss and death!!

42
Q

Types of vasa praevia?

A

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord
Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

43
Q

Risk factors for vasa praevia?

A

Low lying placenta
IVF pregnancy
Multiple pregnancy

44
Q

Clinical features of vasa praevia?

A

Painless vaginal bleeding - APH
Rupture of membranes
Fetal bradycardia

Soft non-tender uterus
Foetal bradycardia
May be detected by vaginal examination during labour - pulsating foetal vessels seen and felt in membranes through dilated cervix

May be asymptomatic and diagnosed by routine USS during pregnancy!

45
Q

Investigations for vasa praevua?

A

Observations
FBC, U&Es, LFTs - rule out pre-eclampsia and HELLP
Clotting profile
Kleihauer test
Group and save &cross match
USS
CTG to monitor foetus

46
Q

Management of vasa praevia?

A

Asymptomatic:
Corticosteroids from 32 weeks to mature foetal lungs
Elective c-section at 34-36 weeks

APH:
Emergency c-section

47
Q

What is uterine rupture?

A

Usually a complication of labour
The myometrium of the uterus ruptures

48
Q

Incomplete vs complete uterine rupture?

A

With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact.
With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.

49
Q

Risk factors for uterine rupture?

A

Previous C-section or other uterine surgery
VBAC
High parity
Increased BMI
Increased age
Induction of labour
Use of oxytocin and prostaglandins to stimulate contractions - uterine hyperstimulation
Trauma

50
Q

Presentation of uterine rupture?

A

Sudden abdominal pain
Vaginal bleeding
Ceasing of uterine contractions
Change of presenting parts e.g. may now feel parts in abdominal cavity
Hypotension, tachycardia and collapse - often out of line with the PV bleeding seen

51
Q

Management of uterine rupture?

A

Resuscitation and transfusion may be requires
Emergency C-section
May require hysterectomy

52
Q

What is placenta accreta?

A

Attachment of the placenta to the myometrium (or beyond) due to a defective decidua basalis, making it difficult to separate the placenta after delivery of the baby

53
Q

The 3 layers of the uterine wall are…

A

Endometrium
Myometrium
Perimetrium

54
Q

What are the 3 conditions that make up the “placenta accreta spectrum”?

A

Placenta accreta - chorionic villi attach to the myometrium rather than being restricted to the decidua basalis
Placenta increta - chorionic villi invade into the myometrium
Placenta percreta - chorionic villi invade through the perimetrium, potentially reaching other organs e.g. bladder

55
Q

Risk factors for placenta accreta?

A

Previous c-section
Placenta praevia

56
Q

Presentation of placenta accreta?

A

Typically doesnt cause symptoms during pregnancy, but may cause APH in the 3rd trimester
May just be diagnosed on antenatal USS
PPH

57
Q

Management of placenta accreta?

A

MRI scans may be used to assess depth and width of invasion
Specialist MDT
Plan for elective C-section at 35-36+6 to reduce risk of spontaneous labour. Give antenatal steroids before dleovery
Options during Caesarian: hysterectomy, uterus preserving surgery or expectant management (leaving placenta in place to be reabsorbed over time- risky!)

58
Q

What is pre-eclampsia?

A

New onset hypertension >=140/90 after 20 weeks of pregnancy and 1 or more of the following:
- proteinuria
- other organ involvement e.g. renal insufficiency, liver, neurological, haematological or uteroplacental dysfunction
may be a precursor to developing eclampsia and other complications

Triad:
- new-onset hypertension
- proteinuria
- oedema

59
Q

Features of severe pre-eclampsia?

A

hypertension: typically > 160/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

60
Q

Consequences of pre-eclampsia?

A

Eclampsia (seizures!)
Other neurological complications - altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotomata
Foetal complications - prematurity or IUGR
Liver involvement - HELLP syndrome
Haemorrhage: placental abruption, intra-abdominal or intra-cerebral
Cardiac failure

61
Q

Pathophysiology of pre-eclampsia?

A

When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium. It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels.

Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile. The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes). Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation.

When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia. Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.

62
Q

Risk fatcors pre-eclampsia?

A

High RF:
- hypertensive disease in a previous pregnancy
- CKD
- Autoimmune disease Ed..g SLE or antiphospholipid syndrome
- type 1 or type 2 diabetes
- chronic hypertension

Moderate RF:

first pregnancy
- age 40 years or older
- pregnancy interval of more than 10 years
- BMI of 35 kg/m² or more at first visit
- FHx of pre-eclampsia
- multiple pregnancy

63
Q

How to reduce risk of hypertensive disorders in pregnancy?

A

women with the following should take aspirin 75-150mg daily from 12 weeks gestation until the birth
≥ 1 high risk factors
≥ 2 moderate factors

64
Q

Diagnosis of pre-eclampsia?

A

Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg

PLUS any of:
- Proteinuria (1+ or more on urine dipstick)
- other maternal organ dysfunction - renal insufficiency, liver involvement, neurological complications, haematological complications or uteroplacental dysfunction

If dipstick screening for proteinuria is 1+ or more then use albumin:cr ratio or protein: ratio to quantify! Use 30 or 8 as diagnostic thresholds respectively

You can use placental growth factor test to rule out preeclampsia at 20-35 weeks - not as good for diagnosing it!

65
Q

Management of pre-eclampsia?

A

NICE recommend arranging emergency secondary care assessment for any woman in whom pre-eclampsia is suspected
women with blood pressure ≥ 160/110 mmHg are likely to be admitted and observed

Oral labetaolol (nifedipine second line) - aim for <135/85
Delivery of baby is most important and definitive step!!

Routine monitoring with bp, symptoms and urine dip
May also monitor foetal growth by serial growth scans

In labour IV magnesium sulphate may be given to prevent seizures
Closely monitor bp in labour
Corticosteroids should be given to women have it premature babies

66
Q

What is eclampsia?

A

Development of seizures in association with pre-eclampsia

67
Q

Management and prevention of eclampsia?

A

IV magnesium sulfate
Continue for 24 hours after last seizure or delivery as 40% of seizures occur post-partum!!
Fluid restriction to avoid potentially serious consequences of fluid overload

68
Q

Monitoring in IV magnesium sulphate treatment for eclampsia?

A

urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment
(Resp depression can occur)

69
Q

First line treatment for magnesium sulphate-induced respiratory depression?

A

Calcium gluconate

70
Q

What is HELLP?

A

Haemolysis, Elevated liver enzymes and Low platelet count
Serious condition that can develop in late stages of pregnancy
10-20% of severe preeclampsia will develop HELLP - although it is its own diagnosis!

71
Q

Symptoms of HELLP syndrome?

A

N&v
RUQ pain
Lethargy

72
Q

Investigtaions for HELLP syndrome?

A

Bloods: FBC, peripheral blood smear, liver enzymes, LDH, bilirubin

73
Q

Management of HELLP syndrome?

A

Delivery of baby

74
Q

Prognosis HELLP syndrome?

A

Mortality rate is up to 25%
Can cause DIC, placental abruption, PPH or renal failure
Risk of developing HELLP syndrome in subsequent pregnancies

75
Q

What affect can obstetric cholestasis have on the mother?

A

Immature foetal liver + excessive bile salts + vasoconstriction effects of bile salts on human placental chorionic veins = can cause sudden asphyxia events in the foetus = anoxia and death

OBSTETRICS (11 decks)

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