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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
Major cause of death in women with placenta praevia?
PPH
26
For women with placenta praevia why is an elective c-section booked foe between 36-37 weeks rather than later?
Due to the risk of spontaneous labour and bleeding!
27
What is a placental abruption?
Separation of a normally sited placenta from the uterine wall resulting in a maternal haemorrhage into the intervening space
28
How common is placental abruption?
1 in 200 pregnancies
29
Risk factors for placental abruption?
Previous placental abruption Pre-eclampsia or HELLP Cocaine use Multiparity Maternal trauma e.g. domestic violence Increased maternal age Smoking during pregnancy
30
Clinical features of placental abruption
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
31
RCOG guidelines on severity of APH
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
Revealed vs concealed placental abruption?
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
Investigtaions for placental abruption?
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
Management of placental abruption if foetus is alive and its <36 weeks?
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
Management of placental abruption if foetus is alive and it’s >36 weeks?
Foetal or maternal distress: immediate c-section No foetal distress: deliver vaginally (Note - active management of third stage is recommended!)
36
Management of placental abruption if intrauterine death occurs?
Induce vaginal delivery If mother is haemodynamically unstable or ongoing massive haemorrhage then c-section (Note - active management of third stage is recommended!)
37
Complications of placental abruption?
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
What is Sheehan syndrome?
Postpartum Hypopituitarism caused by necrosis of the pituitary gland Usually the result of severe massive haemorrhage during or after delivery
39
Why can placental abruption cause DIC?
Placental haematoma can release thromboplastin (aka tissue factor)
40
What is vasa praevia?
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
Aetiology of vasa praevia?
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
Types of vasa praevia?
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
Risk factors for vasa praevia?
Low lying placenta IVF pregnancy Multiple pregnancy
44
Clinical features of vasa praevia?
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
Investigations for vasa praevua?
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
Management of vasa praevia?
Asymptomatic: Corticosteroids from 32 weeks to mature foetal lungs Elective c-section at 34-36 weeks APH: Emergency c-section
47
What is uterine rupture?
Usually a complication of labour The myometrium of the uterus ruptures
48
Incomplete vs complete uterine rupture?
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
Risk factors for uterine rupture?
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
Presentation of uterine rupture?
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
Management of uterine rupture?
Resuscitation and transfusion may be requires Emergency C-section May require hysterectomy
52
What is placenta accreta?
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
The 3 layers of the uterine wall are…
Endometrium Myometrium Perimetrium
54
What are the 3 conditions that make up the “placenta accreta spectrum”?
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
Risk factors for placenta accreta?
Previous c-section Placenta praevia
56
Presentation of placenta accreta?
Typically doesnt cause symptoms during pregnancy, but may cause APH in the 3rd trimester May just be diagnosed on antenatal USS PPH
57
Management of placenta accreta?
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
What is pre-eclampsia?
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
Features of severe pre-eclampsia?
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
Consequences of pre-eclampsia?
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
Pathophysiology of pre-eclampsia?
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
Risk fatcors pre-eclampsia?
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
How to reduce risk of hypertensive disorders in pregnancy?
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
Diagnosis of pre-eclampsia?
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
Management of pre-eclampsia?
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
What is eclampsia?
Development of seizures in association with pre-eclampsia
67
Management and prevention of eclampsia?
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
Monitoring in IV magnesium sulphate treatment for eclampsia?
urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment (Resp depression can occur)
69
First line treatment for magnesium sulphate-induced respiratory depression?
Calcium gluconate
70
What is HELLP?
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
Symptoms of HELLP syndrome?
N&v RUQ pain Lethargy
72
Investigtaions for HELLP syndrome?
Bloods: FBC, peripheral blood smear, liver enzymes, LDH, bilirubin
73
Management of HELLP syndrome?
Delivery of baby
74
Prognosis HELLP syndrome?
Mortality rate is up to 25% Can cause DIC, placental abruption, PPH or renal failure Risk of developing HELLP syndrome in subsequent pregnancies
75
What affect can obstetric cholestasis have on the mother?
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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