O&G Cases 1,4,6,9 Flashcards
Describe what antepartum heamorrhage is:
Vaginal bleeding after 20 weeks of gestation before delivery of fetus.
Where does the bleeding in antepartum heamorrhage most often originate from?
Placental in origin or lower genitourinary tract
What are the causes of antepartum heamorrhage?
- Placental abruption
- Placenta previa
- Uterine rupture (RARE)
- Undetermined/placental edge bleeding
- Lower genital tract i.e cervical poly, ectropian, genital infection, carcinoma (RARE)
What is the aetiology of placental abruption and some common risk factors?
- No known cause.
Risk factors:
- Previous abruption
- Pre-eclampsia/chronic hypertension
- Polyhydroaminos
- Trauma
- Thrombophilia
- High parity and multiple pregnancy. Advanced maternal age.
- Smoking, cocaine
What is the presentation of placental abruption?
Depends on site of placental separation and its severity. i.e massive internal uterine bleeding progressing to CV shock and DIC
NOT all women have vaginal bleeding and thus it is concealed.
What can blood into the uterus lead to?
Blood in the uterus can infiltrate the myometrium, causing inflammation and can cause contractions / labour.
Remember that labour is a inflammatory process and thus inflammation i.e infection or trauma can precipitate labour.
What are the clinical signs of abruption?
Uterine hyperstimulation (5 in 10) and blood stained liqour (In addition to abdo pain and vaginal bleeding)
Contracted uterus: Tender and doesnt relax.
Tachycardia (Hypovolemia)
What investigations can you do for a placental abruption?
- FBC
- Platelets
- Creatinine + Urea + Electro
- Coagulation screen (DIC)
Whats the emergency management for a placental abruption?
- DRSABC
- Call for Help
- Resus + restore blood volume
- Correct anaemia and coagulopathy
- Pain relief
- Monitor fetus
- Fluid balance
- Transfer, delivery baby and placenta, expect PPH
What is placenta previa?
- The placenta partially or completely is in the lower segment of the uterus.
What does placenta previa cause?
PAINLESS vaginal bleeding in a women known to have a low lying placenta.
- Multiple epiodes of light vaginal bleeding are characteristic but large bleeds can occur.
Notebook Antepartum heamorrhage is PAINFUL vaginal bleeding.
How do you manage placenta previa with APH?
Small recurrent bleeds:
- Admit and monitor 24-48hrs
- Corticosteroids if <34 weeks and delivery likely
- Check anaemia
- Anti-D if rhesus neg
If 37-38 weeks, planned C-section
What are the potential complications of placenta previa?
- Heamorrhage
- Pre-term
- C-section
- Placenta accreta
- Maternal death
What is placenta accreta?
When the placenta previa adheres to the myometrium abnormally (can be due to the scar tissue of a previous c section)
Invades myometrium = Increta
Through myometrium = Percreta
What are the gynae causes of lower genital tract bleeding?
- Cervical polyps
- Cervical ectropion
- Genital infection (Cervitis; Chalm and Gon, Vaginitis; thrush)
- Cervical carcinoma
- Vasa previa (placental vessels run run in front of the presenting part infront the cervical OS
How is hypertension in pregnancy defined?
On two occasions at least 6 hours apart:
o Systolic BP ≥ 140mmHg and/or
o Diastolic BP ≥ 90 mmHg
What is chronic or essential hypertension in a pregnant woman?
Hypertension either existed prior to the pregnancy, or occurs before 20 weeks gestation
What is gestational hypertension?
- new-onset hypertension >20 weeks gestation
- no features of pre-eclampsia (no proteinuria, no oedema)
- approximately 25% develop preeclampsia, especially when occurs early
What is pre-eclampsia
HTN (After 20 weeks) +/- Urine protein creatinine ration >30 mg/mmol, +/- multi system impairment i.e renal, pulm, hepatic, heame
=
Uteroplacental dysfunction -> usually showing by slowing growth of fetus
What is eclampsia?
Occurrence of a tonic-clonic seizure in a patient with preeclampsia in the absence of other neurologic conditions that could account for the seizure
What is HELPP syndrome?
Heamolysis, Elevated Liver enzymes (AST + ALT), Low Platelets
Can result in DIC
What is a common presentation of pre-eclampsia?
- Headache
- Visual disturbances
- Epigastric pain
Hyperreflexia, Clonus, Seizures (Eclampsia symptoms)
What can happen to the fetus in pre-eclampsia?
- Fetal growth restriction
- Hypoxaemia
- Acute fetal distress
What fetal morbidity can result from preterm delivery?
- Intraventricular haemorrhage (IVH)
- RDS
- Retinopathy of prematurity
- Sepsis
- Necrotising entercolitis
What presenting complaint features are you looking for in pre-eclampsia?
- HTN history
- Headache and vision
- Abdominal pain
- Urinary symptoms
- Swelling
- Vaginal bleeding, pain, discharge, ROM
- Tightenings
- Fetal movements
What examinations are specific to pre-eclampsia?
- BP
- Abdominal exam
o symphysis fundal height, amniotic fluid volume
o uterine and liver tenderness - Oedema – signs of cardiovascular/renal involvement
- Hyperreflexia and clonus
- Fundoscopy – papilledema (hypertensive retinopathy changes)
What investigations would you order if you suspected pre-eclampsia?
o FBC - hemolysis, thrombocytopaenia <100,000 platelets/mm3
o Coag studies - coagulopathy
o U&Es
o Creatinine
o Urate
o LFTs (AST &ALT) - elevated due to hepatocellular injury
o G&H
- Fetal well-being
o CTG
o USS - fetal growth, amniotic fluid volume, umbilical artery Doppler - in context of IUGR
o Fetal movements
What medications would you use to treat pre-eclampsia?
- If BP ≥ 160/100 mmHg – oral Methydopa (little effect and very slow acting) or Labetolol/Oxprenolol or Nifedipine
- If BP ≥ 170/110 mmHg – short acting Nifedipine or Intravenous Labetolol or Hydralazine as emergency therapy
Why would you use magnesium in pre-eclampsia?
o Prophylaxis to reduce the risk of eclamptic seizures in pregnant women with pre-eclampsia
o Prevent further seizures in pregnant women with eclampsia
o Neuroprotection of the fetus at gestation <30 weeks
o Continue for 24 hrs following birth or 24 hrs after the last seizure, whichever is the later
What can you use to prevent or reduce pre-eclampsia?
Aspirin 100mg OD nocte - start at 12-16 weeks gestation
Calcium supplementation 1.5-2.0g/day - start at 12-16 weeks gestation
When do you aim to deliver in pre-eclampsia vs gestation hypertension?
Gestational and essential hypertension are any time after 37 weeks
Pre-eclampsia aim for 37 weeks. If pt+fetus deteriorates before 34 weeks administer corticosteroids.
What are the major risk factors for developing preeclampsia?
o Autoimmune disease (antiphospholipid antibodies / SLE)
o Previous preeclampsia
o ART (oocyte donation)
o Renal disease
o Chronic hypertension
o Previous history of HELLP
o Diabetes
o FHx – mother or sister with preeclampsia, or first degree relative with HTN
What are other risk factors for developing pre-eclampsia?
o Nulliparity (first pregnancy)
o Multiple pregnancy
o Change in partner (protected non-barrier intercourse with the same partner for 12 months decreases risk; changing partner resets risk)
o Elevated BMI ≥35
o Maternal age <15yo or >35yo
o Pregnancy interval >10yrs
o ART (sperm donation)
How is the diagnosis of labour made?
- Regular painful contractions
+/- Show (mucous plug)
+/- Rupture of membranes
+/- Progressive cervicle dilatation
What is rupture of membranes?
Rupture of the amniotic membrane and loss of amniotic fluid. (Ddx is stress incontinence). This can occur before (Premature ROM) or Spontaneously during labour). Membranes can be artificially ruptured (ARM) and some instances babies can be delivered with membranes in tact “En caul”
PROM requires antibiotics and NO VE
What specific things are found in an abdo and vaginal exam for labour?
Abdo:
- Assess uterine contractions.
- Descent of presenting part.
- Listen to fetal heart sounds.
Vaginal:
- Assessment of progress
- Amniotomy to augment labour
- Confirmation of full dilatation (And cervical position, length, fetal presenting part, its station, Caput, Moulding.
- Colour of liquor.
Whats monitored in labour?
Fetal monitoring:
Cardtidotography
External or internal options.
Liquor
Maternal monitoring:
Uterine contractions.
Heart rate and temperature.
maternal heart rate is monitored to ensure it is different from fetal and can confirm if fetal nodes are detecting maternal heart rate.. i.e if fetal HR drops too low…
What are the antenatal risk factors indicating CTG requirement?
Antenatal risk factors:
Signs of fetal distress
Growth restriction
Pre or post term babies
Multiple pregnancy
Maternal disease - Db, HTN
Advanced maternal age.
BMI 40+
Prev. C-section.
What factors in a labour would indicate need for fetal monitoring?
Risk factors in labour:
Induced or augmented labour.
Prolonged labour.
Liquor: Absent, reduced or muconium stained.
Bleeding in labour, maternal fever >38oC.
Intrapartum heamorrhage.
Uterine hyperstimulation/hypertonic
What are the stages of labour?
First stage:
- latent phase 1-12 hrs
- Active phase
Second stage: Full dilatation and birth
Third stage:
- Oxytocin and delivery of the placenta.
What are the mechanics of birth?
Engagement
Flexion
Internal rotation
Extension
Birth of head
Restitution.
Look at a partogram
PLs
What are the potential causes of slow labour?
The three p’s
Passenger, Passage, Power
Passage (Cephalopelvic disproportion)
Passanger
- Macrosomia
- Position
- Presentation
Power
- Dehydration
- Pain and Fear
- Exhaustion
- Infection
- Idiopathic (25%)
What are the potential consequences of slow labour to the mother?
- Fever
- Amnionitis
- Urinary retention
- Exhaustion
- Endometritis
- Tear
- Ketosis
What are the risks of slow labour to the fetus?
Infection
Hypoxia
Meconium aspiration
How do you manage slow labour?
- IV hydration
- Adequate pain releif
- Oxytocin augmentation
- Operative delivery +/- C section
What does the pregnancy USS at 4-13 weeks indicate?
- Confirm viability
- Confirm location (ectopic)
- Dating.. Crown rump length
- Detect multiple preg (define chorionicity)
What does the pregnancy USS at 11-13 weeks indicate?
- Screening for abnormalities
-> Nuchal translucency
-> Early morphology
What does the pregnancy USS at 13-20 weeks indicate?
Dating scan
- Fetal measurements
- Multiple pregnancy
What does the pregnancy USS at 19-20 weeks indicate?
- Fetal anomaly survey
Why USS in pregnancy at 20+ weeks?
- As clinically indicated
- Antepartum heamorrhage
- Fetal size and wellbeing
What fetal anomalies can be detected by USS?
- Neural tube defects
-> Anencephaly
-> Spina bifida - Cardiac issues (50%)
- Urinary issues
-> Obstructive uropathy
-> Multicystic dysplastic kidney
-> Renal agenesis
Ant. Abdo wall defects (90%)
- Omphalocoele
- Gastroschisis
- Diaphragmatic hernia
Skeletal dysplasic
What screening is offered for pregnant women in NZ?
Chromosome aneuploidy
First trimester: Nuchal translucency scan, blood serum test; PAPP-A, B-HCG
Second trimester: Blood test for serum; aFP, B-hcg, Estriol, Inhibin-A
Integrated test: Nuchal translucency, first and second trimester blood test.
NIPT: Blood test for free floating fetoplacental DNA in maternal circulation
What should be done at every antenatal visit?
- Blood pressure
- Weight
- Assessment of maternal and fetal wellbeing.
- Urinanalysis for proteinuria
What should be done at an antenatal visit thats before 10 weeks gestation?
- Booking visit
- Arrange screening tests
Whats a booking visit?
- Prior to 10 weeks.
- Comprehensive medical and obstetric history.
- Targeted examination
- Dating of pregnancy; LMP or USS
- Health advice; Iodine and folate
What should be done at an antenatal visit thats
- 18-20 weeks.
- 24-28 weeks.
18-20 weeks
- USS for fetal anomalies
24-28 weeks
- Assess fetal growth
- Polycose or oGTT
- FBC and Rhesus status
What should be done at an antenatal visit thats
- 32-41 weeks?
- Assess fetal growth every two weeks.
- FBC and antibodies at 36 weeks.
What investigations are done at the booking appt?
- FBC, Anaemia
- MCV (Thalassaemia or iron deficiency)
- Platelet count (Thrombocytopenia)
- Blood grouping / AB
- Rubella AB status
- Hep serology
- Syphillus
- HIV
- HBA1c
+ Cervical smear
+ Chlamydia Swab
+ MSU
