Obs Flashcards
What are the classifications of placenta accreta spectrum?
Placenta accreta – invasion of placenta beyond decidua basalis, not into myometrium
Placenta increta – invasion of placenta beyond endometrium into myometrium
Placenta percreta – invasion of placenta into serosa +/- invasion into surrounding organs e.g. bladder
What are risk factors for placenta accreta spectrum?
Previous CS (RR 4.5, >/= 4CS RR 45) Previous uterine surgery - STOP, MROP, Curette, Previous accreta Previous placenta praevia AMA Multiparity Smoking ART
Name 11 USS features of placenta accreta
- Loss of hypo-echoic retroplacental clear zone
- Placental lacunae
- Abnormal myometrial/bladder interface
- Thinning <1mm or absence of myometrium beneath placenta
- Focal bulge of serosa
- Exophytic mass
- Hypervascularity between uterus/bladder
- Subplacental hypervascularity
- Bridging vessels from placenta across myometrium
- Placental lacunae feeding vessels
- Parametrial involvement
Management of placenta accreta spectrum
High level of diagnostic suspicion
MDT with tertiary centre input
Stay near to centre
Hb optimisation
MRI for operative planning - NOT diagnosis
Planned early delivery by caesarean section - RANZCOG does not given definite time (RCOG says 35-36+6). Alter if RFs for preterm birth.
Consider antenatal corticosteroids
Consent ahead of time including need for RBC transfusion, hysterectomy, higher risk renal tract injury
Have valid G&H, be prepared to activate MTP
Consider usage of cell saver
Aim regional anaesthesia - consider CSE
Delivery options
- CS, lower segment, attempt delivery of placenta, prepare for hysterectomy if not
- CS with incision away from placenta, delivery, closure of uterotomy and hysterectomy
- CS with incision away from placenta, delivery, trim short placenta cord and closure. Manage conservatively and/or plan hysterectomy at a later date
- CS with incision away from placenta, delivery, partial resection of uterine wall and repair
Conservative treatment - HIGH risk of infection, later emergency hysterectomy
Avoid ecbolic if not planning to separate placenta
Consider ureteric stents if percreta involving bladder, not routinely
What is the differential diagnosis for fetal hydrops?
Fetal anaemia - Immune haemolytic disease - parvovirus - FMH - Alpha thalassaemia - HbH Fetal infection - CMV - Toxoplasmosis - Syphilis - Parvovirus (as aboev) Fetal cardiac anomaly Metabolic Aneuploidy e.g. Turner's syndrome TTTS Fetal chylothorax Idopathic
What are classes of obesity in pregnancy?
Obese Class I BMI 30-34.9
Obese Class II BMI 35-39.9
Obese Class III BMI >40
List complications associated with obesity in pregnancy
Fertility delay
Miscarriage
Fetal anomaly, neural tube defects
Excessive gestational weight gain
Gestational diabetes
Fetal macrosomia
Pregnancy induced hypertension and pre-eclampsia
Undetected intrauterine growth restriction - Limited fundal palpations – more reliant on USS for fetal growth surveillance
Preterm birth
Stillbirth
Venous thromboembolism
Labour dystocia
Shoulder dystocia
Post partum haemorrhage
Assisted vaginal birth
Caesarean section and emergency caesarean (and associated complications all higher – bleeding, infection, injury to viscera)
If obesity hypoventilation and sleep apnoea – chronic intrauterine hypoxia
More complicated anaesthesia – epidural and spinal difficult insertion, higher rate of aspiration with GA
Higher ICU admission
Lower breastfeeding
Infant more likely to become obese
Higher rate of maternal death
Higher obstructive sleep apnoea
What are the benefits of IOL before 39weeks for suspected fetal macrosomia?
Less shoulder dystocia - RR 0.6
Less boney fracture - RR 0.2, NNT 60
No change in CS birth
No change in assisted vaginal birth
BUT
No significant differences in brachial plexus injury (although very infrequent finding)
What are recommended measures to prevent fetal macrosomia?
Regular exercise - aerobic and strengthening, as long as not contra-indicated
Maintenance of near-normal BSLs in diabetic mothers
Pre-pregnancy weight optimisation, recommend discussion re bariatric surgery if class III obesity
What is the definition of GDM?
Evidence of impaired glucose tolerance first diagnosed or developed in pregnancy
What are the WHO 10 steps of breastfeeding?
- Have a written policy
- Train staff to have skills to implement policy
- Inform women about benefits
- Help mothers breastfeed within 30mins of birth
- Show mothers how to breastfeed and how to maintain this
- Don’t offer any alternatives unless indicated
- Practise rooming in
- Encourage breastfeeding on demand
- Give no artificial teats or pacifiers
- Foster support groups and refer mothers to them
What are advantages to breastfeeding?
Neonatal/paediatric:
↓ Reflux, respiratory illness, otitis media, SIDS, atopy, UTIs, T1 and T2DM, obesity
Effective pain relief for minor procedures
Maternal: ↓ ovarian and breast ca risk ↓ PPH as involutes faster Lower cost Provides amenorrhoea and contraception ↑ bonding
How are preterm births classified?
Gestation Classification Frequency
34-36 weeks Late preterm 32-36weeks 84% preterm births
32-34+ weeks Moderate preterm <34weeks 3% all births Aus
28-32weeks Very preterm 10% preterm births, <32weeks 1.2% all births NZ
<28weeks Extremely preterm 5% preterm births, 0.5% all births in NZ
What is the definition of a live birth?
Expulsion from the mother at any gestation and after separation shows signs of life - breathing, heart beating, definite movement of voluntary muscle, cord pulsating
What is the definition of a miscarriage?
Loss of a pregnancy <20weeks
