Obs 6 Flashcards
(55 cards)
1
Q
Define PPH
A
Blood loss >500ml
2
Q
What are the causes of primary PPH?
A
Tone (70%), Trauma (20%), Tissue (10%), Thrombin (1%)
1. Tone – Uterine Atony: Avoid by active mx 3rd stage
- Overdistended uterus – polyhydramnios, multiple gestations, macrosomia
- Uterine muscle exhaustion – prolonged labour, grand multiparity, oxytocin/GA use
- Abnormal uterine anatomy – fibroids, placenta praevia, placental abruption
- Intra-amniotic infection – prolonged ROM
- Unable to empty bladder
2. Trauma – Damage to genital structures: (vagina, cervix, uterus)
- C-section
- Episiotomy
- Instrumental delivery
- Can cause haematoma
3. Tissue – Retained placental products:
- Placenta accreta/increta/percreta
- Retained blood clots in atonic uterus
- Gestational trophoblastic neoplasia
4. Thrombin – Coagulopathy:
- Congenital: Haemophilia, VWD (most common)
- Acquired: DIC, aspirin use, therapeutic anti-coagulation,
3
Q
What are the RFs for primary PPH?
A
- Previous PPH
- Prolonged labour
- Pre-eclampsia
- Increased maternal age
- Polyhydramnios
- Emergency Caesarean section
- Placenta praevia, placenta accreta
- Macrosomia
4
Q
What are the causes of secondary PPH?
A
- Endometritis
- Retained products
- Abnormal involution of placental site
- Trophoblastic disease
5
Q
What are the S/S of PPH?
A
Primary:
- General – shock (tachycardia, hypotension), signs of anaemia
- Uterine atony – relaxed, boggy and soft uterus, uterine fundus may be felt above umbilicus (if uterine cavity filled with blood/clots)
- Tissue - retained products found on bimanual exam
- Thrombin - continued bleeding despite contracted uterus
Secondary:
- Abdomen – tender uterus
- Speculum – assess bleeding, is the cervical os open
- Vaginal – uterine tenderness
6
Q
What are the investigations for PPH?
A
- Bloods: FBC, U&Es, coagulation profile, G&S
- USS: uterine rupture / intraperitoneal bleeding?
7
Q
What signs would indicate a haematoma?
A
- Severe pain
- Persistent bright red PV bleeding despite firmly contracted uterus
8
Q
What is the management of PPH?
A
ABC approach:
- Fluid resus (warmed crystalloid infusion)
- Blood products
- Lie the woman flat
- Catheterisation (prevent bladder distension / monitor UO)
Mechanical:
- Palpate the uterine fundus and rub it to stimulate contractions (‘rubbing up the fundus’)
- Bimanual compression (‘rub up a contraction’ if in theatre)
Medical:
- Step 1 = IM/IV syntocinon (oxytocin) > uterine hyperstimulation = give tocolytics
- Step 2 =IM ergometrine/syntometrine (not in HTN / asthmatics)
- Step 3 = IM carboprost (not in asthmatics)
Surgical:
- Step 4: Balloon tamponade (i.e. Bakri Balloon)
- Step 5: B-lynch suture > ligate arteries > interventional radiology
- Step 6: hysterectomy
9
Q
What are the complications of PPH?
A
- Death, hysterectomy, VTE, renal failure, DIC, Sheehan’s syndrome
- 4th most common cause of maternal death in the UK, leading cause of maternal mortality world-wide
10
Q
Define placenta accreta / increta / percreta
A
Abnormally invasive placentation:
Accreta = placenta invades the surface of the myometrium (strong attachment, not into muscle wall)
Increta = placenta extends into the myometrium
Percreta = placenta penetrates through the myometrium to the uterine serosa and potentially to nearby organs (e.g. bladder)
11
Q
What are the RFs for placenta accreta / increta / percreta?
A
- Hx of accreta
- Previous CS/uterine surgery
- Endometrial curettage
12
Q
What are the investigations for placenta accreta / increta / percreta?
A
- TVUSS
- MRI (assess depth of invasion)
13
Q
What is the management of placenta accreta / increta / percreta?
A
- ELCS at 35 to 36+6 weeks delivery
- ± Caesarean hysterectomy (i.e. for percreta)
Risk of SVD = major haemorrhage and uterine rupture
14
Q
What is Prelabour Rupture of the Membranes (PROM)?
A
Spontaneous rupture of membranes before onset of labour at term (≥37 weeks)
- Occurs in ≤10% of women
- Cause = natural physiological (i.e. Braxton Hicks contractions + cervical ripening > weakening of membranes)
15
Q
What is Pre-term Premature Rupture of the Membranes (PPROM)?
A
Spontaneous rupture of membranes before onset of labour in pregnancy (24+0 to 36+6 weeks)
- Can be caused by weakening of membranes due to infective cause (often subclinical)
- Occurs in 2% of pregnancies
16
Q
When should you not offer a digital vaginal examination?
A
Do not offer if…
- Placental praevia
- PPROM/PROM (SROM)
> Ok in abruption but often cannot tell immediately
17
Q
What are the S/S of PROM?
A
- Sudden gush of fluid PV > constant trickle
- Contractions (regular & painful = PTL; not Braxton-Hicks)
- General examination > assess for signs of infection (tachycardia, fever)
18
Q
What are the investigations for PROM / PPROM?
A
(NO bimanual as increases risk of infection)
1st = Sterile speculum examination:
Only perform if ROM not evident
- Amniotic fluid pooling (filling of speculum) is diagnostic
- If none, test IGFBP-1 or PAMG-1
- Swab for infection (gonorrhoea, chlamydia, GBS)
- Do not use KY jelly – will complicate FFN result
2nd = IGFBP-1 or PAMG-1 (PartoSure):
- IGFBP-1 = Insulin-like Growth Factor-Binding Protein 1
- PAMG-1 = Placental Alpha-Microglobulin 1
- Very sensitive, so -ve result means very low chance of PPROM
If >30w, contractions and os closed = TVUSS for cervical length:
- <15mm = likely to be preterm labour
- > 15mm = unlikely to be preterm labour
Manage the pregnancy as per:
- Membranes not ruptured > PTL
- Membranes ruptured > PPOM, PROM
Do not perform diagnostic tests for PPROM if labour becomes established (i.e. bulging membranes, abdominal pain) in a woman reporting S/S suggestive of PPROM > admit to labour ward
19
Q
What are the RFs for PROM / PPROM?
A
- Previous PROM / PTL
- UTI / STI / vaginal infection
- Smoking
- Multiple pregnancy
- Polyhydramnios
- APH
- Trauma
- Uterine abnormalities
- Cervical incompetence
20
Q
What is the management of PPROM?
A
ADMISSION for monitoring (48–72 h) + expectant management until 37w (if no complications)
- Erythromycin for 10 days or until in established labour (not for infection, to increase time between ROM and spontaneous labour)
- Corticosteroids if ≤34 weeks; max 2 doses (consider between 34-36wks) - induces a DKA in diabetics so co-administer with insulin
- MgSO4 if ≤30 weeks AND contracting OR planned birth <24 hours (consider between 30-34wks)
- If chorioamnionitis - immediate delivery
21
Q
What is the management of PPROM <16wks?
A
- If <16wks, no liquor for lungs to develop
- Even if make it to term - such high mortality from lung hypoplasia
- TOP may be offered
22
Q
What must be monitored for chorioamnionitis?
A
- Clinical assessment
- Bloods – CRP and WCC
- CTG – monitor foetal HR
23
Q
What are the complications of PPROM/PROM?
A
Maternal:
- Sepsis
- Placental abruption
Foetal:
- Chorioamnionitis
- Cord prolapse
- PTL
- Pulmonary hypoplasia
- Limb contractures
- Death
> Increased perinatal mortality due to sepsis, prematurity and pulmonary hypoplasia
24
Q
What is the management of PROM?
A
Most (60%) women will spontaneously labour <24hrs
- IOL is appropriate after 24hrs
- If woman chooses expectant management, she must return for RV every 24hrs (max 96hrs)
Immediate induction offered if:
- Known carrier of GBS
- Meconium or blood stained liquor
- Suspicion of infection
Postnatal:
- Neonatal observation required for at least 12 hours
25
Define pregnancy of unknown location (PUL)
The situation when the pregnancy test is positive but there are no signs of intrauterine pregnancy (IUP) or an extrauterine (ectopic) pregnancy via TVUSS.
*It is not a final diagnosis and in some women a final diagnosis cannot be made*
26
What is the definition of pre-term labour?
**<37w GA labour**
*85% of PTL births occur between 32- and 37-weeks GA*
27
What is the definition of very PTL?
28-32w GA labour
28
What is the definition of extremely PTL?
<28w GA labour
24w is seen as the limit of viability (~55% survivability)
29
What are the RFs for PTL?
- Previous PTL/PROM/PPROM
- Previous miscarriage between 16-24w
- Cervical procedures (e.g. biopsy)
- Infection *(20-40% of spontaneous PTL)*
- Structural - uterine abnormalities, pre-eclampsia
- Mechanical (stretch) - fibroids, polyhydramnios, multiple pregnancy, APH (concealed)
- Social lifestyle -smoking, high BMI, drugs, extreme ages, ethnicity
30
What are the investigations for PLT?
*(in addition to investigations on main topic page)*
- CTG monitor
- Urine dip ± MC&S (if indicated)
31
What is the management of PTL?
*Note, you pay be in PTL without having membranes ruptured…*
**Ruptured membranes:**
PPROM guidance
**Non-ruptured membranes:**
*Medications:*
- Tocolysis (≤34 weeks) - 1st: Nifedipine (CCB); 2nd: Atosiban
- Corticosteroids (≤34 weeks) for 24 hours - induces a DKA in diabetics so co-administer with insulin
- MgSO4 (≤30 weeks; labour OR planned birth <24 hours)
*Surgical:*
Emergency ‘rescue’ cerclage:
- Indication = if 16w to 28w, dilated cervix, exposed unruptured membranes
- Contraindication = infection, bleeding, uterine contractions
32
What is the management for woman at high risk of PTL?
**Measure cervical length every 2w from 16w**
If cervical length <25mm and...
- History of PTL <34w GA
- History of miscarriage >16w GA
- History of PPROM
- Cervical trauma
**1 = Progesterone**
**2 = Cervical cerclage**
33
What are the complications of pre-term birth?
Big four = RDS, NEC, IVH, PVL
- Respiratory Distress Syndrome >O2 > complication = retinopathy of prematurity
- Necrotising Enterocolitis
- Intraventricular Haemorrhage
- Periventricular Leukomalacia
+Sepsis
34
What is Rhesus disease?
**Development of Rhesus antibodies in a RhD -ve mother post-exposure (sensitisation) to RhD antigen (RhD +ve blood cells)**
Population = 85% Rh +ve; 15% Rh -ve (these are the ones we worry about in RhD disease)
35
What are the RFs for rhesus disease?
- Previous pregnancy with insufficient anti-D prophylaxis
- Previous blood transfusion (rare if in UK)
36
How does rhesus disease develop?
- Rh -ve mother has a Rh +ve child
- Sensitising event mixes blood
- Mother develops IgM anti-Rh ABs (IgM do not affect 1st baby as IgM cannot cross placenta)
- Mother delivers or miscarries child
Time passes (and mother develops IgG anti-Rh ABs)
- Mother has a 2nd Rh +ve child
- Mother’s IgG anti-Rh crosses placenta > hydrops fetalis
- If child is Rh -ve, there is no problem. However, we assume they are Rh +ve just in case
>>cffDNA testing can test for the child’s Rh status which reduce the need for anti-D
37
What are examples of a potentially sensitising event (PSE)?
- Termination of pregnancy
- Obstetric interventions (CVS, amniocentesis, ECV)
- Abdominal trauma
- APH / PV bleeding
- Ectopic pregnancy
- Miscarriage
- Intrauterine transfusion / surgery
- Intrauterine death & stillbirth / molar pregnancy
38
What are the investigations for rhesus disease?
- Father status (hence, could the baby inherit)
- Baby status (cffDNA testing)
- Mother’s anti-RhD levels (higher = worse)
- Kleiheur test (only >20w)
- Coomb’s Test / Antiglobulin Test:
- Direct AT = ABs on RBCs
cffDNA testing at 12w can determine baby Rh status
If baby is Rh -ve, no need for anti-D prophylaxis as no HDN can occur
39
What is the management of rhesus disease?
*Only Rh -ve women need any of this…*
**Routine Antenatal Anti-D Prophylaxis:**
- Indirect antiglobulin testing at booking
- Either: 2 doses of 500 IU at 28 and 34 weeks; OR 1 dose of 1500 IU at 28 weeks
- Kleihauer = determines need for more anti-D
- Foetal cord bloods post-delivery and prophylaxis in 72 hours (500 IU anti-D) if baby +ve with Kleiheur
**Prophylaxis < 72hrs of sensitising event:**
- 250 IU <20 weeks
- 500 IU >20 weeks
If mother is found to be RhD -ve and has antibodies at booking > monitor titres and if they peak above a level, monitor baby using Middle Cerebral Artery (MCA) dopplers weekly > if baby affected, consider IU transfusion
If continuous bleeding > anti-D every 6 weeks with Kleihauer every 2 weeks (adjust anti-D if needed)
40
What are the complications of rhesus disease?
hydrops fetalis, intrauterine death, neonatal kernicterus
41
What are some examples of skin diseases in pregnancy?
- Pemphigoid gestationis
- Polymorphic eruption of pregnancy / Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)
- Prurigo of pregnancy
- Pruritis folliculitis
- Atopic eczema
42
How can changes during pregnancy affect the skin?
- Pre-existing conditions (e.g. acne can worsen during pregnancy)
- Acne flares in 3rd trimester – oral or topical erythromycin, retinoids contraindicated
- Increased pigmentation (face, areola, abdo midline) common
- Spider naevi affecting face, arms, upper torso
- Broad pink linear striae – striae gravidarum common over lower abdo and thighs
- Hand and nipple eczema common post-partum
- Psoriasis – topical steroids, methotrexate contraindicated
43
Describe pemphigoid gestationis
**Rare pruritic AI bullous disorder**
- Presents in late 2nd or 3rd trimester
- SS: lesions begin on abdomen 50% of time > widespread clustered blisters, sparing face
- M: relive pruritis and stop new blister formation, use potent topical steroids or oral prednisolone
44
Describe polymorphic eruption of pregnancy (PEP)
*AKA: Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)*
**Self-limiting pruritic inflammatory disorder**
- Umbilical sparing rash
- Presents in 3rd trimester or immediately post-partum
- SS: begin on lower abdomen, involving pregnancy striae > extend to thigh, buttocks, legs, arms, rarely involves face, hands, feet
- In 70% of cases, lesions become confluent and widespread, resemble erythroderma
- M: topical steroids, antihistamines, soothing measures, oral steroids
- C: preterm delivery and SGA births, no increase in pregnancy loss, recurs in most subsequent pregnancies
45
Describe prurigo of pregnancy
**Common pruritic disorder**
- Affects 20% of normal pregnancies, do LFTs to exclude obstetric cholestasis
- Starts 3rd trimester (25-30 weeks) of pregnancy, resolve after delivery, no effect on mother or baby
- SS: present as excoriated papules on extensor limbs, abdo, shoulder
- M: symptomatic treatment + topical steroids and emollients
46
Describe pruritis folliculitis
**Pruritic follicular eruption with papules and pustules affecting trunk can involve limbs**
- 2nd or 3rd trimester, resolve a week after delivery
- SS: acne (considered a type of hormone-induced acne)
- M: topical steroids
47
Describe atopic eczema
**Common pruritic condition affecting up to 5% of population**
- SS: causes commonest pregnancy rash
- M: emollients and bath additives
48
Describe the effects of alcohol on pregnancy
**More cognitive and behavioural abnormalities:**
- Miscarriage, stillbirth, infant mortality, congenital abnormalities, LBW, preterm delivery, SGA
- Foetal alcohol spectrum disorders with later neurodevelopmental abnormalities
- Prenatal drinking associated with long-term effects – cognitive/behavioural change, adverse language outcomes
- Executive functioning defects, psychosocial consequences in adulthood
49
Describe the effects of smoking on pregnancy
*More distinct outcomes:*
- Damage to umbilical cord structure
- Miscarriage
- Increased risk of ectopic pregnancy
- LBW & preterm birth
- Placental abruption
- Increased foetal mortality
50
Describe the affects of cannabis on pregnancy
- Preterm labour, LBW, SGA, increased NICU admission
- Adverse consequences of growth of foetal and adolescent brains
- Reduced attention and executive functioning skills
- Poorer academic achievement
- Behavioural problems
51
Describe the effect of cocaine on pregnancy
- PROM
- Placental abruption
- Preterm birth
- LBW, SGA
Similar to cocaine, methamphetamine use linked with shorter gestational ages, LBW, foetal loss, developmental and behavioural defects, preeclampsia, gestational HTN, intrauterine foetal death
52
Describe the affects of opioids on pregnancy
- Greater risk of LBW
- Respiratory problems
- 3rd trimester bleeding
- Toxaemia
- Mortality
- Growth deficiency
- Microcephaly
- Behavioural problems
- SIDS
53
Describe neonatal abstinence syndrome
**Opiate exposure in utero triggers postnatal withdrawal syndrome**
- 45-94% of infants exposed to opioids in utero (inc. methadone, buprenorphine)
- NAS = substantial neonatal morbidity + increased healthcare utilisation
**Presentation:**
- Irritability
- Feeding difficulties
- Tremors
- Hypertonia
- Emesis
- Loose stools
- Seizures
- Respiratory distress
54
Define primary and secondary PPH
- Primary PPH = within 24h
- Secondary PPH = 24h to 12 weeks [NEW]
55
What are the S/S of foetal alcohol syndrome?
- Microcephaly
- Short palpebral fissure
- Hypoplastic upper lip
- Epicanthic folds
- Cardiac malformations
- Smooth/absent filtrum
- Learning difficulties
- Mental retardation
