Obstetric complications Flashcards
1st stage delivery complication that require C-section?
Malpresentation
Arrest of dilation
Arrest of descent
Non reassuring FHR
Chorioamnionitis
Cord prolapse
Two treatable complications of the second stage of delivery that you would manage with C-section?
- Failure of progress of labor
- Fetal distress
Shoulder dystocia & nuchal cord are complications of what stage of delivery ?
Second stage
Retained placenta, Placenta accreta, Uterine inversion and hemorrhage are complications of what stage of delivery ?
3rd stage
Uterine inversion is a life-threatening emergency for the mother.
What is placenta accreta ?
The placenta has eaten into the wall of the uterus and won’t separate normally.
What are the 2 most common symptoms of complicated pregnancy ?
Pain
Bleeding per vagina
Like HTN, bleeding during pregnancy is never normal.
Spontaneous abortions, ectopic pregnancies and gestational trophoblastic diseases usually manifest when ?
Early pregnancy
- Abortions usually before 20 wks
Signs of fetal growth restriction, oligohydramnios and polyhydramnios tend to occur during the first or second half of pregnancy.
Hemorrhages, or high BP related symptoms usually manifest when ?
Later, in second part of pregnancy.
- Placental abruption
- Abnormal implantation
- Pre-eclampsia, eclampsia, chronic hypertension
First trimester miscarriages main cause vs second trimester miscarriages :
Chromosomal abnormalities vs maternal systemic diseases
What is Asherman’s syndrome and what risk factor is it associated with ?
Intrauterine synechiae (scar tissue)
î risk of abortions
Adherences
What endocrine disease is associated with î risk of spontaneous abortion, even in the absence of overt disease ?
Hypothyroidism
SCREEN FOR ANTI-TPO
Structural anomalies that î risk of spontaneous abortion :
- Adhesions/synechiae
- Uterine leiomyomas
- Abnormally shaped uterus (e.g. septum) & cervical insufficiency
FOR UTERINE LEIOMYOMAS, LOCATION IS MORE IMPORTANT THAN SIZE
Abnormally shaped uterus and cervical insufficiency both can lead to spontaneous abortion in the 2ND TRIMESTER.
Exposure to Diethylstilbestrol (DES) during intrauterine life î risk of :
'’T’’ shaped uterus, a structurally abnormal uterus that î risk of spontaneous abortions.
What is cervical insufficiency ?
Painless cervical dilation in the second trimester and/or significant cervical shortening in the absence of signs and symptoms of labor.
SHORT CERVIX, THAT IS DILATED, WITH AMNION PROTRUSION
Trx : Cerclage (indicated only if recurrent late term abortions)
Risk factors : prior preterm birth with or without rupture of membrane < 32 wks ; prior pregnancy with cervical length measurement < 25 mm at 27 wks of gestation ; prior gynecological sx or mechanical cervical dilation ; congenital factors.
Types of first trimester abortions :
- Threatened
- Inevitable
- Incomplete
- Complete
- Missed
- Septic
Bleeding in the first trimester without loss of fluid or tissue, with a live embryo or fetus ?
Threatened abortion
50% will progress to spontaneous abortion
î risk of preterm delivery and LBW
DDX : implantation bleeding (at time of expected menses – normal), ectopic pregnancy, cervical infection, cervical lesions (dysplasia, neoplasia)
Treatment of threatened abortion ?
Bedrest until bleeding stops
Vaginal rest 2 wks after bleeding has stoped
Vaginal bleeding in the presence of cervical dilation
Q tip test
Inevitable abortion
Trx : uterine evacuation (suction, dilation and curettage)
Conservative management (doing nothing) significantly î risk of maternal infection.
What is incomplete abortion ?
The internal cervical os is open and the patient has passed some tissue but some placental tissue is retained in the uterus or cervical canal.
Trx : uterine evacuation
What is a complete abortion?
Spontaneous ejection of the uterine contents frequently accompanied by heavy bleeding after 8 weeks GA.
BEFORE 10 WKS, THE FETUS & PLACENTA ARE COMMONLY EXPELLED TOGETHER.
If uterus is small & firm, cervix is closed and ultrasound shows empty uterus, no further intervention is required.
Consider a course of atb and uterotonic to prevent infection and limit bleeding.
Vaginal rest x 2 wks post bleeding d/c.
Retention of a failed intrauterine pregnancy for an extended period (> 2 menstrual cycles), often asymptomatic and found on ultrasound done for another reason.
Missed abortion
Trx : wait for spontaneous miscarriage (pref) or evacuate fetus.
Bleeding can be reduced by enhancing hemostasis via uterine contractions using what medication ?
Methylergonovine
What is the indication for chromosomal evaluation in case of spontaneous abortions ?
Chromosomal evaluation is NOT recommended, unless there is history of recurrent abortions or clear family hx.
Most commonly prescribed medication for medically induced abortion ?
Combined Misoprostol-Mefipristone
VERY LOW RATE OF COMPLICATIONS IF DONE DURING THE FIRST TRIMESTER.
Complications may include uterine perforation, cervical laceration, hemorrhage, incomplete uterine evacuation & infection.
What is postabortal syndrome (hematometra)?
When the uterus fails to remain contracted after an abortion, there is accumulation of blood inside the uterus.
Pt presents with pain, bleeding, opened cervix and a large, softer than usual uterus.
The clinical presentation is often indistinguishable from an incomplete abortion.The treatment is the same for both (D&C).
Post evacuation treatment, ergot derivative and atb reduce the risk of postabortal syndrome, bleeding and infection.
Investigations of recurrent first trimester pregnancy loss :
Karyotyping for both parents
Antiphospholipid syndrome, SLE, anticardiolipin screens
Asherman’s syndrome
Genetic & autoimmune factors mostly cause early embryonic losses while anatomic abnormalities are more likely to result in 2nd trimester losses.
Where is the most common location of ectopic pregnancy ?
Fallopian tube (ampulla)
If unruptured, an ectopic pregnancy classically presents as :
Subtle symptoms such as complaints of delayed menstrual period or irregular period, lower abdominal pain, spotting.
Presentation of ruptured ectopic pregnancy :
Sudden severe sharp/tearing abdominal pain, syncope, bleeding, unilateral adnexal pain and fullness on bimanual pelvic exam & + rebound.
Bulging/fullness/tenderness in cul de sac may be noted on bimanual exam.
Diagnosis of ectopic pregnancy :
hCG levels of 1000-2000 with no gestational sac in the uterus is suspiscious for extra-uterine pregnancy. A transvaginal ultrasound should be able to show a intrauterine gestational sac with fetal pole and fetal cardiac activity once the hCG levels have reached 5000-6000. If no sac is visualized, suspect ectopic (may be able to locate with TV echo directly).
hCG levels that dont double q 48h, as they would in a normal pregnancy : look for non viable or ectopic pregnancy.
At 5 wks hCG levels should be around ?
1500 mlU/ml
Medical management of ectopic pregnancy ?
single dose of IM methotrexate
monitor b-hCG levels every week until undetectable
Levels of hCG may continue to rise in first 4 days and then decline by 15% after 7 days. If they do not decline, consider another dose of MTX or surgery.
- Salpingostomy is the pref surgical treatment in stable patients (may cause scar tissue)
- Salpingectomy is required in ruptured tubal pregnancy and/or unstable patients (may cause infertility)
What do you give after every pregnancy for the Rh(-) patients ?
Rhogam
The most common cause of irregular vaginal bleeding in the reproductive group is ?
Pregnancy
Distended fluid filled villi instead of normal villi of pregnancy :
Hydatiform mole
Benign gestational trophoblastic disease
More common in Asians and women < 20 or > 35 y.o.
Presentation of benign GTD (hydatiform mole):
Abnormal vaginal bleeding, amenorrhea, uterus large for date, that feels soft, with no fetal heart tones, BUT 40% of patients are ASYMPTOMATIC.
In lack of prenatal care or advanced pregnancy, associated with passage of vesicles per vagina, preeclampsia and hyper-reflexia.
Ultrasound shows a typical appearance of ‘‘snowstorm’’ in the uterus or may present as a missed abortion ?
Hydatiform mole
Treatment of hydatiform mole :
Uterine evacuation
Careful close monitoring for 12 months is recommended with mandatory use of contraception and serial hCG levels to ensure return to 0 and don’t plateau or rise.
Levels that don’t fall as expected indicate gestational trophoblastic neoplasia, which requires chemo.
Abnormal bleeding for more than 6 wks after any pregnancy should prompt hCG testing to exclude new pregnancy or GTN.
2 most common causes of vaginal bleeding in the 3rd trimester are :
A) placenta previa
B) placental abruption
Painfull bleed : placental abruption
Painless bleed : placenta previa
DIGITAL PELVIC EXAM SHOULD NOT BE PERFORMED UNTIL PLACENTAL POSITION IS CONFIRMED BY ULTRASOUND.
What is a major risk factor for placental abruption ?
Trauma
Chronic hypertension, preeclampsia, multiple gestations, advanced maternal age, chorioamnionitis, substance abuse, multiple fetus.
Main differences between presentation of placenta previa and placental abruption ?
Fetal stress in abruption
Pain in abruption
Associated with infrequent DIC in abruption
Bleeding is usually continuous in placental abruption vs ceases within 1-2h in placenta previa.
Main risk factors for placenta previa :
Placenta previa in prior pregnancy
Prior c-section or other uterine sx
Different types of placenta previa :
Complete : placenta completely blocks internal os
Partial : placenta partly blocks internal os
Marginal : placental edge within 2 cm of edge of internal os
Low lying : placenta extends in the lower uterine segment but at > 2 cm from the internal os edge.
Placenta blocks cervix î risk of bleeding at delivery
What is placenta accreta ?
When the placenta is abnormally adherent to the uterine wall.
A cause of 3rd trimester bleeding
Different types of placental abruptions?
What is labor dystocia
Means Abnormal labor or difficult labor. It is characterized by the abnormal progression of labor & is the leading indication for C-section.
Dystocia results from abnormalities of the ‘‘3 Ps’’
- power (inadequate uterine contractions)
- passenger (fetus position, size or presentation inadequate)
- passageway (pelvis or soft tissues impeding passage e.g. cephalopelvic disproportion)
Dystocia can rarely be diagnosed with certainty. May use term ‘‘failure to progress’’ when there is lack of cervical dilation and/or descent of fetal head.
Cut offs in first stage of pregnancy before characterized as protraction disorder ?
Nulliparous : > 20h & dilation < 1cm/h
Multiparous : > 14h & dilation < 1.2-1.5 cm/h
In the first stage of pregnancy, what is considered arrest disorder ?
No cervical dilation for more than 2h for both nulliparous and multiparous.
If regional anesthesia, no cervical dilation for more than 4h.
In the second stage of pregnancy, what is considered Protraction disorder ?
No regional anesthesia, duration >2h or fetus descends < 1 cm/h ;
Duration of > 3h if anesthesia for both nulliparous and multiparous .
When do you consider Arrest disorder during the second stage of pregnancy ?
No descent after 1h of pushing
Risk factors for preterm labor :
Multifetal gestations
Prior preterm birth
Possible subclinical intrauterine inx
Smoking
Substance abuse
UTIs
Cervical insufficiency
In the context of cervical insufficiency, what therapy might be suggested to prolong pregnancy ?
IM progesterone
Tocolytics and NSAIDs as well as magnesium sulfate have varying success but may allow time (48h) for admin of cortico to accelerate fetal lung development.
Most common indication for hospital admission in the first trimester ?
Hyperemesis gravidarum
Diagnosis of exclusion
What causes î incidence of neonatal hyperbilirubinemia, hypocalcemia and polycythemia ?
Diabetic mother
Macrosomia & polyhydramnios are common complications of :
Diabetes during pregnancy
IUGR is defined as :
Weight less than 10th percentile for GA
Dx is usually suspected by a smaller (>3 cm) fundal height
Upon standard testing with umbelical artery doppler, absent or reversed end-diastolic flow should prompt consideration of delivery.
Risks factors for macrosomia ?
Male fetus
Previous large baby
Excessive wt gain during pregnancy
Underlying poorly controlled diabetes
Cut-off weight for macrosomia diagnosis ?
4500 g
> 5000 g –> C section for all pts
> 4500 g –> C section if db
What are the 3 main causes of PPH ?
Uterine atony ‘‘boggy uterus’’
Lacerations of the lower genital tract
Retained placenta
Other risk factors include rapid labor, preeclampsia, macrosomia, chorioamnionitis, asian or hispanic ethnicity.
Diagnostic values of hypertension during pregnancy :
BP > 140/90 before 20 wks with no or stable proteinuria = chronic hypertension.
New or increased proteinuria, î in BP or HELLP syndrome = preeclampsia superimposed on chronic htn.
After 20 wks, BP > 140/90 + proteinuria = preeclampsia
and if no proteinuria = gestational htn.
ECLAMPTIC SEIZURES CAN OCCUR BEFORE OVERT PROTEINURIA DEVELOPS.
BP > 160/110 is classified as severe hypertensive disorder of pregnancy. Clinically, the patient would present with :
Headaches, visual disturbances, oligoruria, î creat & transaminases, pulmonary edema and obvious fetal growth restriction.
ALL OF WHICH ARE ABSENT OR NON SIGNIFICANT IF NON SEVERE HTN (< 160/110)
Most cases of preeclampsia with convulsions (grand mal or tonic-clonic seizures) occur when ?
24h preceding or following delivery , with up to 10% of cases diagnosed 2-10 days postpartum.
Criteria for diagnosis of HELLP syndrome :
Microangiopathic hemolysis
Thrombocytopenia
Hepatocellular dysfunction
HELLP IS AN INDICATION FOR INDUCING DELIVERY. WOMEN < 34 WKS SHOULD RECIEVE CORTICO FOR LUNG MATURATION.
Risk factors for preeclampsia :
Nulliparity
Multifetal gestation
Maternal age > 40 y.o.
Preeclampsia in previous pregnancy
Chronic htn
Pregestational db
Vascular and connective tissue disorders
Nephropathy and other renal diseases
Obesity
African American race
In vivo fertilization
T or F.
In most cases, severe preeclampsia is an indication for delivery, regardless of GA or maturity ?
True.
True or false.
GTD and hyperemesis gravidarum may affect thyroid function ?
True.
Affects 1/7 women and is one of the most common medical complication encountered in the perinatal period ?
Perinatal depression
Indication for administration of prophylactic surfactant in the first 15 min of birth, even without overt respiratory distress ?
Premature baby of < 24 wks
Diagnostic labs for prematurity:
CBC with Hb and WBC count
Hematocrit and electrolytes
BG levels
Blood typing with direct and indirect coombs
Main complication of perinatal asphyxia :
Hypoxic ischemic encephalopathy
Premature babies are at higher risk
APGAR > 7 less likely to cause perinatal HIE
Cord blood pH < 7 and or base deficit > 12 meq/L, increases likelhood of HIE
MRI diagnosis not CT
Presentation of HIE
Mild: slightly î in muscle tone and deep tendon reflexes - usually resolves in 24h.
Moderate : significant hypotonia and decreased DTR, apnea, seizures, sluggish or absent Moro and sucking reflexes. Full recovery may occur in 1-2 wks.
Severe : generalized seizures, bulging fontanelles, stupor, absent neonatal reflexes, impaired ocular reflex (doll’s eye), poorly reactive & fixed pupils, irregular HR and BP.
Mental retardation, cerebral pasly or death are possible complications.
Main causes of early onset infections that may lead to neonatal sepsis :
Group B strep
E.Coli
Premature rupture of membrane (PROM)
- î risk of infection
Main causes of late onset infections of neonate:
Staph from the environment (IV, KT, central lines, etc.)
LBW infants more at risk of E. Coli & Listeria infections.
MOST IMPORTANT RISK FACTOR OF NEONATAL SEPSIS :
PRETERM DELIVERY
DDx of respiratory distress is what kind of infection ?
Neonate born with group B strep & monocytogenes infection will be born with respiratory distress (different than respiratory distress syndrome)
Moderate to severe neonatal jaundice is treated with ?
Phototherapy
Maybe IVIg with babies with Ab against Rh - blood type
Mild cases usually resolve spontaenously in 2-3 wks.
Basis of treatment of kernicterus :
Rapidity of serum bilirubin concentration rise q 4-8h.
What is consumptive hypothyroidism ?
Rare disorder that develops in the newborn with hepatic hemangiomas due to overexpression of 3-deiodinase (inactivation of T3 & T4) which results in T3 & T4 consumption at a rate higher than their production.
LABS : LOW T3 & T4, HIGH TSH, Î rT3
TRX : Removal of hemangioma, thyroid hormone replacement therapy (liothyronine and levothyroxine) + propranolol (suppression of tumor angiogenesis)
Main clinical features of prematurity :
< 2.5 kg
Thin, shiny pink skin with visible underlying veins
Decreased subcutaneous fat
Extended limbs with decreased muscle tone
Unstable T
Prolonged jaundice
Feeding difficulty
In males, scrotum few rugae, may have undescended testes
Females, labia majora does not cover minora
Reflexes absent
Moro starts at 28-32 wks & well established at 37 wks
Palmar starts at 28 wks & well established at 32 wks
