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