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4th Year GOSH > Obstetric Complications > Flashcards

Obstetric Complications Flashcards

1
Q

Definition of preterm labour?

A

Between 24 and 37 weeks’ gestation - 8% of deliveries

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2
Q

Risk factors for preterm labour?

A
  • Previous history
  • Low SE status
  • Extremes of maternal age
  • Short inter-pregnancy interval
  • Maternal disease (renal/DM)
  • Pregnancy complications (pre-eclampsia/IUGR)
  • Male foetal gender
  • High Hb
  • STIs/vaginal infection (BV)
  • Previous cervical surgery (LETTZ)
  • Multiple pregnancy
  • Uterine abnormalities and fibroids
  • Urinary infection
  • Polyhydramnios
  • Congenital foetal abnormalities
  • Antepartum haemorrhage
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3
Q

Mechanisms of preterm labour? (defenders)

A

Multiple pregnancy and polyhydramnios

Foetal survival response (pre-eclampsia, IUGR, infection, abruption)

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4
Q

Mechanisms of preterm labour? (castle/wall)

A

Uterine abnormalities (fibroids, congenital)

Cervical incompetence

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5
Q

Mechanisms of preterm labour? (enemy)

A

Chorioamnionitis, BV, GBS, trichomonas, chlamydia

UTI/dental infections

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6
Q

Neonatal complications of preterm labour?

A

Prematurity –> 80% neonatal ICU occupancy, 20% perinatal mortality, 50% cerebral palsy.

Long-term
Chronic lung disease, blindness, minor disability.

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7
Q

Maternal complications of preterm labour?

A

Infection –> endometritis

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8
Q

How to predict preterm labour?

A

TV USS of cervical length at 23 weeks (<15mm)

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9
Q

Prevention of preterm labour in high risk individuals?

A

Cervix - suture in cervical incompetence + regular scanning

Infection - screening and treatment (STIs, UTI, BV)

Foetal reduction - higher order pregnancies

Polyhydramnios - needle aspiration, NSAIDs (reduce foetal urine)

Progesterone pessaries - suppositories from early pregnancy

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10
Q

Clinical features of preterm labour?

A

History = painful contractions, cervical incompetence (suprapubic ache), antepartum haemorrhage and fluid loss common

Exam = fever, check lie and presentation, digital vaginal exam unless ruptured membranes - effaced or dilating cervix confirms diagnosis

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11
Q

Investigations in preterm labour?

A

Foetus - CTG and USS

Likelihood of delivery - foetal fibrnoectin assay, TV USS of cervical length

Infection - high vaginal swabs, maternal CRP - WCC unhelpful

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12
Q

Management of preterm labour?

A

Pulmonary maturity - steroids and tocolysis

Infection - IV abx and immediate delivery if chorioamnionitis

Delivery - vaginal usually, c-section for usual indications. Can use forceps but ventouse contraindicated. Abx due to risk of GBS.

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13
Q

What do you need to be careful with with steroids?

A

Glucose control in diabetics

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14
Q

Examples of tocolytics? What do they do? How long should you use them for?

A

o Nifedipine/atsodiban (oxytocin receptor antagonist).

o Delay preterm labour – should not be used for more than 24 hours.

o Allows steroids time to work, or time for in utero transfer to facilitiy with neonatal ICU facilities.

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15
Q

Definition of antepartum haemorrhage?

A

Bleeding from genital tract after 24 weeks’ gestation

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16
Q

Causes of APH?

A

Undetermined origin
Placental abruption
Placenta praevia

Rarer = incidental genital tract pathology, uterine rupture, vasa praevia

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17
Q

What is placenta praevia?

A

Placenta is implanted in lower segment of the uterus

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18
Q

Will a low-lying placenta necessarily be praevia at term?

A

Only 1 in 10 apparently low-lying placentas will be praevia at term (myometrium where placenta inserts moves away from cervical os)

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19
Q

Classification of placenta praevia?

A

Marginal = placenta in lower segment, not over os

Minor = placenta completely or partially covering os

20
Q

Complications of placenta praevia?

A

C-section necessary

Haemorrhage - can be severe (during and after delivery)

Implantation in c-section scar –> accreta or percreta (massive haemorrhage at delivery –> hysterectomy)

21
Q

Clinical features of placenta praveia?

A

History - Intermittent painless bleeds. Increase in frequency and intensity over several weeks.

Exam - Breech presentation and transverse lie common. Foetal head not engaged and high.

22
Q

What should you NEVER do in placena praevia?

A

Vaginal exam - can provoke massive bleeding. Don’t do until praevia excluded.

23
Q

Investigations in placenta praevia?

A

USS – if low-lying placenta diagnosed at 2nd trimester ultrasound, this is repeated at 34 weeks to exclude placenta praevia.

24
Q

Management of placenta praevia?

A

If asymptomatic, admit at 37 weeks.

If bleeding, admit whatever gestation.
Keep blood available, anti-D to rhesus -ve women, maintain IV access, steroids if <34 weeks.

Elective C-section at 39 weeks

25
Q

Definition of placental abruption?

A

When part (or all) or placenta separates before delivery of the foetus.

1% of pregnancies

26
Q

Classification of placental abruption?

A

Concealed = pain with no bleeding

Revealed = pain and bleeding

27
Q

Risk factors for placental abruption?

A

Many affected women have no risk factors.

Main = IUGR, pre-eclampsia, pre-existing hypertension, maternal smoking, previous abruption (6% risk)

AI disease, cocaine usage, multiple pregnancy and high maternal parity.

28
Q

Placental abruption history?

A

History - Pain and/or bleeding (pain due to blood behind placenta in myometrium) -Blood often dark

Examination - tachycardia/hypotension suggests massive blood loss. Uterus tender and often contracting.

29
Q

Features of major placental abruption?

A
  • Maternal collapse
  • Coagulopathy
  • Foetal distress or demise
  • ‘Woody’ hard uterus
  • Poor urine output or renal failure
30
Q

Investigations in placental abruption

A

Foetal = CTG

Maternal = FBC, coagulation screen, X-match.
Catheterisation (hourly urine output), CVP monitoring, regular FBC, coagulation, U+E if severe.

USS NOT needed - diagnosis is clinical - only done to exclude praevia.

31
Q

Initial management of placenta praevia?

A
  • Admission – even without vaginal bleeding if there is pain and uterine tenderness.
  • IV fluid (+ steroids if <34 weeks).
  • Blood transfusion considered
  • Opiate analgesia
  • Anti-D to rhesus negative women
32
Q

Conservative management of placenta praevia?

A

If no foetal distress, pregnancy preterm and degree of abruption appears minor.

Steroids (if <34 weeks) and patient closely monitored on ward.

May be discharged, but now ‘high-risk’ – so more USS for foetal growth.

33
Q

Delivery in placenta praevia?

A

Foetal distress - urgent section

No foetal distress - (>37 weeks) induction and continuous foetal monitoring

34
Q

Postpartum management of placenta praevia?

A

Postpartum haemorrhage is major risk regardless of mode of delivery

35
Q

What is vasa praevia?

A

When vessels run close to or cross the opening of the uterus –> bleeding

36
Q

Indications for episiotomy?

A

Foetal distress
Head not passing over perineum despite maternal effort
Large tear likely

37
Q

Episiotomy process?

A

Perineum filled with LA and 3-5cm cut made with scissors from centre of fouchette to (mother’s) right side of perineum.

38
Q

Delivery after episiotomy?

A

Swab is pushed against (‘guarding’) the perineum as the head distends it – she is asked to stop pushing and to pant slowly –> enables a controlled delivery of head and reduces perineal damage.

39
Q

What is a first degree tear?

A

Injury to skin only

40
Q

What is a second degree tear?

A

Involving perineal muscles but not anal sphincter

41
Q

What is a third degree tear?

A

Involving anal sphincter complex

  • 3a = <50% of anal sphincter torn
  • 3b = >50% of anal sphincter torn
  • 3c = internal anal sphincter also involved
42
Q

What is a fourth degree tear?

A

Involving anal sphincter and anal/rectal epithelium

43
Q

Management of 1st/2nd degree tears?

A
  • Sutured under LA. Absorbable synthetic material used (Dexon or Vircyl) – continuous rather than separate structures for muscle and a subcuticular layer for skin.
  • Rectal/vaginal examination excludes sutures that are too deep and retained swabs respectively.
44
Q

Management of 3rd/4th degree tears?

A
  • Repaired under epidural or spinal in theatre

* Antibiotics, laxatives and analgesia given

45
Q

Long-term consequences of 3rd/4th degree tears?

A

30% have incontinence of flatus/urgency or sometimes frank incontinence

4th Year GOSH (23 decks)

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