Obstetric Complications Flashcards
pregnancy that implants outside uterine cavity
ectopic pregnancy
MCC place for ectopic pregnancy
fallopian tubes - Ampulla
leading cause of maternal death in first trimester
ruptured ectopic pregnancy
risk factors for ectopic pregnancy**
- history of PID - fallopian tube scarring
- history of STI
- previous ectopic pregnancy
- tubal scarring (surg, TB, etc)
- current IUD use
- congenital malformation
- smoking
- assisted reproductive technology
- in utero DES exposure
diagnosis of ectopic pregnancy
- urine hCG to start
- speculum and bimanual exam
- adnexal mass, bleeding
- US (transvaginal best)
- no intrauterine sac
- ectopic sac or cardiac activity
- complex adnexal mass
- fluid in cul de sac
chemical diagnosis of ectopic pregnancy**
- inadequate rise of hC
- <66% q48h in first 6-7 weeks
- progesterone < 5 ng/mL
- 5-25 ng/mL unclear
management of ectopic pregnancy
- ensure pt. hemodynamically stable
- determine if ruptured
- give RhoGAM if pt. D-
- medical vs. surgical
-
methotrexate
- hemodynamically stable
- < 3.5 cm
- compliant for follow-up
- intrauterine pregnancy ruled out
- surgical
- laparotomy (unstable)
- laparoscopy (stable)
-
methotrexate
salpinectomy vs. salpinostomy
complete or partial removal of fallopian tube
vs.
removal while sparing tube
relative contraindications of methotrexate
- fetal cardiac activity
- hCG > 15,000
- > 3.5 cm
absolute contraindications of methotrexate
- hemodynamically unstable/rupture
- leukopenia
- thrombocytopenia
- active renal/hepatic dz
- active peptic ulcer dz
- possible concurrent viable uterine pregnancy
antepartum hemorrhage
- placenta previa
- placenta acreta
- abruption placentae
- uterine rupture
postpartum hemorrhage
- uterine atony
- retained placental tissue
- genital tract trauma
- uterine inversion
dystocia
(dysfunctional or difficult labor)
- uterine contractility/expulsive forces
- cephalopelvic disproportion
obstetric complications
- premature/preterm labor
- premature rupture of membranes
- intrauterine growth restriction
- posterm pregnancy
- intrauterine fetal demise
triad of maternal death
obstetrical hemorrhage
hypertension
infection
single most important cause of maternal death worldwide
hemorrhage
placenta implants of cervical os
placenta previa
types of placenta previa
complete, partial, marginal
Dx and Tx of placenta previa
- Dx
- US
- painless bleeding
- Tx
- pelvic rest
- low-lying placenta safe for labor, vaginal birth
abnormally implanted, invasive, or adhered placenta
placenta accreta
premature separation of placenta from uterine wall
placental abruption
(leading cause of hemorrhage in 2nd and 3rd trimester)
S/s and Tx of placental abruption
- S/s
- back discomfort
- abdominal cramping
- vaginal bleeding
- abdominal pain
- Tx
- expedited birth - c-section mostly
2 types and classifications of uterine rupture and Tx
- types
- primary - no prior scarring
- secondary - preexisting incision, injury
- classes
- complete - all layers separated
- incomplete - visceral peritoneum intact (aka uterine dehiscence)
- Tx
- immediate delivery (MC by laparotomy)
greatest risk for uterine rupture
prior c-section
blood loss > 500mL in vaginal delivery
postpartum hemorrhage
- early postpartum - during first 24h after delivery
- late postpartum - 24h to 6w after delivery
myometrium cannot contract causing bleeding
(MCC postpartum hemorrhage)
uterine atony
most important step in controlling atonic hemorrhage
immediate bimanual uterine compression 20-30 min
pharm agents for uterine atony
- first line
- oxytocin 10-20mL/min IV until bleeding controlled, then 1-2mL/min until transfer
- second line
- methylergonovine 0.2mg IM
cause of 5-10% of postpartum hemorrhages associated with placenta accreta
retained placental tissue
prolapse of fundus through cervix - shock and hemorrhage prominent w/ considerable pain
(what type associated w/ tumors)
uterine inversion
(nonpuerperal w/ polypoid leiomyomas)
difficult or problematic birth
dystocia
3 majors causes of dystocia
- inadequate cervical dilation or fetal descent
- fetopelvic disproportion
- ruptured membranes w/out labor
slower than normal labor
labor protraction disorder
complete cessation of labor progress
arrest disorder
measurement of inadequate uterine contractions
< 180 Montevideo units
1 cause of neonatal morbidity and mortality
premature labor
known causes of premature labor
- infection (cervical-vaginal-urinary)
- placental (vascular)
- psychosocial stress/work strain (fatigue)
- uterine stretch (multiple gestations)
also: smoking, cocaine, cervical malformation/incompetence, HTN, DM, obesity
reasons for preterm birth
- pre-eclampsia
- fetal distress
- small for gestational age
- placental abruption
steps to prevent premature labor
- aggressive control of chronic conditions
- education about smoking, drug abuse
- probiotic
- assess cervical competence
- vaginal progesterone in weeks 20-36 if short cervix
- prior preterm labor:
- vaginal progesterone weeks 16-36
- IM weekly
definition of pre-term labor
uterine contractions 4/20min or 8/60min
and
cervix with 2cm dilation or 80% effacement
- NOT
- cervical changes absent contractions
- regular contractions absent cervical change (Braxton Hicks)
- late s/s:
- watery/bloody show, mucus plug passage, painless contractions, menstrual-like cramps, low back pain
Dx and Tx of pre-term labor
- Dx:
- US of cervical length (normal is 4cm @ 24w)
- fetal fibronectin secretions
- labs: vaginal cultures, UA, C&S, CBCd
- Tx
- lateral decubitus position and reassess
- obs, bed rest, hydration, abx, steroids
- Tocolytics to stop contractions
Uterine Tocolytics
- magnesium sulfate (first line)
- CCB
- Nifedipine
- prostaglandin synthase inhibitor
- Indomethacin
- higher fetal effects
PROM
premature rupture of membranes at least 1 hour before active labor before 37 weeks
Dx of PROM
- Nitrazine test- alkaline if amniotic fluid
- Ferm test- detects salt crystals in amniotic fluid
PROM after 37 weeks - Tx
IP, fetal monitoring, monitor mother for infection, induce labor to decrease infection risk
consider c-section
PROM >34 weeks - Tx
IP, fetal monitoring, strict bedrest, induce labor/c-section if indicated
PROM <34 weeks - Tx
IP, fetal monitoring, steroids (betamethasone or dexamethasone), antibiotics, Tocolytics to inhibit uterine contraction, indiction/c-section if indicated
PROM <24 weeks - Tx
antibiotics, education of risks, consider termination
PROM - indications for immediate delivery
- chorioamnionitis fetal distress
- placental abruption
- advanced/prolonged labor
- cord prolapse
estimated fetal weight < 10th percentile
for gestational age on US
intrauterine growth restriction (IUGR)
Risks of IUGR
- meconium aspiration
- asphyxia
- polycythemia
- hypoglycemia
- mental retardation
Causes of IUGR
maternal, placental, fetal
- maternal
- poor nutrition, smoking, drugs, EtOH, CVS disease, HTN, DM, obesity
- placental
- inadequate substrate transfer: HTN, obesity, CKD, PIH
- fetal
- intrauterine infection (listeriosis, TORCH), congenital anomalies
Types of IUGR
- symmetric (20%)
- organs decreased proportionally
- MC w/ infections and anomalies
- asymmetric (80%)
- organs decreased disproportionally (abdomen > head)
Dx of IUGR
- fundal height 1’ screening tool
- US (GOLD standard)
- abdominal circumference most effective
Management of IUGR
- pre-pregnancy: education, prevention
- antepartum: modifiable risk factors
- smoking, nutrition, etc
- labor & delivery: low threshold for c-section
name for 42+ weeks from onset of LMP
post-term pregnancy
Complications of Post-term Pregnancy
post-maturity syndrome
- loss of SQ fat
- long fingernails
- dry skin
- abundant hair
- macrosomia
- birth weight > 4000g
- incr. shoulder dystocia, birth trauma, c-sect.
fetal death after 20 weeks but before labor onset
intrauterine fetal demise
Dx and Tx of Intrauterine Fetal Demise
- Dx
- absence of fetal movements
- uterus small for dates
- fetal heart tones not detected
- US to confirm these
- Tx
- watchful expectancy
- 80% spontaneous labor in 2-3 weeks of demise
- labor induction
- watchful expectancy
