obstetric complications Flashcards
Vaginal hematoma
Risk
- operative vaginal delivery
- infant over 4000 g
- nulliparity
- prolonged 2nd stage of labor
Clinical features
- potentially life threatening
- protruding vaginal mass (purple)
- injury to uterine artery
- rectal or vaginal pressure
- hypovolemic shock due to occult bleeding
- minimal vaginal bleeding
Treatment
- nonexpanding: observation
- expanding: embolization, surgery
risk of preterm labor
prior preterm labor (number one association)
multiple gestations
history of cervical surgery –> cold knife conization
first step in evaluating risk is transvaginal US to measure cervical length in second semester (shorter is predictor)
labor can be prevented with progesterone or cerclage
screen with cervical length measurement by TVUS
placental abruption
risk
- maternal HTN or preeclampsia/eclampsia
- abdominal trauma
- prior placental abruption
- cocaine and tobacco use
Clinical
- sudden onset vaginal bleeding
- abdominal or back pain
- high frequency, low intensity contractions
- hypertonic, tender uterus
- distended uterus can be sign of concealed abruption
diagnosis
- primarily clinical presentation
- US can rule out placenta previa and may show retroplacental hematoma
management:
- in case of hypovolemic shock: aggressive fluid resuscitation with crystalloids
- left lateral decubitus positioning to maximize cardiac output
complications
- hypovolemic shock
- DIC
Septic abortion
Risk factors
- retained products of conception from
- elective abortion with nonsterile technique
- missed or incomplete abortion
Clinical
- fever, chills, abdominal pain
- sanguinopurulent vaginal discharge
- boggy, tender uterus
- dilated cervix
- pelvic US: retained ROC, thick endometrial stripe
Management
- IV fluids
- broad spectrum antibiotics
- suction curettage
Placenta previa
Risk
- prior placenta previa
- prior c section
- multiple gestation
- smoking
Clinical
- painless vaginal bleeding >20 weeks gestation
- can see effacement
Diagnosis
-transabdominal followed by transvaginal sonogram
mangagement
- no intercourse
- no digital cervical exam
- inpatient admission for bleeding episodes
intrauterine fetal demise
definition
-fetal death over 20 weeks prior to expulsion from mother
risk
- nulliparity
- HTN
- obesity
- DM
diagnosis
- absence of fetal cardiac activity on US
- if no sounds on doppler, needs to be confirmed with US
management
- 20-23 weeks: dilation and evac or vaginal delivery
- over 24 weeks: vaginal delivery
complication
-coagulopathy after several weeks of fetal retention
evaluation of fetal demise
Fetal
- autopsy
- gross and microscopic examination of placenta, membranes, and cords
- karyotype/genetic studies
Maternal
- Kleihauer-Betke test for fetomaternal hemorrhage
- antiphospholipid antibodies
- coag studies
Breech presentation
TYPES
- frank: hips flexed and knees extended (butt first)
- Complete: hips and knees flexed
- incomplete: 1 or both hips not flexed (feet first)
RISK
- advanced maternal age
- mulitparity
- uterine didelphys
- septate uterus
- uterine leiomyomas
- fetal anomalies
- preterm
- oliogo/polyhydramnios
- placenta previa
Management
- external cephalic version
- cesarean delivery
Illicit drug abuse in pregnancy
RISK
- adolescent pregnancy
- late/noncompliant prenatal care
- inadequate pregnancy weight gain
COMPLICATIONS
- spontaneous abortion
- preterm birth
- preeclampsia
- abruptio placentae
- fetal growth restriction
- intrauterine fetal demise
Chorioamnionitis
RISK
- premature rupture of membranes
- prolonged rupture of membranes
- prolonged labor
- internal monitoring
- repetitive vaginal exams
- genital tract pathogens
CLINICAL
- nausea
- vomiting
- uterine focal tenderness
- maternal fever plus fetal tachy, maternal leukocytosis, maternal tachy, or purulent amniotic fluid
- may have abnormal contraction pattern
MANAGE
- broad spectrum antibiotics
- delivery (augementation of labor)
COMPLICATIONS
- maternal: postpartum hemorrhage, endometritis
- fetal: preterm birth, pneumonia, encephalopathy
septic pelvic thrombophlebitis
RISK
- C section
- pelvic surgery
- endometritis
- PID
- pregnancy
- malignancy
PATHOPHYS
- hypercoagulability
- pelvic venous dilation
- vascular trauma
- infection
CLINICAL
- fever unresponsive to antibiotics
- no localizing symptoms
- negative infectious evaluation
- diagnosis of exclusion
TREATMENT
- anticoagulation
- broad spectrum antibiotics
External cephalic version
PROCEDURE
- manual rotation of fetus to cephalic presentation
- decreases cesarean delivery rate
INDICATIONS
- breech/transverse presentation
- over 37 weeks gestation
ABSOLUTE CONTRAINDICATIONS
- same as contraindications to vaginal delivery
- prior classical (vertical incision) cesarean delivery
- prior extensive uterine myomectomy
- placenta previa
COMPLICATIONS
- placental abruption
- intrauterine fetal demise
Uterine rupture
RISK
-scar from prior C section and then trying to deliver vaginally
CLINICAL
- intense, focal, abdominal pain that is relieved by rupture and then resumes
- bleeding
- loss of fetal station
- abnormal heart readings –> decelerations
- palpable fetal parts on abdominal exam
- loss of intrauterine pressure
MANAGEMENT
-emergency laparotomy to confirm diagnosis and expedite delivery
HELLP syndrome
PATHO
- abnormal placentation
- triggers systemic inflammation and activation of clotting cascade that consumes platelets
- MAHA leads to liver damage as well as increased bilirubin production
- hepato necrosis and thrombi
CLINICAL
- preeclampsia
- nausea/vomiting
- right upper quadrant abdominal pain – stretching of hepatic capsule
LAB
- microangiopathic hemolytic anemia – indirect hyperbili
- elevated liver enzymes
- low platelet coutn
TREATMENT
- delivery
- Mg for seizure prophylaxis
- Antihypertensive drugs
pulmonary edema in preeclampsia
PATHOPHYS
- generalized arterial vasospasm leading to increased SVR and high cardiac afterload
- decreased renal function
- decreased serum albumin
- increased capillary permeability due to endothelial damage
CLINICAL
- increased BP
- tachycardia
- tachypnea
- hypoxia
- pitting edema
MANAGE
- oxygen
- fluid resus
- diuresis
Shoulder dystocia
Definition
-failure of usual obstetric maneuvers to deliver fetal shoulders
RISK
- fetal macrosomnia
- maternal obesity
- excessive pregnancy weight gain
- gestational diabetes
- post term pregnancy
WARNING SIGNS
- protracted labor
- prolonged first or second stage of labor
- retraction of fetal head into the perineum after delivery (turtle sign)
Late and post term pregnancy
Definition
- late term is over 41 weeks
- post term is over 42 weeks
RISK
- prior
- nulliparity
- obesity
- AMA
- fetal anomalies
COMPLICATIONS Fetal -macrosomnia -dysmaturity syndrome -oligohydramnios -demise
maternal
- severe obstetric lac
- c section
- postpartum hemorrhage
MANAGE
- frequent fetal monitoring
- delivery prior to 43 weeks
pregnancy related risks due to hypertension
MATERNAL
- superimposed preeclampsia
- post partum hemorrhage
- gestational diabetes
- placental abruption
- c section
FETAL
- fetal growth restriction
- perinatal mortality
- preterm delivery
- oligohydramnios
Preterm prelabor ROM
- less than 34 weeks
- RISK: multiple gest, previous, genital tract infection, antepartum bleeding
IF otherwise UNCOMPLICATED
- expectant management
- latency antibiotics
- corticosteroids
- fetal surveillance
