Obstetrics Flashcards
Define antepartum haemorrhage
A vaginal bleed that occurs after 24 weeks gestation
What is abruptio placenta?
- It is when the normally positioned placenta has separated from the uterus before delivery
- There is continuous severe abdominal pain
- Blood is dark with red clots
- Absence of fetal movement following bleeding
What are the risk factors for Abruptio placenta?
- Previous abruptio placenta (10%; 25%)
- Pre-eclampsia / Hypertensive disorder of pregnancy
- Smoking
- IUGR
- Poor socio-economic circumstances
- History of abdominal trauma
What are the clinical findings in abruptio placenta?
- Patient is shocked out of proportion to blood loss
- Severe abdominal pain
- Tonically contracted hard and tender uterus
- Rigid abdomen
- Fetal parts not palpable
- Uterus big for dates
- Low Hb
What is the classification of abruptio placenta?
- Grade 1 - Small amount of vaginal bleeding and some uterine contractions, no signs of fetal distress or low blood pressure in the mother.
- Grade 2 - Mild to moderate amount of bleeding, uterine contractions, the fetal heart rate may shows signs of distress.
- Grade 3 - Moderate to severe bleeding or concealed (hidden) bleeding, uterine contractions that do not relax (called tetany), abdominal pain, low blood pressure, fetal death.
What is the management of abruptio placenta?
- If in doubt DO NOT PV!
- Certain signs and symptoms of abruptio - PV
- If cervix >9cm - ROM and NVD or emergency C/S
- If fetus not viable - NVD
- While preparing for delivery - resus and intrauterine resus
- If fetal distress + viable fetus - C/S
What is Placenta preavia?
When the placenta is implanted completely or partially in the lower segment of the uterus
What are the risk factors for placenta preavia?
- Grande multiparity (>5)
- Previous C/S
- Multiple pregnancy
- Threatened abortion
- Abnormal presentation
What are the clincal finding of placenta preavia?
- Patient shocked in proportion to blood loss
- Painless bleeding and bright red in colour
- Uterus soft and non-tender
- Fetal parts easily palpated and FH present
- Abnormal presentation
- Fetal head high in cephalic presentation
What is the classification of placenta preavia?
- Minor
Type I - Low-lying placenta - placenta implanted in the lower uterine segment >2cm from the os
Type II - Marginal placenta previa - placental edge at margin <2cm from the internal os - Major
Type III - Partial placenta previa - internal os partly covered by placenta.
Type IV - Complete placenta previa - internal os completely covered by placenta.
What is the management of placenta preavia that is not bleeding?
- <38 weeks and not bleeding
- U/S to localize placentae
- Hospitalized, bed rest, conservative management till 38 weeks / active bleeding
- steroids for lung maturity if >28 and <34
- > 38 weeks
- U/S to localize placentae
- PV in theater if no U/S and C/S
What is the management of placenta preavia that is bleeding?
- > =38 weeks + bleeding
- If actively bleeding - C/S
- Grade 1 - ROM, NVD
- Grade 2 - C/S
- 36 weeks + grade 4 - Emergency C/S
What are the types of Antepartum haemorrhage?
- Abruptio placentae
- Placenta preavia
- Ruptured uterus
- Decidual bleeding
- Vasa Placentae
- Cervical cancer
- Local lesions
- APHUO
What are the causes of Postpartum haemorrhage?
- Primary
- Uterine atony
- Contracted uterus
- Uterine inversion
- Lower genital tract laceration
- Coagulopathy
- Haematoma
- Secondary
- Endometriosis
- Haematoma
- Gestational trophoblastic neoplasm
What is the management of postpartum haemorrhage?
- Prevention
- Refer to higher level of care
- Antepartum correction of anaemia
- Consent for possible hysterectomy
- Counselling regarding sterilization
- Medical
- Uterine atony
- Fundal massage
- Empty bladder
- Oxytocin infusion
- No retained products of conception
- Misoprostol PR
- Prostin
- Surgical
- Local suturing
- Uterine packing
- Subtotal abdominal hysterectomy
- B-lynch suture
What is the definition of preterm labour
The onset of labour before 37 completed gestational weeks OR if the gestation is unknown when the estimated fetal weight is less than 2500g
What are the causes of preterm labour?
- Maternal
- Chorioamonionitis
- Pyrexia of other causes
- Cervical incompetence
- Fetal
- Multiple pregnancy
- Congenital fetal anomaly
- Placental
- Placenta preavia
- Abruptio placenta
What are the risk factors for preterm labour?
- History of PTL
- Unbooked - No ANC
- Smoking, EtOH
- Coitus in second half of pregnancy
Management of Preterm labour?
- Determine GA
- <24 weeks - Inevitable abortion
- 24-33 weeks - Suppression
- 34-36 weeks - If pulmonary mature – allowed to continue
- Any fetal distress ? - Prompt delivery if viable
- Treatable causes addressed (eg pyelonephritis)
- Suppression of labour
- CCB (Nifedipine)
- Salbutamol (acute suppression, eg cord prolapse)
Contraindications for suppression of labour?
- Fetal distress
- > 34 weeks OR <24 weeks
- Chorioamnionitis
- Congenital abn incompatable with life
- Pre-eclampsia
- APH of unknown cause
DDx for poor SF-growth?
- Constitutional (familial)
- Fetal
- congenital abnormalities
- congenital infection
- Placental insufficiency
- Pre-placental (malnutrition, PE)
- Abruptio placentae
- Post-term pregnancy
DDx for large for gestational age
- Wrong dates
- Maternal obesity
- Multiple pregnancy
- Polyhydramnios
- Macrosomia (DM)
- Uterine leiomyomas
DDx for Polyhydramnios
- Multiple pregnancy
- Maternal Diabetes
- Fetal anomaly
- spina bifida
- anencephaly
- oesophageal atresia
DDx for oligohydramnios
- IUGR
- Urinary tract obstruction/abnormality of the fetus
Management of Breech presentation at term
- External cephalic version
- Counsel about mode of delivery
- C/S - elective at 39 weeks
- Vaginal delivery upon request if suitable
Vaginal Birth:
- If good progress in labour, allow for spontaneous delivery to the scapula
- Assist delivery of the head
Management of Cord prolapse
A. General
- Cord presentation – do C/S
- Cord prolapse – Indication for immediate delivery if viable
B. Assessment
- Replace cord in vagina or cover with warm, wet towel
- Avoid unnecessary handling
- Determine the degree of dilatation of cervix
- Determine nature and station of presenting part
- Elevate presenting part digitally
- Confirm that fetus is alive by lightly palpating the pulsatile cord and confirm viability
C. Delivery (only if longitudinal, full dilatation, presenting part at pelvic floor)
D. Tocolysis
- Reassure patient
- Administer oxygen by face mask
- Tocolytic – Salbutamol
- Position patient in knee-chest position or insert 300ml into bladder with catheter
E. C-section
- Prepare for fetal resus
- Empty bladder
- Prophylactic antibiotics
What is Gestational Diabetes?
Diabetes which develops in pregnancy and resolves spontaneously after delivery
What are the complications of gestational diabetes?
- Infection - candida and UTIs
- Congenital abnormalities
- Pre-eclampsia
- Polyhydramnios
- Large baby - Cephalopelvic disproportion / shulder dystocia
- Increased risk of PPH
- Neonatal hypoglcaemia
- Hyaline membrane disease
Management of Gestational diabetes
- Admit to secondary level of care
- Control blood sugar - Diabetic diet and ?Metformin
- Adjust insulin levels accordingly
- @36 weeks test placental function and determine fetal size
- Induce labour if macrosomia at 36 weeks
- @38-40 weeks induce labour
