Obstetrics- Late Pregnancy Complications

Question 1

Presentation of acute faty liver of pregnancy

Answer 1

RUQ pain
↑ transaminases
Fulminant Hepatic Failure 
	-Scleral icterus 
	-Encephalopathy
Leukocytosis 
Platelet ≤ 100k
Intrauterine Fetal Demise (IUFD)

Question 2

Intrahepatic cholestasis of pregnancy

Answer 2

Third trimester complication in which increased estrogen and progesterone cause hepatobilliary tract stasis resulting in ↑ total bile acids.

Increased risk with prior ICP, >35yo, multiple gestations

Question 3

S&S intrahepatic cholestasis of pregnancy

Answer 3

Pruritus (worse hands & feet)
No skin rash
RUQ pain 
↑ Total Bile Acids (≥10)
↑Bilirubin
↑Transaminases
IUFD

Question 4

Fetal complications with intrahepatic cholestasis of pregnancy

Answer 4

Bile acid crosses placenta, gets into fetal circulation and becomes increasingly toxic.

IUFD (proportional to bile acid level, high risk > 100)
Meconium- stained amniotic fluid
Preterm Delivery
NRDS

Question 5

Abruptio placentae

Answer 5

premature placental separation from the uterine wall prior to fetal delivery.

Question 6

Mechanism of abruptio placentae in uterine overdistention

Answer 6

Uterine overdistention (twins, polyhydramnios) + Uncontrolled gush of amnio fluid –>
Rapid uterine decompression–>
shearing of decimal vessels–>
Bleeding at decimal- placental interface

Question 7

Risk factors for abruptio placentae

Answer 7

Hypertension/ preeclampsia
Abdominal trauma
Prior Abrupt placentae
Cocaine/ tobacco use

Question 8

S&S abrupt placentae

Answer 8

• Sudden-onset vaginal bleeding
• Abd/ back pain
• High frequency, low intensity contractions
• Rigid/ Firm uterus (bleeding ↑pressure)
• Tender uterus

Question 9

Management of abruptio placentae

Answer 9

If self-limiting= observation

Acute abruption with active bleeding and evidence of fetal hypoxia requires emergent delivery.

Question 10

Complications of abruptio placentae

Answer 10

Fetal hypoxia, preterm birth, fetal demise

Maternal hemorrhage, DIC

Question 11

Vasa previa

Answer 11

Fetal placental vessels overlay the cervix. Can cause painless vaginal bleeding with rupture of membranes or labor

Question 12

Placenta accreta

Answer 12

Attachment of the placental villi directly to the myometrium. Occurs with prior c-sec and implantation over uterine scar.

Question 13

Placenta previa

Answer 13

placenta covers the cervix. commonly diagnosed in an asymptomatic pt during ultrasound. Can be symptomatic after 20wks.

Question 14

S&S placenta previa

Answer 14

Painless vaginal bleeding after 20wks gestation.
Irregular non painful contractions
Physiological cervical changes

Question 15

Fetal heart tracings in placenta previa

Answer 15

Early: bleeding is maternal in origin. A reactive FHR is seen.

Late: continued maternal blood loss can lead to fetal compromise

Question 16

Fetal heart tracings in vasa previa

Answer 16

Hemorrhage is primarily of fetal origin. Typically rapid deterioration of the fetal heart tracing.

Question 17

Management for placenta previa

Answer 17

No intercourse
No digital cervical examinations
Admit to monitoring for bleeding episodes

Question 18

Risk factors for placenta previa

Answer 18

Multiparity
Smoking
Prior C-sec
Prior Placenta previa

Question 19

Risk factors of cervical insufficiency

Answer 19

Collagen abnormalities
Uterine Anomalies
Prior oysters trauma
Cervical Conization

Question 20

S&S cervical insufficiency

Answer 20

Even with advance dilation symptoms are mild.

Increased vaginal discharge
mild vaginal bleeding
Pelvic pressure

Question 21

Management cervical insufficiency

Answer 21

Rescue Cerclage (suture reinforcement closure and prevent dilation)

Contraindications: Multiple gestations, Bulgins/ prolapsing of amniotic membranes, >24wks.

Question 22

Management of placenta accreta

Answer 22

Typically diagnosed during 2-trimester. Planned cesarean hysterectomy (prior to onset of spontaneous labor).

Undiagnosed: Attempts to remove the placenta can increase bleeding and are unsuccessful (dense adhesions). Best Next step: hysterectomy with placenta in situ

Question 23

Complications of placenta accreta

Answer 23

Severe postpartum hemorrhage
Hemorrhagic shock
Consumptive coagulopahty
maternal death