Obstetrics- Late Pregnancy Complications Flashcards
Presentation of acute faty liver of pregnancy
RUQ pain ↑ transaminases Fulminant Hepatic Failure -Scleral icterus -Encephalopathy Leukocytosis Platelet ≤ 100k Intrauterine Fetal Demise (IUFD)
Intrahepatic cholestasis of pregnancy
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
S&S intrahepatic cholestasis of pregnancy
Pruritus (worse hands & feet) No skin rash RUQ pain ↑ Total Bile Acids (≥10) ↑Bilirubin ↑Transaminases IUFD
Fetal complications with intrahepatic cholestasis of pregnancy
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
Abruptio placentae
premature placental separation from the uterine wall prior to fetal delivery.
Mechanism of abruptio placentae in uterine overdistention
Uterine overdistention (twins, polyhydramnios) + Uncontrolled gush of amnio fluid –>
Rapid uterine decompression–>
shearing of decimal vessels–>
Bleeding at decimal- placental interface
Risk factors for abruptio placentae
Hypertension/ preeclampsia
Abdominal trauma
Prior Abrupt placentae
Cocaine/ tobacco use
S&S abrupt placentae
- Sudden-onset vaginal bleeding
- Abd/ back pain
- High frequency, low intensity contractions
- Rigid/ Firm uterus (bleeding ↑pressure)
- Tender uterus
Management of abruptio placentae
If self-limiting= observation
Acute abruption with active bleeding and evidence of fetal hypoxia requires emergent delivery.
Complications of abruptio placentae
Fetal hypoxia, preterm birth, fetal demise
Maternal hemorrhage, DIC
Vasa previa
Fetal placental vessels overlay the cervix. Can cause painless vaginal bleeding with rupture of membranes or labor
Placenta accreta
Attachment of the placental villi directly to the myometrium. Occurs with prior c-sec and implantation over uterine scar.
Placenta previa
placenta covers the cervix. commonly diagnosed in an asymptomatic pt during ultrasound. Can be symptomatic after 20wks.
S&S placenta previa
Painless vaginal bleeding after 20wks gestation.
Irregular non painful contractions
Physiological cervical changes
Fetal heart tracings in placenta previa
Early: bleeding is maternal in origin. A reactive FHR is seen.
Late: continued maternal blood loss can lead to fetal compromise
Fetal heart tracings in vasa previa
Hemorrhage is primarily of fetal origin. Typically rapid deterioration of the fetal heart tracing.
Management for placenta previa
No intercourse
No digital cervical examinations
Admit to monitoring for bleeding episodes
Risk factors for placenta previa
Multiparity
Smoking
Prior C-sec
Prior Placenta previa
Risk factors of cervical insufficiency
Collagen abnormalities
Uterine Anomalies
Prior oysters trauma
Cervical Conization
S&S cervical insufficiency
Even with advance dilation symptoms are mild.
Increased vaginal discharge
mild vaginal bleeding
Pelvic pressure
Management cervical insufficiency
Rescue Cerclage (suture reinforcement closure and prevent dilation)
Contraindications: Multiple gestations, Bulgins/ prolapsing of amniotic membranes, >24wks.
Management of placenta accreta
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
Complications of placenta accreta
Severe postpartum hemorrhage
Hemorrhagic shock
Consumptive coagulopahty
maternal death
