Obstrectical Complications Flashcards
Preterm Labor
- b/w 20 and 37 wks
- uterine contractions with cervical change or dilation of 2 cm and/or 80% effaced
PTL- etiology
- spontaneous
- mult gestations
- PPROM
- HTN
- cervical incompetence or uterine anomalies
- antepartum hemorrhage
- IUGR (intrauterine growth restriction)
PTL- risk factors
- prev hx of PTL
- hx of second trimester abortion
- spontaneous 1st trimester abortions
- bleeding in 1st trimester
- UTI
- mult gestation
- uterine anomalies
- polyhydramnios
- incompetent cervix
prevention of PTL
- infection (Cervical)
- placental-vascular
- psychosocial stress and work strain
- uterine stretch
Infection pathway
- bacterial vaginosis- tx of women in preterm labor with abx
- tx cervical infections
Cervix and PTL
- risk of PTL inc as cervical length dec!!! (RR 6.2 for 2.5 cm)
- US- to screen- check cervical length
- fetal fibronectin (FFN)- released in response to disruption of membranes (uterine activity, cervical shortening, infection)
Placental-vascular pathway
-immunologic, vascular components, low resistance connection of spiral a’s
Stress-Strain pathway
- inc release of cortisol and catecholamines
- cortisol- inc CRH- assist in labor
- catecholamines- affect blood flow and can cause uterine contractions
Uterine Stretch Pathway
- uterine stretch as a result of inc volume
- risk factor in- polyhydramnios, mult gestations-
dx of PTL
- 20-37 wks
- must have:
- uterine contractions
- cervical change: cervical dilation of 2 cm and/or 80% effacement
PTL- management
- cervical exam- assess dilation, effacement
- evaluate for underlying correctable problems (infection)
- monitor uterine activity and fetal HR
- oral or IV hydrate
PTL- management- 2
- hydration and bed rest- resolve contractions in 20%
- cultures for Group B Strep
- abx given empirically
if no response to IV hydration and rest or dx 2 cm and/or 80% effaced- then begin?
tocolysis!!!
- Magnesium Sulfate
- Nifedipine
- Indomethacin (prostaglandin syn inhibitor)
Magnesium Sulfate
- competes with calcium
- continue tx until received both doses of steroids
- role in neuroprotection- prevent against cerebral palsy
Magnesium Sulfate- SE’s
- maternal- warmth, flushing, N/V, resp depression, cardiac conduction defects
- neonate- loss of m tone, drowsiness, lower Apgar scores
Nifedipine
- oral!
- minimal maternal and fetal SE’s
Prostaglandin Synthetase Inhibitors
- inhibits prostaglandin prod (induce myometrial contractions)
- used for extreme prematurity
- Indomethacin- can result in oligohydramnios, premature closure of fetal ductus arteriosis
NSAIDs (ibuprofen)
- dec uterine activity
- not used for primary tx of preterm labor
- used when not met dx of preterm labor or after discontinuing magnesium
Glucocorticoids- used for?
fetal lung maturation (in premature babies)
-given b/w 24-34 wks
prevention of PTL- tx
- progesterone- give from 16-36 wks- smooth m relaxant
- vaginal progesterone- in women with shortened cervix
- Arabin pessary
PROM
-premature rupture of membranes before the onset of labor at any gestational age
PROM- risk factors
- vaginal/cervical infections
- abnormal membranes
- incompetent cervix
- nutritional def
PROM- dx
- loss of fluid
- confirmation of amniotic fluid in vagina
- do not check the cervix of a presumed ruptured preterm pt!!!- inc risk of infection
Confirmation of PROM
- pooling
- nitrazine paper (turns blue)
- ferning
false + and neg nitrazine results
positive:
-urine, semen, cervical mucus, blood, vaginitis
neg:
-remote PROM with no remaining fluid, minimal leakage
PPROM (preterm premature rupture of membranes)- management
- risk of infection and risk of preterm delivery- must be balanced
- maternal risks- endomyometritis, sepsis, failed induction
PPROM- management depends on?
- gestational age at time of rupture- < 24 wks = pulm hypoplasia
- amniotic fluid index- < 5 cm = oligohydramnios
- fetal status
- maternal status
PPROM- management
- continue pregnancy until lung profile is mature!!
- most deliver at 34 wks!
- must monitor for signs/sxs of chorioamnionitis- maternal T > 100.4, fetal or maternal tachycardia, tender uterus, foul smelling amniotic fluid/purulent discharge
- abx!!!- ampicillin and erythromycin
tests for fetal lung maturity
- lecithin, PI, PG- important for fetal lung maturity
- measure these substances by amniocentesis
- L/S ratio > 2= mature (lecithin-spingomyelin)
- PG present = mature
other tests for fetal lung maturity
-LBND (lamellar body number density assessment)
IUGR (intrauterine growth restriction)
-birth weight of a newborn is below the 10% for a given gestational age
growth restricted fetuses- at risk for
- meconium aspiration
- asphyxia
- polycythemia
- hypoglycemia
- mental retardation
- adult onset conditions
maternal causes of IUGR
- poor nutritional intake
- cig smoking
- drug abuse
- alcoholism
- cyanotic HD
- pulm insuff
- antiphospholipid syndrome
placental causes of IUGR
- insuff substrate transfer thru placenta and defective trophoblast invasion
- HTN, renal dz, placental or crd abnormalities, diabetes
fetal causes of IUGR
- intrauterine infections
- congenital anomalies/genetic disorders
- mult gestations
- chromosomal abnormalities
IUGR dx
- fundal ht!!!
- US- used for high risk conditions that predispose to IUGR (HTN, renal dz, diabetes, drug abuse, antiphospholipid syndrome)
- amniocentesis
- percutaneous umbilical blood sampling
IUGR- management
- optimize dz processes (diabetes, HTN)
- dec any modifying factors (stop smoking, improve nutrition)
- deliver b/f fetal compromise but after fetal lung maturity!!!
- non stress test 2x/wk, biophysical profile, doppler studies of umbilical a
Nonstress testing
-fetal HR accelerates at least 15 beats /min above baseline
doppler study of umbilical a
- assess vascular impedance
- with IUGR- diminution of umbilical a diastolic flow
post-term pregnancy
- past 42 wks
- postmaturity syndrome (in 20%)- aging and infarction of placenta- loss of subcutaneous fat, long fingernails, dry and peeling skin
post-term pregnancy- etiology
- unsure dates
- fetal adrenal hypoplasia
- anencephaly
- placental sulfatase def
- extra-uterine pregnancy
IUFD (intrauterine fetal demise)
- fetal death after 20 wks gestation but before onset of labor
- most cases etiology is unknown (50%)
IUFD- dx
- absence of fetal movements or if unable to Doppler fetal heart tones
- confirm- US w/ lack of fetal activity and absence of fetal cardiac activity
IUFD- management
- spontaneous labor will occur within 2-3 wks of fetal demise
- induction of labor
- monitor coagulopathy- at risk for DIC
