Preterm Delivery and APH Flashcards
What are complications of preterm delivery?
Cerebral palsy
Chronic lung disease
Blindness
Minor disability
Maternal infection -> endometritis
What are risk factors for spontaneous preterm labour?
Previous history Low socioeconomic class Extremes of maternal age Short interval between pregnancies Maternal renal failure, diabetes, thyroid disease Pre-eclampsia IUGR Male gender High Hb STI, urinary and vaginal infections Previous cervical surgery Multiple pregnancy Uterine abnormalities - fibroids Polyhydramnios Congenital abnormalities APH
What causes preterm labour?
Increased contents of uterus: multiple pregnancy, polyhydramnios
Fetus at risk: pre-eclampsia, IUGR, placental abruption
Weakened wall: uterine abnormalities - fibroids, congenital, cervical incompetence, previous cervical surgery
Infection: choriomanionitis, offensive liquor, neonatal sepsis, endometritis
How is preterm labour predicted?
TV USS measurement of cervical length
Bedside fibronectin - good at ruling out women who won’t go into labour in next 7 days
Repeat VE
How is preterm labour prevented?
Cervical cerclage - usually vaginal, pre-pregnancy or elective at 12-14 weeks
Progesterone supplementation suppositories
Fetal reduction
Treat polyhydramnios - needle aspiration or NSAIDs to reduce fetal urine outpur
How do women in preterm labour present?
Painful contractions - half will stop and labour will not occur til term
Cervical dilation
APH or fluid loss
What investigations are done in preterm labour?
CTG
Fibronectin
TV USS of cervical length
Vaginal swabs - CRP
How is preterm labour managed?
Steroids given between 24 and 34 weeks, take 1 day to act so delivery is delayed
Tocolysis - nifedipine or atosiban (oxytocin receptor antagonist)
Magnesium sulphate
C-section, forceps, antibiotics
What is PROM?
Premature prelabour rupture of the membranes
Occurs before 1/3 preterm deliveries
What are complications of PROM?
Preterm delivery
Infection of fetus (chorioamnionitis) or placenta (funisitis)
Absence of liquor -> pulmonary hypoplasia and postural deformities
What is the management of PROM?
Admit and give steroids
Induce at 36 weeks
Give erythromycin
What causes APH?
Placental abruption
Placenta praevia
Uterine rupture
Vasa praevia
What is placenta praevia?
Placenta is implanted in lower section of uterus
At 20 weeks, placenta is low lying in many pregnancies but appears to move upwards
What is the classification of placenta praevia?
Marginal - not over os
Major - completely or partially covering os
What are risk factors for placenta praevia?
Twins
High parity
Older
Scarred uterus
What are complications of placenta praevia?
Obstructs engagement of head -> transverse lie and c-section
Haemorrhage - may continue during and after delivery as lower segment is less able to contract
Placenta accreta - implants in c-section scar and stops placental separation -> massive haemorrhage at delivery and hysterectomy
Placenta percreta - penetrates into bladder
How does placenta praevia present?
Intermittent painless bleeds which increase in frequency and intensity
Breech presentation and transverse lie
NO VAGINAL EXAMINATION
How is placenta praevia investigated?
USS - most picked up at 20 week scan
If placenta is posterior repeat at 32 weeks to exclude placenta praevia
How is placenta praevia managed?
Kept in hospital until delivery unless asymptomatic providing they can get to hospital easily
Blood, anti-D for rhesus -ve
Elective C-section at 39 weeks by most senior person
Emergency delivery if bleeding is severe
What is placental abruption?
Part (or all) of the fetus separates before delivery of the fetus
Considerable maternal bleeding behind placenta may cause fetal distress
What are complications of placental abruption?
Fetal death common (30%)
Blood transfusion
DIC
Renal failure
What are risk factors for placental abruption?
IUGR Pre-eclampsia Pre-existing HTN Autoimmune disease Maternal smoking Cocaine Previous history Multiple pregnancy High parity
How does placental abruption present?
PAINFUL dark bleeding
Tender, contracting uterus
Woody hard uterus
What investigations are done for placental abruption?
CTG
USS to rule out placenta praevia
Bloods - FBC, coag, cross-match
How is placental abruption managed?
ADMISSION
IV fluids, blood transfusion, anti-D
C-section if fetal distress
Amniotomy to induce labour if not in fetal distress and >37 weeks
Watch out for PPH
If no fetal distress and pregnancy is preterm then steroids are given and patient is monitored
Can be discharged if symptoms settle but now needs fetal growth scans
What are the the key differences between abruption and placenta praevia?
Pain: common, severe
- none, ?contractions
Bleeding - absent, dark
- red, profuse
Tender uterus - usual, hard, severe
- rare
Fetus - lie normal, engaged
- lie abnormal with high head
What is vasa praevia?
Fetal blood vessel runs in membrane in front of presenting part
Occurs when umbilical cord is attached to membranes rather than placenta
When membranes rupture, vessel ruptures too
How does vasa praevia present?
Painless, moderate vaginal bleeding at amniotomy or SROM
Often kills baby
