Preterm Delivery and APH

Question 1

What are complications of preterm delivery?

Answer 1

Cerebral palsy
Chronic lung disease
Blindness
Minor disability

Maternal infection -> endometritis

Question 2

What are risk factors for spontaneous preterm labour?

Answer 2

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

Question 3

What causes preterm labour?

Answer 3

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

Question 4

How is preterm labour predicted?

Answer 4

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

Question 5

How is preterm labour prevented?

Answer 5

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

Question 6

How do women in preterm labour present?

Answer 6

Painful contractions - half will stop and labour will not occur til term

Cervical dilation

APH or fluid loss

Question 7

What investigations are done in preterm labour?

Answer 7

CTG
Fibronectin
TV USS of cervical length
Vaginal swabs - CRP

Question 8

How is preterm labour managed?

Answer 8

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

Question 9

What is PROM?

Answer 9

Premature prelabour rupture of the membranes

Occurs before 1/3 preterm deliveries

Question 10

What are complications of PROM?

Answer 10

Preterm delivery

Infection of fetus (chorioamnionitis) or placenta (funisitis)

Absence of liquor -> pulmonary hypoplasia and postural deformities

Question 11

What is the management of PROM?

Answer 11

Admit and give steroids
Induce at 36 weeks
Give erythromycin

Question 12

What causes APH?

Answer 12

Placental abruption
Placenta praevia
Uterine rupture
Vasa praevia

Question 13

What is placenta praevia?

Answer 13

Placenta is implanted in lower section of uterus

At 20 weeks, placenta is low lying in many pregnancies but appears to move upwards

Question 14

What is the classification of placenta praevia?

Answer 14

Marginal - not over os

Major - completely or partially covering os

Question 15

What are risk factors for placenta praevia?

Answer 15

Twins
High parity
Older
Scarred uterus

Question 16

What are complications of placenta praevia?

Answer 16

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

Question 17

How does placenta praevia present?

Answer 17

Intermittent painless bleeds which increase in frequency and intensity

Breech presentation and transverse lie

NO VAGINAL EXAMINATION

Question 18

How is placenta praevia investigated?

Answer 18

USS - most picked up at 20 week scan

If placenta is posterior repeat at 32 weeks to exclude placenta praevia

Question 19

How is placenta praevia managed?

Answer 19

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

Question 20

What is placental abruption?

Answer 20

Part (or all) of the fetus separates before delivery of the fetus

Considerable maternal bleeding behind placenta may cause fetal distress

Question 21

What are complications of placental abruption?

Answer 21

Fetal death common (30%)
Blood transfusion
DIC
Renal failure

Question 22

What are risk factors for placental abruption?

Answer 22

IUGR
Pre-eclampsia
Pre-existing HTN
Autoimmune disease
Maternal smoking
Cocaine
Previous history
Multiple pregnancy
High parity

Question 23

How does placental abruption present?

Answer 23

PAINFUL dark bleeding
Tender, contracting uterus
Woody hard uterus

Question 24

What investigations are done for placental abruption?

Answer 24

CTG
USS to rule out placenta praevia

Bloods - FBC, coag, cross-match

Question 25

How is placental abruption managed?

Answer 25

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

Question 26

What are the the key differences between abruption and placenta praevia?

Answer 26

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

Question 27

What is vasa praevia?

Answer 27

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

Question 28

How does vasa praevia present?

Answer 28

Painless, moderate vaginal bleeding at amniotomy or SROM

Often kills baby