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MID4000 > Wk 1: Bleeding in early pregnancy, vaginal bleeding + pre-term labour > Flashcards

Wk 1: Bleeding in early pregnancy, vaginal bleeding + pre-term labour Flashcards

1
Q

Define early pregnancy bleeding

A

= bleeding prior to 20 weeks gestation

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2
Q

What are some causes of bleeding in early pregnancy?

A
  • endometrial implantation aka ‘implantation bleed’
  • miscarriage/spontaneous abortion
    - may be incomplete and have massive haemorrhage risk
  • ectopic pregnancy rupture
  • cervical or vaginal lesions
  • uterine infection
  • Hydatidiform mole
  • infection
  • Subchorionic haemorrhage/intrauterine haematoma
  • gestational trophoblastic disease (Molar pregnancy)
  • cervical shock (bradycardia and hypotension from cervical stimulation or presence of products of conception in cervix during miscarriage)
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3
Q

What investigations may be carried out on a women with early pregnancy bleeding and why?

A
  • ultrasound
    - if >6wks to see heartbeat and diagnose misscarriage
    - assess gestation
    - to confirm location of pregnancy and rule out ectopic
  • ultrasound at <6 wks may help with locating pregnancy
  • internal pelvic ultrasound
    - determine size of uterus and look for signs of bleeding
  • Blood hCG test
    - if lower then expected may mean the women is at an earlier gestation or the pregnancy is not progressing as normal.
    - usually repeated after 2 days
    - if rising slowly may be the pregnancy is miscarrying or ectopic
    - if falling, may mean pregannacy is sending and will miscarry
    - Kleihauer may be used +/- anti D if neg blood group also to see if placenal abruption or other issues that may cause fetal blood cells to enter maternal circulation are the cause.
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4
Q

What are key things to investigate when a pt has bleeding early in pregnancy?

A
  • Parity and previous history
  • Gestational age when bleeding occurred
  • Volume of blood loss
  • Recent intercourse
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5
Q

Expain the pathophysiology of implantation bleeding

A

= Occurs when trophoblast erodes endometrial epithelium and blastocyst implants.
*signifiacnt when determining expected due date (EDD)/agreed due date (ADD)

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6
Q

What are some characteristics of implantation bleeding?

A
  • occurs around the time of expected menstruation
  • light blood loss - a few drops
  • V + V
  • light cramps
  • 1-2 days duration
  • light pink to brown colour
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7
Q

Define miscarriage

A

= a spontaneous pregnancy loss before the fetus reaches viability that is, prior to the 20 weeks of gestation completion.

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8
Q

Define early pregnancy loss

A

= occurs prior to the 12 weeks of gestation completion
*75-80% of miscarriages occur in the first 12 weeks of pregnancy

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9
Q

What is the most common cause of misscarriage?

A

Major genetic factors
- parental chromosomal rearrangement
- embryonic chromosomal abnormalities

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10
Q

What are some factors that may contribute to pregnancy loss

A
  • Maternal age
  • Number of previous miscarriages/reproductive history
  • Anti-phospholipid syndrome - most important and treatable cause for miscarriage
  • Uterine malformations
  • Cervical weakness/incompetence
  • Endocrine disorders - diabetes mellitus and thyroid disease there is an association but if well controlled and treated are not risk factors
  • Any severe infection in the woman that causes bacteraemia/viraemia is linked to miscarriage [TORCH infections appear not to be linked to this risk]
  • Inherited thrombophilic defects e.g. Factor V Leiden mutation
  • Smoking
  • Alcoholic drinks > 3 in a week
  • Chorionic villi sampling or amniocentesis
  • Intimate Partner Violence/Domestic Violence
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11
Q

Define complete miscarriage and how does it present?

A

= complete expulsion of the products of conception of an intrauterine pregnancy
- presents with bleeding

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12
Q

Define threatened miscarriage

A

= any vaginal bleeding (other than spotting) with or without abdominal pain prior to 20 weeks’ completed gestation, the cervix is closed and the fetus is viable with cardiac ativity within the uterus.

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13
Q

What does a threatened miscarriage place the mother at increased risk of?

A
  • antepartum haemorrhage
  • pre labour rupture of membranes
  • preterm birth
  • intrauterine growth restriction
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14
Q

How is a threatened miscarriage managed?

A
  • u/s= most reliable confirmation of confirming viability
  • support for women and family
  • Rh negative women should receive 250 IU anti-D with consent in1st trimester and 625 IU if beyond the 1st trimester
  • if PV bleeding worsens or persists beyond 14 days-> seek further advice from a health professional, however, if the bleeding stops, continue/commence antenatal care.
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15
Q

Define inevitable miscarriage and how does it present?

A

= passage of the products of the conception of an non-viable intrauterine pregnancy occurring or expected to occur soon.
- presents as heavy bleeding, clots, pain and the cervical os is open.
- cramping and bleeding present
- rupture of membranes can occur
- dilated cervical os
- products of conception may be seen or felt at or above cervical os

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16
Q

Define an incomplete miscarriage and how does it present?

A

= partially expelled products of conception of a non viable intrauterine pregnancy.
- vaginal bleeding and cramping present
- cervical os is dilated

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17
Q

Define missed miscarriage and how does it present?

A

= an empty intrauterine gestational sac with no fetal heart or cardiac activity present diagnosed on ultrasound
- no vaginal bleeding to persistent dark brown discharge
- non-viable fetus retained.
- closed cervical os

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18
Q

When is a woman considered to be having recurrent miscarriage?

A

= after 3 or more consecutive pregnancies

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19
Q

Define a septic miscarriage

A

= expulsion of the products of conception of an intrauterine pregnancy complicated by infection.

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20
Q

Explain the assessment of a women with early pregnancy bleeding

A

*spiritual and cultural preferences
*support both physically and psychologically
- a medical and reproductive history
- is the woman haemodynamically stable or not?
- degree of pain
- amount of bleeding
- gestational age of the pregnancy, if known
- abdominal examination looking for any areas of tenderness, guarding or rigidity and/or signs of distension
- speculum examination to assess location and amount of bleeding
- Bimanual examination may be performed to assess uterine size, pelvic tenderness, cervical dilatation

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21
Q

What investigations may be needed for a women with early pregnancy bleeding?

A
  • Ultrasound assessment (abdominal and transvaginal) to determine location and viability of the fetus, if pain and /or bleeding are not severe
  • Serum hCG level measurements
  • Blood group and antibody testing to determine need for Rh D immunoglobulin and potential transfusion
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22
Q

What are some management options for early pregnancy bleeding?

A
  • Appropriate referral
  • Expectant
  • Medical
  • Surgical
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23
Q

When might a urine pregnancy test be carried out?

A
  • all women who present with ABDOMINAL PAIN, VAGINAL BLEEDING OR SUDDEN ONSET GASTROINTESTINAL SYMPTOMS OF CHILD BEARING AGE (as it may indicate their symptoms)
  • may also assist to exclude ectopic pregnancy
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24
Q

Define an ectopic pregnancy and where are possible locations for implantation?

A

= pregnancy occurs when a fertilized ovum implants outside of the uterine cavity.

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25
Q

Explain the relationship of the hormones and implantation in an ectopic pregnancy

A

= hCG is produced to maintain the corpus luteum and pregnancy hormones (oestrogen and progesterone) prepare the uterus for fertilisation.
- when the ovum implants outside the uterus-> life-threatening bleeding occurs
- common cause of mortality and morbidity child bearing women.

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26
Q

What are risk factors for an ectopic pregnancy?

A
  • IVF (2-5% affected) + ART
  • Fallopian tube damage including previous tubal and pelvic surgery (Tubal ligation/sterilisation, Caesarean section, ovarian cystectomy)
  • Previous abdominal surgery including bowel surgery and appendicectomy
  • Genital tract infection and Pelvic Inflammatory disease (PID) - chlamydia infection the most common cause
  • Tubal disease - salpingitis and associated scarring
  • Endometriosis
  • Unexplained infertility
  • Progesterone only contraception
  • Intrauterine device (IUD)
  • Cigarette smoking, particularly >20 cigarettes/day
  • Advancing maternal age - Age >35 years
  • Previous ectopic pregnancy
  • Previous spontaneous or induced abortion

*1-2% of pregnancies effected

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27
Q

What are some signs and symptoms of an ectopic pregnancy?

A
  • Usual signs of pregnancy- amenorrhoea, hyperemesis and breast tenderness
  • Commonly women present with pain and spotting/vaginal bleeding often between the 6-10 weeks gestation
  • Abdominal tenderness
  • Pain is often unilateral though on its own not always indicative of ectopic pregnancy
  • Pain in lower back/lower abdomen
  • Pain is often persistent and severe- if the fallopian tube ruptures
  • Shoulder tip pain
  • Syncope
  • Shock in up to 20% of presentations
    **can mimic a miscarriage, pelvic inflammatory disease or endometriosis and may initially appear as a normal pregnancy
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28
Q

What are the clinical symptoms of a ruptured ectopic pregnancy?

A
  • positive pregnancy test AND syncope, signs of shock (tachy, palor, collapse)
  • abdo distension and marked tenderness
  • pain
    *Approximately 15% of ectopic pregnancies are diagnosed in the Emergency department after the fallopian tube has ruptured.
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29
Q

Explain the management of a suspected ectopic pregnancy

A
  • u/s to confirm empty uterus
  • Expectant - ‘wait and see”
  • Medical - injection of methotrexate if early gestation, stops cells from growing and reabsorb cells
  • Surgical – laparoscopic to remove ectopic, which may result in salpingectomy and/or laparotomy to control bleeding
  • Blood group and antibody testing to determine need for Rh D immunoglobulin
  • emotional support and counselling on future pregnancies
    - increased risk of having another
    - is there a problem we can optimise?
    - may be recommended to wait 2/12
    - may be reccoended to take folate 1/12 before and 3/12 into pregnancy
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30
Q

What are some suspected causes of an ectopic pregnancy?

A
  • it isnt fully known
  • damage has blocked or narrowed the fallopian tube preventing it from passing though
  • fallopian tube wall problems that result in them no carrying out their function of tightening and carrying the fertalised egg to the uterus.
  • hormonal imblanaces
  • infection
  • malfunction of uterus or tube
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31
Q

Explain the use of methotrexate in an ectopic pregnancy

A

= used to dissolve pregnancy tissue
- prevents further cellular growth and promotes reabsorption
- used in early gestation
- IM injection

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32
Q

What are some occasions in which bleeding may occur in pregnancy but not be related to pregnancy?

A
  • cervical polyps
  • Cervical ectropion/erosion
  • Cervical Neoplasm (abnormal/benign growth) (1:2000 pregnancies) (MHW 2018)
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33
Q

Describe a cervical polyp, the impact it has in pregnancy and the treatment required.

A

= small, vascular, pedunculated growths on the cervix that have a rich blood supply.
- higher estrogen and increased number of blood vessels in tissues/cervix can result in bleeding in pregnancy
- no treatment is required unless the bleeding is severe or a Pap smear suggests malignancy

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34
Q

Describe cervical ectropion/erosion, the manifestations and the teratement

A

= A physical response to the hormonal changes of pregnancy, particularly Oestrogen, making the cervix very vascular and the cells that line the inside of the cervix extend to the outside of the cervix
- high oestrogen levels encourage the proliferation of columnar epithelium cells within the cervix.

Manifestations
- soon bleeding
- bleeding after intercourse

Treatment
- no treatment generally required
- postnatally the ectropion returns to pre- pregnant cervical cells

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35
Q

Define Cervical Neoplasm/Cancer, the presentation and treatment

A

= a common gynaecological malignant disease/cancer diagnosed during pregnancy

Presentation
- vaginal bleeding
- increased vagunal discharge

Treatment
- depend on gestation and stage of disease

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36
Q

Define a gestational trophoblastic disease (GTD)

A

= a group of rare diseases in which a tumour develops inside the uterus from abnormal tissue that forms after conception (the joining of sperm and egg).

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37
Q

Define a molar pregnancy and list the two types

A

= unusual and rapid growth of part or all of the placenta.
- The placenta becomes larger than normal and contains a number of cysts (sacs of fluid)

Types
- complete Hydatidiform Mole
- partial molar pregnancy

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38
Q

Define a complete Hydatidiform Mole

A

= results from the female ovum is fertilised by either 2 sperm from the father or 1 sperm that replicates in the ovum.
- The ovum has no material within and as a result no fetal formation
- the placenta grows abnormally resulting in clusters of abnormal cells or clusters of water filled sacs inside the uterus.

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39
Q

Define a partial molar pregnancy

A

= results in normal placental tissue as well as abnormal placental tissue development.
- There may also be fetal formation but the fetus is unable to survive often resulting in an early miscarriage/pregnancy loss.
- Most molar pregnancies are benign however approximately 10% may become malignant.

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40
Q

Define a Gestational Trophoblastic Neoplasia (GTN)/ choriocarcinoma and how is it treated?

A

= the malignant form of a molar pregnancy
- most likely to be a complication of a complete molar pregnancy than a partial molar pregnancy.
- treated with cytotoxic drugs.

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41
Q

What are some risk factors for a molar/Hydatidiform Mole

A

Hydatidiform Mole

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42
Q

What is a Hydatidiform Mole/molar pregnancy

A

= an umbrella term an abnormal growth of the placenta producing high levels of pregnancy hormones resulting in the woman ‘feeling’ pregnant.

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43
Q

What are risk factors for a molar pregnancy

A
  • Maternal age - a molar pregnancy is higher if a woman is older than 35 or younger than 20 years of age
  • Previous molar pregnancy - a repeat molar pregnancy occurs approximately 1:100 pregnancies
  • Nulliparity
  • Low folic acid, beta-carotene and animal fat in diet
  • Smoking
  • Oral contraceptive pill
  • Blood Group A
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44
Q

What are some signs and symptoms of a molar pregnancy?

A

Initially the pregnancy appears quite normal and then:
- dark brown to bright red vaginal bleeding during 1st trimester
- severe nausea and vomiting
- sometimes vaginal passage of grape-like cysts
- pelvic pressure or pain

When an assessment is made by a health professional, additional features may also include:
- Rapid uterine growth - the uterus is too large for dates
- High blood pressure
- Pre-eclampsia
- Ovarian cysts
- Anaemia
- Hyperthyroidism

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45
Q

What is the necessary management following the diagnosis of a molar pregnancy

A
  • Dilatation and Curettage (D&C) and samples sent to Pathology - this is adequate treatment for most molar pregnancies
  • Frequent blood tests for hCG levels, initially weekly post D&C until the hCG levels return to normal and remain normal for at least 6 months
  • Blood group and antibody testing to determine need for Rh D immunoglobulin

**Once a woman has either GTD or GTN she is ‘at risk’ of further molar pregnancies and will require blood tests for hCG levels for 6 weeks following any pregnancy whether a live birth, miscarriage, ectopic pregnancy

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46
Q

What is the management of a diagnosis of GTN?

A
  • MRI/CT scans
  • Chemotherapy until hCG levels return to normal
  • Surgery - hysterectomy

The disease can reoccur (either GTD or GTN) so hCG levels are monitored for
- 6 months following a Complete Molar pregnancy
- 12 months following chemotherapy for GTN

**Once a woman has either GTD or GTN she is ‘at risk’ of further molar pregnancies and will require blood tests for hCG levels for 6 weeks following any pregnancy whether a live birth, miscarriage, ectopic pregnancy

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47
Q

Explain then Gestational Trophoblastic Disease Registry

A

= are set up to monitor and coordinate the follow-up of women who have had a molar pregnancy
- The Royal Women’s Hospital is the only registry in Victoria
- Ongoing monitoring and hCG levels required until levels normal
- 10% of cases result in persistent trophoblastic disease and may require further investigation regarding including chest X-ray or CT scan and ultrasound
- Women should be advised not to become pregnant until discharged from the registry

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48
Q

Expalin the different disease processes that may result from a Gestational Trophoblastic Disease and recognise why follow up is important?

A

GTD
-> hydatiform
- complete
- partial
-> placental site nodule
-> exaggerated placental site
-> GTN
- invasive mole
- choriocarcinoma
- PLacenta site trophoblastic tumor
- epithelioid trophoblastic tumor

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49
Q

Define an antepartum haemorrhage (APH)

A

= bleeding from the genital tract after the 20th week of pregnancy and before the onset of labour

  • Occurs in approximately 2-5% of pregnancies
  • PH can be a life threatening situation for both the woman and her baby.
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50
Q

What are the important points for the management of APH?

A
  • close monitoring for shock as blood loss is often underestimated
  • 10% have no identifiable cause but may result in preterm birth and induction of labour
  • serial u/s to assess growth and fetal health going forward
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51
Q

What are some complications of an APH?

A
  • may result in preterm birth
    - PH from unknown causes before 34 weeks gestation is associated a 60% risk of birth within a week if accompanied by contractions
    - Without accompanying contractions the risk is still 13.6%, therefore administration of corticosteroids is important.
  • induction of labour
  • SGA and growth restriction
  • oligohydramnios
  • premature rupture of membranes
  • preterm labour
  • increased rates of caesarean section

Increased risk of Post Partum Haemorrhage (PPH)

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52
Q

What is the necessary initial assessment for an APH?

A
  1. Assess blood loss
    - Weigh blood loss
    - Document ongoing blood loss
    - Document history of blood loss in this pregnancy
    - Consider possible causes of APH:
    • placenta praevia
    • placental abruption
    • show
    • post-coital bleed
    • trauma
    • cervical abnormalities
    • infection
    • vasa praevia
  2. maternal examination
    - Vital signs - heart rate, blood pressure, respiratory rate, O2 saturation, temperature
    - Document a running total of blood loss
    - Gentle abdominal palpation
    - Assess pain, rigidity, fetal presentation, size and movement
    - Avoid vaginal examination until placenta praevia is excluded.
  3. fetal surveillance
    - CTG is indicated from 26 wks
    - CTG should be continued if there is:
    - ongoing bleeding
    - abdominal pain
    - uterine activity
  4. History
    - Document obstetric, medical, surgical and social history.
  5. Speculum examination
    - Observe and document:
    - blood loss
    - cervical dilatation and length
    - membranes
    - presenting part

**Digital examination should be avoided for women with an APH until placenta praevia is excluded.

  • ultrasound and pathology tests will be required.
  • Blood group and antibody testing to determine need for Rh D immunoglobulin and potential transfusion
53
Q

Explain the immediate management of a women presenting with APH

A
  • medical emergency if APH and is haemodynamically unstable or if significant haemorrhaging.
  • DRSABCD
  • Summon help - consider MET Call, Code Blue or Code Pink (pending on the location of where you are working)
  • Resuscitate and assess simultaneously
  • IV access x 2 16 g
  • Fluid replacement
  • Oxygen 8 L/min
  • In-dwelling catheter (IDC)
54
Q

What si the management of an APH if birth is immediate?

A
  • Consult with obstetric and paediatric clinicians
  • Prepare resuscitation equipment appropriate for gestation:
    - consider a rapid infusion of 20 ml/kg of Rh O-negative uncross-matched blood, for infants symptomatic of hypovolaemia secondary to blood loss
    - Notify SCN/NICU
    - Counsel the woman and family about what to expect in terms of baby’s condition and care.
    - Blood transfusion of the woman may be required
55
Q

Explain the management of a women admitted/inpatient post an APH?

A
  • prolonged inpatient= increased risk of venous thromboembolism (VTE):
    - encourage mobility
    - use TED stockings
    - ensure adequate hydration
  • Prophylactic anticoagulation in women at high risk of bleeding can be hazardous and the decision to use it should be taken on an individual basis.
  • Weekly FBE
  • Treat anaemia:
    - prescribe elemental iron (100-200 mg daily) and monitor the response to therapy
    - if the response is inadequate, use IV iron
  • Administer Anti-D if indicated
  • Plan for timing of birth
  • observation
    - Frequency of observation depends on; maternal condition, ongoing bleeding, other clinical findings.
  • Fetal monitoring daily and as clinically indicated
  • Review by the paediatric/neonatal and anaesthetic teams
  • Ultrasound (US) as clinically indicated.
  • Discharge will depend on type of bleeding, cause of bleeding and gestation.
56
Q

Define low lying placenta

A

= occurs when the placenta extends into the lower uterine segment and its edge lies too close to the internal os of the cervix, without covering it.
- The edge of the placenta lies within 2-3.5cm of the internal cervical os.
- most are visualsed on roiutein anomaly u/s 18-20wks gestation
*most resolve by time of birth as development of lower uterine segment aiding in the migration of the placenta away from the os.

57
Q

Define placenta previa and what are the types?

A

= the placenta attaches low in the uterus, near the os.

Placenta praevia is a condition where the placenta is:
1. Partial
- placenta covers a portion of the internal cervical os
2. Complete
- placenta covers the entire internal cervical os
3. Marginal
- the edge of the placenta is within 2cm of the internal cervical os

58
Q

What is the recommended mode of action if a mother has placenta previa?

A

**should be based on clinical judgement supplemented by ultrasound information.

  • A placental edge less than 2 cm from the internal os is more likely to need birth by caesarean section.
  • Posterior placenta praevia where the presenting part is prevented from entering the pelvis may be an indication for caesarean at more than 2 cm from the cervical os.
  • In cases where the presenting part is engaged, we need to consider re-scan to confirm the placental site and the decision regarding the mode of birth to be made accordingly.
59
Q

Explain the consideration of the timing of birth in the presence of placenta previa

A
  • Elective c/s is recommended at 38/40
60
Q

Define adherent placenta and the different types/degrees.

A

= Morbidly adherent placentas to the uterine wall
- potentially life-threatening obstetric complication
- frequently requires interventions such as caesarean hysterectomy and high-volume blood transfusion.

  • Includes placenta accreta, increta and percreta as it penetrates through the decidua basalis then through the myometrium.
61
Q

Define placenta accreta

A

= abnormal adherence of the placenta, specifically chorionic villi attach to the myometrium, with no plane of separation.

62
Q

Define placenta increta

A

= placenta, specifically the chorionic villi, invade/penetrates into the myometrium

63
Q

Define placenta percreta

A

= the whole thickness of the myometrium is infiltrated/invaded by the placenta, specifically the chorionic villi, invading the serosal surface or beyond e.g. bladder, bowel

64
Q

What are some causes of the adherent placenta?

A
  • implantation over a previous Caesarean scar
  • manual removal after a previous pregnancy
  • placenta praevia
  • previous rigorous or repeated currettage, particularly postpartum
  • previously treated uterine adhesions
65
Q

How is adherent placenta diagnosed?

A
  • a/n doppler u/s
  • MRI (assesses depth)
  • Definitive diagnosis of the type of the morbidly adherent placenta is made intra-operatively and histologically
66
Q

What is the management of a adherent placenta?

A
  • transfer to appropriate hospital with the technology, skills and expertise to manage this potentially life threatening situation
  • c/s is recommended management plan at 35-38 weeks (but may be individual and women centered)
  • Obs + specialist bladder and bowel surgeons experienced in managing placenta accreta should be present
  • utalise expert anaesthetists
  • consider Blood transfusion services
  • consider/alert Intensive care unit (ICU)
  • get Interventional radiologists present– uterine artery embolisation or ligation of internal iliac arteries
  • consider hysterectomy with the placenta still attached
  • Leave both the placenta and uterus inside the woman and use of Methotrexate to manage the placenta if the woman is stable
  • For many women with a placenta accreta, immediate hysterectomy is the safest option as it generally reduces the amount of blood loss.
67
Q

Define placental abruption

A

= a normally situated placenta prematurely separates from the uterine wall before the birth of the fetus, may be either partial (affecting part of the placenta) or complete ( the entire placenta) and may be concealed or revealed.

68
Q

Define partial placental abruption

A

= part of the placenta prematurely separates from the uterine wall

69
Q

Define complete placental abruption

A

= The entier placenta abruption is where the placenta prematurely separates from the uterine wall.

70
Q

Define a concealed placental abruption

A

= abruption where bleeding in contained behind the separated part of the placenta

71
Q

Define revealed placental abruption

A

= abruption where bleeding in presents and escapes from the placenta

72
Q

How is a placental abruption diagnosed?

A
  • abnormal fetal heart trends (late decelerations, loss of variability, variable decelerations, sinusoidal fetal heart rate trace, fetal bradycardia, absent fetal hear)
  • FBE
  • clotting profile- disseminated intravasular coagulation (DIC) can occur in large abruptions resulting in fetal death and may be suspected if bleeding and the blood is not clotting
  • Kleihauer - may be of assistance but required for women who are Rh Negative to determine the amount of Rh immunoglobulin required.
  • Blood group and antibody testing to determine need for Rh D immunoglobulin and potential transfusion
  • Ultrasound to visualise
73
Q

What are some differential diagnoses for placental abruption?

A
  • Preterm labour
  • Placenta praevia
  • Chorioamnionitis
  • Acute pyelonephritis
  • Urinary tract infection
  • degeneration of a uterine fibroid
74
Q

What are the general initial management principles for a placental abruption?

A
  • stabilisation
  • monitorying
  • prevention of hypovolemia
  • prevention of anemia
  • prevention of DIC
75
Q

What is the management for a placental abruption?

A
  • IV access w/ wide bore canulas
  • FBC for evidence of anaemia + Hct and Hb levels may be low.
  • Coagulation profile looking for evidence of impaired coagulation.
    - Low fibrinogen levels
    - a prolonged PT are suggestive of impaired coagulation due to (DIC).
  • Monitoring haemodynamic status (BP, pulse, volume intake, and urine output)
  • Continuous fetal monitoring.
  • Anti-D immunoglobulin in Rh-negative women.
  • Fluid, antifibrinolytics, blood, or blood-product replacement, as indicated. May include TXA, blood transfusion
  • Ultrasound for placental location and for evidence of abruption. Placenta praevia found ultrasound makes placental abruption unlikely.
76
Q

What are key midwifery considerations when supporting a women experiencing a placental abruption?

A
  • This is a situation that is very stressful for the woman, her partner and/or family and equally for the health professionals.
  • effective communication is vital to all persons involved together with effective listening skills.
  • Debrief most be in a supportive and non -threatening environment.
  • Pregnancy loss may also need to be discussed and supports in place in this situation.
77
Q

Define born still

A

= the birth of a baby without signs of life after 20 weeks gestation and if the gestation is unknown if the baby weighs >400g.

78
Q

Which groups are at increased risk of still birth?

A

For indigenous women and women from other disadvantaged groups, the risk of stillbirth/Born still is often doubled

79
Q

Explain some key areas of management for a women whos baby was born still.

A
  • know this has a huge psychological and social impact on parents and staff caring for the woman and family and is a major Public Health issue.
  • for many the reason is unexplained
80
Q

From what gestation should women be recommended to sleep on their side?

A

= 28 weeks gestation
- recommend that they roll back over

81
Q

What are some potential risk factors for still birth/born still

A
  • Advanced maternal age i.e. > 35 years and particularly 40 years or more
  • Pre-pregnancy obesity
  • Smoking, drug taking and alcohol consumption
  • Gestational diabetes
  • Hypertension/ Pre-eclampsia
  • Congenital abnormalities
  • Premature birth particularly extreme prematurity
  • Placenta or cord problems/accidents
  • First pregnancy
  • Fetal growth restriction
  • Maternal medical conditions - diabetes, hypertension, renal disease, thyroid disease, cardiac disease, systemic lupus erythematosus (SLE), obstetric cholestasis, obstructive sleep apnoea
  • Congenitally acquired infections
  • Multiple pregnancy- 4 times higher than with a singleton pregnancy
  • Poor or no access to maternity care can triple the risk of stillbirth
    Ethnicity - South Asian (India, Pakistan, Sri Lanka, Afghanistan and Bangladesh) women have higher rates of stillbirth and the reason remains unclear (Stillbirth, Centre of Research Excellence 2019), however the Study - Preventing Term Stillbirth in South Asian Born Mothers, Prof E Wallace, Dr M Davies-Tuck suggests that there is a connection to “accelerated placental ageing as South Asian women have shorter pregnancies and more likely to have signs of fetal compromise at the end of pregnancy
  • Intimate Partner Violence (IPV)/Domestic Violence (DV)
  • Maternal sleep position
  • Diabetic Ketoacidosis
  • Cystic fibrosis
82
Q

What are important communication point when caring for a women whos baby has been born still?

A
  • Sensitivity, honesty, compassion, validation of the parents’ emotions.
  • provision of clear and understandable information
  • information that is provided appropriately and timely
  • together with a high level of empathy are key to the conversations with the woman and her partner/family
  • allow the parents time
  • communication must be include any cultural, spiritual and linguistic requirements for the woman and her partner/family - seek advice from the woman or from an appropriate health worker/interpreter/chaplain as the woman requests
  • Maternity care providers actions and behaviours may have lasting impacts on the woman, her partner and/or family in relation to grief, anxiety, depression and self-blame.
83
Q

What is the EDPS, what is it about and which are significant questions?

A
  • used both antenatally and postnatally to assess the risk of adverse mental health status.
  • includes 1- self-reported questions
  • about how the woman has been feeling in the past 7 days
  • questions 3,4,5= anxiety related
  • Question 10- thoughts of self harm
  • scored out of 30
84
Q

What is a significant EDPS score?

A

= ≥13 in other women
= ≥9 in CALD women
*however you must look at the trends in scores and which questions specifically are scoring high

Anxiety sub-score cut-off= ≥4

**Question 10 is regarding self harm so must address any score of this

***consdier the whole women situation

85
Q

Define pre-term birth

A

= birth before 37 completed weeks’ gestation.

86
Q

What are risk factors for pre term birth?

A
  • smoking mothers
  • multiples
87
Q

What are some common complications for babes born pre term?

A
  • Respiratory issues
  • Underdeveloped suck reflex/feeding issues
  • Hypothermia
  • Hypoglycaemia
  • Developmental issues
  • Long-term cognitive/behavioural/psychiatric issues
  • Gastrointestinal issues
  • Visual impairment
  • Hearing impairment
  • Chronic illness
88
Q

Explain the management of a mother in pre term labour

A

*if a woman presents in preterm labour at a gestation outside of that facilities capability, discussion with PIPER and aim for transfer preferably in-utero wherever possible.
Medication management
- steroids
- tocolysis
- antibiotics
- magnesium sulfate for neuro protection

89
Q

Explain the indication for corticosteroids in pre-term labour

A

= recommended for pregnant women between 24.0 weeks and ≤ 36.6 weeks of gestation who are at risk of preterm delivery within 7 days, including for those with ruptured membranes and multiple gestations.
- may be considered for pregnant women starting at 23.0 weeks of gestation who are at risk of preterm delivery within 7 days, based on a family’s decision regarding resuscitation, irrespective of membrane rupture status and regardless of fetal number.
- A single course of betamethasone is recommended for pregnant women between 34.0 weeks and 36.6 weeks of gestation at risk of preterm birth within 7 days, and who have not received a previous course of antenatal corticosteroids.
- A single repeat course of antenatal corticosteroids should be considered in women who are less than 34.0 weeks of gestation who are at risk of preterm delivery within 7 days, and whose prior course of antenatal corticosteroids was administered more than 14 days previously.
- preterm ROM with no infection or signs of

90
Q

What is an example of a corticosteroid used in pre term labour?

A

= Betamethasone e.g. Celestone

91
Q

What are some key points of management around corticosteroid administration for threatening pre term labour in the next 7 day?

A
  • unless birth is imminent, even if only one dose is anticipated, a course of antenatal corticosteroids should be commended for all women at risk of pre-term birth as its still shown to reduce mortality and morbidity.
  • If there are no contra-indications for tocolysis it should be considered to allow time for a completed course of antenatal corticosteroid therapy for gestations under 34 weeks only.
  • The administration of antenatal corticosteroids to reduce the risk of RDS if a planned elective caesarean section (ELUSCS) is arranged between 37- 39 week gestation, is debated
  • The benefit of corticosteroid administration is greatest at 2–7 days after the initial dose.
92
Q

What are some benefits and risks associated with corticosteroid administration in preterm labour?

A

Benefits
- multiple doses have been shown to reduce neonatal RSD

Complications
- no harm shown in earlyhood, hweber long term risk to mother and baby is not known thus;
**regular repeated courses of more than two are not currently recommended.
- must monitor maternal BGL if pre-existing or GDM

93
Q

What is the dose regimen of betamethasone for the management of pre-term labour?

A

Dose: two 11.4 mg IM, 24 hours apart
**Consider the second dose at 12 hours if birth likely within 24 hours
- if ≤36+6 week

  • If risk of preterm birth remains ongoing in seven days, repeat a single dose
    ** Maximum in any one pregnancy is three, single, repeat doses
94
Q

What is the act of Betamethasone and dexamethasone on a pre term baby?

A

= administered for lung maturity as it readily crosses the placenta.
- best effect at 2-7 days post administration.

Mechanisms underlying the benefits of ACS include:
- Maturation of fetal lungs and increased surfactant production
- Improved pulmonary blood flow and adaptation at birth
- Increased fluid clearance from the alveolar lumen to the interstitium

95
Q

Identify the choice tocolytic in the prevention of preterm labour and the dose regemine of it

A

= nifedipine
Dose: 20mg Oral
- if contraction persists after 30 mins, repeat 20mg orally
- If contractions persist after a further 30 minutes, repeat nifedipine 20 mg oral

Maintenance therapy= 20 mg every six hours for 48 hours

Maximum dose = 160mg/day

Maintenance dose= 20mg three times per day for 48- 72 hours when indicated.

**Other tocolytics may be used if failure of Nifedipine tocolysis however there should be at least 2 hours of treatment with Nifedipine before considering other options of tocolytics.

96
Q

What are some contraindications of nifedipine for the suppression of contractions?

A
  • Contraindications to any suppression of labour including antepartum haemorrhage, pre-eclampsia, chorioamnionitis and fetal distress
  • Cardiac disease including cardiac conduction defects and left ventricular failure
  • Hypotension
  • Concomitant use of betamimetics such as Salbutamol

**Caution should be taken with simultaneous administration of Magnesium Sulphate (MgSO4). This is not an absolute contraindication but care must be taken since hypotension may result.

97
Q

Explain the antibitoic use in preterm labour including the indication, ideal drugs used and the dose regimines.

A

= for GBS prophylaxis

Benzylpenicillin 3g loading dose IV
then
IV Benzylpenicillin 1.8g every four hours

If the woman has a penicillin hypersensitivity with no history of anaphylaxis
IV Cephazolin 2g loading dose
then
IV Cephazolin 1g every eight hours

If the woman has a penicillin allergy with history of anaphylaxis
IV Clindamycin 900mg every eight hours

for Suspected/diagnosed chorioamnionitis
- Loading dose Ampicillin or amoxycillin 2 g IV, then 1 g every six hours
and
- Gentamicin 5 mg/kg IV daily
and
- Metronidazole 500 mg IV every 12 hours

Penicillin allergy/hypersensitivity
- Lincomycin or clindamycin 600 mg IV every eight hours
and
- Gentamicin 5 mg/kg IV daily
and
- Metronidazole 500 mg IV every 12 hours

98
Q

Explain the use of magnesium sulphate in the management of pre-term birth?

A

= used for neuroprotection
- prevents the incidence of cerebral palsy
- beneficial on substantial gross motor function in early childhood

99
Q

What is the recommended dose regimen for MgSo4 for neuroprotection in threatening ore term about?

A

If <30 weeks:
- loading dose MgSO4 4 g IV bolus over 20 minutes
- maintenance dose MgSO4 1 g/hr IV for 24 hours or until birth - whichever is first.

Loading dose:
- using a 10ml vial of MgSO4 prepare 4gram (i.e. 8ml) of magnesium sulphate 50% in a 10mL syringe, configure pump to accept the 10mL syringe and set the pump to 32mL an hour for 15 minutes.

Maintenance:
- once the loading dose has been completed, using the 50mL vial of magnesium sulphate, magnesium sulphate 50% in a 50mL syringe, re-set the pump to accept 50mL syringe and set the pump to administer the maintenance rate of 1g/hr (2mL/hour) or as ordered.

Continue the regime until birth or 24 hours, whichever comes first

Repeat doses: In the event that birth does not occur after giving MgSO4 for neuroprotection of the infant, and preterm birth (less than 30 weeks gestation) again appears imminent (planned or definitely expected within 24 hours), a repeat dose of MgSO4 may be considered.

100
Q

When is MgSO4 recommended in pre-term management?

A
  • when women are at risk of imminent preterm birth before 30 weeks gestation
  • when preterm birth before 30 weeks gestation is planned or definitely expected within 24 hours.
  • regardless of the number of babies in utero
  • regardless of the anticipated mode of birth
  • whether or not antenatal corticosteroids have been given
    **Urgent delivery: In situations where urgent delivery is necessary because of actual or imminent maternal or fetal compromise then delivery should not be delayed to administer MgSO4.
101
Q

What are some midwifery considerations/management principles in the administration of mag sulf in per term about?

A
  • assess for signs of toxicity
  • Serum magnesium concentrations should be checked every 6 hours in the antepartum and intrapartum phase (therapeutic level of magnesium: 1.7 to 3.5 mmol/L).
  • Magnesium is excreted by the kidneys and regular monitoring of serum levels should be conducted in women with oliguria (urine output <100mL over 4 hours) or urea >10mmol/L and those with renal impairment.

Obs
During administration of the loading or bolus dose:
- 5 minutely blood pressure and pulse (x 4 readings)
- observe for the development of side effects
- check patellar reflexes after administration.

During administration of the maintenance infusion:
- ½ hourly blood pressure, pulse, and respiratory rate (pre-treatment respiratory rate should be ≥ 16per
minute). These may be undertaken hourly post-birth.
- 1 hourly patellar reflexes
- 1 hourly urine measures, 4 hourly testing of urinary protein
- 2 hourly temperature
- continuous electronic fetal monitoring from 26 weeks gestation until clinical review/discussion by medical
staff. Between 24- 26 weeks gestation, individualised management with regard to fetal monitoring will be
considered
- maintain strict fluid balance chart.

Record patella reflexes as
A: absent
N: normal
B: brisk

102
Q

What is the antidote for mag sulf toxicity and what is the dose/administartion considerations?

A

=10mL calcium gluconate available as 2.2 mmol calcium in 10mL vial (formerly known as 10% solution) over 10 minutes by slow intravenous injection.
- The patient requires ECG monitoring during and after administration because of the potential for cardiac arrhythmias.

  • Resuscitation and ventilator support should be available during and after dose administration of both
    magnesium sulphate and calcium gluconate.
103
Q

if a woman has a hisotory of preterm birth or is diagnosed with a short cervix by u/s what may be the management?

A

= progesterone therapy or cervical cerclage may be appropriate to prevent preterm labour.

104
Q

What are the medical and surgical interventions to support pregnancy in the case of a shortened cervix?

A

Medical: Progesterone
- if cervical length= <20 mm, vaginal progesterone pessaries should be started
- estimated dose from 90-200mg daily

Surgical: cervical cervlage
- a non-absorbable suture to mechanically support the cervix
- used for high risk pregnancies
- no evidence of improved outcomes if used for women whos diagnosis of a short cervix is an incidental finding
- must be rescue

105
Q

What are some common signs and symptoms of threatening pre term labour?

A
  • regular uterine activity
  • lower abdominal cramping
  • Vaginal loss
    - mucous
    - blood
    - fluid
    - meconium
  • Lower back pain
  • Pelvic pressure
  • Presenting part fixed or engaged
106
Q

Why are PPROM or PROM a major concern before 37/40?

A
  • ROM may result in intrauterine infection or, of course, precede a premature birth.
  • Our most immediate concern when assessing for PROM is the possibility of a cord prolapse.
107
Q

How may ROM be assessed?

A
  • asking the women of her symptoms
  • visualising any loss
  • spec to visualise amniotic fluid
  • biochemical swab test (amnisure)
  • u/s to assess marked reduction in AFI in the presence of normal fetal kidneys and the absence of fetal growth is suggestive of ROM **normal liquor volume does not exclude the diagnosis.
108
Q

What is considered a diagnosis of pre-term labour?

A

= four contractions in 20 minutes on abdo palp, coupled with changes to the cervix

109
Q

What is the management of a woman with confirmed pre-term labour?

A
  • admission to hospital
  • 20min timing to diagnose
  • medication administration
  • CTG if >26ks
  • consider if the facility is equipped to support this case
  • void vaginal examinations (as this is thought to increase risk of introducing bacteria, where as sterile speculums are thought to bare a lesser risk)
110
Q

What is a fibronectin test and what is it used for in the management of pre term labour?

A

= fFN is a protein that assists with keeping the amniotic sac adhered to the uterine wall and is found in very low levels in cervicovaginal fluid during pregnancy, however an increased presence of fFN between 22-36/40 can be an indication that pre-term labour is likely to occur.
- because of this is can be used to aid in the management and planning of care of a women with threatening but not active pre term labour and risk factors (i.e. abdominal pains at 33/40 with a past history of a 34/40 pre-term birth).

111
Q

What are some situations where an fFN should not be performed and what can cause a false positive?

A
  • significant vaginal bleeding
  • ruptured membranes (membranes need to be intact)
  • before any digital/vaginal examination of the cervix
  • any use of lubrication
  • no sexual intercourse in the past 24hours.

*Blood, liquor, lubricants, semen and irritation of the cervix, can all create false positive results

112
Q

Who may be involved in a woman’s interprofessional/multidisciplinary team when she has threatening/pre term labour?

A
  • Obstetric team (Registrar or Consultant - dependent upon severity of prematurity, presenting part, and various other risk factors)
  • Paediatric team
  • SCN or NICU nurse/midwife
  • PIPER (if not birthing at a hospital with the appropriate level of nursery care available)
  • At least one additional midwife to receive the baby and assist with resus if necessary.
113
Q

What are some midwifery considerations for a women in pre term labour?

A
  • continous CTG as pre-term are at increased risk of hypoxia
  • avoid opoid analgesia in labour due to the resp effect being greater in pre terms
  • prepare the room
    - Ensure the heat is turned up, whether in a birth suite or in theatre
    - Ensure the resus cot is set up and fully stocked, with working oxygen and suction
    - Ensure the woman feels supported and informed
    - Keep up to date with documentation (things can change very quickly)
    - Call for help or ask for assistance if ever you feel unsure
  • Birth may be precipitate, as with events such as placental abruption or uterine infections the body tends to progress through labour very quickly in order to protect the woman.
  • possibility that the woman may not need to reach 10cm dilation before the baby can be birthed, as the largest diameter of the fetal head may be significantly smaller than that of a term fetus.
  • Consider, also, that the baby may not be able to go to the woman immediately after birth, and may be taken straight to the resus cot for resuscitation. It is important to be honest with the woman and her supports about this possibility.
  • Skin-to-skin and early initiation of breastfeeding are incredible for pre-term infants, and can act as protective factors, however if a baby requires resuscitation, this obviously is not able to be the priority.
  • Some hospitals are practicing leaving umbilical cords intact for pre-term resus, and have a cot that can be brought to the bedside. This is ideal, but is not always achievable.
114
Q

What are some short term risk of pre term birth?

A
  • increased risk of SCN and NIC admission
  • risk of readmission
  • RDS
  • immature brain
115
Q

What are some long term risk of pre term birth?

A
  • cerebral palsy
  • visual and hearing impairments
  • poor health and growth

Preterms often have long-term difficulties such as:
- Behavioral and social-emotional problems
- Learning difficulties
- Increased risk of conditions such as Attention Deficit-Hyperactivity Disorder (ADHD)
- Increased risk for Sudden Infant Death Syndrome (SIDS)
- Children born preterm are more likely to require early intervention and special education services
- Children born preterm are more likely as adults to have chronic diseases such as heart disease, hypertension and diabetes.

116
Q

What is cerebral palsy in terms of preterm birth?

A
  • multi factors contribute
  • more prem the higher the risk of complications
  • These small, early babies are at risk for bleeding in the brain and, in severe cases, for accumulating fluid in the brain. These brain complications can cause lasting brain damage associated with cerebral palsy.
  • LBW is a risk factor for cerebral palsy
117
Q

Define FGM infibulation

A

is a narrowing or partial closure of the vaginal introitus resulting from the traditional practice of female genital mutilation or cutting.

118
Q

Define deinfibulation in FGM

A

a surgical procedure dividing scar tissue (resulting from infibulation) which partly obstructs the vaginal
introitus and/or urethrea

119
Q

What language should not be used in the context of FGM?

A
  • ‘Reversal’ when referring to deinfibulation
  • ‘mutilation’
120
Q

Define Reinfibulation in FGM

A

suturing following deinfibulation and
usually birth, intended to restore the previous infibulation state.
- It is a traditional practice which is harmful and illegal

121
Q

Why might deinfibulation be preferred?

A
  • if adequate VEs and/or catheterisation in labour is likely to be difficult or impossible
  • due to more straight forward after care
  • usually done anytime a/n 34/40wks
122
Q

What are some key points of management for a women with FGM?

A
  • identification
  • early education and offering of..
  • de-infibibulation in the a/n period
  • discussion about having a female child
  • referral for de-infibulation
123
Q

If deinfibulation has been planned but the birth has progressed to a c/s, what is the management?

A

= when intrapartum deinfibulation
has been planned, deinfibulation may be undertaken following
delivery with consent

124
Q

What are the signs and symptoms of a revealed placenta abruption in relation to;
- PV bleeding
- abdo pain
- shock
- anemia
- uterus characteristics
- urine output
- vaginal inspection findings

A

PV bleeding: usually slight, continuous, darker, rarely severe
Abdo pain: no sever pain but discomfort
Shock: absent
Anemia: usually absent
Uterus characteristics: localised tenderness, fetal presentation usual and FHR auscultated
Urine output: normal
Vaginal inspection findings: slight to heavy bleeding

125
Q

What are the signs and symptoms of a concealed placenta abruption in relation to;
- PV bleeding
- abdo pain
- shock
- anemia
- uterus characteristics
- urine output
- vaginal inspection findings

A

PV bleeding: absent, but present in case of mixed
Abdo pain: acute, agonising
Shock: present (mod to sever)
Anemia: always absent
Uterus characteristics: tender, tensed, hard with rising fundal height, FHR not audible, fetal part is not palpable
Urine output: usually diminished
Vaginal inspection findings: absent

126
Q

What are some clinical manifestations of a placental abruption?

A
  • Tense, ‘woody’ feel on abdominal palpation, so-called Couvelaire
    uterus
  • Vaginal bleeding- may or may not be present and is associated with abdominal pain
  • Uterine contractions
  • Uterine tenderness on palpation
  • Rigid, hard abdomen particularly with a concealed abruption
  • Lower back pain - may be the presenting symptom of a
    concealed abruption
  • Fetal death Inutero, particularly if >50% of the placenta has separated.
  • Signs of fetal compromise or uterine irritability (contractions >5 in 10
    minutes)
127
Q

What are some risk factors for placental abruption?

A
  • Lower socioeconomic background
  • Inadequate intake of Folic acid and Vitamin B12
  • Low BMI
  • Hypertensive conditions- chronic and pre-eclampsia
  • Smoking- doubles the risk
  • Illicit drug use - cocaine, methamphetamine
  • Alcohol use
  • Sudden decompression of the uterus
  • Preterm pre-labour rupture of membranes
  • Previous history of placental abruption
  • Trauma, particularly abdominal i.e. motor vehicle accident
  • Increasing maternal age
  • Multiparity
    Fetal malposition
  • Polyhydramnios/oligohydramnios
  • Assisted reproduction - ART/IVF
  • Intrauterine infection - chorioamnionitis
  • Multiple pregnancy
  • Some blood conditions – particularly any condition that affects the blood’s ability to clot
  • Amniocentesis –
    a prenatal test that involves a needle inserted through the mother’s abdomen and into the
    uterus to withdraw amniotic fluid. Very rarely, the needle puncture causes bleeding.
  • Amnioreduction – This procedure uncommonly causes bleeding.
  • External cephalic version – This procedure can occasionally (rarely) dislodge the placenta.
  • Intimate Partner Violence/Domestic Violence
  • Spontaneous
  • Previous Caesarean sectio
128
Q

What are some causes of placental abruption?

A
  • pre-eclampsia

MID4000 (6 decks)

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