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Complications of Pregnancy Medical Student Teaching Oct 2024Mennear ST3 O&GContent ● APH ● PPH ● Cord Prolapse ● Perineal Tears ● Exam QuestionsAntepartum Haemorrhage Definition ● Bleeding, from 24 weeks of pregnancy to birth ● Affects 3-5% of pregnancies ● Minor <50ml ● Major 50 - 1000ml ● Massive >1000mlAntepartum Haemorrhage Causes ● Placenta Previa ● Placental abruption ● Vasa Previa ● Local causes ● Uterine RuptureAntepartum Haemorrhage - Placenta Previa ● Placenta is located at anomaly scan ● Low lying placenta <20mm from cervical os ● Placenta previa - covering cervical os ● Risk factors: ○ Previous Caesarean section ○ IVF ○ Smoking ● 90% cases will resolve by term ● Prevalence 1:200 at termAntepartum Haemorrhage - Placenta Previa ● Presentation ○ Painless bleeding ○ UNLESS - contracting ○ Fetal distress? ○ Usually known - take a history/check notes ● Management ○ ?Maternal shock - Resuscitate if necessary ○ ?Fetal Distress ○ Consider delivery - caesarean section ○ Consider steroids ○ Consider tocolysis to allow steroidsAntepartum Haemorrhage - Placenta Accreta Spectrum ● Not a cause of APH, but associated with Placenta PreviaAntepartum Haemorrhage - Placental Abruption ● Separation of placenta from uterus ● Risk factors: ○ Previous abruption ○ Smoking ○ Drug use - cocaine ○ Abdominal trauma ○ Pre-eclampsia ○ First trimester bleedingAntepartum Haemorrhage - Placental Abruption ● Presentation ○ Constant abdominal pain ○ “Woody” uterus ○ Tender uterus ○ Fetal distress ○ Contractions ○ Bleeding can be absent ● Note - presentation is variable, diagnosis is entirely clinical ● Management ○ ?Maternal distress - Resuscitate if necessary ○ ?Fetal Distress ○ Consider delivery - caesarean section - GAAntepartum Haemorrhage - Vasa Previa ● Rare (approx 1:5000)Antepartum Haemorrhage - Vasa Previa ● Presentation ○ Painless bleeding following rupture of membranes ○ Fetal distress - fetal mortality 60% ● Diagnosis ○ Picked up at USS ○ Sometimes felt on VE ○ Not enough evidence for screening ● Management ○ Caesarean section if fetus alive ○ If diagnosed in advance - planned caesarean section (34-36 weeks) consider admission from 30-32 weeksAntepartum Haemorrhage - Uterine Rupture ● Usually after previous caesarean section/other uterine surgery ● Prevalence 1:200 for VBAC ● Usually in labour Presentation: ● Constant pain ● Scar tenderness ● Elevation of fetal parts Management: Caesarean sectionAntepartum Haemorrhage ● General Management ○ Maternal distress? - resuscitate - plan for DIC ○ Fetal distress? - consider delivery ○ Look for a cause ○ Consider Rh status - Kleihauer - Anti D ○ Consider steroids if preterm ○ Plan ongoing management - discharge / observe / deliverQuestions on APH?Post-partum Haemorrhage Definition: ● Minor 500 - 1000ml ● Major >1000ml ○ Moderate 1-2L ○ Severe >2L ● Primary within 24 hours of birth ● Secondary 24 hrs - 12 weeks after birthPost-partum Haemorrhage Causes: ● Tone ● Tissue ● Trauma ● ThrombinPost-partum Haemorrhage Risk Factors: ● Previous PPH ● Multiparity ● Pre-eclampsia ● LGA ● Prolonged 2nd or 3rd stage ● Retained placenta/placenta accreta ● Perineal trauma ● GA ● High BMIPost-partum Haemorrhage Reducing Risk: ● Correct anaemia ● Correct place of birth ● Active management of 3rd stage (but not early cord clamping) - uterotonics ● Consider TXA at caesareanPost-partum Haemorrhage Management: ● Depends on the cause! ● BUT always think resuscitate ● Weigh blood loss ● Have a scribe ● Think about activating MOH ● Large bore cannula and bloods - FBC, coag (incl. fibrinogen), G&S, U&E, LFTs ● Empty bladder ● Observations ● Warmed crystalloid fluids ● Consider blood - 4 RBCs then FFP ● Cryoprecipitate if fibrinogen <2 ● Platelets if <75Post-partum Haemorrhage Management: ● Tone ○ Uterine massage/bimanual compression ○ Uterotonics ■ Oxytocin ■ Ergometrine ■ Carboprost/misoprostol ○ Surgical management ● Tissue ○ Remove it ● Trauma ○ Repair it ○ TXA ● Thrombin ○ Blood products - cryoprecipitate (fibrinogen), FFP, platelets, specific factors, reversal agentsPost-partum Haemorrhage Surgical Management: ● Bakri Balloon ● B-Lynch suture ● Uterine artery embolisation ● Sequential devascularization of uterus ● Internal iliac ligation ● HysterectomyPost-partum Haemorrhage Surgical Management:Questions on PPH?Umbilical Cord Prolapse Definition - delivery of the umbilical cord through the cervix before, or with the presenting part Prevalence 0.1-0.6% Perinatal mortality 91:1000Umbilical Cord Prolapse Risk factors: ● Transverse/oblique/unstable lie ● Breech ● Preterm labour ● Multiparity ● Polyhydramnios ● Second twinUmbilical Cord Prolapse Management: ● Delivery - usually caesarean ● While await this: ○ Elevate presenting part - manually or bladder filling ○ Avoid handling cord ○ Maternal position ○ Consider tocolysis if birth is delayedQuestions on Cord prolapse?Perineal Tears Tears involving the vaginal muscosa, perineal skin, perineal muscles or anal sphincter Affects 90% of primips 3.5% of women have a 3rd or 4th degree tearPerineal Tears ● 1st degree - vaginal mucosa only ● 2nd degree - vaginal mucosa, perineal skin, perineal muscles ● 3rd degree - involves anal sphincter ● 4th degree - torn anal mucosaPerineal TearsPerineal Tears ● Risk factors ○ Primparous ○ LGA ○ Asian ethnicity ○ OP presentation ○ Prolonged second stage ○ Shoulder dystocia ○ Instrumental DeliveryPerineal Tears Reducing risk: ● Perineal massage ● Warm compress at delivery ● Manual perineal protection ● Controlled birth ● Episiotomy when indicatedPerineal Tears Management ● 1st degree - stitches/no treatment ● 2nd degree - suture ● 3rd/4th degree ○ Repair in theatre ○ Need laxatives and antibiotics ○ Physiotherapy ○ Follow up ● Watch for PPH, consider TXAPerineal Tears Risks: ● Discomfort, superficial dyspareunia ● Chronic pain ● Infection, wound breakdown ● Urinary symptoms ● Bowel symptoms - urgency, incontinence of stool or flatus ● Recto-vaginal fistulas 60-80% women with 3rd/4th degree tears are asymptomatic at 12 monthsQuestions?Exam Questions - 1Exam Questions - 2Exam Questions - 3 Exam Questions - 4a Helena is a 28 year old G2P1 who has presented at 25 weeks with vaginal bleeding 1. Give 2 differentials for this presentation 2. Upon taking a history, Helen describes severe lower abdominal pain, 10/10 not relieved by paracetamol or a hot water bottle a. What “classic” examination findings would you expect b. What would this suggest Exam Questions - 4b 3. List 3 causes of placental abruption The CTG is normal, Helen is given a course of steroids and observed for 48 hours. 4. What would the management be if the CTG was abnormal? Exam Questions - 5a A G2P1 patient at 39+4 weeks has been in the second stage of labour for just over an hour. 1. Describe the factors that govern progress in labour Following a change in position the baby and placenta are delivered. On examination the midwife finds a midline perineal tear which extends into a small portion of the external anal sphincter. 2. How would you classify this tear? 3. List 3 risk factors for perineal tears Exam Questions - 5b 4. How would this tear be managed? 5. Name 2 long term complications this patient is at risk of 6. What 2 additional measure could you take to reduce the risk of long term complications?Exam Questions - 6 Exam Questions - 7 Mrs Smith is G1P0 with a background history of asthma and eczema. During the course of the pregnancy she develops PET and is treated with nifedipine. She is now 38+2/40 and presents in labour. She has an uneventful normal delivery followed by brisk blood loss. EBL is 500ml with ongoing bleeding. a. Which medications for treating PPH are contraindicated in this patient? b. Which medications for treating PPH are safe in this patient? Exam Questions - 8a Mrs Smith is G3P2 with a history of 2 previous caesarean sections. She presents at 34/40 with vaginal bleeding. a. What is the differential diagnosis She tells you that could not attend her 20 week scan as she was on holiday at the time. She reports no pain. b. What is the differential diagnosis now? There is no history of rupture of membranes. CTG is normal. EBL is 100ml but stopped. c. What would you management be? Exam Questions - 8b USS confirms an anterior placenta covering the interal os. d. What else do you now need to consider? Later that day you are called to review Mrs Smith. There has been further bloods loss of 400ml with ongoing bleeding. Mrs Smith has a HR of 130bpm and a BP of 90/50. e. What is your management? Who else do you need? Exam Questions - 9 Mrs Jones is G2P1 previous NVD. She presents at 41+4 for postdates induction of labour. The midwife is about the perform an ARM but feels some nodularity in the membranes and asks for your advice. What is the most important diagnosis to exclude? Exam Questions - 10 Miss Stevens is G2P1 and presents at 40+0 in labour. She had an emergency caesarean in her last pregnancy for fetal distress. She is contracting 3-4:10 and has a well working epidural. You are asked to review her as she is having increasing pain and the liquor is now blood stained. a. What is the differential diagnosis? She is now in severe pain and the CTG show decelerations. b. What would your management be? Exam Questions - 11 Miss Shaw presents at 25/40 with vaginal bleeding. She has no pain. She has recently moved from abroad but doesn’t give many details. She saw her midwife to register her pregnancy last week and had a normal USS. a. What is the differential diagnosis? b. What would your management be? On examination there is period like loss from the vagina with some clots, and a soft mass at the top of the vagina. You cannot see the cervix. FH is normal. What is the likely diagnosis?