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Antenatal obstetric complication Prepared by: Nibal Shawabkeh

Supervised by: Dr. Bassam Alkhdar

2 Outline

Problems due to abnormalities of the pelvic organ

ANTI PARTUM HEAMORRHAGE

Post term pregnancy

Urinary tract infection

Venous thromboembolism

AMNIOTIC FLUID proplems

3 Problems due to abnormalities of the pelvic organ

Fibroids

Retroversion of the uterus

Congenital uterine anomalies

Ovarian cyst in pregnancy

4 Fibroids (leiomyomata)

non-cancerous (benign) growths that develop in the muscular wall of the uterus

Uterine fibroids are the most common tumors of the female genital tract.

Fibroids may grow as a single tumour (growth) or in a cluster.

They can range in size from very tiny (a quarter of an inch) to larger than a melon .

Fibroids can dramatically increase in size during pregnancy.

fibroids are the product of many factors, which could be genetic, hormonal, environmental, or a combination of all three.

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6

Prolonged and heavy bleeding or painful periods

Bleeding between periods.

Anaemia

Frequent passing of urine.

Lower back pain

Constipation

Painful sex

Miscarriages

Symptoms

Risk factors child bearing age (between 25 to 45 years of age)

Afro-Caribbean origin women

weighed or obese women

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Diagnosis

Treatment

RECOMMENDATIONS

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9 Retroversion of the uterus

A retroverted uterus means the uterus is tipped backwards so that it aims towards the rectum instead of forward towards the belly.

Some women may experience symptoms including painful sex.

In most cases, a retroverted uterus won’t cause any problems during pregnancy.

Treatment options include exercises, a pessary or surgery.

10 Congenital uterine anomalies

11 Problems associated with bicornuate uterus

Miscarriage

Preterm labour

PPROM

Abnormalities of lie and presentation

Higher CS rate

12 Ovarian cyst in pregnancy

small fluid-filled sacs that develop in a woman's ovaries

Most cysts are harmless, but some may cause problems

13Types

Follicular Cyst

Corpus luteum cyst

Hemorrhagic cyst

Dermoid cyst

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15 Symptoms

Lower abdominal or pelvic pain

Pain or pressure with urination or bowel movements

Irregular menstrual periods

Nausea and vomiting

Increased facial hair similar to a male pattern

16 Risk Factors of Ovarian Cysts

History of previous

ovarian cysts

Irregular menstrual

cycles

Increased body fat

distribution

Early menstruation (11 years or

younger)

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Diagnosis

Treatment

18 ANTI PARTUM HEAMORRHAGE

BLEEDING FROM THE VAGINA DURING PREGNANCY FROM THE 24 th WEEKS GESTATION TELL DELIVERY.

Incidence is 3%

19 History

How much bleeding ?

Triggering factors

Associated with pain or contraction

Is the baby moving?

Last cervical smear?

20 Examination

Pulse , blood pressure

Is the uterus soft or tender or firm ?

Fetal heart auscultation

Speculum vaginal examination

21 Investigations

Full blood count

Cross match six units of blood

Ultrasound ( fetal size , presentation, amniotic fluid , placental position and morphology )

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Causes

OBSTERTIC

PLACENTA UTERUS

NONOBSTETRIC

LOWER GENITAL TRACT

BLEEDING

BLEEDING FROM GIT OR URINAY TRACT

23 Placental causes

PLACENTA PREVIA

PLACENTA ABRUOTION

VASA PREVIA

24PLACENTA PREVIA

DEFINITION

•IS A PLACENTA THAT IS IMPLANTED ENTIRELY OR IN PART IN THE LOWER UTERINE SEGMENT

CAUSES OF BLEEDING

• HEAMORRHAGE OCCURE WHEN CONTRACTIONS DILATE THE CX THERBY APPLYING SHEARING FORCES TO THE PLACENTAL ATTACHMENT IN THE LOWER SEGMENT

• WHEN SEPARATION IS PROVOKED BY UNWISE DIGITAL VAGINAL EXAMINATION

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26 GRADES

G1 •THE PLACENTA ENCROACHES ON THE LOWER SEGMEN T BUT DOES NOT REACH THE INTRNAL CERVICAL OS

G2 •THE PLACENTA DOES REACH THE EDGE OF THE CX. BUT DOES NOT COVER IT

G3 •THE PLACENTA DOES COVER THE CX BUT WOULD NOT DO SO AT FULL CX.DILATATION

G4 •THE PLACENTA IS SYMETRICALLY IMPLANTED IN THE LOWER SO THAT IT COVERS THE CX TOTALLY

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28 ABRUBTIO PLACENTA

VAGINAL BLEEDING FROM NORMALLY IMPLANTED PLACENTA IN UPPER UTERINE SEGMENT

29 VASA PREAVIA

FETAL VESSELS CROSSING OR RUNNING IN CLOSE PROXIMITY TO THE INNER CERVICAL OS.

ASSOCIATED WITH

ACCESSORY PLACENTAL LOBES

MULTIPLE GESTATION

30 Initial management of APH

History Examination NO PV before excluding

Placenta praevia Nurse on side IV access/ resuscitate Input-output chart Clotting screen Cross match

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Kleihauer test

CTG

Observation

U/S Placental localization

Speculum examination when placenta praevia excluded, bleeding settled

Anti-D if Rh-negative

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1-MATERNAL WELLBEING

• 1- GENERAL CONDITIONS OF THE MOTHER • 2- VITAL SIGNS – BP / PULSE• 3-SEVERITY OF BLEEDING• 4- CBC / HB• 5-RH-GP FOR ANTI-D

2-FETAL WELL BEING

•1- US EXAMINATION FOR FETAL WELLBEING WHICH INCLUDES FH / MOVEMENT / LIQOUR•2-FETAL WT•3- NST•4- CONFERM GESTATIONAL AGE

3-GEATATIONAL

AGE

•AFTER EVALUATING MATERNAL AND FEATL CONDITIONS SO DELIVERY OR CONSERVATIVE MANAGEMENT

33 DELIVERY

BY CS

DEPENDS ON FETAL GESTATIONAL AGE – ASK ABOUT LMP –SURE DATES / EARLY US

LUNG MATURITY

DEPENDS ON MATERNAL CONDITIONS AND SEVERITY OF BLEEDING

IN SEVER BLEEDING – BLOOD TRANSFUSION

SOMETIMES AFTER CS BLEEDING DON’T STOP FROM LOWER UTERINE SEGMENT SO MUST DO TAH

34 Post term pregnancy

Refers to a pregnancy that has extended to or beyond a gestational age of 42.0 weeks or 294 days from the first day of the LMP

Affect 10% of al pregnancies and the aetiology is unknown .

Post term pregnancy is associated with increased perinatal mortality and morbidity.

35 Risk factors

Primiparity

Prior post term

pregnancy

Fetal anencephaly

Placental sulfatase deficiency

36 Indications of induction of labor in post date

There is reduced Amniotic fluid on scan

Fetal growth is reduced

There are reduced fetal movement

The CTG is not perfect

The mother is hypertensive or suffers a significant medical condition.

37 Cardiotocography CTG

38Risks

Fetal and Neonatal Risks

Reduced placental perfusion

Oligohydramnios

Meconium aspiration

39 Management

Induction of labour.

Cesarean section

40 Urinary tract infection

It’s common in pregnancy

8% of women have asymptomatic bacteruria

If not treated , it may progress to UTI or even pyelonephritis associted with low birth weight and preterm delivery.

41 Predisposing factors :hx of recurrent

cystitis Renal tract

abnormalities

*Diabetesbladder

emptying problems

42Symptoms

low back pain

malaise

flu like symptoms

Examination

tachycardia

pyrexia

dehydration

loin tenderness

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Investigation

•CBC•MSU -> send for urine microscopy , culture ,sensitivities .

organism

•E.Coli most common •less common Klebseilla , proteus ,Pseudomonas, strep

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More than 10^5 organisms are present at culture , this confirm the diagnosis .

MSU repeated after a week . 1st line ATB -> amoxycillin , oral cephalosporin

45 Pyelonephritis

Dehydration

Very high temperature

> 38.5 c

Systemic disturbance

Occasionally shock

IV fluids Opiates analgesia

IV AB (cephalosporin or gentamicin)

Renal function should be

determined

Baby should monitored with CTG

Features

Management

46 Venous thromboembolism

Occurs 1\1000-2000 pregnancies

Leading cause of maternal death in developed countries

Pregnancy associated with 6-10 fold increase in the risk of VTE compared to non pregnant situation

Virchow’s Triad

Clinical Dx of acure VTE is unreliable , therefore women who are suspected to have DVT , PE should be investigated promptly

47 Risk factors for thromboembolic disease

Pre existing

•maternal age > 35•Thrombophilia •Obesity > 80 kg •Previous thromboembolism •Sever varicose vein •Smoking •malignancy

Specific to pregnancy

•Multiple gestation •Pre-eclampsia •CS •Damage to pelvic vein •Sepsis •Prolonged bed rest

48 Deep vein thrombosis

most common symptom pain in calf with varying degree of redness or swelling

Women’s legs are often swollen during pregnancy therefore unilateral symptoms should ring alarm bells

Investigation : compression US ,Venography

49 Pulmonary embolism

It’s crucail to recognize PE as missing the Dx could have fatal implications

The most common Presentationis of : mild breathlessness or inspiratory chest pain , in a woman who is not cyanosed but may be slightly tachycardia (>90bpm) with mild pyrexia(>37.5)

Investigation : ECG , Chest x-ray , ABGs to exclude other Respiratory diagnosis , we should investigate the lower limbs for DVT by US

V\Q scan , CTPA

50 Treatment of VTE

LMWHs : are now the Tx of choice

Warfarin : Rarely recommended for use in pregnancy ( exception include women with mechanical heart valves )

Following delivery women can choose to convert to warfarin , warfarin and LMWHs safe in breastfeeding

Graduated elastic stockings shoulde be used for intital Tx of DVT and should be worn for 2 years following DVT

51 AMNIOTIC FLUID

The liquid that surrounds the developing fetus during pregnancy. It is contained within the amniotic sac.

Amniotic fluid is mainly derived from the blood plasma. After the fetal kidneys form and become functional at about 10-11 weeks, fetal urine becomes the main source of amniotic fluid. In addition to lung fluid ,fetal oral and nasal secretions and fetal surface of placenta .

It is removed due to fetal swallowing and absorption into the fetal blood. Uptake also occurs across the placental surface.

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53AMNIOTIC FLUID

54 Functions

Protect fetus from pressure or trauma.

Permitting fetal lungs to expands and develop.

Protects cord from compression.

Permits fetal movements – development of musculoskeletal system,

Swallowing of AF enhances growth & development of GIT.

Maintenance of fetal body temperature.

55 OLIGOHYDRAMNIOS

Too little amniotic fluids , AFI less than 5th centile for gestation

56 Causes

Too little production:

•Renal agenesis.•Multicystic kidneys.•Urinary tract abnormalities or obstruction.•IUGR & placental insufficency .•Maternal drugs( NSAIDS) ( ACE inhibitor).

Post-date pregnancy :

•Leakage : PPROM

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Fetal prognosis depends on the cause of oligohydramnios but both pulmonary hypoplasia and limbs deformeties are common in severe early onset (<24 weeks ) oligohydraminos

Renal agenisis and bliateral multicystic kidneys carry a lethal prognosis

Oligohydraminos due to FGR\uteroplacental unsuffeciency less severe degree and less commonly causes limb and lung problems .

58 MANAGEMENT

DEPENDS UPON

AETIOLOGY

GESTATIONAL AGE

SEVERITY

FETAL STATUS &

WELL BEING

59 Women who have a healthy pregnancy, developing mild oligohydramnios often do not need any treatment

Delivery is the most appropriate management option if oligohydramnios occurs during the last stage of pregnancy.

More severe cases of pre-term oligohydramnios may require the following treatment measures:

Amnioinfusion

It involves infusing sodium chloride solution into the amniotic cavity using an intrauterine catheter.

Maternal Rehydration & Bed Rest

Using oral fluids and IV fluids to rehydrate the mother’s body helps to raise the amniotic fluid level

Termination of pregnancy may be the only option in severe cases occurring during the first trimester

60 POLYHYDRAMNIOS Excess of amniotic fluid ,AFI more than 95th centile for gestation on US

estimation

61 Causes

Maternal

• Diabetes

Placental

• Chorioangioma• Arterio-venous fistula

Fetal• Multiple gestation• Oesophageal atresia• Deudenal atresia• Neuromuscular fetal conditions• Anencephaly • Idiopathic

62Signs and symptoms

Abdominal swelling and discomfort .

On examination: The abdomen may be

tense and tender and fetal poles will be hard to palpate.

In addition to:Dyspenea

EdemaOliguria

Dyspepsia

63 Management

According to the cause and severity .

Mild cases of polyhydramnios rarely require treatment.

Treatment for an underlying condition ,such as diabetes ,may help resolve polyhydramnios.

Amniocentesis 500 ml/h

1500-2000 ml/d

carries a small risk of complications, including preterm labor, placental abruption and premature rupture of the membranes

Indomethacin

Decreases lung liquid production

Decreases fetal urine production

Increases fluid movement across fetal membranes

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End of Lecture

May 2014