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1
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.
5
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
7
Diagnosis
Treatment
RECOMMENDATIONS
8
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
14
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)
17
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 )
22
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
25
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
27
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
31
Kleihauer test
CTG
Observation
U/S Placental localization
Speculum examination when placenta praevia excluded, bleeding settled
Anti-D if Rh-negative
32
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
43
Investigation
•CBC•MSU -> send for urine microscopy , culture ,sensitivities .
organism
•E.Coli most common •less common Klebseilla , proteus ,Pseudomonas, strep
44
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.
52
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
57
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
64
End of Lecture
May 2014