Antenatal obstetric complication

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  • 1. Antenatal obstetric complication Prepared by: Nibal Shawabkeh Supervised by: Dr. Bassam Alkhdar 1
  • 2. Outline  Problems due to abnormalities of the pelvic organ  ANTI PARTUM HEAMORRHAGE  Post term pregnancy  Urinary tract infection  Venous thromboembolism  AMNIOTIC FLUID proplems 2
  • 3. Problems due to abnormalities of the pelvic organ 3 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. 4
  • 5. 5
  • 6. 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 7
  • 8. 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. 9
  • 10. Congenital uterine anomalies10
  • 11. Problems associated with bicornuate uterus Miscarriage Preterm labour PPROM Abnormalities of lie and presentation Higher CS rate 11
  • 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 12
  • 13. Types Follicular Cyst Corpus luteum cyst Hemorrhagic cyst Dermoid cyst 13
  • 14. 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 15
  • 16. Risk Factors of Ovarian Cysts History of previous ovarian cysts Irregular menstrual cycles Increased body fat distribution Early menstruation (11 years or younger) Infertility Hypothyroidism or hormonal imbalance Tamoxifen therapy for breast cancer 16
  • 17. 17 Diagnosis Treatment
  • 18. ANTI PARTUM HEAMORRHAGE  BLEEDING FROM THE VAGINA DURING PREGNANCY FROM THE 24 th WEEKS GESTATION TELL DELIVERY.  Incidence is 3% 18
  • 19. History How much bleeding ? Triggering factors Associated with pain or contraction Is the baby moving? Last cervical smear? 19
  • 20. Examination Pulse , blood pressure Is the uterus soft or tender or firm ? Fetal heart auscultation Speculum vaginal examination 20
  • 21. Investigations Full blood count Cross match six units of blood Ultrasound ( fetal size , presentation, amniotic fluid , placental position and morphology ) 21
  • 22. Causes OBSTERTIC PLACENTA UTERUS NONOBSTETRIC LOWER GENITAL TRACT BLEEDING BLEEDING FROM GIT OR URINAY TRACT 22
  • 23. Placental causes PLACENTA PREVIA PLACENTA ABRUOTION VASA PREVIA 23
  • 24. PLACENTA PREVIA •IS A PLACENTA THAT IS IMPLANTED ENTIRELY OR IN PART IN THE LOWER UTERINE SEGMENT DEFINITION • 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 CAUSES OF BLEEDING 24
  • 25. 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 26
  • 27. 27
  • 28. ABRUBTIO PLACENTA  VAGINAL BLEEDING FROM NORMALLY IMPLANTED PLACENTA IN UPPER UTERINE SEGMENT 28
  • 29. VASA PREAVIA  FETAL VESSELS CROSSING OR RUNNING IN CLOSE PROXIMITY TO THE INNER CERVICAL OS.  ASSOCIATED WITH  ACCESSORY PLACENTAL LOBES  MULTIPLE GESTATION 29
  • 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 30
  • 31.  Kleihauer test  CTG  Observation  U/S Placental localization  Speculum examination when placenta praevia excluded, bleeding settled  Anti-D if Rh-negative 31
  • 32. • 1- GENERAL CONDITIONS OF THE MOTHER • 2- VITAL SIGNS – BP / PULSE • 3-SEVERITY OF BLEEDING • 4- CBC / HB • 5-RH-GP FOR ANTI-D 1-MATERNAL WELLBEING • 1- US EXAMINATION FOR FETAL WELLBEING WHICH INCLUDES FH / MOVEMENT / LIQOUR • 2-FETAL WT • 3- NST • 4- CONFERM GESTATIONAL AGE 2-FETAL WELL BEING • AFTER EVALUATING MATERNAL AND FEATL CONDITIONS SO DELIVERY OR CONSERVATIVE MANAGEMENT3-GEATATIONAL AGE 32
  • 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 33
  • 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. 34
  • 35. Risk factors Primiparity Prior post term pregnancy Fetal anencephaly Placental sulfatase deficiency Fetal gender: male 35
  • 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. 36
  • 37. Cardiotocography CTG37
  • 38. Risks Fetal and Neonatal Risks Reduced placental perfusion Oligohydramnios Meconium aspiration Maternal Risks Increased incidence of forceps , vacuum assisted or cesarean birth Increased incidence of shoulder dystocia 38
  • 39. Management  Induction of labour.  Cesarean section 39
  • 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. 40
  • 41. Predisposing factors : hx of recurrent cystitis Renal tract abnormalities *Diabetes bladder emptying problems 41
  • 42. Symptoms low back pain malaise flu like symptoms 42 Examination tachycardia pyrexia dehydration loin tenderness
  • 43. • CBC • MSU -> send for urine microscopy , culture ,sensitivities . Investigation • E.Coli most common • less common Klebseilla , proteus ,Pseudomonas, strep organism 43
  • 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 44
  • 45. Pyelonephritis Dehydration Very high temperature > 38.5 c Systemic disturbance Occasionally shock 45 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 11000-2000 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 46
  • 47. Risk factors for thromboembolic disease •maternal age > 35 •Thrombophilia •Obesity > 80 kg •Previous thromboembolism •Sever varicose vein •Smoking •malignancy Pre existing •Multiple gestation •Pre-eclampsia •CS •Damage to pelvic vein •Sepsis •Prolonged bed rest Specific to pregnancy 47
  • 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 48
  • 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  VQ scan , CTPA 49
  • 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 50
  • 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. 51
  • 52. 52
  • 53. AMNIOTIC FLUID53
  • 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. 54
  • 55. OLIGOHYDRAMNIOS55 Too little amniotic fluids , AFI less than 5th centile for gestation
  • 56. Causes • Renal agenesis. • Multicystic kidneys. • Urinary tract abnormalities or obstruction. • IUGR & placental insufficency . • Maternal drugs( NSAIDS) ( ACE inhibitor). Too little production: • Leakage : PPROM Post-date pregnancy : 56
  • 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 FGRuteroplacental unsuffeciency less severe degree and less commonly causes limb and lung problems . 57
  • 58. MANAGEMENT  DEPENDS UPON 58 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 59
  • 60. POLYHYDRAMNIOS  Excess of amniotic fluid ,AFI more than 95th centile for gestation on US estimation 60
  • 61. Causes • Diabetes Maternal • Chorioangioma • Arterio-venous fistulaPlacental • Multiple gestation • Oesophageal atresia • Deudenal atresia • Neuromuscular fetal conditions • Anencephaly • Idiopathic Fetal 61
  • 62. Signs and symptoms 62 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 Edema Oliguria 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 63
  • 64. End of Lecture May 2014 64