Antepartum complications Week 1 2015. Obstetrical assessment unit/ triage Antepartum complications...
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Transcript of Antepartum complications Week 1 2015. Obstetrical assessment unit/ triage Antepartum complications...
Antepartum complications
• Week 1 2015
Obstetrical assessment unit/ triage
• Antepartum complications eg. cystitis, abdo pain, injury• Antepartum hemorrhage• ? PROM• Preterm labour• Gestational HTN/pre-eclampsia• Outpatient inductions
Antepartum Complications
• APH • Antepartum Hemorrhage
• PPROM • Pre-labour Rupture of Membranes
Antepartum HemorrhageAntepartum Hemorrhage
Definition:
- Vaginal bleeding any time from 20 weeks to term- 2% to 5% of all pregnancies affected
Antepartum Hemorrhage
Causes:
Abruptio Placenta 40%Placenta Previa 20%Unclassified 35%Lower Genital Tract Lesion 5%
Antepartum Hemorrhage
Physiology:
- Uterus receives 1% of maternal cardiac output in non gravid state
- Rises to 20% in the third trimester- Potential for massive bleeding and significant
mortality and morbidity- Previa and Abruption 60% of APH
Placenta Previa
Definition:
Localization of the placenta near or over the cervical os
-detectable by antenatal ultrasound- Complete, partial or marginal
Incidence:- 0.3%-0.5% of all pregnancies
Placenta Previa
Low lying placenta:
- Affects appx. 30% of early pregnancies but only 0.5% persist
- Repeated US advised in second trimester- If placenta is within 2 cm of the os (by
transvaginal ultrasound), risk exists for bleeding through effacement and dilatation
Placenta Previa
Predisposing Factors:• Prior placenta previa• First pregnancy following any
uterine surgery eg. C/S• Multiple gestation• Uterine malformation• Multiparity• Advanced maternal age
Abruptio Placenta
Definition:Premature separation from the uterine wall of a
normally implanted placenta
Incidence:- 1%-2% of all pregnancies- 5%-16% if previous Hx of abruption (identify on
antenatal records if possible)
Abruptio Placenta
Classification:
Abruptio PlacentaPredisposing Factors:• Maternal hypertension• Prior abruption• Abdominal trauma• Maternal smoking (> 1 ppd)• Multiparity• Advanced maternal age (> 35 years)• Substance abuse (cocaine and alcohol)• Uterine malformation
Abruptio Placenta
Predisposing Factors (cont):• A short umbilical cord• Rapid uterine decompression (multiple
gestation, polyhydramnios)• Thrombophilia
However…Most abruptions are idiopathic
Antepartum Hemorrhage
Placenta Previa and Abruptio Placenta Diagnosis:
• Avoid a pelvic exam until Placenta Previa has been ruled out (see antenatal record/OASIS)
• History and physical may give clues• TV ultrasound is definitive for Dx previa• Abruption is not a radiologic diagnosis, however
Abruptio vs. Placenta Previa
Antepartum Hemorrhage
Previa and Abruptio Management:• Remember you have 2 patients• Determine hemodynamic stability• Prompt Fetal Health Surveillance• If unstable
ABC’s, large bore IV’sx-match, INR/PTT, fibrinogenO2 (fetus sensitive to hypoxia)continued maternal-fetal surveillance
Antepartum Hemorrhage
Previa and Abruptio Management (cont):• Kleihauer-Betke test may confirm abruption• WinRho (Rh immune globulin) when indicated• Monitor 4-24 hours for evidence of fetal
compromise• Consider transfer to high risk centre• Consider steroids for <34 weeks• Always weigh risk of significant subsequent
bleeding vs. fetal maturity
Pre-labour Rupture of MembranesPre-labour Rupture of Membranes
• ROM before labour
• PROM >37 weeks• PPROM <37 weeks
PROM
• Latent period = interval between PROM and onset of labour
• 90% of term PROM will have spontaneous labour within 24 hours
• Likelihood decreases with PROM more remote from term
• 28-32 week PPROM has 50% likelihood of labour by 24 hours, 80% by 1 week
PROM
Incidence:• Term PROM
• 2-10% of pregnancies
• PPROM • 2-3% of pregnancies• 33% of preterm deliveries
PROM
Etiology:• Idiopathic• Infection – check VSS, esp. temp.• Polyhydramnios - ? Recent US• Cervical incompetence• Uterine abnormality• Following cervical cerclage or amniocentesis• Trauma• Previous cervical surgery (e.g. conization)
PROM
Etiology (cont.):
• Past OB history (gestational age at delivery, including PPROM)
• Black Race• Smoker• Drugs, lifestyle, stress• Nutrition
PROM
Complications - Term PROM
• Fetal/neonatal infection• Maternal infection• Umbilical cord compression / prolapse
PROM
Diagnosis:
• History• 30% of women with Hx of leakage do not have ROM• Ddx: vaginitis (infectious vs. physiologic), urine, semen, sweat
• Routine digital exam is not indicated because of infection risk
• Speculum exam - for confirmation of ROM, cervical status, and to exclude cord prolapse
• Determine GBS status
PROM
Speculum Exam (RN assist):
• Sterile technique• Must visualize cervix• Fluid pooling in posterior fornix• Free flow of fluid from cervical os – may try coughing or
fundal pressure• pH testing of fluid Nitrazine test - non specific• Causes of false positive: blood, semen, BV• Ferning
PROM
Ferning
PROMManagement - all gestations:
• Confirmation of the diagnosis• Assessment of maternal and fetal well-being• Determination of the presence of any associated
condition• Abdominal exam for presentation • Assessment of cervical status• Digital examination should be avoided whenever possible
(especially when preterm and expectant management is being considered)
PROM
Management - >37 weeks:
Term PROM Trial – Hannah et al, NEJM 1996;334:1005-1010
• induction of labor with oxytocin or prostaglandin E2, and expectant management, result in similar rates of neonatal infection and cesarean section
• induction with oxytocin resulted in a lower risk of maternal infection and women viewed induction of labor more positively than expectant management
• Don’t induce if not cephalic!
PROM
Management - >34 weeks:
PROM
Management - >34 weeks:
PROM
Management - >34 weeks:
PROM
Management >37 weeks - Bottom Line :• Avoid digital exam• Assess for infection - mat and fetal vital signs• Do appropriate swabs• Recommend GBS chemoprophylaxis at the onset
of labour, if GBS +• Offer oxytocin
PROM
Management 34-37 weeks - Bottom Line :
• As for Term PROM but also… • Consider transfer to higher centre/OBS consult• Ultrasound for fluid, cervical length, position• Individualized mgt. based on risks, patient preference
and availability of resources• Consider induction more readily if GBS positive• Maternal-fetal surveillance if expectant management
Pre-labour Rupture of Membranes
Management <34 weeks - Bottom Line :
• Consider transfer to higher centre• Ultrasound for fluid, cervical length, position• Refer to OB• Collect Fluid for fetal lung maturity if possible• Steroids• Antibiotics (IV x 2 days then PO x 5 days) • Try for expectant management (OP if possible)
Preterm LabourPreterm Labour
Definition:
• Regular uterine contractions accompanied by cervical dilatation/effacement at gestation <37 weeks
Preterm Labour
Incidence
• 7-10% of pregnancies• 1-2% pregnancies before 34 weeks
Preterm Labour
Importance of Accurate Dating
• >34 week delivery have survival rate approximately equal to term babies
• They may need longer hospital stay for feeding or other difficulties
Preterm Labour
Importance of Accurate Dating
• Long term neonatal adverse sequelae occur mainly in <30 week
• In extreme preterm deliveries, 10 days can make a big difference
• E.g.. Survival can go from 0-30% or from 30-55% in a 10 day period
Preterm Labour
Importance of Accurate Dating• By 20 weeks, women should know the EDD, from accurate menstrual
data, or by 18 week or earlier ultrasound
Preterm Labour
Preterm Labour
Etiology:
• Idiopathic• Antepartum hemorrhage• PPROM• Chorioamnionitis• Multiple pregnancy• Incompetent Cervix• Maternal Disease (e.g. HTN)• Smoking, stress, drugs, EtOH
Preterm LabourEtiology:
• 72% spontaneous labour• 28% indicated deliveries
• GDM• IDDM• Non reassuring FHR• IUGR• Abruption• Fetal Demise• Chorioamnionitis
Preterm LabourDiagnosis:
Women should be instructed early to watch for • Contractions• PV fluid• PV bleeding• Low Back pain/pressure• Change in vaginal discharge
Diagnosis must be made by physical examination, NOT over the telephone
Preterm Labour
Diagnosis:
Newer strategies include
Cervical SonographyFetal Fibronectin
Fetal Fibronection (FFN)
• Large molecular weight glycoprotein• Promotes cellular adhesion• Released when the extracellular matrix of the
chorionic/decidual interface is disrupted• Normally found in cervico-vaginal secretions
until 22 weeks gestation but is virtually never found between 24 and 34 weeks gestation unless the cervix has undergone premature effacement and dilatation
Contraindications to FFN
• Estimated gestational age <24 weeks or >34 completed weeks
• Preterm rupture of membranes • Cervix ≥3 cm dilatation • Cervical cerclage • Active vaginal bleeding • Vaginal exam or sexual intercourse in the past 24
hours
Fibronectin
• A negative test confers a more than 95% likelihood of the woman remaining undelivered for the 14 days
Fibronectin
False positive tests may be caused by: • i. Digital exam prior to the speculum collection of
the sample • ii. More than a minimal amount of blood in the
specimen (fFN is present in plasma) • iii. The presence of amniotic fluid in the
specimen(amniotic fluid contains high levels of fFN) • iv. Intercourse within the previous 24 hours (fFN is
present in seminal fluid)
Preterm Labour
Management:
• Strategies are not particularly effective• Especially when not instituted early
Preterm Labour
Treatment:
• No evidence to suggest that bed rest will prolong or arrest preterm labour
• <40% will be candidate for tocolysis
Preterm Labour
Tocolysis:
• No evidence for • Fluid• Sedation• Mag Sulfate (MgSO4)
• Yes evidence for • CCBs (nifedipine)• Oxytocin antagonists (antocin - not approved in Canada/USA)• PG synthetase inhibitors (indomethecin)
Preterm Labour
Tocolysis - Contraindication:
• Contraindication to specific agent
• Contraindication to prolonging pregnancy• Medical indication e.g. PIH with protein• Chorioamnionitis• Mature fetus• IUFD• Imminent delivery
Preterm Labour
Minimizing Neonatal Morbidity/Mortality:
• Respiratory Distress Syndrome (RDS) is significant cause of M&M
• Other conditions such as intraventricular hemorrhage, necrotizing enterocolitis, persistent pulmonary hypertension are more likely in the setting of RDS
• Prevention with antenatal glucocorticoid therapy is well established
Preterm Labour
When should glucocorticoids be given?:
• Lower gestation limit - 24 weeks• Upper gestation limit - 34 weeks• Prophylactic administration - depends on diagnosis and
risk, e.g. preterm previa and bleeding• Repeated administration - not recommended
Preterm Labour
Steroid options:
• Betamethasone 12mg IM q 24h x 2 doses
• Dexamethasone 6mg IV/IM q 12h x 4 doses.
• Don’t use in the presence of chorioamnionitis• Always use with tocolytics• Often used without tocolytics as well
Preterm LabourSummary - Preterm Labour:
• Prompt and accurate diagnosis• Identify and treat underlying cause, if possible• Attempt to prolong pregnancy if appropriate• Intervene to minimize neonatal morbidity and mortality• Antenatal steroid therapy• GBS prophylaxis• Maternal transport (best place in Level III hospital, worst
place is during transport)
GBS (Group B strep)GBS (Group B strep)
• Incidence of serious neonatal infection 0.32 per 1000 births (NEJM, 2009)
• Early (0-6 days) vs Late (6-90) • 50 % of infants will be colonized, but only 2% will
develop symptoms• Universal screening at 35-37 weeks• Vaginal-rectal swab• Self collections just as good (Hicks 2009)
GBS
• Recent study (NEJM, 2009)• 74.4% of GBS disease occurred in term infants
( although preterm ones have higher incidence)• 61% of term infants with GBS disease were born
to GBS negative women
GBS
• Role of PCR rapid testing (low sensitivity 30-80%)• Role for vaccine• Widespread use of antibiotics contributes to resistance• Does positive test mean pregnancy is higher risk?
R-July 2003 CDC (August 16, 2002) Prevention of Perinatal Group B Streptococcal Disease, 51(RR11);1-22
OR
MATERNAL MANAGEMENT-GROUP B STREP (GBS) POSITIVE OR UNKNOWN CULTURES
Guidelines for The Ottawa Hospital
UNIVERSAL GBS CULTURE AT 35-37 WEEKS GESTATION
If no GBS cultures results on admission, obtain culture if: PTL (<36 weeks) Term PROM (> 37 weeks) – if birth not expected within 24hours
GBS PROPHYLACTIC INTRAPARTUM ANTIBIOTICS RECOMMENDED FOR:
All Women with: Prior newborn with GB disease Previous documented GBS bacteriuria (at any time) GBS positive culture during pregnancy
All Women with unknown GBS status if: Preterm labour < 37 weeks ROM > 18 hours (Notify MD of ROM status by 12 hours) Fever > 38 oral during labour
TREATMENT
Do vaginal rectal swab prior to initiation of antibiotics if unknown cultures status (lower 1/3 of vaginal mucosa + rectum)
DO NOT START ANTIBIOTICS IF BIRTH IS EXPECTED WITHIN 4 HOURS Adequate prophlaxis means antibiotics must be administered at least 4 hours prior to birth AT TERM, START ANTIBIOTICS IN ACTIVE LABOUR (dilated 3-4 cm & contracting q5
min), if fever present or multip with history of precipitous labour is induced. Discontinue antibiotics at birth or with cessation of preterm labour.
IV Pen G 5 million units, then 2.5 million units q 4 h
NO PENICILLAN ALLERGY
HISTORY OF PENICILLAN ALLERGY
Low risk for anaphylaxis
IV Cefazolin 2 gm, then 1gm q8h
High risk for anaphylaxis
IV Clindamycin 900 mg q8h
No sensitivity testing or resistant
to clindamycin/ erythromycin
IV Vancomycin 1 gm q12h
High risk for penicillin anaphylaxis includes: history of hypotension, laryngeal edema, respiratory difficulty, shortness of breath, angioedema, or hives immediately, or within 48 hours of receiving penicillin.
DRAFT 4 approved by Dr. Nimrod 03-07-15
GBS Prophylactic Intrapartum Antibiotics NOT Recommended if GBS Negative Culture within last 5 weeks for: * Elective C-Birth with intact membranes & no labour * ALL gestational ages * ROM > 18 hours * Fever > 38 oral. Chorioamnionitis should be treated - consider
use of broad spectrum antibiotics.
GBS Prophylactic Intrapartum Antibiotics NOT Recommended if GBS Negative Culture within last 5 weeks for: * Elective C-Birth with intact membranes & no labour * ALL gestational ages * ROM > 18 hours * Fever > 38 oral. Chorioamnionitis should be treated - consider
use of broad spectrum antibiotics.
Out-patient induction
• Reasons must be documented – compelling, convincing and consented
• Method should match the situation• Patient preference must be considered
Outpatient induction
• CERVIDIL - most commonly used at TOH-Civic campus• Increasing use of Foley inductions• Ensure patient is suitable for OP induction
• Needs reassuring U/S within 48-72 hr• Bishop Score…
Outpatient induction
• Cervidil (10mg dinoprostone) - PGE2
• Bishop score <7• Posterior fornix• Monitor FHR & uterine activity – 1-2 hours • If no labour, may repeat x1 (24 hr later)• DOCUMENTATION