Pregnancy Part 4 – TN2014/SOGC2013

9 In a patient with clinical evidence of complications in labour (e.g., abruption (see part 3), uterine rupture, shoulder dystocia, non-reassuring fetal monitoring (see part 3)):

a) Diagnose the complication.
b) Manage the complication appropriately.

Shoulder Dystocia

  • Anterior shoulder impaction against pubic symphysis; life threatening emergency
  • Occur when breadth of shoulders is greater than biparietal diameter of the head
Risk Factors
  • Over 50% of shoulder dystocia cases are not predictable and have no risk factors
  • Maternal: obesity (BMI>50), diabetes, multiparity, previous shoulder dystocia, prev birth of a macrosomic infants, xs wt gain (>20kg)
  • Fetal: Prolonged gestation (post-term), macrosomia (u/s is not an accurate measure)
  • Labour: prolonged 2nd stage, prolonged deceleration phase (8-10cm), instrumental midpelvic dlivery, IOL, epidural anesthesia
Clinical Features
  • “Turtle sign” – head delivered but retracts against inferior portion of pubic symphysis
C/I:
  • Chest compression by vagina or cord compression by pelvis can lead to hypoxia
  • Brachial plexus injury (Erb’s palsy: C5-C7; Klumpke’s palsy: C8-T1) – 90% resolve in 6mo
  • Fetal fracture – clavicle, humerus, cervical spine
  • Maternal perineal injury, may result in PPH
Tx: ALARMER
  • Ask for help
  • Legs in full flexion – McRobert’s
  • Anterior shoulder disimpaction – suprapubic pressure
  • Release posterior shoulder by rotating it anteriorly
  • Manual corkscrew – rotate the fetus by the posterior shoulder until the anterior shoulder emerges from behind the maternal symphysis
  • Episiotomy
  • Rollover on hands and knees
  • Cleidotomy – fracture clavicle; symphysiotomy / Zavanelli – replace fetus into uterine cavity and emergent c/s;
Prognosis: 1% risk of long term disability for infant

Uterine Rupture

  • Associated with previous uterine scar, hyperstimulation with oxytocin, grand multiparity, prev intrauterine manipulation
  • Generally occurs during labour, but can occur earlier with a classical incision
Clinical Features
  • Prolonged fetal bradycardia – most common presentation;
  • acute onset abdominal pain; hyper or hypotonic uterine contractions / tender uterus with palpable fetal parts.
  • Painful hemhorrage / vaginal bleed, shocky
  • Regression of dilation/station.
Risk Factors
  • Uterine scarring (C/S, perforation with D&C)
  • XS uterine stimulation – protracted labour, oxytocin
  • Uterine trauma – operative equipment, ECV; uterine abnormalities
  • Multiparity – Grand Multip
Tx:
  • r/o placental abruption
  • STAT OR – Immediate delivery for fetal survival
  • Maternal stabilization – may require hysterectomy
C/I:
  • Maternal mortality 1-10%; maternal hemorrhage, shock, DIC
  • Amniotic fluid embolus
  • Hysterectomy if uncontrollable hemorrhage
  • Fetal distress, associated with 50% fetal mortality

Chorioamnionitis

  • Infection of the chorion, amnion, amniotic fluid – ascending infection by normal vaginal flora
Etiology
  • 1-5% term & up to 25% preterm, ascending from vagina
  • GBS, Bacteroides, Prevotella species, E coli, anaerobic streptococcus
Risk factors
  • Prolonged ROM, long labour, multiple vaginal exams, internal monitoring
  • BV & other vaginal infections
Clinical features
  • Maternal fever
  • Maternal or fetal tachycardia
  • Uterine tenderness
  • Foult and purulent cervical discharge
Ix:
  • CBC – leukocytosis
  • Amniotic fluid – leukocytes / bacteria
Tx:
  • IV abx:
    • ampicillin 2g IV q6h + gentamicin 1.5mg/kg q8h
    • anaerobic coverage if c/s: clindamycin
  • Expedient delivery regardless of gestational age
Complications
  • Bacteremia of mother or fetus, wound infection if c/s, pelvic abscess, infant meningitis

Amniotic Fluid Embolus

  • Amniotic fluid debris in maternal circulation triggering an anaphylactoid immunologic response
  • Rare – 60-80% maternal mortality, leading cause of maternal death in indued abortions / miscarriages
Risk Factors
  • Placental abruption, uterine rupture, uterine manipulation
  • rapid labour, multiparity
DDx:
  • PE, chronic coagulopathy
  • drug induced anaphylaxis, septic shock
  • eclampsia, HELLP syndrome, abruption
Clinical Features:
  • Sudden onset of respiratory distress, ARDS
  • LV dysfunction, cardiovascular collapse (HoTN, Hypoxia) and coagulopathy
  • Sz in 10%
Tx:
  • Supportive measures – high flow O2, ventilation support, fluid resuscitation, inotropic support, intubation,  coagulopathy correction
  • ICU

Meconium in Amniotic Fluid

  • in up to 25% of all labours, usually NOT associated with poor outcome, but extra care is required at time of delivery to avoid aspiration
Etiology
  • Likely cord compression ± uterine hypertonus
  • May indicate undiagnosed breech
  • Increasing meconium during labour may be a sing of fetal distress
Features
  • Consistency and color
  • Light yellow/green or dark green-black (assoicated with lower APGARs & ↑ meconium aspiration) in color – may be water or thicker
Tx:
  • Call peds to delivery room
  • Oropharynx suctioning upon head expulsion or immediately after delivery if baby not breathing spontaneously (do NOT stimulate infant)
  • Consider amnioinfusion of 800ml IV NS over 50-80min during active phase of labour and a maintenance dose of 3ml/min until delivery
  • Closely monitor FHR for s/s of fetal distress

Umbilical cord accident causes

  • Nuchal cord – Type A (looped), Type B (hithced)
  • Body loop
  • Single AA
  • True knot
  • Torsion
  • Velamentous
  • Short <35cm or Long >80cm cord

Umbilical Cord Prolapse

  • Descent of the cord to a level adjacent to or below the presenting part, causing cord compression between presenting part and pelvis
Risk Factors
  • Prematurity / PROM, male, fetal congenital anomalies, BW <2500g
  • fetal malpresentation (50%), unstable lie (OT/oblique), CPD, pelvic tumor
  • low-lying placenta / placenta previa, polyhydramnios, multiple gestation, grand multiparity
Etiology
  • 47% of cases associates with iatrogenic factors
  • Amniotomy, scalp electrode application, intrauterine pressure catheter insertion
  • Attemped external cephalic version, manual rotation of fetal head
  • Expectant management of PPROM
Clinical Features / dx
  • Visible or palpable cord – VE to determine dilatation / effacement / station / presence of pulsation within the cord vessels
  • FHR changes (variable decelerations with contractions associated with a prompt return to baseline, bradycardia or both) – often the first indication of cord prolapse
Prevention
  • Amniotomy – carefully timed and thoughtfully considered
  • Fetal surveillance asap after ROM
Tx
  • Emergency C/S, O2 to mother, monitor fetal heart (if SVD imminent – then acceptable to proceed)
  • Alleviate P of the presenting part on the cord by placing digit in vagina – until c/s
  • keep cord warm & moist by replacing it into the vagina ± applying warm saline soaks – Don’t attempt to replace the cord
  • Position mother in Trendelenburg or knee to chest position
  • If fetal demise or too premature (<22wk), allow labour and delivery
  • If prolonged time to c/s – foley to fill the bladder with 500-700cc NS and clamp the foley  (drain prior to c/s) + tocolysis

10 In the patient presenting with clinical evidence of a postpartum complication (e.g., delayed or immediate bleeding, infection):

a) Diagnose the problem (e.g., unrecognized retained placenta, endometritis, cervical laceration).
b) Manage the problem appropriately.

Routine Postpartum f/u at 6 week

  • Ensure pap smear is uptodate

Retained Placenta

  • Placenta undelivered after 30min pp
Etiology
  • Placenta separated but not delivered
  • Abnormal placental implantation (placenta accreta / increta / percreta)
Risk factors
  • Placenta previa, uterine infection
  • Prior c/s, post-pregnancy curettage, prior manual placenta removal
Clinical Features
  • Incomplete placenta removed
  • Risk of pp hemorrhage and infection
Ix
  • explore uterus
  • assess degree of blood loss
Tx
  • 2 large bore IV, type and screen
  • Brant Maneuver – firm traction on umbilical cord with one hand applying suprapubic pressure to avoid uterine inversion
  • Intraumbilical cord injection of misoprostol (800 µg) or oxytocin (10 to 30 IU) in 30ml NS can be considered as an alternative intervention before manual removal of the placenta.
    • use an NG tube, insert in umbilical vein, advance till resistance, inject, clamp catheter, and wait for 30min
  • Manual removal if above fails
  • Gentle D&C if required

Uterine Inverison

  • Inversion of the uterus through cervix / vaginal introitus
Etiology
  • Often iatrogenic (xs cord traction with fundal placenta)
  • Xs use of uterine tocolytics
  • More common in grand multiparous (lax uterine ligaments)
Clinical Features
  • Profound vasovagal response with vasodilation and hypovolemic shock
  • shock may be disproportionate to maternal blood loss
Tx
  1. Urgent Tx essential – call anesthesia – may require GA ± laparotomy
  2. ABCs, IV NS, use tocolytic drug / nitroglycerin IV to relax uterus and aid replacement
  3. In OR – replace uterus w/o removing placenta –> Remove placenta manually and withdraw slowly
  4. IV oxytocin infusion (only after uterus repalced) then re-explore uterus

Postpartum Hemorrhage (5-15%)

  • >500ml EBL with SVD & >1000ml with c/s
  • Early – within 24hr; late – 24hr to 6wk pp
Assessment
  • For blood loss estimation, clinicians should use clinical markers (signs and symptoms) rather than a visual estimation
Etiology  – Early PPH – 4 Ts
  • Tone – uterine atony – most common cause, occurs within 24hr pp
    • Avoid by
      • giving oxytocin 10u IM @ ant shoulder or placenta in SVD
      • Carbetocin (long half-life) 100 μg IV bolus over 1 minute, should be used instead of continuous oxytocin infusion in elective C/S
      • SVD with 1 risk factor for PPH, Carbetocin, 100 μg IM decreases the need for uterine massage to prevent PPH when compared with continuous infusion of oxytocin
    • Due to
      • Uterine muscle exhaustion – labor – prolonged, precipitous, oxytocin induced / augmented, Maternal – high parity, gestational HTN
      • Bladder distension, which may prevent uterine contraction
      • Overdistension of uterus – Polyhydramnios, Multiple gestation, Macrosomia
      • Intraamniotic infection – Prolonged ROM / fever
      • Functional/anatomic distortion of uterus – Placenta – abruption, previa or fibroids / uterine anomalies
      • Uterine-relaxing medications – Halothane anesthesia, Nitroglycerin
  • Tissue – retained placental products / clots in an atonic uterus / Retained cotyledon or succenturiate lobe
    • ddx: gestational trophoblastic neoplasia
  • Trauma
    • laceration (vagina, cervix, uterus), episiotomy
    • hematoma (vaginal, vulvar, retroperitoneal),
    • uterine rupture / inversion
  • Thrombin – Coagulopathy
    • Low plt prior to delivery increases risk
    • includes hemophilia, DIC, Aspirin use, ITP, TTP, vWD (most common), therapeutic anti-coagulation

– Late PPH

  • Retained products / endometritis
  • Sub-involution of uterus
Ix / Tx
  • Assess shock – ABCs, 2 large bore IV NS
    • CBC, coagulation profile, cross and type 4 units of pRBCs
  • Tx underlying cause:
    • Explore uterus & lower genital tract for tone/tissue/trauma
    • Observe red-topped tube of blood – no clot in 7-10 min indicates coagulation issue
  • No evidence that, in an uncomplicated delivery without bleeding, interventions to accelerate delivery of the placenta before the traditional 30 to 45 minutes will reduce the risk of PPH
  • Placental cord drainage cannot be recommended as a routine practice since the evidence for a reduction in the duration of the third stage of labour is limited to women who did not receive
    oxytocin as part of the management of the third stage. There is no evidence that this intervention prevents PPH.
Medical Therapy
  • Misoprostol (Cytotec) 800-1000ug PR/SL/po x 1 (also used for NSAID-induced gastric ulcer – warn pt about this and SA 3-7 days after methotrexate)
    • Alt/addition to oxytocin; Pyrexia more common if >600 ug
  • Oxytocin 20 u /l NS continuous infusion – can also give 10u IM after placenta
  • Ergotamine 0.25mg IM q5min up to 1.25mg / 0.125 IV bolus – may exacerbate HTN
  • Hemabate 0.25mg IM q15min up to 2mg (carboprost – PGF-1a analog)
    • Prostaglandin s/e: C/I in CV, pulm, renal, hepatic dysfunction
Local Control
  • Bimanual compression: elevate uterus & massage
  • Uterine packing – mesh with abx tx
  • Bakri balloon for uterine tamponade can be an efficient and effective intervention to temporarily control active PPH due to uterine atony that has not responded to medical therapy
Surgical Tx for intractable PPH
  • D&C / laparotomy with bilateral ligation of uterine artery, internal iliac artery (not proven), ovarian artery, hypogastric artery
  • IR – embolization of uterine artery / internal iliac artery
  • Hysterectomy last resort with angiographic embolization if post-hysterectomy bleeding

Postpartum Pyrexia

  • Fever >38oC on any 2 of the 10d pp, except the first day
Etiology – B-5W
  • Breast – engorgement, mastitis (see below)
  • Wind: atelectasis, pneumonia
  • Water: UTI
  • Wound: episiotomy, c/s site infection
  • Walking: DVT, throbophlebitis
  • Wound: endometritis – infection of uterine myometrium / parametrium
    • Risk factors: C/S, intrapartum corioamnionitis, prolonged labour, prolonged ROM, multiple vaginal exams
    • Features: F/C, abd pain, uterine tenderness, foul-smelling d/c or lochia
    • Tx: abx ± admission
Ix:
  • Detailed Hx & PEx, relevant cultures
  • For endometritis: blood & genital cultures
Tx: depends on etiology
  • Infection: empiric abx
  • Endometritis: Clindamycin + gentamycin IV
  • Mastitis: cloxacillin or cefazolin
  • Wound infection: cephalexin
  • DVT: anticoagulants
  • Prophylaxis against post-C/S endometritis: begin abx after cord clamping for 1-3 doses – cefazolin most common

Mastitis

  • Inflammation of mammary glands
  • r/o inflammatory carcinoma
  • differentiate from mammary duct ectasia
    • mammary ducts beneath nipple clogged / dilated
    • ± ductal inflammation / d/c (thick, grey to green),
    • often postmenopausal women
Lactational Mastitis Non-lactational mastitis
More common, often 2-3 pp Periductal mastitis most common, mean age 32yo
S Aureus May be sterile or with S. aureus or other anaerobes.

Risk factors: smoking, mammary duct ectasia

Unilateral localized pain, tenderness, erythema Subareolar pain / mass

Discharge (variable color)

Nipple inversion

Heat or ice packs

Continue nursing/pumping

Abx: cephalexin (erythromycin if pen-allergy)

Broad-spectrum abx and I & D

Total duct excision (definitive)

Abscess: Fluctuant mass, purulent nipple discharge, fever, leukocytosis

Tx: Discontinue nursing, IV abx, I&D usually required

If mass doesn’t resolve, FNA to exclude cancer & u/s to assess presence of abscess

Tx: Abx, aspiration or I&D

May develop mammary duct fistula

Minority – peripheral with no associatd periductal mastitis (S. Aureus)


11 In pregnant or postpartum patients, identify postpartum depression by screening for risk factors, monitoring patients at risk, and distinguishing postpartum depression from the “blues.’’

Postpartum Blues:

  • 50-85% of new mothers, onset day 2-4d pp, extension of normal hormonal changes and adjustment to new baby.
  • Self limited and resolves by 2 weeks: usually last 48hr – doesn’t req psychotropic medication
  • Transient mild depression, mood lability, anxiety, decreased [ ], increased concern over own health and baby’s health,
  • depressed affect, increased sensitivity to criticism, tearfulness, fatigue, irritability, poor concentration / despondency
  • increased risk of PPD

Postpartum Depression (PPD)

Dx:
  • MDE, onset within 4 wk, may present with psychosis / mania (10-20% & 50% recurrence)
  • Severe symptoms: extreme disinterest in baby, SI, infanticidal ideation
Risk factors
  • Personal /prenatal / family Hx of depression /anxiety / PPD
  • Stressful life situation, poor support system, unemployment, marital conflict, unwanted pregnancy, colicky or sick infant
Clinical features:
  • suspect if the pp blues last beyond 2 week or
  • if the symptoms in the first 2 wk are severe (extreme disinterest in the baby, SI/HI/infanticide ideation)
Assessment: Edinburgh Postnatal Depression Scale
Tx: antidepressant, CBT, supportive care, ECT if refractory
Prognosis:
  • interferes with bonding and attachment between mother and baby, can have long term effect
  • Impact on child development: increased risk of cognitive delay, insecure attachment, behavioural disorders
  • Tx of mother improves outcome for child at 80 through increased mother-child interaction

References:
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Posted in 76 Pregnancy, 99 Priority Topics, FM 99 priority topics, OB

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