complications of pregnancy: third trimester bleeding, preterm labor, PROM

Placenta previa

Placental abruption

Uterine rupture

Vasa previa

obstetric emergencies associated with third trimester bleeding

Cervical lesions (polyp, ectropion, cancer)

Cervicitis/infection

Vaginal trauma

Bloody show (labor)

non-emergent causes of 3rd trimester bleeding

⚠️ Golden rule: NO digital vaginal exam until placenta previa is excluded

before you do a vaginal exam due to 3rd trimester bleeding......

Kleihaur-betke

test administered to determine RhoGAM dose if mother is at increased risk of feto-maternal hemorrhage (e.g. trauma); determines the quantity of fetal RBCs in the maternal circulation

placenta previa

-painless bright red bleeding

-soft uterus

-normal FHR

placental abruption

-painful, dark bleeding

-rigid, tender uterus

-distressed FHTs

uterine rupture

-sudden bleeding

-severe pain

-abnormal contour of uterus

-brady FHT

vasa previa

painless bleeding

-soft uterus

-FHR: acute fetal distress

vasa previa

occurs when the umbilical cord vessels cross the internal os of the cervix

Severe hemorrhage

Postpartum hemorrhage

Transfusion

C-section

maternal complications associated with placenta previa

Prematurity

Malpresentation

Growth restriction

fetal complications associated with placenta previa

Hemorrhagic shock

DIC

Acute renal failure

Maternal death

maternal complications associated with placental abruption

Massive hemorrhage

Hysterectomy

Death

maternal complications associated with uterine rupture

Acute hypoxia

Neurologic injury

Death

fetal complications associated with uterine rupture

Stable → expectant management

Unstable or term → C-section

management of placenta previa (stable vs unstable)

Mild & stable → close monitoring

Severe or fetal distress → immediate delivery

management of placental abruption (stable vs unstable)

Emergent laparotomy + C-section

Possible hysterectomy

management of uterine rupture

DIC

most feared complication of placental abruption

vasa previa

fetal bleeding → rapid fetal demise

HTN, cocaine, trauma, smoking

risk factors for placental abruption

placental abruption presentation

PAINFUL Vaginal bleeding, ABD pain, back pain, contractions, firm, rigid, tender uterus

clinically (US often normal)

how do you diagnose placerntal abruption

may be minimal

vaginal bleeding associated with uterine rupture

presentation of uterine rupture

-sudden onset of intense abdominal pain

-vaginal bleeding

-nonreasurring fetal testing

-abnormal abdominal contour

-cessation of uterine contractions

-disappearance of fetal heart tones

-regression of the presenting part

brady cardia

fetal heart rate associated with uterine rupture

clinical

how to diagnose uterine rupture

vasa previa

painless bleeding occuring after rupture of membranes

vasa previa

fetal vessels cross cervical os

Velamentous cord, IVF, low-lying placenta

risk factors for vasa previa

Antenatal US with color Doppler

how do you diagnose vasa previa

vasa previa

Painless bleeding after rupture of membranes

Rapid fetal bradycardia

Mother looks fine

Blood is fetal

emergent c-section

-fetal death if missed!

management of vasa previa

prior preterm birth

strongest predictor of preterm birth

<37 weeks

define preterm labor

Multiple gestation

Uterine anomalies

Short cervix

Placenta previa or abruption

Cervical insufficiency

Maternal age <17 or >35

non-modifiable risk factors for preterm labor

Smoking

Alcohol or cocaine use

Poor prenatal care

Low maternal BMI / malnutrition

Short interpregnancy interval

High stress / domestic violence

modifiable risk factors for preterm birth

Infection/inflammation (chorioamnionitis)

Uterine overdistention

Cervical insufficiency

Placental pathology

Maternal medical disease (HTN, DM)

most common causes of preterm birth

Cervical dilation ≥2 cm

Cervical effacement ≥80%

Shortened cervix on ultrasound

exam findings defingin labor

Confirm gestational age

Continuous fetal monitoring

Cervical exam (sterile speculum)

Rule out:

Infection

Placental abruption

Preterm premature rupture of membranes (PPROM)

immediate steps in management of preterm labor

tocolytics

used to delay delivery by 48 hours

Buy time for steroids & magnesium

what is the purppose of tocolytics?

34 weeks

tocolytics cannot be used beyond this week

Nifedipine (1st line)

Indomethacin (<32 weeks)

Terbutaline (short-term only)

options for tocolytics

nifedipine

1st line tocolytic

indomethacin

tocolytic indiated if before 32 weeks

24-34 weeks gestation

High risk of delivery within 7 days

indications for antenatal corticosteroids

Betamethasone

Dexamethasone

drugs used as antenatal steroids

↓ Respiratory distress syndrome

↓ Intraventricular hemorrhage

↓ Necrotizing enterocolitis

↓ Neonatal mortality

benefits of antenatal corticosteroids

Necrotizing enterocolitis

Pre-term infants have lower immune function, bacteria proliferate in bowel and cause ischemia and air in the bowel. Dx: thin curvilinear lines of lucency

GBS unknown or positive

Suspected infection

PPROM

indications to give antenatal abx

no

are antibiotics routinely given for preterm labor?

≥32 weeks

Oligohydramnios

Renal disease

contraindications to indomethacin as a tocolytic

Premature ductus arteriosus closure

risk of indomethacin as a tocolytic

terbutaline

beta agonist used as a short term rescure tocolytic

myasthenia gravis

contraindications to magnesium sulfate therapy

<32 weeks for fetal neuroprotection

indicaiton for magnesium sulfate in preterm labor

24-34 weeks

time window to give steroids in case of preterm labor

Sudden gush or continuous leakage of fluid

Clear or pale fluid soaking underwear

signs confirming rupture of membranes

⚠️ Sterile speculum exam only

🚫 No digital cervical exam

physical exam to do when pt comes in with ROM

rupture of membranes

pooling of fluid in posterior fornix indicates

nitrazine test

this is a test of vaginal secretions if the client is uncertain whether the membranes have ruptured. Color will indicate whether amniotic fluid is present. Yellow = urine. Blue = Amniotic fluid.

amniotic fluid is alkaline and will appear blue, indicating ROM

how does the nitrazine test work?

Ferning test

Swab vaginal area, rub on slide, under microscope it should look like a fern; positive indicates ROM

AmniSure ROM Test

detects the presence of the placental alpha macroglobulin (PAMG-1) in vaginal discharge

-indicates ROM

Amniocentesis

Cerclage

Uterine overdistention

iatrogenic causes of premature rupture of membranes

Immediate induction (usually oxytocin)

management of term PROM

Often delivery recommended

Consider short expectant management if stable

No tocolytics

Steroids may be considered

management of late preterm ROM (34-36 6/7 weeks)

No chorioamnionitis

No placental abruption

Reassuring fetal status

indications for expectant management of PPROM

blood/semen

causes of nitrazine false positives