Obstetrics PDF

## Breast Care - Wash breasts with clean tap water. - It is not recommended to massage the breast, this may stimulate oxytocin hormone secretion and possibly lead to contraction. - Advise the mother to be mentally prepared for breastfeeding. ### Breast Changes During Pregnancy | Stage | Descrip...

## Breast Care - Wash breasts with clean tap water. - It is not recommended to massage the breast, this may stimulate oxytocin hormone secretion and possibly lead to contraction. - Advise the mother to be mentally prepared for breastfeeding. ### Breast Changes During Pregnancy | Stage | Description | |---|---| | Non-Pregnant | Shows a non-pregnant breast, with a darker areola. | | Early Pregnancy | Shows a slightly enlarged breast with a darker areola. | | Late Pregnancy | Shows a more enlarged breast, with a very dark areola. | ## Schedule of ANC - Check up every four weeks up to 28 weeks gestation. - Every 2 weeks until 36 weeks of gestation. - Visit each week until delivery. - More frequent visits may be required if there are abnormalities or complications or if danger signs arise during pregnancy. ## Laboratory Investigations & Ultrasound ### Lab Tests - Routine tests - Specific tests ### Ultrasound - Estimate the gestational age. - Check amniotic fluid volume. - Check the position of the placenta. - Detect the multiple pregnancy and congenital malformations. - The position of the baby. ## Dental Care - The teeth should be brushed carefully in the morning and after every meal. - Encourage the woman to see her dentist regularly for routine examination and cleaning. - A tooth can be extracted during pregnancy, but local anesthesia is recommended. ## Diet - Daily requirement in pregnancy is about 2500 calories. - Women should be advised to eat more vegetables, fruits, proteins, and vitamins and to minimize their intake of fats. ### Purpose of Diet - Growing fetus. - Maintain mother health. - Physical strength in labor. - Successful lactation. ## Exercises - Exercise should be simple. - Walking is ideal, but long periods of walking should be avoided. - The pregnant woman should avoid lifting heavy weights such as: mattresses or furniture, as they may lead to abortion. - She should avoid long periods of standing because it predisposes her to varicose veins. - She should avoid sitting with legs crossed because it will impede circulation. ## Early Pregnancy Signs - Softening and enlargement of the cervix (Hegar sign) observed at approximately 6 weeks. - The Chadwick sign is a bluish discoloration of the cervix from venous congestion and can be observed by 8-10 weeks. - Breast changes. ## Types of Pregnancy Tests ### Serum Pregnancy Tests - Qualitative serum pregnancy test detect hCG levels of 5 to 10 milli-int. units/mL - Quantitative serum pregnancy test measure hCG values as low as 1 to 2 milli-int. units/mL ### Urine Pregnancy Tests - Urine pregnancy testing is the most common method for diagnosing pregnancy in the office setting. - A variety of affordable and reliable urine tests are available for use in office practices, and they take only one to five minutes to perform. - hCG threshold of 20 to 50 milli-int. units/mL ## Danger Signs of Pregnancy - Vaginal bleeding including spotting. - Persistent abdominal pain. - Severe and persistent vomiting. - Sudden gush of fluid from vagina. - Absence or decrease of fetal movement. - Severe headache. - Edema of hands, face, legs and feet. - Fever above 100 F (greater than 37.7°C). - Dizziness, blurred vision, double vision. - Painful urination. ## Causes of False Negative Pregnancy Test Results 1. Missed abortion. 2. Ectopic pregnancy. 3. Too early pregnancy. 4. Urine stored too long in room temperature. 5. Interfering medications. ## Human Chorionic Gonadotropin (HCG) - **Structure:** glycoprotein hormone comprised of two glycosylated subunits (alpha and beta). - **Source:** syncytiotrophoblast - **Function:** maintenance of corpus luteum and progesterone production - **Time:** HCG is secreted into the maternal circulation after implantation, which occurs 6 to 12 days after ovulation. - **Concentration:** The hCG concentration doubles every 29 to 53 hours during the first 30 days after implantation of a viable, intrauterine pregnancy. This indicates a slower rise, which is suggestive of an abnormal pregnancy (ectopic and early embryonic death). ## Causes of False Positive Pregnancy Test Results 1. Proteinuria. 2. Haematuria. 3. At the time of ovulation (cross-reaction with LH). 4. HCG injection for infertility treatment within the previous 30 days. 5. Thyrotoxicosis (high TSH). 6. Premature menopause (high LH & FSH). 7. Early days after delivery or abortion. 8. Trophoblastic diseases. 9. hCG secreting tumours. ## Metabolic Changes ### Weight Gain - The average weight gain in pregnancy is 10-12 kg. - This increase occurs mainly in the second and third trimesters at a rate of 350-400 gm/week. - Six kg of the average 11 kg weight gain is composed of maternal tissues (breast, fat, blood, and uterine tissue), and 5 kg of the fetus, placenta, and amniotic fluid. - Of this 11 kg, 7 kg are water, 3 kg fat, and 1 kg protein. ## The Uterus - **Increases in size:** From 50 gm in non-pregnant state to 1000 gm at term. - This is due to: - Hypertrophy of the muscle fibers (estrogen effect) and their multiplication (progesterone effect). - Increased mass of connective tissue. - **Capacity:** Increases - **Shape:** Becomes globular by the 8th week and pyriform by the 16th week until term. - **Position:** With ascent from the pelvis, the uterus usually undergoes rotation with tilting to the right (dextro-rotation), probably due to the rectosigmocolon on the left side. - **Consistency:** Becomes progressively softer due to: - Increased vascularity - The presence of amniotic fluid - **Contractility:** From the first trimester onwards, the uterus undergoes irregular contractions called Braxton Hicks contractions, which are normally painless. They may cause some discomfort late in pregnancy and may account for false labor pain. - **Uteroplacental blood flow:** Uterine and ovarian vessels increase in diameter, length, and tortuosity. Uterine blood flow increases progressively and reaches about 500 ml/minute at term. - **Formation of the lower uterine segment:** After 12 weeks, the isthmus (0.5cm) starts to expand gradually to form the lower uterine segment which measures 10 cm in length at term. ## The Breasts - In the early weeks, the pregnant woman experiences tenderness and tingling of the breasts. - After the second month, the breasts increase in size and become nodular as a result of hypertrophy of the mammary alveoli. Delicate veins become visible beneath the skin. - The primary areola becomes deeply pigmented. The nipples become larger, deeply pigmented, and more erectile. - Montgomery's follicles, which are hypertrophic sebaceous glands, appear as non-pigmented elevations in the primary areola. - Nearly after the third month, colostrum, which is a thick yellowish fluid, can be expressed from the nipple. - During the fifth month, a pigmented area appears around the primary areola called secondary areola. ## Respiratory System - Dyspnea may occur due to: - Increased sensitivity of the respiratory center to CO2, possibly due to high progesterone levels. - Elevation of the diaphragm by the pregnant uterus. ## Hematologic changes ### Blood Volume - The total blood volume increases steadily from early pregnancy, reaching a maximum 35-45% above the non-pregnant level at 32 weeks. - Plasma volume increases by 40%, whereas red cell mass increases by 20% leading to hemodilution (physiological anemia). ## Endocrine System ### Pituitary Gland - The anterior pituitary enlarges due to an increase in prolactin-secreting cells (lactotrophs). - Prolactin levels increase up to 150 ng/ml at term to ensure lactation. ### Thyroid Gland - Increases in size, increasing in size. - BMR increases in T3 T4 TBP. ### Parathyroid Glands - Increase in size and activity to regulate the increasing calcium metabolism. ### Adrenal Glands - Hypertrophy occurs, particularly in the cortex, resulting in increased mineralocorticoids (aldosterone) and glucocorticoids (cortisol). ## Urinary System ### Kidney - Renal blood flow and glomerular filtration rate increases by 50%. ### Ureters - Dilatation of the ureters and renal pelvis is due to: - Relaxation of the ureters by the effect of progesterone, - Pressure against the pelvic brim by the uterus, particularly on the right side. ### Bladder - Frequency of micturition in early pregnancy is due to: - Pressure on the bladder by the enlarged uterus. - Congestion of the bladder mucosa. - Urinary stress incontinence may develop for the first time during pregnancy and is spontaneously relieved later on. ## Cardiovascular System ### Arteries - Arterial blood pressure usually declines during the second trimester due to peripheral vasodilatation caused by progesterone and prostaglandins. - The posture of the pregnant woman affects arterial blood pressure. Typically, it is highest when she is sitting; lowest when lying in the lateral recumbent position; and intermediate when supine. - Supine hypotensive syndrome may develop in some women late in pregnancy in supine position. This is due to compression of the inferior vena cava by the large pregnant uterus, resulting in deceased venous return, decreased cardiac output, and low blood pressure, leading to fainting. ## Etiology of Anemia in Pregnancy There are three main causes: 1. **Decreased erythrocyte production (hypo proliferative anemia)** - Iron deficiency - Folic acid - Vitamin B12 (animal origin) - Hemoglobinopathies (thalassemia and sickle cell disease. ) 2. **RBC destruction)** 3. **RBC loss** - 90% of anemia during pregnancy is due to iron deficiency. ## Anemia in Pregnancy - **Definition:** Anemia is defined by the World Health Organization (WHO) as follows: - **1st trimester/3rd trimester:** Hb < 11 gm/dl - **2nd trimester:** Hb < 10.5 gm/dl. - **Severe anemia:** Hb < 7 gm/dl. ## Effects of Anemia on the Mother and the Fetus ### Effects on the Mother - High output cardiac failure (more likely if preeclampsia is present. Inadequate tissue oxygenation increases requirements for excessive blood flow.) - Postpartum hemorrhage (PPH) - Predisposes to infection. - Delayed general physical recovery, especially after a cesarean section. ### Effects on the Fetus - **Intrauterine growth restriction (IUGR)** - **Preterm birth** - **Delayed cognitive function** ## Megaloblastic Anemia - Complicates up to 1% of pregnancies. - Characterized by: - **Red blood cells with high MCV**: White blood cells with altered morphology (hypersegmented neutrophils). - **Usually caused by:** - Folate deficiency, which may occur after exposure to sulfa drugs or hydroxyurea anticoulsants. - Vitamin B12 deficiency. ## Folate Deficiency Anemia - **Maternal risk:** Megaloblastic anemia. - **Fetal risk:** Neural tube defects. ## Common Anemias in Pregnancy ### Common Types - Nutritional deficiency anemias - Iron deficiency - Folate deficiency - Vitamin B12 deficiency - Hemoglobinopathies: - Thalassemia - Sickle cell disease (SCD) ### Rare Types - Aplastic - Autoimmune hemolytic - Leukemia - Hodgkin's disease ## Investigations for Anemia - **Decreased serum iron** - **Increased total iron binding capacity** - **Low serum ferritin ( < 15 pg/l) ** is the first test to become abnormal. It can be used to differentiate iron deficiency anemia from other types. ## Management of Anemia ### Objectives 1. To achieve a normal Hb by the end of pregnancy. 2. To replenish iron stores. ### Methods for Correcting Anemia - **Iron supplementation:** - **Oral iron** - **Parenteral iron** - **Blood transfusion** ### Factors Influencing the Choice of Method - Severity of the anemia. - Gestational age. - Presence of additional risk factors. ## Beta Thalassemia Minor - **Beta Thalassemia trait**: Heterozygous inheritance from one parent; most frequently encountered variety; partial suppression of Hb synthesis. - **Mild anemia**: Hb levels are around 10 g/dl; red cell indices are low MCV, low MCH, and normal MCHC. - **Diagnostic test:** Hb electrophoresis. ## Management of Beta Thalassemia Minor - **Management:** Same as a normal woman during pregnancy. - **Frequent Hb testing.** - **Iron and folate supplement in usual doses.** - **Parenteral should be avoided (iron overload & blood transfusion close to time of delivery or severe anemia)** ## Beta Thalassemia Major - **Homozygous inheritance from both parents**: Severe anemia; diagnosed in paediatric era; treatment is blood transfusion. ## Sickle Cell Disease (SCD) ## Sickle Cell Disease (SCD) - **Sickling crises frequently occur in pregnancy, puerperium and in states of:** - Growth - Anemia - Bleeding - Dehydration - Hypoxia - Pain - Infection - **Increased incidence of:** - Abortion - Intrauterine fetal death (IUFD) - Intrauterine growth restriction (IUGR) - Premature birth - Intrapartum fetal distress - Increased perinatal mortality. ### Diagnosis - **Hb electrophoresis** ## Management of Sickle Cell Disease - **No curative treatment.** - **Supportive treatment.** - **Well hydration** - **Effective analgesia** - **Prophylactic antibiotics** - **Oxygen inhalation** - **Folic acid** - **Oral iron** - **Avoid blood transfusions in severe anemia.** ## Management of Sickle Cell Disease During Labor - Comfortable position - Adequate analgesia - Oxygen inhalation - Low threshold of assisted delivery - Avoid ergometrine - Prophylactic antibiotics - Continue iron and folate therapy for 3 months after delivery. - Appropriate contraceptive advice. ## Iron Deficiency Anemia - **Iron required during pregnancy:** 1000 mg. ## Management of Iron Deficiency Anemia - **Recommended supplementation:** - Non-anemic: 30-60 mg/day of elemental iron - Anemic: 120-240 mg/day of elemental iron - **In tolerance to iron tablets:** Enteric coated tablet/liquid suspension - **Supplementation with:** Folic acid + Vitamin C. - **Therapeutic results:** Rise in Hb% level of 0.8 gm/dl/week with good compliance. Treatment is continued in the postpartum period to fill the stores. ## Septic Abortion - **Definition:** An abortion complicated by infection. - **Symptoms:** - Abdominal pain - Fever - Vaginal discharge (foul-smelling). - **Signs:** - Sick-looking (febrile or jaundiced). - Tender uterus. - Offensive vaginal discharge or bleeding. - The cervix is usually soft and may be dilated. ### Clinical Grading - **Grade 1:** The infection is localized in the uterus. - **Grade 2:** The infection spreads beyond the uterus to the parametrium. - **Grade 3:** Generalized peritonitis or endotoxic shock or jaundice or acute renal failure. ## Complications of Septic Abortions ### Immediate - Hemorrhage - Peritonitis - Pelvic abscess, endometritis - Septicemia - Septic/Hemorrhagic shock ### Late - Pelvic inflammatory disease (PID) - Pelvic adhesions - Secondary infertility ## Abortion - **Definition:** Termination of pregnancy before the fetus is capable of extrauterine survival, for example, at 20 weeks or 500 gm birth weight. ## Blighted Ovum - This is an image of an ultrasound showing a blighted ovum. This is a condition where a fertilized egg develops in the uterus, but does not develop into a fetus. ## Early Pregnancy Bleeding - **Definition:** Any vaginal bleeding before 20 weeks gestation. ## Types of Abortion ### Spontaneous Abortion (Miscarriage) - **Isolated** - **Threatened abortion**. - **Inevitable abortion**. - **Complete abortion.** - **Incomplete abortion** - **Missed abortion** - **Septic abortion.** - **Recurrent** ### Induced Abortion - **Legal abortion** - **Illegal abortion** ## Etiology of Abortion - **Aetiology:** Can be established in only 30% of cases. - **Genetic factors** - **Endocrine factors** - **Anatomic causes:** - Congenital anomalies: incompetence - Infectious causes - Immunologic problems ## Complete Abortion - **Definition:** Expulsion of all products of conception; cessation of bleeding and abdominal pain; closed cervix; an empty uterus on ultrasound (US). - **Management:** - US - Anti - D gamma globulin ## Incomplete Abortion - This is an image of an ultrasound showing an incomplete abortion. This is a condition where some of the products of conception are retained in the uterus. ## Recurrent Miscarriage - **Definition:** Defined as 3 or more consecutive pregnancy losses. - **Other terms:** - Habitual abortions - Habitual miscarriage - Recurrent abortions - Recurrent miscarriages. ## Ectopic Pregnancy - **Definition:** Is one in which the fertilized ovum is implanted and develops outside the normal endometrial cavity. ## Complete Hydatidiform Mole - This is an image of an ultrasound showing a complete hydatidiform mole. This is a condition where a fertilized egg develops in the uterus but does not develop into a fetus. Instead, it develops into a mass of abnormal tissue. The classic "snowstorm" appearance on the ultrasound is caused by multiple placental vesicles. ## Causes of Bleeding in Early Pregnancy - **Related to the pregnant state:** - Abortion - Ectopic pregnancy - Molar pregnancy - Implantation bleeding - **Associated with the pregnant state:** - Cervical lesions - Ruptured varicose veins - Cervical erosion - Cervical polyps - Cervical malignancy ## Features of Partial and complete Hydatidiform Mole | Feature||Partial Mole|Complete Mole| |---|---|---|---| |Karyotype| |69, XXX or - XXY| 46, XX or - XY| |Pathology| | | | |Fetus| |Often present|Absent| |Amnion, fetal RBC | |Usually present|Absent| |Villous edema| |Variable, focal|Diffuse| |Trophoblastic proliferation| |Focal, slight - moderate|Diffuse, slight - severe,| |Clinical Presentation| | | | |Diagnosis| |Missed abortion|Molar gestation| |Uterine size | |Small for dates | 50% large for dates | |Theca lutein cysts| |Rare|25-30%| |Medical complications| |Rare|10-25%| |Postmolar CTN| | 2.5-7.5%|6.8-20%| ## Complications of Hydatidiform Mole 1. Haemorrhage 2. Infection due to the absence of the amniotic sac. 3. Perforation of the uterus. 4. Pregnancy-induced hypertension 5. Hyperthyroidism. 5. The subsequent development of choriocarcinoma ## Management of Hydatidiform Mole - As soon as the diagnosis of vesicular mole is established, the uterus should be evacuated. The selected method depends on the size of the uterus, whether partial expulsion has already occurred, the patient's age and fertility desire. Cross - matched blood should be available before starting. - **Suction evacuation** - **Hysterotomy** - **Hysterectomy** - **Medical induction** ## Investigations of Hydatidiform Mole 1. **Urine pregnancy test** : Positive in high dilutions. - 1/200 is highly suggestive. - 1/500 is surely diagnostic. - In normal pregnancy, it is positive in dilutions up to 1/100. 2. **Serum beta-hCG level**: Highly elevated (> 100,000 mIU/m1) 3. **Ultrasonography** reveals the characteristic intrauterine "snow storm" appearance, with no identifiable foetus. Bilateral ovarian cysts may be detected. 4. **X-ray:** Shows no foetal skeleton. ## Antepartum Hemorrhage - **Definition:** Vaginal bleeding after 24 weeks gestation (before the delivery of the fetus at 20 weeks). Approximately 3-4% of pregnancies. ### Types - **Spotting**: - **Mild**: Less than 50 mL loss of blood. - **Major**: 50-1000 mL loss. - **Massive:** More than 1000 mL loss. ## Etiology of Antepartum Hemorrhage - **Bleeding from the lower genital tract:** - Cervicitis - Cervical neoplasm - Cervical polyp - Cervical ectropion - Trauma - Neoplasm - Vulval varices - Infection - **Inherited bleeding problems:** Very rare, approximately 1 in 10,000 women. - **Unexplained:** No definitive cause is diagnosed in about 40% of cases. ## Examination for Antepartum Hemorrhage - **Pulse:** - **Blood pressure** - **Check the uterus:** Is it soft, tender, or firm? - **Fetal heart rate using a cardiotocograph (CTG),** - **Speculum vaginal examination**, with particular importance placed on visualizing the cervix (ensure that placenta previa is ruled out, preferably using a portable ultrasound). ## Initial Investigations for Antepartum Hemorrhage - **Complete blood count (CBC)** - **Disseminated intravascular coagulation (DIC) workup:** Platelets, PT, PTT (partial), fibrinogen, D-Dimer). - **Type and crossmatch** - **Ultrasound (US) to determine the location of the placenta** **Never Perform pelvic or Speculum examination Until You Exclude Placenta previa by US!** ## Abruptio Placenta - **Definition:** Premature detachment of the placenta from the uterine wall, which can occur before, during, or after delivery. ### Abruptio Placenta Severity | Severity | FHR | Percentage of Placenta Separated| |---|---|---| |Mild|Normal|0%| |Moderate|Tachycardia, variability, mild late decelerations|50%| |Severe|Severe late decelerations. Bradycardia, death.|100%| **Placental abruption is a continuous process** ### Character of Bleeding - **Painful**: This is a key sign of abruptio placenta. ### Placental Location - **Normal:** Not in the lower uterine segment. ### Key Phrases - **Painful late-trimester bleeding**: A key phrase indicating the possibility of abruptio placenta. ### Abruptio Placenta Triads - Late trimester painful bleeding - Normal placental implantation - Disseminated intravascular coagulation (DIC) ## Risk Factors for Abruptio Placenta 1. **Idiopathic** (Majority). 2. **Defective trophoblastic invasion**, as in preeclampsia and intrauterine growth restriction. 3. **Direct trauma** e.g., road traffic accidents (RTAs) and external cephalic version. 4. **High parity** 5. **Uterine over distention** (as in polyhydramnios and multiple pregnancy). 6. **Sudden decompression of the uterus** e.g., after delivery of the first twin or release of polyhydramnios. 7. **Hypertension** 8. **Smoking.** 9. **Folic acid deficiency** ## Diagnosis of Abruptio Placenta - **Painful**, late-trimester vaginal bleeding with a **normal fundal or lateral uterine wall placental implantation** (not over the lower uterine segment.) - **Ultrasound (US)** can be helpful in some cases, demonstrating retro-placental clot and excluding placenta previa. However, because the bleeding can be concealed, its absence does not exclude the diagnosis. - **Abruptio placenta usually occurs near term and frequently during labor.** ## Management of Abruptio Placenta - **The management depends on:** - The severity of bleeding - The gestational age - The fetal and maternal condition. ### Management of Abruptio Placenta | Severity | Description| |---|---| | **Emergency** | **Cesarean Section (C/S)** | | **In-Hospital** | **Conservatively managed:** Vaginal delivery | **Maternal or fetal jeopardy:** Term, labor, stable mother and fetus. | | **In-Hospital** | **Conservatively managed:** Vaginal delivery | **Maternal or fetal jeopardy:** Preterm, uterine contractions (UC) subsides, stable mother and fetus. | | **Scheduled** |**C/S** | **Marginal placenta previa (more than 2 cm from the internal os):** Term, stable mother, and fetus. | ## Complications of Abruptio Placenta ### Maternal Complications - **Acute tubular necrosis** - **Disseminated intravascular coagulation (DIC)**. - **Couvelaire uterus:** Blood extravasating between the myometrial fibers. - **Postpartum hemorrhage (PPH)** - **Feto-maternal hemorrhage** - **Maternal mortality** - **Recurrence:** After 1st attack 10%; after 2nd attack 25% ### Fetal Complications - **Impaired fetal growth and/or hypoxic ischemic encephalopathy (HIE) or Cerebral Palsy.** ## Placenta Previa (PP) - **Definition:** Implantation of the placenta in the lower uterine segment at 28 weeks. - **Usually, the lower implanted placenta atrophies, and the upper placenta hypertrophies,** resulting in the migration of the placenta. - **At term, placenta previa is found in only 0.4-0.8% of pregnancies.** - **Symptomatic placenta previa occurs when painless vaginal bleeding develops through avulsion of the anchoring villi of an abnormally implanted placenta** as the lower uterine segment stretches during the later stages of pregnancy. - **Bleeding from placenta previa accounts for about 30% of all cases of antepartum hemorrhage (APH)** ## Predisposing Factors for Placenta Previa 1. **Multiple gestation** 2. **Previous cesarean section (C/S) scar** 3. **Advanced maternal age (AMA)** (More than 40 years old, 9 fold more likely than women younger than 20 years old.) 4. **Multiparity** 5. **Previous placenta previa** 6. **Assisted conception** 7. **Endometritis** 8. **Uterine structural anomalies** (e.g. septate uterus). 9. **Smoking** 10. **Fetal congenital anomalies or malpresentation** ## Placenta Previa ### Character of Bleeding - **Painless**: This is a key sign of placenta previa. ### Key Phrases - **Painless late-trimester bleeding**: A key phrase indicating the possibility of placenta previa. ### Triads - Late-trimester bleeding - Low segment placental implantation - No pain ### Pathophysiology of Bleeding - **Avulsion of villi**: Stretching of the lower uterine segment. ## Grading of Placenta Previa - **Grade 1 (lateral placenta):** The placenta is implanted in the lower uterine segment, but does not reach the internal os. - **Grade 2 (marginal placenta):** The edge of the placenta reaches the internal os but does not cover it. - **Grade 3 (partial placenta previa):** The placenta partially covers the internal os. - **Grade 4 (complete placenta previa):** The placenta completely covers the internal os. - **Placenta previa**: - **Grade 1 & 2**: Minor. - **Grade 3&4**: Major. ## Management of Placenta Previa ### Asymptomatic Low-Lying Placenta - **All women with a low-lying placenta diagnosed in early pregnancy should be rescanned at 34 weeks gestation.** - **There are no need to restrict work activities or sexual intercourse in women with a low-lying placenta on ultrasound unless they bleed.** - **If a low-lying placenta is still present at 34 weeks gestation and it is Grade I or II, the woman should be rescanned on a fortnightly basis but does not need to be admitted unless they bleed.** - **Clinically, a high-presenting part or an abnormal lie at 37 weeks implies that the placenta is covering the cervix and a cesarean section should be performed electively.** ### Placenta Previa with Bleeding - **Admit to the hospital** - **Insert a wide-bore intravenous (I.V.) cannula with IV fluids.** - **Take blood for cross-matching and hemoglobin (Hb) estimation** - **If the woman is anemic, does not have active bleeding, and the baby is less than 37 weeks, she should be transfused aiming for a hemoglobin level of more than 10.5 g/dl.** - **Avoid all digital vaginal examinations** (just speculum examinations) - **Perform ultrasound as soon as possible** (it is more precise) - **Keep cross-matched blood available permanently.** - **Monitor placental position and fetal growth.** ### Management of Placenta Previa | Severity | Description| |---|---| | **Emergency** | **Cesarean Section (C/S)** | | **In-Hospital** | **Conservatively managed:** Vaginal delivery | **Maternal or fetal jeopardy:** Preterm, stable mother, and fetus. | | **Scheduled** |**C/S** | **Marginal placenta previa (more than 2 cm from the internal os):** Term, stable mother, and fetus. | ## Placental Abruption vs Placenta Previa | Feature | Placental Abruption | Placenta Previa | |---|---|---| | Pain | Painful | Painless | | Uterus | Tender, hard | No tenderness | | Bleeding | Absent or dark | Fresh red | | Shock | Inconsistent with external loss | Consistent with external loss | | Fetal lie | Normal, head engaged | Abnormal, head high | | Fetal heart rate | Distressed | Normal | | Ultrasound | Placenta normal | Placenta low | ## Vasa Previa - **Definition**: Very rare, occurring approximately 1 in 3000 pregnancies. ### What is it? - **Velamentous insertion of the umbilical cord into the membranes** The fetal blood vessels run through the membranes, rather than within the umbilical cord, which is attached to the placenta. - **At the time of spontaneous or artificial rupture of the amnion, the fetal vessels can rupture.** This causes severe fetal bradycardia and a massive blood loss. - **Immediate cesarean section (C/S) is the treatment.** ## Vasa Previa - **Triad**: - **Rupture of membranes (ROM)** - **Vaginal bleeding** - **Fetal bradycardia** ## Case Scenarios ### Scenario 1 **What is the diagnosis, and why?** - A **32-year-old multigravida** at **31 weeks' gestation** is **admitted to the birth unit** after **a motor vehicle accident.** - **She complains of sudden onset of moderate vaginal bleeding in the past hour.** - **She has intense, constant uterine pain and frequent contractions.** - **Fetal heart tones are regular at 145 beats/minute.** - **On inspection, her perineum is grossly bloody.** **Diagnosis:** **Placental Abruption** **Why?** - This patient has the classic triad of abruptio placenta: **pain, vaginal bleeding, and fetal distress.** ### Scenario 2 **What is the diagnosis, and why?** - A **34-year-old multigravida** at **31 weeks' gestation** comes to the **birthing unit** **stating that she woke up in the middle of the night in a pool of blood.** - **She denies pain or uterine contractions. ** - **Examination of the uterus shows the fetus to be in transverse lie.** - **Fetal heart tones are regular at 145 beats/minute.** - **On inspection, her perineum is grossly bloody.** **Diagnosis:** **Placenta Previa** **Why?** - This patient presents with painless vaginal bleeding. The fetal heart rate is normal, and ultrasound reveals the placenta previa. ### Scenario 3 **What is the diagnosis and why?** - A **21-year-old primigravida** at **38 weeks' gestation** is **admitted to the birthing unit** at **6 cm dilation** with **contractions occurring every 3 minutes**. - **Amniotomy (artificial rupture of membranes) is performed.** - **This results in the sudden onset of bright red vaginal bleeding.** - **The electronic fetal monitor tracing, which had shown a baseline fetal heart rate (FHR) of 135 beats/minute with accelerations, now shows bradycardia at 70 beats/minute.** - ** The mother's vital signs are stable with normal blood pressure and pulse.** **Diagnosis:** **Vasa Previa** **Why?** - This patient had a sudden onset of bleeding. It was painless. The fetal heart rate showed bradycardia. This indicates an avulsion of the fetal blood vessels in the vasa previa.