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