1. Antenatal obstetric
complication
Prepared by: Nibal Shawabkeh
Supervised by: Dr. Bassam Alkhdar
1

2. Outline
 Problems due to abnormalities of the pelvic organ
 ANTI PARTUM HEAMORRHAGE
 Post term pregnancy
 Urinary tract infection
 Venous thromboembolism
 AMNIOTIC FLUID proplems
2

3. Problems due to abnormalities of the
pelvic organ
3
Fibroids
Retroversion of the uterus
Congenital uterine anomalies
Ovarian cyst in pregnancy

4. Fibroids (leiomyomata)
 non-cancerous (benign) growths that develop in the muscular wall of the
uterus
 Uterine fibroids are the most common tumors of the female genital tract.
 Fibroids may grow as a single tumour (growth) or in a cluster.
 They can range in size from very tiny (a quarter of an inch) to larger than a
melon .
 Fibroids can dramatically increase in size during pregnancy.
 fibroids are the product of many factors, which could be genetic,
hormonal, environmental, or a combination of all three.
4

5. 5

6. 6
Prolonged and heavy bleeding or painful periods
Bleeding between periods.
Anaemia
Frequent passing of urine.
Lower back pain
Constipation
Painful sex
Miscarriages
Symptoms
Risk factors
child bearing age (between 25 to 45 years of age)
Afro-Caribbean origin women
weighed or obese women

7. Diagnosis
Treatment
RECOMMENDATIONS
7

8. 8

9. Retroversion of the uterus
 A retroverted uterus means the uterus
is tipped backwards so that it aims
towards the rectum instead of
forward towards the belly.
 Some women may experience
symptoms including painful sex.
 In most cases, a retroverted uterus
won’t cause any problems during
pregnancy.
 Treatment options include exercises, a
pessary or surgery.
9

10. Congenital uterine anomalies10

11. Problems associated with bicornuate uterus
Miscarriage
Preterm labour
PPROM
Abnormalities of lie and presentation
Higher CS rate
11

12. Ovarian cyst in pregnancy
 small fluid-filled sacs that develop in a woman's ovaries
 Most cysts are harmless, but some may cause problems
12

13. Types
Follicular Cyst
Corpus luteum cyst
Hemorrhagic cyst
Dermoid cyst
13

14. 14

15. Symptoms
Lower abdominal or pelvic pain
Pain or pressure with urination or bowel movements
Irregular menstrual periods
Nausea and vomiting
Increased facial hair similar to a male pattern
15

16. Risk Factors of Ovarian Cysts
History of
previous
ovarian cysts
Irregular
menstrual
cycles
Increased body
fat distribution
Early
menstruation
(11 years or
younger)
Infertility
Hypothyroidism
or hormonal
imbalance
Tamoxifen
therapy for
breast cancer
16

17. 17
Diagnosis
Treatment

18. ANTI PARTUM HEAMORRHAGE
 BLEEDING FROM THE VAGINA DURING PREGNANCY FROM THE 24 th WEEKS
GESTATION TELL DELIVERY.
 Incidence is 3%
18

19. History
How much bleeding ?
Triggering factors
Associated with pain or contraction
Is the baby moving?
Last cervical smear?
19

20. Examination
Pulse , blood pressure
Is the uterus soft or tender or firm ?
Fetal heart auscultation
Speculum vaginal examination
20

21. Investigations
Full blood count
Cross match six units of blood
Ultrasound ( fetal size , presentation, amniotic fluid , placental position and
morphology )
21

22. Causes
OBSTERTIC
PLACENTA UTERUS
NONOBSTETRIC
LOWER
GENITAL TRACT
BLEEDING
BLEEDING
FROM GIT OR
URINAY TRACT
22

23. Placental causes
PLACENTA PREVIA
PLACENTA ABRUOTION
VASA PREVIA
23

24. PLACENTA PREVIA
•IS A PLACENTA THAT IS
IMPLANTED ENTIRELY OR
IN PART IN THE LOWER
UTERINE SEGMENT
DEFINITION
• HEAMORRHAGE OCCURE WHEN
CONTRACTIONS DILATE THE CX THERBY
APPLYING SHEARING FORCES TO THE
PLACENTAL ATTACHMENT IN THE LOWER
SEGMENT
• WHEN SEPARATION IS PROVOKED BY
UNWISE DIGITAL VAGINAL EXAMINATION
CAUSES OF
BLEEDING
24

25. 25

26. GRADES
G1
•THE PLACENTA ENCROACHES ON THE LOWER SEGMEN T
BUT DOES NOT REACH THE INTRNAL CERVICAL OS
G2
•THE PLACENTA DOES REACH THE EDGE OF THE CX. BUT
DOES NOT COVER IT
G3
•THE PLACENTA DOES COVER THE CX BUT WOULD NOT DO
SO AT FULL CX.DILATATION
G4
•THE PLACENTA IS SYMETRICALLY IMPLANTED IN THE LOWER
SO THAT IT COVERS THE CX TOTALLY
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27. 27

28. ABRUBTIO PLACENTA
 VAGINAL BLEEDING FROM
NORMALLY IMPLANTED PLACENTA
IN UPPER UTERINE SEGMENT
28

29. VASA PREAVIA
 FETAL VESSELS CROSSING OR RUNNING
IN CLOSE PROXIMITY TO THE INNER
CERVICAL OS.
 ASSOCIATED WITH
 ACCESSORY PLACENTAL LOBES
 MULTIPLE GESTATION
29

30. Initial management of APH
 History
 Examination
 NO PV before excluding
Placenta praevia
 Nurse on side
 IV access/ resuscitate
 Input-output chart
 Clotting screen
 Cross match
30

31.  Kleihauer test
 CTG
 Observation
 U/S Placental localization
 Speculum examination when placenta praevia excluded, bleeding settled
 Anti-D if Rh-negative
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32. • 1- GENERAL CONDITIONS OF THE MOTHER
• 2- VITAL SIGNS – BP / PULSE
• 3-SEVERITY OF BLEEDING
• 4- CBC / HB
• 5-RH-GP FOR ANTI-D
1-MATERNAL
WELLBEING
• 1- US EXAMINATION FOR FETAL WELLBEING
WHICH INCLUDES FH / MOVEMENT / LIQOUR
• 2-FETAL WT
• 3- NST
• 4- CONFERM GESTATIONAL AGE
2-FETAL WELL
BEING
• AFTER EVALUATING MATERNAL AND FEATL
CONDITIONS SO DELIVERY OR CONSERVATIVE
MANAGEMENT3-GEATATIONAL
AGE
32

33. DELIVERY
 BY CS
 DEPENDS ON FETAL GESTATIONAL AGE – ASK ABOUT LMP –SURE DATES /
EARLY US
 LUNG MATURITY
 DEPENDS ON MATERNAL CONDITIONS AND SEVERITY OF BLEEDING
 IN SEVER BLEEDING – BLOOD TRANSFUSION
 SOMETIMES AFTER CS BLEEDING DON’T STOP FROM LOWER UTERINE
SEGMENT SO MUST DO TAH
33

34. Post term pregnancy
 Refers to a pregnancy that has extended to or beyond a gestational age of
42.0 weeks or 294 days from the first day of the LMP
 Affect 10% of al pregnancies and the aetiology is unknown .
 Post term pregnancy is associated with increased perinatal mortality and
morbidity.
34

35. Risk factors
Primiparity
Prior post
term
pregnancy
Fetal
anencephaly
Placental
sulfatase
deficiency
Fetal gender:
male
35

36. Indications of induction of labor in post
date
There is reduced Amniotic fluid on scan
Fetal growth is reduced
There are reduced fetal movement
The CTG is not perfect
The mother is hypertensive or suffers a significant medical condition.
36

37. Cardiotocography CTG37

38. Risks
Fetal and
Neonatal Risks
Reduced placental
perfusion
Oligohydramnios
Meconium aspiration
Maternal Risks
Increased incidence
of forceps , vacuum
assisted
or cesarean birth
Increased incidence
of shoulder dystocia
38

39. Management
 Induction of labour.
 Cesarean section
39

40. Urinary tract infection
 It’s common in pregnancy
 8% of women have asymptomatic bacteruria
 If not treated , it may progress to UTI or even pyelonephritis associted with
low birth weight and preterm delivery.
40

41. Predisposing factors :
hx of recurrent
cystitis
Renal tract
abnormalities
*Diabetes
bladder
emptying
problems
41

42. Symptoms
low back pain
malaise
flu like symptoms
42
Examination
tachycardia
pyrexia
dehydration
loin tenderness

43. • CBC
• MSU -> send for urine microscopy
, culture ,sensitivities .
Investigation
• E.Coli most common
• less common Klebseilla , proteus
,Pseudomonas, strep
organism
43

44.  More than 10^5 organisms are present at culture , this
confirm the diagnosis .
 MSU repeated after a week .
 1st line ATB -> amoxycillin , oral cephalosporin
44

45. Pyelonephritis
Dehydration
Very high
temperature
> 38.5 c
Systemic
disturbance
Occasionally
shock
45
IV fluids
Opiates
analgesia
IV AB
(cephalosporin
or gentamicin)
Renal function
should be
determined
Baby should
monitored with
CTG
Features
Management

46. Venous thromboembolism
 Occurs 11000-2000 pregnancies
 Leading cause of maternal death in developed countries
 Pregnancy associated with 6-10 fold increase in the risk of VTE compared to
non pregnant situation
 Virchow’s Triad
 Clinical Dx of acure VTE is unreliable , therefore women who are suspected to
have DVT , PE should be investigated promptly
46

47. Risk factors for thromboembolic disease
•maternal age > 35
•Thrombophilia
•Obesity > 80 kg
•Previous thromboembolism
•Sever varicose vein
•Smoking
•malignancy
Pre existing
•Multiple gestation
•Pre-eclampsia
•CS
•Damage to pelvic vein
•Sepsis
•Prolonged bed rest
Specific to
pregnancy
47

48. Deep vein thrombosis
 most common symptom pain in calf with varying degree of
redness or swelling
 Women’s legs are often swollen during pregnancy
therefore unilateral symptoms should ring alarm bells
 Investigation : compression US ,Venography
48

49. Pulmonary embolism
 It’s crucail to recognize PE as missing the Dx could have fatal implications
 The most common Presentationis of : mild breathlessness or inspiratory chest
pain , in a woman who is not cyanosed but may be slightly tachycardia (>90bpm)
with mild pyrexia(>37.5)
 Investigation : ECG , Chest x-ray , ABGs to exclude other Respiratory
diagnosis , we should investigate the lower limbs for DVT by US
 VQ scan , CTPA
49

50. Treatment of VTE
 LMWHs : are now the Tx of choice
 Warfarin : Rarely recommended for use in pregnancy ( exception include
women with mechanical heart valves )
 Following delivery women can choose to convert to warfarin , warfarin and
LMWHs safe in breastfeeding
 Graduated elastic stockings shoulde be used for intital Tx of DVT and should
be worn for 2 years following DVT
50

51. AMNIOTIC FLUID
 The liquid that surrounds the developing fetus during pregnancy. It is
contained within the amniotic sac.
 Amniotic fluid is mainly derived from the blood plasma. After the fetal
kidneys form and become functional at about 10-11 weeks, fetal urine
becomes the main source of amniotic fluid. In addition to lung fluid ,fetal oral
and nasal secretions and fetal surface of placenta .
 It is removed due to fetal swallowing and absorption into the fetal blood.
Uptake also occurs across the placental surface.
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52. 52

53. AMNIOTIC FLUID53

54. Functions
Protect fetus from pressure or trauma.
Permitting fetal lungs to expands and develop.
Protects cord from compression.
Permits fetal movements – development of musculoskeletal system,
Swallowing of AF enhances growth & development of GIT.
Maintenance of fetal body temperature.
54

55. OLIGOHYDRAMNIOS55
Too little amniotic fluids , AFI less than 5th centile for gestation

56. Causes
• Renal agenesis.
• Multicystic kidneys.
• Urinary tract abnormalities or obstruction.
• IUGR & placental insufficency .
• Maternal drugs( NSAIDS) ( ACE inhibitor).
Too little
production:
• Leakage : PPROM
Post-date
pregnancy :
56

57. Fetal prognosis depends on the cause of
oligohydramnios but both pulmonary
hypoplasia and limbs deformeties are
common in severe early onset (<24
weeks ) oligohydraminos
Renal agenisis and bliateral multicystic
kidneys carry a lethal prognosis
Oligohydraminos due to
FGRuteroplacental unsuffeciency less
severe degree and less commonly causes
limb and lung problems .
57

58. MANAGEMENT
 DEPENDS UPON
58
AETIOLOGY
GESTATIONAL
AGE
SEVERITY
FETAL STATUS
& WELL BEING

59.  Women who have a healthy pregnancy, developing mild oligohydramnios often
do not need any treatment
 Delivery is the most appropriate management option if oligohydramnios occurs
during the last stage of pregnancy.
 More severe cases of pre-term oligohydramnios may require the following
treatment measures:
 Amnioinfusion
It involves infusing sodium chloride solution into the amniotic cavity using an
intrauterine catheter.
 Maternal Rehydration & Bed Rest
Using oral fluids and IV fluids to rehydrate the mother’s body helps to raise
the amniotic fluid level
 Termination of pregnancy may be the only option in severe cases occurring
during the first trimester
59

60. POLYHYDRAMNIOS
 Excess of amniotic fluid ,AFI more than 95th centile for gestation on US
estimation
60

61. Causes
• Diabetes
Maternal
• Chorioangioma
• Arterio-venous fistulaPlacental
• Multiple gestation
• Oesophageal atresia
• Deudenal atresia
• Neuromuscular fetal conditions
• Anencephaly
• Idiopathic
Fetal
61

62. Signs and symptoms
62
Abdominal swelling and
discomfort .
On examination: The abdomen
may be tense and tender and
fetal poles will be hard to
palpate.
In addition to:
Dyspenea
Edema
Oliguria
Dyspepsia

63. Management
 According to the cause and severity .
 Mild cases of polyhydramnios rarely require treatment.
 Treatment for an underlying condition ,such as diabetes ,may help resolve
polyhydramnios.
 Amniocentesis
 500 ml/h
 1500-2000 ml/d
 carries a small risk of complications, including preterm labor, placental abruption and
premature rupture of the membranes
 Indomethacin
 Decreases lung liquid production
 Decreases fetal urine production
 Increases fluid movement across fetal membranes
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64. End of Lecture
May 2014
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