diseases of pregnancy

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DISEASES OF PREGNANCY II
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Bleeding during pregnancy

• Vaginal bleeding can occur frequently in the
  first trimester of pregnancy and may not be a
  sign of problems.

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But bleeding that occurs in the second and third
trimester of pregnancy can often be a sign of a
possible complication. Bleeding can be caused by
a number of reasons.
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• Miscarriage
• Bleeding can be a sign of miscarriage but does
  not mean that miscarriage is imminent.
• Studies show that anywhere from 20-30 of women
  experience some degree of bleeding in early
  pregnancy.

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Approximately half of pregnant women who bleed
do not have miscarriages . Approximately 15-20
of all pregnancies result in a miscarriage, and
the majority occur during the first 12 weeks
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• Signs of Miscarriage include
• Vaginal bleeding
• Cramping pain felt low in the stomach (stronger
  than menstrual cramps)
• Tissue passing through the vagina

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Placental abruption

• Definition
• Placental abruption (abruptio placentae) is an
  uncommon yet serious complication of pregnancy

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The placenta is a structure that develops in the
uterus during pregnancy to nourish the growing
baby.
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If the placenta peels away from the inner wall of
the uterus before delivery either partially or
completely it's known as placental abruption
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Placental abruption can deprive the baby of
oxygen and nutrients and cause heavy bleeding in
the mother Placental abruption often happens
suddenly. Left untreated, placental abruption
puts both mother and baby in jeopardy
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• Occurs when a normally implanted placenta
• completely or partially separates from the
  decidua basalis after the 20th week of gestation
  and before the third stage of labor

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Placental abruption
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Placental abruption
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Placental abruption
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• Grade 1, mild (10- 20 marginal seperation)
• Vaginal bleeding is slight or absent (lt500 ml).
• Uterine tenderness.
• No fetal heart rate abnormalities are present.
• There is no evidence of shock or coagulopathy.

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• Grade 2, moderate (20-50)
• External bleeding may be absent to moderate
  (1000-1500 ml).
• Uterine tone may be increased.
• Tetanic uterine contractions and uterine
  tenderness may be present.

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1. Fetal heart tones may be absent and, when
   present, often show evidence of fetal distress.
2. Maternal tachycardia, narrowed pulse pressure,
   and orthostatic hypotension may be present.
3. Early evidence of coagulopathy

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• Grade 3, severe (gt50)
• External bleeding may be moderate or excessive
  (gt1500 ml)
• but may be concealed.

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1. The uterus is tetanic and tender to palpation.
2. Fetal death is common.
3. Maternal shock is usually present.
4. Coagulopathy is frequently present.

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• Pre-eclampsia and hypertensive disorders
• History of placental abruption (recurrence rate
  approximately 10)
• High multiparity
• Extremes of age ( lt20 years or gt 35 years old
• Trauma

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Cigarette smoking Cocaine use Excessive alcohol
consumption Preterm, premature rupture of the
membranes
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Rapid uterine decompression after delivery of the
first fetus in a twin gestation, or rupture of
membranes with polyhydramnios
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• Vaginal bleeding is present in 80 of patients
  and concealed in 20.
• Pain is present in most cases of placental
  abruption
• and is usually of sudden onset, constant, and
  localized to the uterus and lower back.

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Localized or generalized uterine tenderness and
increased uterine tone. The uterus may increase
in size with placental abruption when the
bleeding is concealed
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• Amniotic fluid may be bloody.
• Shock is variably present.
• Fetal compromise is variably present.
• Placental abruption may cause preterm labor

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• Proteinuria
• Consumptive coagulopathy
• Placental separation precedes the onset of the
  consumptive coagulopathy, which in turn
  progresses until the uterus is evacuated.

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Coagulation occurs retroplacentally as well as
intravascularly, with secondary
fibrinolysis. Levels of fibrinogen, prothrombin,
and platelets are decreased. Fibrin split
products are elevated, adding an anticoagulant
effect. Hypofibrinogenemia occurs within 8 hours
of the initial separation.
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• Ultra sound visualize concealed or active Hge,
  aid in identifying retro placental hematoma.

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Placenta previa occurs when any part of the
placenta implants in the lower uterine segment in
advance of the fetal presenting part. Bleeding
condition that occurs during the last two
trimesters of pregnancy
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• in approximately 1 in 200 pregnancies.
• More than 90 of placenta previas diagnosed in
  the second trimester resolve as pregnancy
  advances,
• secondary to differential growth of the
  placental trophoblastic cells toward the fundus

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• Total (complete) placenta previa occurs when the
  entire internal cervical os is covered by
  placenta.
• Partial (incomplete) placenta previa occurs when
  part of the internal cervical os is covered by
  placenta.

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Marginal placenta previa occurs when the
placental edge extends to within 2 cm of the
internal cervical os. Low-lying pp occurs when
the placenta is implanted in the lower uterine
segment and is near the internal os but doesnt
reach it.
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• The cause of placenta previa is unknown
• Endometrial damage from previous pregnancies
• and defective decidual vascularization have been
  postulated as possible mechanisms

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• At times more common at age 35 than at age 25.
• Increasing parity.
• Previous uterine scar.
• Prior placenta previa.

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Tobacco and cocaine use. Multiple
gestation. Previous myomectomy to remove fibroid
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• Sudden onset of painless vaginal bleeding in the
  second or third trimester.
• Bleeding and uterine contractions without uterine
  tetany.

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Malpresentation. Coagulation disorders are rare
in cases of placenta previa
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Symptoms

• contractions that don't stop (and may follow one
  another so rapidly as to seem continuous)
• pain in the uterus

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tenderness in the abdomen vaginal bleeding
(sometimes) uterus may be disproportionately
enlarged pallor
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• Immediate delivery
• In a pregnancy of 36 weeks or greater with
  documented fetal lung maturity, the neonate
  should be delivered by cesarean delivery.
• In the case of marginal placenta previa, with
  documented fetal lung maturity, double-setup
  examination should be performed to determine
  whether the patient is a candidate for a trial of
  vaginal delivery.

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1. Low vertical uterine incision is probably safer
   in patients with an anterior placenta previa.
2. Cesarean delivery may be performed regardless of
   gestational age if hemorrhage is severe and
   jeopardizes the mother or fetus.

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Chorioamnionitis

• Chorioamnionitis is an inflammation of the fetal
  membranes (amnion and chorion) due to a bacterial
  infection.
• It typically results from bacteria ascending into
  the uterus from the vagina and is most often
  associated with prolonged labor.

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The risk of developing chorioamnionitis increases
with each vaginal examination that is performed
in the final month of pregnancy
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• Background
• The fetal membranes consist of two parts
• The outer membrane is the chorion.
• It is closest to the mother and physically
  supports the much thinner amnion.
• The inner membrane is the amnion.
• It is in direct contact with the amniotic fluid,
  which surrounds the fetus

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• Diagnosis
• Clinical
• Chorioamnionitis is diagnosed clinically in the
  setting of
• maternal fever.

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• uterine tenderness in the presence of confirmed
  premature rupture of membranes (PROM)
• Exclusions
• maternal upper respiratory infection.
• maternal urinary tract infection

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• Pathologic
• Chorioamnionitis can be diagnosed from a
  histologic examination of the fetal membranes.
• Infiltration of the chorionic plate by
  neutrophils is diagnostic of (mild)
  chorioamnionitis.

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More severe chorioamnionitis involves subamniotic
tissue and may have fetal membrane necrosis
and/or abscess formation.
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Severe chorioamnionitis may be accompanied by
vasculitis of the umbilical blood vessels (due to
the fetus' inflammatory cells) and, if very
severe, funisitis (inflammation of the umbilical
cord's connective tissue
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• The amnion is seen at the very top of the image
  and composed of a simple cuboidal epithelium and
  a layer of eosinophilic (pink) connective tissue.
  
• It has a few scattered neutrophils - which makes
  the diagnosis of chorioamnionitis.
• Below the amnion is a cleft and then the
  chorion, which also has neutrophils

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amniotic fluid

• Highlights
• Where does amniotic fluid come from?
• How much amniotic fluid should one have?
• How will one know if there is too much amniotic
  fluid?
• What could be causing this problem?
• What will happen if it diagnosed that one has
  polyhydramnios?

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Where does amniotic fluid come from?

• During the first 14 weeks of your pregnancy,
  fluid passes from your circulatory system into
  the amniotic sac.

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Early in the second trimester, the baby starts to
swallow the fluid, pass it through his kidneys,
and excrete it as urine, which he then swallows
again, recycling the full volume of amniotic
fluid every few hours. (Yes, this means that
most of the fluid is eventually baby's urine!)
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amniotic fluid

• Thus, the baby plays an important role in keeping
  just the right amount of fluid in the amniotic
  sac.

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Sometimes, though, this system breaks down,
resulting in either too much Fluid
(polyhydramnios) or too little
fluid(Oligohydramnios) both of which can
present problems
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How much amniotic fluid should one have?

• Under normal circumstances, the amount of
  amniotic fluid you have increases until the
  beginning of your third trimester.
• At the peak of 34 to 36 weeks, one carries about
  a quarter of amniotic fluid.

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After that, it gradually decreases until delivery
of the baby. If there is too much fluid at any
point in pregnancy, it's called polyhydramnios.
When there's too little, it's called
(oligohydramnios.)
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PHYSIOLOGY OF AMNIOTIC FLUID

• Early pregnancy composition of AF
• similar to ECF. Transfer of water across
• amnion and through fetal skin.
• By second trimester fetus begins to
• urinate, swallow, and inspire AF ? During
  last 2/3 of pregnancy,
• AF is principally comprised of fetal urine.

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NORMAL AMNIOTIC FLUID VOLUME
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DEFINITIONS

• Polyhydramnios ?2000 cc amniotic fluid
• Amniotic Fluid Index largest vertical
• pocket in 4 quadrants
• polyhydramnios ?24 cm

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ETIOLOGY OF POLYHYDRAMNIOS

• Idiopathic
• Fetal Anomalies
• Diabetes
• Multifetal gestation
• Immune/Non-immune hydrops
• Fetal infection
• Placental haemangiomas

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Etiology of Polyhydramnios Fetal Anomalies

• Problems with swallowing and GI absorption
• Increased transudation of fluid
• anencephaly, spina bifida
• Increased urination anencephaly (lack of ADH,
  stimulation of urination centers)
• Decreased inspiration

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Polyhydramnios- SYMPTOMS

• Dyspnea
• Abdominal pain
• Venous stasis
• Contractions ? preterm labor
• Decreased Perception of Fetal
• Movements

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DIAGNOSIS

• Fundal height gt gestational age
• Difficulty palpating fetal parts/hearing
• heart tones
• Tense uterine wall
• Sonography

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(fetus)?

• Fetal prognosis worsens with more severe
  hydramnios and congenital anomalies
• 15-20 fetal malformations
• Preterm delivery
• Suspect diabetes
• Prolapse of cord
• Abruption

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(Mother)?

• Dyspnea
• Venous Stasis
• Placental abruption
• Uterine dysfunction
• Post-partum hemorrhage
• Abnormal presentation -- ?C/S

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TREATMENT

• Mild to Moderate hydramnios rarely requires
  treatment
• Hospitalization, bed rest
• Amniocentesis
• Non-steroidal anti-inflammatory analgesia
• Blood sugar control

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OLIGOHYDRAMNIOS

• DEFINITION
• AFI ?50cc

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A ETIOLOGY

• Postdate
• Fetal Anomalies obstruction of fetal
• urinary tract/renal agenesis
• IUGR
• ROM
• Twin/Twin transfusion
• Exposure to ACE inhibitors, and
• Non-steroidal anti-inflammatory

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SIGNS/SYMPTOMS

• Fundal height lt gestational age
• Decreased fetal movement
• Fetal Heart Rate tracing abnormality
• Diagnosis Ultrasound

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OLIGOHYDRAMNIOS

• Extremely poor fetal prognosis, especially in
  early pregnancy
• Adhesions between amnion and fetal parts
  ---?malformations and amputations

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Musculoskeletal deformities Pulmonary
hypoplasia Cord Compression -- gtfetal hypoxia
Passage of meconium into low AF volume thick
particulate suspension --gtrespiratory compromise
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