1. Antepartum complications
Week

2. Obstetrical assessment unit/ triage
Antepartum complications eg. cystitis, abdo pain, injury
Antepartum hemorrhage
? PROM
Preterm labour
Gestational HTN/pre-eclampsia
Outpatient inductions

3. Antepartum Complications
APH
Antepartum Hemorrhage
PPROM
Pre-labour Rupture of Membranes

4. Antepartum Hemorrhage
Definition:
- Vaginal bleeding any time from 20 weeks to term
- 2% to 5% of all pregnancies affected

5. Antepartum Hemorrhage
Causes:
Abruptio Placenta 40%
Placenta Previa 20%
Unclassified 35%
Lower Genital Tract Lesion 5%

6. 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

7. 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

8. 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

9. Placenta Previa Predisposing Factors: Prior placenta previa
First pregnancy following any uterine surgery eg. C/S
Multiple gestation
Uterine malformation
Multiparity
Advanced maternal age

10. Abruptio Placenta Definition: Incidence:
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)

11. Abruptio Placenta
Classification:

12. Abruptio Placenta Maternal hypertension Prior abruption
Predisposing Factors:
Maternal hypertension
Prior abruption
Abdominal trauma
Maternal smoking (> 1 ppd)
Multiparity
Advanced maternal age (> 35 years)
Substance abuse (cocaine and alcohol)
Uterine malformation

13. Abruptio Placenta A short umbilical cord
Predisposing Factors (cont):
A short umbilical cord
Rapid uterine decompression (multiple gestation, polyhydramnios)
Thrombophilia
However…Most abruptions are idiopathic

14. 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

15. Abruptio vs. Placenta Previa

16. 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’s
x-match, INR/PTT, fibrinogen
O2 (fetus sensitive to hypoxia)
continued maternal-fetal surveillance

17. 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

18. Pre-labour Rupture of Membranes
ROM before labour
PROM >37 weeks
PPROM <37 weeks

19. 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

20. PROM Incidence: Term PROM 2-10% of pregnancies PPROM
33% of preterm deliveries

21. 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)

22. PROM
Etiology (cont.):
Past OB history (gestational age at delivery, including PPROM)
Black Race
Smoker
Drugs, lifestyle, stress
Nutrition

23. PROM Complications - Term PROM Fetal/neonatal infection
Maternal infection
Umbilical cord compression / prolapse

24. 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

25. 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

26. PROM
Ferning

27. PROM Management - 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)

28. PROM Management - >37 weeks:
Term PROM Trial – Hannah et al, NEJM 1996;334:
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!

29. PROM
Management - >34 weeks:

30. PROM
Management - >34 weeks:

31. PROM
Management - >34 weeks:

32. 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

33. 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

34. 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)

35. Preterm Labour Definition:
Regular uterine contractions accompanied by cervical dilatation/effacement at gestation <37 weeks

36. Preterm Labour Incidence 7-10% of pregnancies
1-2% pregnancies before 34 weeks

37. 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

38. 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

39. 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

40. Preterm Labour

41. Preterm Labour Etiology: Idiopathic Antepartum hemorrhage PPROM
Chorioamnionitis
Multiple pregnancy
Incompetent Cervix
Maternal Disease (e.g. HTN)
Smoking, stress, drugs, EtOH

42. Preterm Labour Etiology: 72% spontaneous labour
28% indicated deliveries
GDM
IDDM
Non reassuring FHR
IUGR
Abruption
Fetal Demise
Chorioamnionitis

43. Preterm Labour Diagnosis:
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

44. Preterm Labour Diagnosis: Newer strategies include Cervical Sonography
Fetal Fibronectin

45. 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

46. 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

47. Fibronectin
A negative test confers a more than 95% likelihood of the woman remaining undelivered for the 14 days

48. 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)

49. Preterm Labour Management: Strategies are not particularly effective
Especially when not instituted early

50. Preterm Labour Treatment:
No evidence to suggest that bed rest will prolong or arrest preterm labour
<40% will be candidate for tocolysis

51. Preterm Labour Tocolysis: No evidence for Yes evidence for Fluid
Sedation
Mag Sulfate (MgSO4)
Yes evidence for
CCBs (nifedipine)
Oxytocin antagonists (antocin - not approved in Canada/USA)
PG synthetase inhibitors (indomethecin)

52. 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

53. 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

54. 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

55. 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

56. Preterm Labour Summary - 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)

57. 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 weeks
Vaginal-rectal swab
Self collections just as good (Hicks 2009)

58. 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

59. 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?

61. Out-patient induction
Reasons must be documented – compelling, convincing and consented
Method should match the situation
Patient preference must be considered

62. 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 hr
Bishop Score…

63. 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
Show them how to insert cervidil. Look at the explicit instructions that come in the box. ? Is there a video? Don’t hesitate to call staff in for the first one, if uncertain.