OBS Complications

YOSOR FIESAL- IMLE

LANGE 12th Edition
ABORTION
US Findings:
➢ 4–5 weeks of gestation, gestational sac may be visualized in uterus.
➢In normal IU pregnancy, sac is spherical and is eccentrically placed within the
endometrium.
➢A t 5–6 weeks’ gestation, a yolk sac will be present.
➢Gestational sac with a mean sac diameter (MSD) of ≥8 mm should contain a yolk
sac. Similarly, a gestational sac with an MSD of> 25 mm should also contain an
embryo
➢Fetal heart motion is expected in embryos with a crown to rump length of >7 mm
or at 6–7 weeks’ gestation. If a repeat US in 1 week does not show embryonic
cardiac activity, Dx of embryonic demise is made.

➢Any abnormalities in these findings indicate abortion

➢ Abnormal karyotype: 50% of spontaneous abortions occurring during first trimester. Majority of
chromosome abnormalities are trisomies (56%), polyploidy (20%), monosomy X (18%)
➢ Other causes: infection, anatomic defects, endocrine factors (antiphospholipid, thyroid), teratogenic
drugs, uterine or cervical factors (bicornuate uterus, cervical insufficiency)
➢ Infections: Toxoplasma gondii, herpes simplex virus, cytomegalovirus, and Listeria monocytogenes

Cervical incompetence (insufficiency):

➢ Normal cervical length 25 to 50 mm (2- 5 cm)
➢ Painless cervical shortening or dilation in 2nd or early 3rd trimester, up to 28 weeks, resulting in preterm
birth.
➢ Congenital uterine anomalies and DES anomalies are associated with cervical insufficiency.
➢ Procedures to Tx dysplasia of cervix: cervical conization, increase the risk for cervical insufficiency.
➢ TVUS)to identify cervical incompetence
➢ Evaluation: Tx with cerclage, which surgically reinforces a weak cervix by some type of purse-string
suturing.
➢ Cerclage ideally is performed prophylactically before cervical dilatation. Elective cerclage generally is
performed between 12 and 16 weeks
 Recurrent pregnancy loss
• 3 or more consecutive pregnancy losses before 20 weeks of gestation, each
with a fetus weighing < 500 g
• APLA MCC
• Divided into 6 categories of possible causes: genetic, immunologic,
endocrinologic, anatomic, microbiologic, thrombophilia.
For recurrent miscarriage, the following workup should be performed:
1. Karyotype of abortus specimen
2. Parental karyotype
3. Survey for cervical and uterine anomalies
4. Screening of hormonal abnormalities (hypothyroidism)
Summer 2021
A 36-year-old woman, unmarried with no children comes for
consultation following 2 miscarriages. She is currently not pregnant,
and reports that her brother and his wife had 3 miscarriages as well.
Which of the following tests is recommended in this case?
a. PAP smear
b. FSH levels at day 2 of the cycle
c. Karyotype for both parents (correct)
d. Diagnostic laparoscopy
Antiphospholipid syndrome (APLA):
➢lupus anticoagulant or anticardiolipin antibodies or B2 glycoprotein antibodies
➢Most common and serious complications are venous and arterial thrombosis, in
which majority of thrombotic events are venous.
➢Increased thrombotic potential in women with APLAS is associated with recurrent
pregnancy loss after 10 weeks’ gestation. Tx→
➢Warfarin life-long
Thrombophilia (hypercoagulability):
➢Increased risk of venous thromboembolism
➢Factor V Leiden mutation, prothrombin gene mutation, hyperhomocysteinemia,
methylenetetrahydrofolate reductase polymorphisms, and deficiencies in protein
S, protein C, and antithrombin III.
➢Treatment: LMWH (if Hx of thrombosis)
 ECTOPIC PREGNANCY
Risk Factors→
1. Pelvic inflammatory disease/ infections
2. Previous ectopic pregnancy
3. ART (2-8%)
4. Intrauterine devices (5%)
5. Smoking
6. Tubal surgeries/ ligation
7. DES exposure
8. Leiomyoma/ endometriosis
Clinical features:
➢Pain: pelvic or abdominal pain 100% of cases.
➢Bleeding: occurs in 75% of cases, decidual sloughing. usually presents as
intermittent, light spotting.
➢Syncope: ruptured ectopic and heavy bleeding, hemodynamic instability
➢Tenderness
➢Adnexal mass: with empty uterus increases suspicion

Laboratory and imaging:

➢B-HCG: qualitative (positive). Quantitative (with conjunction with TVUS) → hCG
level should rise at a minimum of 53% over 48 hours in a normal pregnancy.
Inappropriate rise in hCG has a sensitivity of 99% for an abnormal gestation
➢Progesterone: progesterone level < 5 ng/mL has a 100% specificity for identifying
an abnormal pregnancy. levels > 20 ng/mL are associated with normal
intrauterine pregnancies.
➢US: should detect an IU gestation when hCG falls within or surpasses the
“discriminatory zone,” defined as an hCG between 1500 and 2000 mIU/mL
Medical Tx:
➢MTX: 3 different regimens:
1. Single 50 mg/m2 dose of IM MTX is most commonly used. hCG measured
at 4 and 7 days posttreatment with an expected 15% decrease from day
4 to day 7. Weekly hCG levels are then checked until zero
2. If hCG levels do not drop appropriately, a second MTX dose or surgical
intervention is advised.
 Preterm Labor
➢ Defined as→ labor after 20 weeks’ but before 37 weeks’ gestation
➢ Contractions (generally) need to be regular and at frequent intervals (>4 contractions/hr are needed to
cause cervical change). Must be demonstrated cervical effacement or dilatation to meet a diagnosis of
preterm labor.
➢ Prevention: women with a Hx of a prior spontaneous preterm birth, progestin administered via either
vaginal suppositories of progesterone or weekly IM injections of 17-a hydroxyprogesterone caproate
starting at 16–20 weeks until 36–37 weeks reduces the risk of recurrent preterm birth by 30%
• Criteria of preterm labor:
1. X> 4 contractions per hour needed to cause cervical change. There must be
demonstrated cervical effacement or dilatation to meet a Dx of preterm labor.
2. Uterine contractions—Regular contractions at frequent intervals as documented
by tocometer, generally >2 in one-half hour. (>2 / 30 min, > 4/1 hr)
3. Dilation and effacement of cervix—at least 1 cm or a cervix that is well effaced
and dilated (at least 2 cm) on admission is considered diagnostic.

Management:
• Decisions based on EGA, estimated weight of fetus, existence of contraindications
to suppressing preterm labor (table next slide)

• Once patient is determined to NOT have any of these contraindications, mt of

preterm labor depends on fetal gestational age.
• Generally, management falls into 1 of 2 categories: expectant management
(observation) or intervention. For pregnancies btw 24 0/7 and 34 0/7 weeks’ EGA,
intervention with corticosteroids has been shown to be of benefit in reducing
neonatal morbidity and mortality rates
➢ 20–22 weeks EGA or estimated fetal
weight [EFW] less than 550 g → NOT
considered to be viable.
➢ 22-24 weeks → antenatal steroids and
magnesium sulfate
➢ 34–37 weeks’ EGA or EFW greater
than 2500 gr→ steroids, expectant
management is usually the
recommended course of action.
(tocolytic NOT indicated) as imminent
delivery expected
➢ 24 and 34 weeks, follow the protocol
for management (next slide)
• 24 0/7- 33 6/7 weeks protocol:
1. Bed rest: NOT demonstrated to reduce risk of preterm
2. Corticosteroids: for all women btw 24 and 34 weeks’ EGA (effect after 24 hr, peal 48 hr). Decrease
incidence of NRDS, IVH, neonatal mortality.
(1 ) betamethasone 12 mg intramuscularly (IM) every 24 hours for a total of 2 doses; or (2) dexamethasone 6
mg IM every 12 hours for a total of 4 doses.
3. Tocolysis: use for 48 hrs allows steroids and magnesium to work. considered in patient with cervical
dilatation <5 cm. Successful tocolysis is generally considered fewer than 4–6 uterine contractions per
hour without further cervical change. (B mimetic- terbutaline and nifedipine)

Protocol of Mg sulfate for fetal neuroprotection:

• Offer magnesium sulfate to any woman between 24 0/7 and 32 0/7 weeks of gestation immediately before
delivery to reduce the risk of adverse neurologic outcomes
Summer 2021
A 33-week pregnant woman presents with contractions. Examination
reveals she is 2 cm dilation, with 70% effacement, the head is at S-2,
and she is not bleeding. Monitor shows 2-3 contractions over 20
minutes, with a normal fetal monitor. Which of the following is the
most important component of her treatment?
a. Rest
b. Steroids
c. Magnesium
d. Indomethacin
Premature rupture of membrane (PROM)

Risk factors:
1. Decidual hemorrhage
2. History of preterm birth
3. Bacterial colonization
4. Invasive procedures (amniocentesis)
Clinical features:
➢ Sudden gush of fluid or continued leakage.
➢ Color and consistency of fluid and presence of flecks of vernix or meconium
➢ Reduced size of the uterus, and increased prominence of the fetus to palpation
Sterile Speculum Examination:
1. Pooling—collection of amniotic fluid in the posterior fornix
2. Nitrazine test: sterile cotton-tipped swab should be used to collect fluid from the posterior fornix and
apply it to Nitrazine (phenaphthazine) paper. In the presence of amniotic fluid, the Nitrazine paper
turns blue, demonstrating an alkaline pH (7.0–7.25)
3. Ferning: fluid from the posterior fornix is placed on a slide and allowed to air-dry. Amniotic fluid will
form a fernlike pattern of crystallization.

CHORIOAMNIONITIS: most common organisms are those ascend from the vagina (E-coli, Bacteroides,
GBS). The most reliable signs of infection include the following:
➢ (1) Fever: temperature should be checked every 4 hours.
➢ (2) Maternal leukocytosis: daily leukocyte count and differential can be obtained.
➢ (3) Uterine tenderness: check every 4 hours.
➢ (4) Tachycardia—maternal pulse >100 beats/min or fetal HR >160 beats/min—is suspicious.
➢ (5) Foul-smelling amniotic fluid.
Treatment:
• Depends on gestational age, -+ chorioamnionitis
➢ A. Chorioamnionitis: DELIVERY regardless gestational age +ABX → if pt not in labor > Induction
➢ B. W/O chorioamnionitis: divided into>> 1* term, late preterm 2* early preterm
1. Term/Late preterm: active mt with induction of labor at time of presentation for woman with PROM at term
(>37) is preferred. Late preterm (34-36 6/7).
2. Early preterm: (btw 24-33 6/7) → ABX (ampicillin + erythromycin), corticosteroids (lung maturity), Mg+
(neuroprotection, btw 24-32 weeks not beyond).
• Timing of delivery preterm: optimal is 34 0/7 weeks.

• BUT immediate regardless age if: →Non-reassuring fetal status, labor, chorioamnionitis, or mature lung indices on
AF evaluation.
• Tocolytic: in PPROM, should be avoided entirely, or limited to 48 hrs duration.
January 2021
Which of the following is included in the management of premature
rupture of membranes on the 33rd week of gestation during the first
48 hours given chorioamnionitis was ruled out?
A) Ampicillin & Erythromycin & steroids (correct)
B) Ampicillin & steroids & tocolytics
C) Ampicillin & steroids & magnesium for fetal neuroprotection
D) Ampicillin & erythromycin & steroids & tocolytics & magnesium for
fetal neuroprotection
E) Ampicillin & steroids & induction of labor
Breech presentation
➢ 3–4% of all pregnancies
➢ 3 types according to attitude→ 1) frank (hip flexed, extended knees), 2) complete (hip
and knees flexed), 3) footling ( 1 single footling breech, double footling, legs extended
below level of buttocks)
➢ Fetal position→ determined by fetal sacrum as point of reference to maternal pelvis. 8
options (SA, SP, LST, RST, LSA, LSP, RSA, RSP)
➢ Station→ location of sacrum with regard to maternal ischial spine
• Before 28 weeks, fetus is small enough in relation to intrauterine volume to rotate from cephalic to
breech presentation and back again with relative ease.
• Causes:
1. Oligohydramnios, polyhydramnios
2. Uterine anomalies (bicornuate or septate uterus)
3. Pelvic tumors obstructing the birth canal
4. Abnormal placentation (placenta previa)
5. Advanced multiparity
6. Contracted maternal pelvis
7. Multiple gestation (25% incidence of breech in first twin, 50% for second twin)

• Antepartum Management:
➢ Version is procedure used to turn the fetal presenting part from breech to cephalic presentation
(cephalic version) or from cephalic to breech presentation (podalic version)
➢ External cephalic version (ECV)→ cephalic version is performed by manipulating the fetus through
the abdominal wall (used frequently), used in singleton breech presentations or in a nonvertex
second twin
➢ Internal podalic version (IPV)→ performed by means of internal maneuvers (rarely used),
primarily for delivering second twin
• External Cephalic Version (ECV):
➢ Used in mt of singleton breech presentations or in a nonvertex second twin
➢ Performed in patients at or beyond 37 0/7 weeks
➢ Unengaged singleton breech presentations of at least 37 weeks’ gestation are candidates for
ECV
➢ Successful in→ multigravidas, those with a transverse or oblique lie, those with a posterior
placenta
➢ Use of terbutaline tocolytic increases success rate

➢ C/I→ 1. Placenta previa, vasa previa Relative C/I:

1. Engagement of presenting part in pelvis
2. Hx of classical cesarean 2. Oligohydramnios
3. Non-reassuring fetal status 3. Uterine anomaly/ previous uterine surgery
4. Hyperextended fetal head 4. PROM
5. Maternal HTN

➢ Complications→ placental abruption, uterine abruption, PROM, umbilical cord prolapse,

amniotic fluid embolism, preterm labor, fetal distress, feto-maternal hemorrhage
Summer 2021
Breech presentation at 37 weeks of pregnancy – which of the following
is a contraindication for external version?
a. Estimated fetal weight of 3500 gr
b. Anterior placenta
c. Amniotic fluid index of 2 cm
d. 2cm dilation
Management of Persistent Breech at Term:
• 1. Mode of delivery decision→ criteria for vaginal delivery, if CS planned is
should be scheduled for 39 0/7 weeks
February 2022
A 38-weeks pregnant woman presents in active labor. Her fetus is in
breech presentation, and she is interested in a vaginal delivery. Which
of the following is a contraindication for this type of delivery?
1. Frank breech presentation
2. Gestational diabetes
3. A cesarean section in her previous delivery
4. The fetal head is in hyperreflexia
 Shoulder dystocia
➢ Inability to deliver shoulders after the head delivered
➢ After delivering the head the chin presses against perineum tightly as the anterior shoulders impacted
behind pubic symphysis
➢ Acute obstetric emergency prompt skillful mt to prevent damage or fetal death
➢ Incidence 0.15- 1.7%
RISK FACTORS:
• Fetal macrosomia/ or Hx of it
• Gestational DM
• Hx of dystocia
• Prolonged 2nd stage
• Instrumental delivery (midpelvic delivery)
• Maternal obesity
• Multiparity
• Post-term pregnancy
• McRoberts’ maneuver→ used initially
resolves shoulder dystocia in 42% of
cases. Maternal legs hyperflexed onto
abdomen, resulting in flattening of
sacrum and cephalad rotation of the
symphysis pubis. If the shoulders remain
undelivered, suprapubic pressure is
applied by an assistant to dislodge the
anterior shoulder while gentle downward
pressure on the head is applied
2. Rubin maneuver→ If McRober’s unsuccessful, the examiner can attempt to
rotate the fetal shoulders into the oblique position by placing 2 fingers against
the posterior shoulder and pushing it around toward the fetal chest
3. Woods screw maneuver→ pushing the posterior shoulder around toward the
fetal back in a corkscrew fashion.
4. Zavanelli maneuver→ if all previous techniques fail. performed in which the
fetal head is replaced in anticipation of a caesarean delivery
February 2022
 Abruptio placentae
➢ Premature separation of normally implanted placenta from uterine wall after 20 weeks but prior to delivery
➢ Diagnosed retrospectively → only evident when inspection of placenta reveals clot over bed with disruption
of underlying tissue
➢ Essentials of Dx → Bleeding from vagina
Uterine activity
FHR abnormalities
Changes in maternal hemodynamic status
Risk factors:
1. Mechanical trauma (violence, accident, BAT, rapid deceleration)
2. Maternal HTN >140/90 mmHg
3. Smoking
4. Increased parity (incidence 2.5% vs prima 1%) → due to impaired decidualization after implantation
5. Thrombophilias (factor V Leiden)
6. Cocaine abuse
7. History of placental abruption (after 2 abruption the risk is 25%)
➢Symptoms→ 1. Fetal distress: first clinical sx, Non-reassuring FHR tracing or
poor BPP score
2. Tetanic uterine activity (contractions, hypertonic, tender)
3. Bleeding (externa/ concealed-internal) PAINFUL

➢Mode and timing of delivery→ depend on severity and gestational age

> 37 weeks: induction, augmentation
Preterm: conservative, short-term
hospitalization, corticosteroids if <34 weeks