Obstetrics Case Based Learning

Question 1

You are a registrar working in the maternity hospital.
Gabrielle is a very distressed primiparous 26-year-old who has presented with heavy vaginal bleeding at 31 weeks gestation.
Gabrielle is not in pain.

what is the most likely cause?

Answer 1

placenta praevia

Question 2

how is placenta praevia diagnosed?

Answer 2

Ultrasound scan - transvaginal may be required to provide accurate measurement of how placenta is related to cervix
- vaginal exam contraindicated

Question 3

how does low lying placenta differ from placenta praevia?

Answer 3

• placenta praevia is when the placenta lies directly over the internas os
• For pregnancies greater than 16 weeks of gestation, the placenta should be reported as ‘low lying’ when the placental edge is less than 20 mm from the internal os.

Question 4

how is placenta praevia managed?

Answer 4

Management:
- ABCDE approach
- IV access, cross match and transfusion if shocked
- Foetal monitoring CTG
- Ultrasound if diagnosis in doubt and patient stable
- Maternal monitoring HR, BP, temp.
- Steroids if preterm delivery likely - IM betamethasone/dexamethasone
- Magnesium sulphate if preterm delivery imminent
- Anti-D if rhesus negative

Corticosteroids are given between 34 and 35 + 6 weeks gestation to mature the fetal lungs, given the risk of preterm delivery.
Planned delivery is considered between 36 and 37 weeks gestation. It is planned early to reduce the risk of spontaneous labour and bleeding. Planned cesarean section is required with placenta praevia and low-lying placenta (< 20mm from the internal os).
Depending on the position of the placenta and fetus, different incisions may be made in the skin and uterus, for example, vertical incisions. Ultrasound may be around the time of the procedure to locate the placenta.
Emergency caesarean section may be required with premature labour or antenatal bleeding.

Question 5

what are some complications of placenta praevia?

Answer 5

• premature delivery
• post-partum haemorrhage
• hysterectomy
• blood loss, and in severe cases, death

Question 6

38-year-old G2P1 has rupture of membranes at 33 weeks gestation
what is meant by the term G2P1?

Answer 6

• Gravida 2, para 1
• Gravida = total number of confirmed pregnancies that a woman has had (including current pregnancies), regardless of the outcome
• parity = no. deliveries alive or dead after 24 weeks gestation, + no. deliveries alive or dead before 24 weeks gestation (e.g. ectopic, miscarriage)
• this lady has one child and is expecting another

Question 7

You are a registrar working in O&G.
Tracy, a 38-year-old with gestational diabetes, presents with a clear gush of liquid from the vagina.
Tracy reports no contractions.

Onset of labour before how many weeks is defined as ‘preterm’?

Answer 7

Onset of labour before 37 completed weeks gestation

32-36 weeks mildly preterm
28-32 weeks very preterm
24-28 weeks extremely preterm

Question 8

Tracy has ruptured membranes but has had no contractions yet.
Has labour started?
What is the name of this condition?

Answer 8

No; labour is defined as the onset of contractions with progressive cervical change

Prelabour premature rupture of membranes (PPROM)

Question 9

what are some complications of Prelabour premature rupture of membranes (PPROM)?

Answer 9

• Pre-term delivery – resulting in neonatal morbidity (e.g. low birth weight, respiratory hypoplasia, sepsis)
• Chorioamnionitis (inflammation foetal membranes due bacterial infection)leading to sepsis in baby and/or mother
• Abruption

Question 10

Tracy, a 38-year-old with gestational diabetes, presents with a clear gush of liquid from the vagina.
Tracy reports no contractions.
You perform a sterile speculum examination. The cervix is closed, and a foetal fibrinonectin (fFN) test is negative. A high vaginal swab is taken to check for infection.

What does a negative fFN test tell us?

Answer 10

Negative - labour unlikely in the next 2 weeks

If positive, likely in next 2 weeks => therefore steroids, tocolysis, analgesia and hospital observation may be indicated

Question 11

Tracy, a 38-year-old with gestational diabetes, presents with a clear gush of liquid from the vagina.
Tracy reports no contractions.
She has PPROM.
Tracy receives prophylactic antibiotics to reduce risk of chorioamnionitis, and corticosteroids (IM betamethasone). The recommendation is to observe then discharge, with the aim to induce birth after 36 weeks gestation.

why were corticosteroids administered?

Answer 11

Induce foetal lung maturation. 2 IM injections (dexamethasone or betamethasone) 24 hrs apart (effect is maximal 24hrs after the second dose) are given.

Question 12

Tracy, a 38-year-old with gestational diabetes, presents with a clear gush of liquid from the vagina.
Tracy reports no contractions.
She has PPROM.
Tracy receives prophylactic antibiotics to reduce risk of chorioamnionitis, and corticosteroids (IM betamethasone). The recommendation is to observe then discharge, with the aim to induce birth after 36 weeks gestation.
Sometimes tocolytics are administered too, why not here?

Answer 12

Tocolytics aim to stop contractions to allow time for steroids to work before birth or to allow transfer to an appropriate facility for birth. As Tracy has no contractions here, tocolytics are not indicated.

Question 13

what are some signsd of respiratory distress syndrome in a baby?

Answer 13

• STERNAL and SUBCOSTAL RECESSION
• Increased RESP RATE
• Expiratory Grunting
• Diminished Breath Sounds
• Cyanosis
• Nasal Flaring

Question 14

how is respiratory distress syndrome managed in a baby?

Answer 14

Oxygen. Early treatment with surfactant if required. Continuous positive airway pressure (CPAP) and minimal intervention.