Chorioamnionitis, Placenta Previa, Placental Abruption

What is required for a diagnosis of IAIS?

- presence of fever (>38° C or >100.4° F) and - at least two other findings: maternal and/or fetal tachycardia maternal leukocytosis (defined as a white blood cell count >15,000), uterine tenderness foul-smelling amniotic fluid

How is placenta previa diagnosed?

-Transabdominal ultrasonography has an accuracy of 95% for placenta previa detection. -Transvaginal ultrasonography can accurately diagnose placenta previa in virtually 100% of cases. The classic presentation of placenta previa is painless vaginal bleeding in a previously normal pregnancy. The mean gestational age at onset of bleeding is 30 weeks, with one-third presenting before 30 weeks.

What are the risk factors for placenta previa?

1) multiparity, which is associated with changes in the size and shape of the uterus, providing more space in the lower uterine segment for implantation (2) increased maternal age (3) prior placenta previa (4) multiple gestation (5) cesarean delivery, which also changes the shape of the lower uterine segment. Patients with a prior placenta previa have a 4-8% risk of having placenta previa in a subsequent pregnancy.

What are the symptoms of hydatidiform moles?

: Most patients with hydatidiform moles present with irregular or heavy vaginal bleeding during the first or early second trimester of pregnancy. The bleeding is usually painless, although it can be associated with uterine contractions. In addition, the patient may expel molar "vesicles" from the vagina and occasionally may have excessive nausea, even "hyperemesis gravidarum." Irritability, dizziness, and photophobia may occur, because some patients experience preeclampsia. Patients may occasionally exhibit symptoms related to hyperthyroidism, such as nervousness, anorexia, and tremors

What do partial moles look like histologically?

A partial mole has some hydropic villi, whereas other villi are essentially normal. Fetal vessels are seen in a partial mole, and the trophoblastic tissue exhibits less striking hyperplasia.

painful vaginal bleeding in association with uterine tenderness, hyperactivity, and increased tone.

Abruptio Placentae The signs and symptoms of placental abruption are variable, however. The most common finding is vaginal bleeding, which is seen in 80% of cases. Abdominal pain and uterine tenderness are present in 66% of cases, fetal distress in 60%, uterine hyperactivity and increased uterine tone in 34%, and fetal death in 15%.

What are the fetal risks of abruptio placenta?

Abruption places the fetus at significant risk of hypoxia and, ultimately, death. The PMR due to placental abruption is 35%, and the condition accounts for 15% of third-trimester stillbirths. Fifteen percent of live-born infants have significant neurologic impairment.

How long should antibiotics be given in IAIS?

Antibiotic regimen should be continued until the patient has been afebrile (temperature <38° C or <100° F) for 24 hours.

Which patients should get antibiotic prophylaxis before c-section?

Antimicrobial prophylaxis is associated with a 50% reduction in infection in all populations studied. ***All patients undergoing cesarean delivery, either elective or emergent, are candidates for antibiotic prophylaxis.

Whats the management of abruption?

Careful maternal hemodynamic and fetal monitoring Serial evaluation of the hematocrit and coagulation profile (watch for DIC) Delivery- unless very mild and very premature

appears grossly as a vascular-appearing, irregular, and "beefy" tumor, often growing through the uterine wall (Figure 42-4). Metastatic lesions appear hemorrhagic and have the consistency of currant jelly.

Choriocarcinoma

Whats the treatment for PPE?

Clindamycin plus gentamicin has proved to be the most effective regimen in treating PPE, especially if PPE occurs after cesarean delivery. Alternative regimens. Multiple broad spectrum options alternatives exist

What is the treatment for IAIS?

Delivery of the fetus and placenta removes the sites of infection, much like draining an abscess, making this intervention a significant part of therapy. Because group B streptococci and E. coli are the most common isolates from infected newborns and maternal therapy initiates fetal therapy, a combination of ampicillin plus gentamicin is a reasonable initial regimen for IAIS.

How are hydatidiform moles diagnosed?

Diagnosis of hydatidiform mole can usually be made ultrasonographically. Ultrasonography is noninvasive and reveals a "snowstorm" pattern that is diagnostic Often a partial mole will look very similar to a missed abortion on a sonogram

arise from separate eggs, they are structurally distinct pregnancies coexisting in a single uterus, each with its own amnion, chorion, and placenta.

Dizygotic twins

What is the treatment for hydatiform moles?

Evacuation = The standard therapy for hydatidiform mole is suction evacuation followed by sharp curettage of the uterine cavity, regardless of the duration of pregnancy. This should be performed in the operating room with general or regional anesthesia. Intravenous oxytocin is given simultaneously to help stimulate uterine contractions and reduce blood loss. This technique is associated with a low incidence of uterine perforation and trophoblastic embolization.

How is hCG monitored following evacuation of a mole?

Following the evacuation of a hydatidiform mole, the patient must be monitored with weekly serum assays of β-hCG until three consecutive levels have been normal. Monthly β-hCG levels should then be followed until three consecutive levels have been normal. Because β-hCG drops to a low level, a nonspecific pregnancy test cannot be used, because of the possibility of cross-reactivity with luteinizing hormone. The radioimmunoassay, sensitive to levels of 1 to 5 mIU/mL, should be used. Following the evacuation, the β-hCG levels should steadily decline to undetectable levels, usually within 12 to 16 weeks.

When should antibiotics benign considering the imprecision of IAIS diagnosis?

Given the imprecision of the diagnosis of IAIS, antibiotic therapy should be considered in laboring gravidas with fever (>38° C or > 100.4° F). Improved neonatal and maternal outcome is noted when antibiotic therapy is begun intrapartum rather than immediately postpartum

consists of sheets of malignant cytotrophoblast and syncytiotrophoblast with no identifiable villi.

Histologically = choriocarcinoma

What has increased the rate of twinning?

However, in recent years, the incidence of multizygotic multifetal gestation has increased markedly with the more widespread use of ovulation induction agents and the practice of transferring multiple embryos after in vitro fertilization. The incidence of multiple gestations following the use of clomiphene is about 6-8% and about 20-30% following gonadotropin therapy.

What influences dizygotic twins?

However, the frequency of dizygotic twinning, which arises from multiple ovulations in the mother, is strongly influenced by family history, ethnicity, and maternal age and use of fertility drugs. A family history of dizygotic but not monozygotic twins in the maternal pedigree increases the likelihood of dizygotic twinning in subsequent generations. In western Nigeria, twinning occurs in 1 of 22 gestations, whereas in the Native American and Inuit populations, twinning is less than one-fifth of that rate. Twins are twice as common in women over 35 as in women at 25 years of age

Besides DIC what else can occur with abruptio placenta?

Hypovolemic shock and acute renal failure as a result of massive hemorrhage may be seen with a severe abruption if hypovolemia is left uncorrected. Sheehan syndrome (amenorrhea as a result of maternal postpartum pituitary necrosis) may be a delayed complication resulting from coagulation within the portal system of the pituitary stalk. Assessment of pituitary function should be considered in the postpartum follow-up of women after a serious abruption with a coagulation disorder.

What happens if twins are not split after day 13?

If after day 13- conjoined twins

Why give both ampicillin and gentamicin?

If cesarean delivery is required, up to 15% of patients given only ampicillin and gentamicin will develop postpartum endometritis.

If splitting occurs 4-8 days after fertilization what will the membranes be?

If division occurs after 4 to 8 days of development, when the chorion has already formed, monochorionic, diamniotic twins will evolve with a thin, two-layered septum.

If splitting occurs 72 hours after fertilization what will the membranes be?

If division occurs within the first 72 hours of fertilization, the membranes will be diamniotic, dichorionic with a thick, four-layered intervening membrane.

If splitting occurs 9-12 days after fertilization what will the membranes be?

If splitting occurs after 8 days, when both amnion and chorion have already formed, the result will be monochorionic, monoamniotic, twins residing in a single sac with no septum.

What do dichorionic twins look like on ultrasound?

Imaging of discordant fetal gender confirms a dizygotic gestation. - Visualization of a thick amnion-chorionic septum is suggestive of dizygotic twins -presence of a "peak" or inverted :V" at the base of the membrane septum

What is placenta previa?

Implanted low on the gravid uterus such that placenta covers the cervical os.

What karyotype are partial moles?

In the "incomplete" or partial mole, the karyotype is usually a triploid, often 69,XXY (80%). The majority of the remaining lesions are 69,XXX or 69,XYY.

What percent of antepartum hemorrhage are due to placenta previa?

Incidence of placenta previa- 0.5%. Approximately 20% of all cases of antepartum hemorrhage are due to placenta previa.

What causes GTN?

It appears that GTN may result from defective fertilization, a process that is more common in both younger and older individuals. Diet may play a causative role. The incidence of molar pregnancy has been noted to be higher in geographic areas where people consume less β-carotene (a retinoid) and folic acid.

Whats the pathogenesis of placentae abruptio?

Its inciting cause is unknown, but placental separation may be due to an inherent weakness or anomaly in the spiral arterioles. Placental separation is initiated by hemorrhage into the decidua basalis with formation of a decidual hematoma.

What are ALL of the risk factors for abruptio placentae?

Maternal hypertension (chronic or pregnancy-induced) Placental abruption in a prior pregnancy Pregnancy after in vitro fertilization (IVF) Trauma Polyhydramnios with rapid decompression Premature rupture of membranes Substance abuse (e.g., cocaine, amphetamines, tobacco)

arise from cleavage of a single fertilized egg at various stages during embryogenesis, and thus the arrangement of the fetal membranes and placentas will depend on the time at which the embryo divides.

Monozygotic twins

How do most cases of IAIS occur?

Most cases of IAIS originate when vaginal microorganisms ascend into the intrauterine cavity after rupture of the membranes

How are twins made?

Multiple gestations occur either as the result of the splitting of an embryo (i.e., identical or monozygotic twinning) or the fertilization of two or more eggs produced in a single menstrual cycle (i.e., fraternal or dizygotic twinning).

How is placenta previa managed?

Once the diagnosis of placenta previa is established, management decisions depend on the gestational age of the fetus and the extent of the vaginal bleeding With a preterm pregnancy, the goal is to attempt to obtain fetal maturation without compromising the mother's health. If bleeding is excessive, delivery must be accomplished by cesarean, regardless of gestational age. When the bleeding episode is not profuse or repetitive, the patient is managed expectantly in the hospital on bed rest. If the patient reaches 36 weeks, would move for delivery of the fetus. Elective delivery is preferable, as spontaneous labor places the mother at greater risk for hemorrhage and the fetus at risk for hypovolemia and anemia

What is the pathogenesis of postpartum endometritis?

Pathogenesis of this infection involves inoculation of the amniotic fluid after membrane rupture or during labor with vaginal microorganisms. The myometrium, leaves of the broad ligament, and the peritoneal cavity are then exposed to this contaminated fluid during cesarean surgery. The reported incidence of PPE after cesarean delivery is less than 10% in patients receiving appropriate antibiotic prophylaxis.

implies an abnormal attachment of the placenta through the uterine myometrium as a result of defective decidual formation (absent Nitabuch layer).

Placenta accreta

Whats the most common cause of DIC?

Placental abruption is the most common cause of DIC in pregnancy.. Clinically significant DIC complicates 20% of cases and is most commonly seen when the abruption is massive or fetal death has occurred. Hypovolemic shock and acute renal failure as a result of massive hemorrhage may be seen with a severe abruption if hypovolemia is left uncorrected.

What organisms cause PPE?

Polymicrobial infection caused by a wide variety of bacteria. Group B streptococci, enterococci, other aerobic streptococci, G. vaginalis, E. coli, P. bivia, Bacteroides spp., and peptostreptococci are the most common endometrial isolates, with group B streptococci and G. vaginalis the most common isolates from the blood.

What is the most common cause of puerperal fever?

Postpartum infection of the uterus, the most common cause of puerperal fever, is designated endomyometritis. Cesarean delivery, particularly after labor or rupture of the membranes of any duration, is the most accurate predictor of postpartum endomyometritis (PPE).

What special about X chromosomes in complete moles?

Specialized studies indicate that both of the X chromosomes are paternally derived. This androgenic origin probably results from fertilization of an "empty egg" (i.e., an egg without chromosomes) by a haploid sperm (23 X), which then duplicates to restore the diploid chromosomal complement (46,XX). Only a small percentage of lesions are 46,XY. Complete molar pregnancy is only rarely associated with a fetus, and this may represent a form of twinning.

True or false = GTN is known to occur more frequently in women younger than age 20 years and in those older than 40 years of age.

TRUE

What influences monozygotic twins?

The frequency of monozygotic twinning, which depends on a very infrequent biologic event (embryo splitting), is constant in all populations studied at about 1 in 250 births.

What are the majority of moles?

The majority of hydatidiform moles are "complete" moles and have a 46,XX karyotype.

What are the risk factors for abruptio placentae?

The most common of these risk factors is maternal hypertension, either chronic or as a result of preeclampsia. The risk of recurrent abruption is 10% after one abruption and 25% after two.

How do the B-hCG levels look early in pregnancy?

The β-hCG levels can be high for early pregnancy. This should alert the physician that the patient might have GTD or a multiple gestation. The condition must also be distinguished from a threatened spontaneous abortion or an ectopic pregnancy.

What is the difference between accreta, increta, and percreta?

This abnormal myometrial attachment of the placental villi is usually superficial (accreta), but the villi may invade more deeply into the myometrium (increta) or extend through to the uterine serosa (percreta).

What is the definitive diagnosis for zygosity?

Thus, definitive diagnosis of zygosity may require detailed examination of the placenta after delivery. If all these do not confirme, studies, such as human leukocyte antigen (HLA) typing or DNA analysis, will be required to allow determination of zygosity.

What is the risk of accreta and management?

Two-thirds of patients with this complication require hysterectomy when an attempt to remove the placenta leads to severe hemorrhage intrapartum.

How can you determine zygosity?

Ultrasonographic evaluation of the pregnancy is frequently very helpful in determining zygosity.

Can ultrasound identify abruptio placentae?

Ultrasonography may detect only 2% of abruptions. Because placental abruption may coexist with a placenta previa, the reason for doing an initial ultrasonic examination is to exclude the previa

complete separation of the uterine musculature through all of its layers, ultimately with all or a part of the fetus being extruded from the uterine cavity. The overall incidence is 0.5%.

Uterine Rupture

What organisms cause IAIS?

Women with IAIS have a select group of high virulence microorganisms, such as Group-B streptococcus, Escherichia coli, genital mycoplasmas, and pathogenic anaerobes, e.g., Prevotella bivia, present in significantly high quantities, causing an inflammatory response and systemic signs of infection. Many of these microorganisms (especially anaerobic bacteria, the mycoplasmas, and Gardnerella vaginalis) are associated with bacterial vaginosis.

Do partial moles coexist with fetus?

YES Occasionally, mosaic patterns occur. These lesions, unlike complete moles, often present with a coexistent fetus. The fetus usually has a triploid karyotype and is defective

Chorioamnionitis

a clinically detectable infection of the amniotic fluid and fetal membranes during pregnancy.

What are the 3 histologic findings for a complete mole?

a hydatidiform mole (complete) appears as multiple vesicles that have been classically described as a "bunch of grapes" . The characteristic histopathologic findings associated with a complete molar pregnancy are (1) hydropic villi, (2) absence of fetal blood vessels, and (3) hyperplasia of trophoblastic tissue .

What percent of twins are fraternal?

approximately two-thirds of spontaneously conceived twins are fraternal and one-third are identical (monozygotic

What do many patients who develop postcesarean endometritis despite prophylaxis have histologically?

evidence of incipient infection.

The majority of patients (80-90%) with GTD have a malignant course true or false?

false majority are benign

What is complete placenta previa?

implies that the placenta totally covers the cervical os. A complete placenta previa may be central, anterior, or posterior, depending on where the center of the placenta is located relative to the os. Partial placenta previa implies that the placenta partially covers the internal cervical os. marginal placenta previa is one in which the edge of the placenta extends to the margin of the internal cervical os.

Which type of twins are more likely to have congenital anomalies?

monozygotic twins are more likely to have congenital anomalies, weight discordance, twin-twin transfusion syndrome, neurologic morbidity, premature delivery, and fetal death. Thus, determination of zygosity is the most important next step after multifetal pregnancy has been first diagnosed.

Painless vaginal bleeding in the third trimester

placenta previa (20 percent) Seventy percent of patients with placenta previa present with painless vaginal bleeding in the third trimester, 20% have contractions associated with bleeding, and 10% have the diagnosis made incidentally on the basis of ultrasonography or at term.

What is abruptio placentae?

premature separation of the normally implanted placenta, complicates 0.5-1.5% of all pregnancies (1 in 120 births). Abruption severe enough to result in fetal death occurs in 1 in 500 deliveries.

What are the risk factors for the fetus during previa?

primarily risk to fetus is of premature delivery since bleeding may force early delivery

What are risk factors for IAIS?

prolonged duration of labor or rupture of membranes multiple vaginal examinations young age low socioeconomic class nulliparity preexisting bacterial vaginosis.

What are the risk factors for post cesarean endomyometritis?

prolonged labor or rupture of the membranes presence of bacterial vaginosis frequent vaginal examinations use of internal fetal monitoring.

What are the risk factors for mom during previa?

risk of bleeding both prior to and after delivery. Massive blood loss at delivery can lead to DIC. Patients with placenta previa are at increased risk for placenta acreta

What tumor marker is used for all gestational trophoblastic disease?

sensitive tumor marker, human chorionic gonadotropin (hCG), that allows accurate follow-up and assessment of the diseases.

What are the clinical signs of PPE

suggested by the development of fever, usually on the first or second postpartum day. Other consistently associated findings are lower abdominal pain, uterine tenderness, and leukocytosis. These women may also exhibit a delayed postoperative return of bowel function due to an associated local peritonitis.

The prognosis and expected morbidity of twins is strongly dependent on zygosity: true or false

true

Just remember if a patient has had a prior cesarean section and she is trying the have a vaginal delivery after cesarean (VBAC) and she has severe pain, fetal distress then what?

uterine rupture