Labor Complications

Labor Complications US Medical PG Question 1: A 30-year-old woman, gravida 2, para 1, at 12 weeks' gestation comes to the physician for a prenatal visit. She feels well. Pregnancy and vaginal delivery of her first child were uncomplicated. Five years ago, she was diagnosed with hypertension but reports that she has been noncompliant with her hypertension regimen. The patient does not smoke or drink alcohol. She does not use illicit drugs. Medications include methyldopa, folic acid, and a multivitamin. Her temperature is 37°C (98.6°F), pulse is 80/min, and blood pressure is 145/90 mm Hg. Physical examination shows no abnormalities. Laboratory studies, including serum glucose level, and thyroid-stimulating hormone concentration, are within normal limits. The patient is at increased risk of developing which of the following complications?

• A. Placenta previa
• B. Abruptio placentae (Correct Answer)
• C. Spontaneous abortion
• D. Polyhydramnios
• E. Uterine rupture

Labor Complications Explanation: ***Abruptio placentae*** - The patient's history of **chronic hypertension** (145/90 mmHg) and her noncompliance with antihypertensive medication significantly increase her risk for **abruptio placentae**. Hypertension is a major risk factor for this condition. - Abruptio placentae involves the **premature separation of the placenta** from the uterine wall, which can lead to severe maternal hemorrhage, fetal distress, and preterm birth. *Placenta previa* - **Placenta previa** is characterized by the placenta covering the cervical os and is primarily associated with risk factors like **previous C-section**, multiple gestations, or advanced maternal age. - While a serious complication, it is **not directly linked to chronic hypertension** in the same manner as abruptio placentae. *Spontaneous abortion* - **Spontaneous abortion** typically occurs in the **first trimester** and is often due to chromosomal abnormalities, endocrine disorders, or uterine anomalies. - While hypertension could theoretically contribute to some pregnancy complications, it is **not a primary risk factor** for spontaneous abortion at 12 weeks gestation. *Polyhydramnios* - **Polyhydramnios** is an excessive accumulation of amniotic fluid, often associated with **maternal diabetes**, fetal anomalies (e.g., GI obstruction, anencephaly), or multiple gestations. - Maternal hypertension is **not a direct risk factor** for polyhydramnios. *Uterine rupture* - **Uterine rupture** is a rare but catastrophic event, most commonly associated with a **previous uterine scar** (e.g., from a prior C-section or myomectomy). - The patient's history of a prior vaginal delivery and absence of uterine surgery means she is **not at increased risk** for uterine rupture at this stage.

Labor Complications US Medical PG Question 2: A 39-year-old woman, gravida 3, para 2, at 32 weeks' gestation comes to the emergency department 1 hour after the sudden onset of severe abdominal pain and nausea. She has had one episode of nonbloody vomiting. Pregnancy has been uncomplicated, except for a blood pressure measurement of 150/90 mm Hg on her last prenatal visit. Her first child was delivered vaginally; her second child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. She appears anxious and pale. Her temperature is 36.1°C (96°F), pulse is 115/min, and blood pressure is 92/65 mm Hg. Extremities are cool and clammy. Pelvic examination shows a rigid, tender uterus. The cervix is 30% effaced and 1 cm dilated; the vertex is at -1 station. The fetal heart rate is 100/min. Which of the following is the most likely diagnosis?

• A. Ruptured vasa previa
• B. Placenta accreta
• C. Abruptio placentae (Correct Answer)
• D. Ruptured uterus
• E. Placenta previa

Labor Complications Explanation: ***Abruptio placentae*** - The sudden onset of **severe abdominal pain**, **uterine rigidity and tenderness**, maternal hypovolemic shock (tachycardia, hypotension, cool and clammy extremities), and **fetal bradycardia** are classic signs of **abruptio placentae**. - **Hypertension** (150/90 mm Hg) is a risk factor, and a prior **cesarean section** may slightly increase the risk as well, although the primary risk factor here is hypertension. *Ruptured vasa previa* - **Vasa previa** typically presents with **painless vaginal bleeding** when membranes rupture, accompanied by rapid fetal deterioration due to fetal blood loss, and would not cause severe maternal abdominal pain and shock. - The bleeding in vasa previa originates from fetal vessels, leading to a profound impact on fetal heart rate *before* significant maternal symptoms. *Placenta accreta* - **Placenta accreta** is typically diagnosed prenatally via ultrasound or suspected at delivery due to difficulty with placental separation. It does not usually present with acute, severe abdominal pain and hypovolemic shock during pregnancy. - Patients with placenta accreta are at high risk for significant hemorrhage *after* delivery of the fetus, but before placental delivery. *Ruptured uterus* - While a prior **cesarean section** is a risk factor for uterine rupture, the presentation of **rigid and tender uterus** is more characteristic of abruptio placentae. Uterine rupture often involves a **sudden cessation of contractions**, palpable fetal parts outside the uterus, and often severe, sharp pain, but not typically a rigid uterus. - The fetal heart rate in uterine rupture often shows a **sudden, profound deceleration** or absence, but the specific finding of a rigid, tender uterus with ongoing severe pain points away from frank rupture. *Placenta previa* - **Placenta previa** typically presents with **painless vaginal bleeding** in the second or third trimester. - It does not usually cause severe abdominal pain, uterine tenderness, or maternal hypovolemic shock unless accompanied by abruptio placentae, which is the more dominant and acute finding here.

Labor Complications US Medical PG Question 3: A 27-year old primigravid woman at 37 weeks' gestation comes to the emergency department because of frequent contractions for 4 hours. Her pregnancy has been complicated by hyperemesis gravidarum which subsided in the second trimester. The contractions occur every 10–15 minutes and have been increasing in intensity and duration since onset. Her temperature is 37.1°C (98.8°F), pulse is 110/min, and blood pressure is 140/85 mm Hg. Uterine contractions are felt on palpation. Pelvic examination shows clear fluid in the vagina. The cervix is 50% effaced and 3 cm dilated. After 4 hours the cervix is 80% effaced and 6 cm dilated. Pelvic examination is inconclusive for the position of the fetal head. The fetal heart rate is reassuring. Which of the following is the most appropriate next step?

• A. Administer oxytocin
• B. Perform external cephalic version
• C. Administer misoprostol
• D. Perform Mauriceau-Smellie-Veit maneuver
• E. Perform ultrasonography (Correct Answer)

Labor Complications Explanation: ***Perform ultrasonography*** - The examination notes that the **pelvic examination is inconclusive for the position of the fetal head**, which is a critical piece of information needed for safe delivery. **Ultrasonography** is the most appropriate next step to ascertain the fetal presentation and position, especially given the dilated cervix. - Determining fetal position is essential to rule out **malpresentation**, such as **breech** or **transverse lie**, which would significantly impact the delivery plan and potentially necessitate a **cesarean section**. *Administer oxytocin* - **Oxytocin** is used to induce or augment labor when contractions are insufficient or labor is prolonged, but in this case, the cervix is progressing well (from 3 cm to 6 cm dilation in 4 hours), indicating **active labor**. - Without knowing the fetal presentation, administering oxytocin could exacerbate issues if there's a **malpresentation**, potentially leading to **fetal distress** or **uterine rupture**. *Perform external cephalic version* - **External cephalic version (ECV)** is performed to change a **breech presentation** to a **cephalic presentation** by external manipulation, typically done before labor onset or early in labor at term. - This patient is already in **active labor** with significant cervical dilation (6 cm), making ECV less likely to be successful and potentially increasing risks like **placental abruption** or **umbilical cord compression**. *Administer misoprostol* - **Misoprostol** is a prostaglandin analog used for **cervical ripening** and **labor induction** in cases where the cervix is unfavorable or labor needs to be initiated. - This patient is already in **active labor** with progressive cervical dilation, making misoprostol unnecessary and potentially harmful due to the risk of **uterine hyperstimulation**. *Perform Mauriceau-Smellie-Veit maneuver* - The **Mauriceau-Smellie-Veit maneuver** is a technique used during a **vaginal breech delivery** to deliver the fetal head, specifically in cases of **frank or complete breech** that are being delivered vaginally. - This maneuver is only performed *during* delivery of a breech baby, and the fetal position is currently unknown. It would be premature and inappropriate to consider this maneuver without first confirming a **breech presentation** and the decision for vaginal delivery.

Labor Complications US Medical PG Question 4: Immediately following prolonged delivery of the placenta at 40 weeks gestation, a 32-year-old multiparous woman develops vaginal bleeding. Other than mild asthma, the patient’s pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Previous pregnancies were uncomplicated. She has no history of a serious illness. She is currently on intravenous infusion of oxytocin. Her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 17/min. Uterine palpation reveals a soft enlarged fundus that extends above the umbilicus. Based on the assessment of the birth canal and placenta, which of the following options is the most appropriate initial step in patient management?

• A. Intramuscular carboprost
• B. Manual exploration of the uterus
• C. Discontinuing oxytocin
• D. Intravenous methylergonovine
• E. Uterine fundal massage (Correct Answer)

Labor Complications Explanation: ***Uterine fundal massage*** - The patient presents with **postpartum hemorrhage** indicated by vaginal bleeding and a **soft, enlarged fundus** after placental delivery, suggesting **uterine atony**. - **Uterine fundal massage** is the **first-line intervention** to encourage uterine contraction and reduce bleeding by expelling clots and compressing vessels. *Intramuscular carboprost* - **Carboprost** is a **prostaglandin F2 alpha analog** used to treat **uterine atony** when initial measures like uterine massage and oxytocin are insufficient. - It is contraindicated in patients with **asthma** due to its bronchoconstrictive effects, which this patient has. *Manual exploration of the uterus* - **Manual exploration of the uterus** is indicated when there is suspicion of **retained placental fragments** or **uterine rupture**. - While these can cause postpartum hemorrhage, the primary finding of a soft, boggy uterus points more strongly to atony, making massage the immediate priority. *Discontinuing oxytocin* - The patient is already on an **intravenous oxytocin infusion**, which is a uterotonic agent used to prevent and treat uterine atony. - Discontinuing it would worsen **uterine atony** and increase blood loss, directly contradicting the goal of management. *Intravenous methylergonovine* - **Methylergonovine** is an **ergot alkaloid** used to treat **uterine atony**, but it is contraindicated in patients with **hypertension**, which is not explicitly present here, but it is a potent vasoconstrictor and second-line. - It is often used as a **second-line agent** if oxytocin and massage are ineffective and there are no contraindications.

Labor Complications US Medical PG Question 5: A 34-year-old G3P2 is admitted to the hospital after being physically assaulted by her husband. She developed severe vaginal bleeding and abdominal pain. She is at 30 weeks gestation. Her previous pregnancies were uncomplicated, as has been the course of the current pregnancy. The vital signs are as follows: blood pressure, 80/50 mmHg; heart rate, 117/min and irregular; respiratory rate, 20/min; and temperature, 36.2℃ (97.1). The fetal heart rate is 103/min. On physical examination, the patient is pale and lethargic. Abdominal palpation reveals severe uterine tenderness and tetanic contractions. The perineum is grossly bloody. There are no vaginal or cervical lesions. There is active heavy bleeding with blood clots passing through the cervix. An ultrasound shows a retroplacental hematoma with a volume of approximately 400 ml. Laboratory workup shows the following findings: Red blood cells count: 3.0 millions/mL Hb%: 7.2 g/dL Platelet count: 61,000/mm3 Prothrombin time: 310 seconds (control 20 seconds) Partial prothrombin time: 420 seconds Serum fibrinogen: 16 mg/dL Elevated levels of which of the following laboratory markers is characteristic for this patient’s complication?

• A. C-reactive protein
• B. D-dimer (Correct Answer)
• C. Creatinine
• D. Pro-brain natriuretic peptide
• E. Procalcitonin

Labor Complications Explanation: *** **D-dimer*** - This patient's presentation with **severe vaginal bleeding**, **abdominal pain**, **uterine tenderness**, **tetanic contractions**, and **fetal distress** following trauma, along with the ultrasound finding of a **retroplacental hematoma**, is highly suggestive of **abruptio placentae**. - The abnormal coagulation panel (low platelets, prolonged PT/PTT, low fibrinogen) indicates **disseminated intravascular coagulation (DIC)**, a common complication of severe placental abruption due to extensive activation of the coagulation cascade and subsequent breakdown of clots. **D-dimer levels** are characteristically **elevated** in DIC as they are degradation products of **fibrin** from enhanced fibrinolysis. *C-reactive protein* - **C-reactive protein (CRP)** is an **acute-phase reactant** primarily elevated in response to **inflammation** or **infection**. - While trauma could induce some inflammation, very high CRP levels are not specific for **DIC** or the direct complications of **placental abruption** described. *Creatinine* - **Creatinine** is a marker of **renal function**. While severe shock and hypoperfusion from significant bleeding could lead to **acute kidney injury** and elevated creatinine, it is not a direct or characteristic marker of the **coagulopathy** or **DIC** seen in this patient. - The primary issue presented is one of **bleeding and coagulation abnormalities**, not primarily renal dysfunction. *Pro-brain natriuretic peptide* - **Pro-brain natriuretic peptide (pro-BNP)** is a biomarker primarily used to assess **cardiac stretch** and **heart failure**. - There are no clinical signs or symptoms presented that suggest **cardiac dysfunction** as the primary or most characteristic complication in this setting. *Procalcitonin* - **Procalcitonin** is a biomarker that is significantly elevated in **bacterial infections** and **sepsis**. - Although the patient's condition is critical, the clinical picture strongly points towards **hemorrhage** and **DIC** due to **placental abruption** rather than a primary **bacterial infection**.

Labor Complications Flashcard 1 of 5

Question: Inflammation of the endometrium due to retained products ofconception, miscarriage, abortion, or foreign body (IUD) is known as _____

Answer: endometritis

Labor Complications Flashcard 2 of 5

Question: Tocolytics are generally used to decrease contraction frequency in _____ labor

Answer: preterm

Labor Complications Flashcard 3 of 5

Question: _____ is a complication of pregnancy that presents with a triad of membrane rupture, painless vaginal bleeding, and fetal bradycardia (< 110 beats/min)

Answer: Vasa previa

Labor Complications Flashcard 4 of 5

Question: A full-thickness disruption of the uterine wall that typically presents with intense, acute abdominal pain, profuse vaginal bleeding, and fetal distress is most likely what condition?_____

Answer: Uterine rupture

Labor Complications Flashcard 5 of 5

Question: leiomyoma (fibroid)

Answer:

Extra Information: asymptomatic, abnormal uterine bleeding, miscarriagewell-demarcated edges, whorled smooth muscle bundlesgood, does NOT progress to leiomyosarcoma20-40 years, black race