6. Placental problems in pregnancy

Question 1

What are the different problems that can occur to the placenta during pregnancy?

Answer 1

Exaggerated symptoms of pregnancy
Bleeding disorders of pregnancy
Medical problems of pregnancy
Multiple pregnancies

Question 2

What are the different stages of pregnancy?

Answer 2

Antepartum - prior to labour: early is <24 weeks and late is >24 weeks
Intrapartum - in labour: the first and second stages
Postpartum - from delivery of the foetus up to 6 weeks later

Question 3

When is the line between miscarriage and stillbirth?

Answer 3

If the foetus dies prior to 24 weeks - miscarriage

If the foetus dies after 24 weeks - stillbirth

Question 4

What is hyperemesis gravidarum?

Answer 4

Severe complication of pregnancy in the form of exaggerated symptoms
There is extreme nausea and vomiting which can lead to dehyrdation and weight loss
Affecst 70-80% of women in early pregnancy

Question 5

What is the treatment for hyperemesis gravidarum?

Answer 5

Woman will be admitted for IV fluids, dietary advice - eat about 6 meals a day - to increase weight and hydration and nutrition
Finally, administer antiemetics to prevent further episodes

Question 6

What is a spontaneous miscarriage?

Answer 6

This is when the foetus dies or is delivered dead prior to 24 weeks - the majority of these occur prior to 12 weeks
This is more common is older women

Question 7

What are the different types of (spontaneous) miscarriage?

Answer 7

Threatened
Inevitable
Incomplete
Complete
Septic 
Missed

Question 8

What is a threatened miscarriage?

Answer 8

Light and painless bleeding
The foetus is alive at this stage 
The uterus is at the expected size 
The cervical os is closed 
Only about 25% of these patients will go on to miscarry

Question 9

What is an inevitable miscarriage?

Answer 9

Heavy bleeding
The foetus may be alive at this point
The cervical os is open 
Crampy pelvic pain will occur
The miscarriage is about to occur - it is inevitable

Question 10

What is an incomplete miscarriage?

Answer 10

Only some parts of the foetus have been passed out of the vagina
Bleeding continues
The cervical os is open
Often need medical aid to remove the rest of the membranes etc

Question 11

What is a complete miscarriage?

Answer 11

All the foetal tissues have been passed
The bleeding has diminished/stopped
The uterus is no longer enlarged
The os is closed

Question 12

What is a septic miscarriage?

Answer 12

The contents of the uterus is infected and this causes endometritis
Tender uterus
Fever may be absent
May progress to a pelvic infection and this can cause abdominal pain and peritonism

Question 13

What is a missed miscarriage?

Answer 13

The foetus has not developed or has died in utero
This is only recognised later when bleeding occurs or an ultrasound scan is performed
The uterus is smaller than the expected dates
The cervical os is closed
Abdominal pain and vaginal bleeding is minimal

Question 14

What investigations are carried out for spontaneous miscarriages?

Answer 14

Ultrasound scan:
Detects the location and viability of the foetus
May show any retained foetal tissue
Serum bHCG:
Normally increases by >66% in 48hours with a viable pregnancy 
Bloods:
FBC
Rhesus group

Question 15

How might a missed miscarriage show on an ultrasound?

Answer 15

The scan can show either an abnormal shaped amniotic sac with no embryo inside
OR can show a foetus with no heartbeat

Question 16

What are the different management options for a miscarriage?

Answer 16

Expectant: wait for a spontaneous resolution - no medical input
Medical management: removal of the foetal tissue - generally involving the usage of prostaglandins
Surgical management - curettage or surgical aspiration to remove any remaining foetal matter

Must provide support and counselling to the patient

Question 17

What is meant by recurrent miscarriage?

Answer 17

This is where a woman has three or more consecutive miscarriages
This affects 1% of couples

Question 18

What are the causes of recurrent miscarriages?

Answer 18

Autoimmune disease e.g. anti-phospholipid syndrome
Chromosomal defects in couples
Hormonal factors e.g. LH hypersecretion
Anatomical factors e.g uterine septa, cervical incompetence
Infection e.g. bacterial vaginosis
Other factors e.g. obesity, smoking, high maternal age, drug abuse

Question 19

What investigations are used for recurrent miscarriages?

Answer 19

Autoimmune and thrombophilia screen
Karyotyping - parents and products of conception
Pelvic ultrasound scan

Question 20

What is the management for recurrent miscarriage?

Answer 20

Management is dependent on the cause

Can include anticoagulation therapy, genetic counselling, metformin, cervical cerclage

Question 21

What is meant by cervical incompetence?

Answer 21

This is where the cervix fails to retain the pregnancy

Question 22

What is an ectopic pregnancy?

Answer 22

This is where implantation of the fertilised ovum occurs outside of the endometrial/uterine cavity
More common with advanced maternal age and lower social class

Question 23

What are the risk factors for an ectopic pregnancy?

Answer 23

Previous STIs/PID
Usage of emergency contraception
Assisted conception
Pelvic surgery 
Failed sterilisation
Previous ectopic pregnancy 
Congenital abnormalities of the tube e.g. diverticulum

Question 24

What is the clinical presentation of an ectopic pregnancy?

Answer 24

Women of reproductive age
PV bleeding - scanty and dark
Lower abdominal pain - initially this will be colicky and then will become constant over time

Question 25

What are the investigations for an ectopic pregnancy?

Answer 25

Urine bHCG - to confirm pregnancy
Trans-vaginal USS - allows visualisation of an intrauterine pregnancy
Quantitate serum
Diagnostic laparoscopy

Question 26

What are the treatment options for an ectopic pregnancy?

Answer 26

Surgical - laparoscopy for removal of ectopic from tube
Medical - single dose methotrexate
Conservative - observe if small, unruptured ectopic with declining bHCG levels

Question 27

What is a molar pregnancy?

Answer 27

This is where a non-viable fertilised egg implants into the uterus - this egg will fail to come to term
The egg does not contain a maternal nucleus and the tissue is entirely paternal in origin
There is no foetal tissue and rather, the trophoblastic tissue of the uterus differentiates and expands more aggressively than normal

Question 28

What is a partial molar pregnancy?

Answer 28

This is where there is some presence of foetal tissue but still not a complete presence and the pregnancy will not come to term

Question 29

What is gestational trophoblastic disease (GTD)?

Answer 29

This is a name for a group of pregnancy-related tumours

Cells in the uterus start to proliferate uncontrollably e.g. a mole

Question 30

What are the clinical features for GTDs?

Answer 30

PV bleeding
Hyperemesis gravidarum
Passage of vesicles via the rectum

The uterus will often be large
The patient may have pre-eclampsia and hyperthyroidism

Question 31

What is an antepartum haemorrhage?

Answer 31

This is bleeding from the genital tract >24 weeks gestation but before the delivery of the baby

Question 32

What are the causes of antepartum haemorrhage?

Answer 32

Undetermined causes are common
Placental abruption
Placenta praevia

Question 33

What is placental abruption?

Answer 33

This is painful vaginal bleeding from a normally sited placenta
The placenta partially or completely separates from the uterus before the baby is born - can deprive the baby of oxygen and nutrients

Question 34

What are the clinical features of placental abruption?

Answer 34

Intense abdominal pain, with or without vaginal bleeding
Profound shock 
Tense, tender (woody) uterus 
Foetal parts not easily felt 
Foetal heart may be weak or absent

Question 35

What is placenta praevia?

Answer 35

When the placenta is inserted into the lower segment of the uterus after 24 weeks
Major - inserts wholly into the uterine segment and covers the os
Minor - inserts partially into the uterine segment and does not cover the os

Question 36

How does placenta praevia present?

Answer 36

Painless vaginal bleeding of various amounts, most commonly between 32-37 weeks

Question 37

What is pre-eclampsia?

Answer 37

This is a state of high blood pressure in pregnancy and high protein level in the urine
Usually occurs within the third trimester and gets worse over time

Question 38

Why does pre-eclampsia occur?

Answer 38

Occurs due to an abnormal maternal adaptation to the trophoblast

Question 39

How is pre-eclampsia treated?

Answer 39

The only treatment of this is to birth the baby but the foetus should stay in utero for as long as possible
If there is harm to the mother’s or foetus’s health then induced pregnancy or c-section should be considered
May give anti-hypertensives and anti-convulsants

Question 40

What are the risk factors for pre-eclampsia?

Answer 40

Genetics - recessive homozygous
Pre-existing hypertension or diabetes
Multiple pregnancy
Molar pregnancy

Question 41

How is pre-eclampsia managed?

Answer 41

Rest of the mother and close observation of mother and foetus
Anti-hypertensives and anti-convulsants
Timely delivery