6. Placental problems in pregnancy Flashcards
What are the different problems that can occur to the placenta during pregnancy?
Exaggerated symptoms of pregnancy
Bleeding disorders of pregnancy
Medical problems of pregnancy
Multiple pregnancies
What are the different stages of pregnancy?
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
When is the line between miscarriage and stillbirth?
If the foetus dies prior to 24 weeks - miscarriage
If the foetus dies after 24 weeks - stillbirth
What is hyperemesis gravidarum?
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
What is the treatment for hyperemesis gravidarum?
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
What is a spontaneous miscarriage?
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
What are the different types of (spontaneous) miscarriage?
Threatened Inevitable Incomplete Complete Septic Missed
What is a threatened miscarriage?
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
What is an inevitable miscarriage?
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
What is an incomplete miscarriage?
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
What is a complete miscarriage?
All the foetal tissues have been passed
The bleeding has diminished/stopped
The uterus is no longer enlarged
The os is closed
What is a septic miscarriage?
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
What is a missed miscarriage?
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
What investigations are carried out for spontaneous miscarriages?
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
How might a missed miscarriage show on an ultrasound?
The scan can show either an abnormal shaped amniotic sac with no embryo inside
OR can show a foetus with no heartbeat
What are the different management options for a miscarriage?
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
What is meant by recurrent miscarriage?
This is where a woman has three or more consecutive miscarriages
This affects 1% of couples
What are the causes of recurrent miscarriages?
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
What investigations are used for recurrent miscarriages?
Autoimmune and thrombophilia screen
Karyotyping - parents and products of conception
Pelvic ultrasound scan
What is the management for recurrent miscarriage?
Management is dependent on the cause
Can include anticoagulation therapy, genetic counselling, metformin, cervical cerclage
What is meant by cervical incompetence?
This is where the cervix fails to retain the pregnancy
What is an ectopic pregnancy?
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
What are the risk factors for an ectopic pregnancy?
Previous STIs/PID Usage of emergency contraception Assisted conception Pelvic surgery Failed sterilisation Previous ectopic pregnancy Congenital abnormalities of the tube e.g. diverticulum
What is the clinical presentation of an ectopic pregnancy?
Women of reproductive age
PV bleeding - scanty and dark
Lower abdominal pain - initially this will be colicky and then will become constant over time
What are the investigations for an ectopic pregnancy?
Urine bHCG - to confirm pregnancy
Trans-vaginal USS - allows visualisation of an intrauterine pregnancy
Quantitate serum
Diagnostic laparoscopy
What are the treatment options for an ectopic pregnancy?
Surgical - laparoscopy for removal of ectopic from tube
Medical - single dose methotrexate
Conservative - observe if small, unruptured ectopic with declining bHCG levels
What is a molar pregnancy?
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
What is a partial molar pregnancy?
This is where there is some presence of foetal tissue but still not a complete presence and the pregnancy will not come to term
What is gestational trophoblastic disease (GTD)?
This is a name for a group of pregnancy-related tumours
Cells in the uterus start to proliferate uncontrollably e.g. a mole
What are the clinical features for GTDs?
PV bleeding
Hyperemesis gravidarum
Passage of vesicles via the rectum
The uterus will often be large
The patient may have pre-eclampsia and hyperthyroidism
What is an antepartum haemorrhage?
This is bleeding from the genital tract >24 weeks gestation but before the delivery of the baby
What are the causes of antepartum haemorrhage?
Undetermined causes are common
Placental abruption
Placenta praevia
What is placental abruption?
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
What are the clinical features of placental abruption?
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
What is placenta praevia?
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
How does placenta praevia present?
Painless vaginal bleeding of various amounts, most commonly between 32-37 weeks
What is pre-eclampsia?
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
Why does pre-eclampsia occur?
Occurs due to an abnormal maternal adaptation to the trophoblast
How is pre-eclampsia treated?
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
What are the risk factors for pre-eclampsia?
Genetics - recessive homozygous
Pre-existing hypertension or diabetes
Multiple pregnancy
Molar pregnancy
How is pre-eclampsia managed?
Rest of the mother and close observation of mother and foetus
Anti-hypertensives and anti-convulsants
Timely delivery
