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Repro > Complicated Pregnancy 1 > Flashcards

Complicated Pregnancy 1 Flashcards

1
Q

Define miscarriage [2]

A

Spontaneous termination <24 weeks gestation with no evidence of life

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2
Q

Define a threatened miscarriage? [3]

A

Vaginal bleeding (small amount) +/- pain
Viable pregnancy <24 weeks
Cervix closed on speculum examination – cervix not dilated

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3
Q

Inevitable miscarriage definition [2]

Outcome [2]

A

Cervix open, bleeding heavy ~ clots
viable pregnancy <24 weeks
Outcome: most likely will progress to miscarriage

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4
Q

Whats the difference between a complete or incomplete abortion?

A

Complete all POC have been expelled, the cervix closed and bleeding stopped.
In incomplete POC expelled but some remain, cervix open and bleeding ongoing

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5
Q

How do we confirm if a woman has had a complete abortion?

A

We need to either see the POC and confirm them to be that.

Or have a previous scan that confirms there was a viable pregnancy before

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6
Q

Define a septic miscarriage [2]

NB More common in incomplete miscarriage

A

When infection ascends into the uterus and throughout the pelvis following a miscarriage.

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7
Q

Define a missed abortion [2]

Appearance on US [2]

A

When the foetus has died but the uterus hasn’t attempted to expel the POC.

It can appear on US like a gestational sac lacking a foetus or a foetal pole <7mm without heart beat

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8
Q

List the major causes of a miscarriage [4]

A
  • Abnormal conceptus, mainly chromosomal
  • Uterine abnormality
  • Cervical Incompetence
  • Maternal conditions
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9
Q

What 2 uterine abnormalities could cause a miscarriage?

A

A congenital abnormality

Fibroids

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10
Q

What causes cervical incompetence?

How can this be managed?

A

Trauma including past surgical procedures eg LLETZ

Mx: Cervical suture at 14w

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11
Q

What maternal problems could cause a miscarriage? [5]

A 
Increasing age
Low progesterone
SLE
DM, Thyroid disease
Acute infections e.g. appendicitis
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12
Q

How would we manage a threatened abortion? [1]
Why?
Advice [2]

A

Conservative management

Why? best to try to get the foetus past 24wks so we can deliver and it will survive

Avoid strenuous activity and sexual intercourse but bed rest not necessary
Hormones or tocolytic agents are ineffective

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13
Q

How would we manage an inevitable abortion? [3]

NB Attempts to save fetus are futile

A

Conservative: rescan at 2w to ensure no retained POC

Profuse bleeding: ergometrine IM

Unacceptable bleeding >2w, pain or retained POC: SMM

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14
Q

How would we manage a missed miscarriage? [5]

A

Expectant
- waiting 7-14d for miscarriage to complete spontaneously
Medical
- Vaginal MISOPROSTOL
- Seek senior help if bleeding hasn’t stopped in 48h
- Indicated if higher haemorrhage risk
SMM:
- Manual vacuum aspiration under LA or GA

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15
Q

How do we define a recurrent miscarriage?

How do we manage a septic miscarriage? [2]

A

> 3 losses before 24w with same biological father

Mx:

  • Abx
  • Evacuate the uterus of remaining POC
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16
Q

Define an Antepartum Haemorrhage [1]

A

Bleeding from genital tract >24wks but before delivery

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17
Q

List the major causes of an APH [5]

A 
Placenta Praevia
Placental Abruption
Local lesion of genital tract
APH - idiopathic
Vasa Praevia
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18
Q

In what women is Placenta Praevia a risk? [5]

A 
Multiparous
Multiple pregnancy
Previous C-section
IVF assisted
Previous surgical termination
19
Q

Placenta previa grading and classification [4]

NB First 2 minor, last 2 major

A

Graded 1-4:

1) Placenta doesn’t touch internal cervical orifice (Os)
2) Placenta reaches Os
3) Placenta eccentrically covers Os
4) Central Placenta Praevia (directly over Os)

20
Q

How does a case of placenta praevia present? [4]

A
  • Painless PV bleeding
  • ~Malpresentation - transverse or oblique
  • Soft non-tender uterus
  • Shock if lot of blood loss
  • Maternal condition correlates with amount of bleeding PV
21
Q

How do we confirm a case of placenta praevia?

A

TVUSS
Often picked up on routine 20w scan
Don’t do vaginal exam till you’ve ruled it out with US as it could trigger a bigger bleed.

22
Q

Management of placenta previa:
Caution during c-section [1]

Mx is dependent on:
Gestation
Severity

A

Watch out for PPH if c-section

Mx is dependent on gestation

  • 30 weeks = conservative
  • But if severe bleeding > disregard GA
23
Q

Define Placental Abruption

A

Hemorrhage resulting from premature separation of placenta before birth

24
Q

What are the types of placental abruption? [3]

A

Revealed - blood can escape through Os
Concealed - Blood trapped between placenta/uterine wall
Mixed

25
Q

How does a Placental Abruption present? [3]

A

Painful PV bleed

  • may be minimal (So doesn’t correlate with symptoms)
  • Increased uterine tone, contractions
26
Q

How extra can a Concealed placental abruption present?

A

Blood can’t escape through os so builds up –> Uterine volume increases –> Fundal height excessive

Couvelaire Uterus (bruising in myometrium)

27
Q

Placental abruption risk factors [5]

A 
Increasing age, parity
Previous abruption, previous c-section
Pre-eclampsia, chronic HTN, smoking
Multiple pregnancy - overstretching of abdomen
Polyhydramnios
Cocaine use
28
Q

Placenta Abruption complications [5]

A
  • Maternal shock and collapse
  • Fetal death due to fetal distress
  • Maternal DIC > Renal failure
  • PPH
  • Couvelaire Uterus
29
Q

List some local genital tract lesions that could be the source of APH? [3]

A
  • Cervical polyps
  • Cervical Cancer
  • Vaginal Thrush
30
Q

If shock suspected in the miscarrying woman, immediately begin treatment. What do you do?
[2]

A

Blood group and save, cultures

IV drip

31
Q

Medical management of miscarriage

A

IM syntometrine
IV oxytocin
PG vaginal pessary

32
Q

If POC is minimal e.g. <2-5cm - what is the line of management [3]

A

Before offering surgical evacuation
Watch and wait
F/u in 1-2 weeks

33
Q

Surgical management of miscarriage

A

Suction/manual evacuation by electric pump

D&C if protruding

34
Q

Important management modality if woman is rhesus-negative

A

Give anti-D immunoglobulin

35
Q

Approach to management in placental previa [1]
Rx [5]
Surgical mx [3]

A 
If possible be conservative  to get the baby to term then deliver by C-section.
Rx:
-Oxytocin
Ergometrine
Carbaprost
Transexamic acid
Balloon tamponade

Surgical mx

  • B Lynch suture
  • Ligation of uterine and iliac vessels
  • Hysterectomy
36
Q

Management of placenta praevia split into 2 pathways

Complications of PP?

A

Low lying placenta at 16-20w scan

Placenta praevia with bleeding

Complications: PPH

37
Q

Management of low lying placenta [4]

Management of PP with bleeding [3]

A

• Low-lying placenta at 16-20w scan:

  • rescan at 34w
  • no need to limit activity or intercourse unless bleeding
  • if still present at 34w and grade I/II then scan every 2w
  • if high presenting part or abnormal lie at 37w then LSCS

• Placenta praevia with bleeding:

  • final USS at 36-37w to determine method of delivery
  • If grade III/IV = LSCS at 27-38w
  • If grade I = vaginal delivery
38
Q

Causes of early pregnancy bleed [3]

Causes that are important to rule out (could be fatal) [4]

A

Idiopathic - harmless
Implantation bleeding
Cervical ectropion, polyps

Spontaneous abortion
Ectopic
Hyatidiform mole
STI

39
Q

Causes of 2nd trimester bleeds [3]

A

Spontaneous abortion
Hyatidiform mole
Placental abruption

40
Q

General mx of APH
Antenatal
Immediate mx [2]
L&D [2]

A

Antenatal care: serial growth scans if abruption or unexplained

Admit if APH heavier than spotting
Give CCS between 24 and 34 GA

Labour and delivery

  • Fetal death > NVD
  • Fetal compromise > C-SECTION
41
Q

Investigation of APH [8]

A
  • Assess if maternal compromise. If in shock > ABCDE
  • Abdominal palpation
  • Speculum exam
  • Digital vaginal (caution in placenta praevia)
  • Kleihauer test
  • TVUSS
  • Bloods
  • Fetal ix
42
Q

Explain what you would find on:

  • Abdominal palpation [3]
  • Speculum exam
  • Kleihauer test [2]
A

Abdominal palpation

  • Woody feel - placental abruption
  • Uterine contractions
  • SNT > lower genital tract cause or bleeding from placenta or vasa praevia

Speculum
- Identify cervical dilation or lesion

Kleihauer test

  • Performed in Rhesus D negative women to quantify fetomaternal haemorrhage
  • Gauge dose of anti-D Ig required
43
Q

When should you NOT do a digital vaginal exam?

TVUSS - what can doing this test do?

A

• Digital vaginal examination
If placenta praevia is POSSIBLE then should not be performed until an ultrasound can exclude PP.

TVUSS can diagnose placenta praevia

44
Q

What bloods to do for APH? [4]

What fetal investigation is necessary?

A

Bloods

  • FBC, Coagulation screen, cross matching, G&S
  • U&Es, LFTs
  • Initial Hb may not reflect blood loss
  • Low platelet count > DIC

Monitor FHR with CTG

Repro (34 decks)

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