Complicated Pregnancy 1 Flashcards
This deck covers:
Misscarriage & Antepartum Haemorrhage
Define a misscarriage/abortion?
Spontaneous termination <24wks gestation with no evidence of life
Define a threatened miscarriage/abortion?
When a viable pregnancy (confirmed on US) presents with vaginal bleeding +/- pain
Must be <24 wks (otherwise its APH) and must be closed cervix.
What if a patient presents <24wks with vaginal bleeding and the cervix is dilating?
At that point its termed an Inevitable Miscarriage
Whats the difference between a complete or incomplete abortion?
In complete all the Products of conception have been expelled, the cervix closed and bleeding stopped.
In incomplete the POC are still partly inside, cervix open and bleeding ongoing
How do we confirm if a woman has had a complete abortion?
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
Define a septic miscarriage?
When infection ascends into the uterus and throughout the pelvis following a miscarriage.
Its most common if it was an incomplete abortion
Define a missed abortion?
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 without a developed heart
List all the major causes of a miscarriage you can think of?
- Abnormal conceptus (problems with the foetus, mainly chromosomal)
- Uterine abnormality (problems with the uterus)
- Cervical Incompetence (problems with cervix)
- Maternal conditions (problems with the mother)
What uterine abnormalities could cause a misscarriage?
A congenital abnormality
Fibroids
What causes cervical incompetence?
Trauma including past surgical procedures
What maternal problems could cause a misscarriage?
Low progesterone
SLE
Thyroid disease
Acute infections e.g. appendicitis
How would we manage a threatened abortion?
Conservative Management, best to try to get the foetus past 24wks so we can deliver and it will survive
How would we manage an inevitable abortion?
At this point there’s no point trying to save the foetus.
If the bleeding is heavy they may need evacuation of the uterus
How would we manage a missed misscarriage?
Several options:
- Conservative in the hope the uterus will self-evacuate
- Push the uterus with prostaglandins (MIsoprostol)
- Surgical Management of Misscarriage (SMM)
How do we manage a septic misscarriage?
Abx
Evacuate the uterus of remaining POC
Define an Antepartum Haemorrhage?
Bleeding from genital tract >24wks but before delivery
Contrast to a miscarriage which is used for bleeds <24wks
This is because 24wks is when the foetus is considered viable
List the major causes of an APH?
Placenta Praevia Placental Abruption Local lesion of genital tract Idiopathic Vasa Praevia (Very rare)
In what women is Placenta Praevia a risk?
Multiparous
Multiple pregnancy
Previous C-section
What are the types of placenta praevia?
GRaded 1-4:
1) Placenta doesn’t touch internal cervical orifice (Os)
2) Placenta reaches Os
3) Placenta covers Os
4) Central Placenta Praevia (directly over Os)
How does a case of placenta praevia present?
Painless PV bleeding >24wks
With a soft non-tender uterus and often malpresentation.
Often they present because we spot malpresentation on exam, send for an US and discover placenta praevia as the source of the bad alignment
How do we confirm a case of placenta praevia?
US!
Don’t do vaginal exam till you’ve ruled it out with US as it could trigger a bigger bleed
How do we handle a Placenta Praevia?
If possible be conservative e.g. blood transfusions etc to get the baby to term then deliver by C-section.
Either way you can’t deliver vaginally.
Define placental Abruption?
The placenta seperates from the wall early, usually with a retroplacental clot forming
What are the types of placental abruption?
Revealed - blood can escape through Os
Concealed - Blood trapped between placenta/uterine wall
Mixed
How does a Placental Abruption present?
Severe abdo pain and APH
May increase uterine tone & have contractions
Foetus will be longitunidal
How extra can a Concealed placental abruption present?
Blood can’t escape through os so builds up –> Uterine volume increases –> Fundal height excessive
Couvelaire Uterus (bruising in myometrium)
What are the risk factors for a placenta abruption?
Hypertensive disorders (chronic hyp or pre-eclampsia) Multiple pregnancy Polyhydramnios Smoking, Age & Parity H/o Cocaine
Placenta Abruption can be very dangerous, especially if the bleed is concealed. What complications can it trigger? (Think big bleed and clot)
- Maternal shock & collapse
- Foetal Death
- Maternal DIC & renal failure
- PPH
- Coevelaire Uterus
List some local genital tract lesions that could be the source of APH?
- Cervical polyps
- Cervical Cancer
- Vaginal Thrush
So how do manage an APH over?
IT varies based on severity, maternal/foetal condition and gestation but includes:
- Expectant treatment
- Conservative e.g. blood transfusions
- Attempt a vaginal delivery
- Emergency C-sections
