Complicated Pregnancy Flashcards
What is Hyperemesis Gravidarum? RF?
- Severe vomiting with onset before 20w of gestation. Most common between 8-12w
- Related to increased levels of bHCG
RF:
- Molar pregnancies (higher bHCG)
- Multiple pregnancies (higher bHCG)
- First pregnancy
- Obesity
Dx of Hyperemesis Gravidarum? How is severity assessed? When is admission considered?
Prolonged N+V in pregnancy PLUS:
(1. ) >5% wt loss compared with before pregnancy
(2. ) Dehydration
(3. ) Electrolyte imbalance
(4. ) Severity assessed using PUQE.
Admission considered when:
- Unable to tolerate oral antiemetics/ fluids
- > 5% wt loss compared with pre-pregnancy
- Ketonuria
- Other medical conditions need treating that required admission g. unable to tolerate oral abx for UTI
Management of Hyperemesis Gravidarum?
Mild cases, managed at home
- Antiemetics
- Omeprazole if reflux problem
Moderate-severe cases
- IV/IM antiemetics
- IV fluids (saline + KCl)
- Daily U&Es
- Thiamine + folic acid to prevent Wernicke’s encephalopathy
- VTE prophylaxis
Define:
- Chronic HTN
- Pregnancy-induced/gestation HTN
- Pre-eclampsia
- Eclampsia
- Chronic hypertension = Hi BP <20w, it is not caused by placenta dysfunction and thus not pre-eclampsia.
- Pregnancy-induced/gestational HTN = hi BP after 20w without proteinuria.
- Pre-eclampsia = pregnancy-induced HTN associated with organ damage
- Eclampsia = seizures as a result of pre-eclampsia.
What is pre-eclampsia and complications for it?
- Hi BP in pregnancy with end-organ dysfunction. Occurs >20w due to abnormal spiral arteries of placenta leading to a high vascular resistance.
- Complications: maternal organ damage, fetal growth restrictions, seizures, early labour, death, HELLP Syndrome (Haemolysis + Elevated Liver enzymes + Low Platelets)
RF for pre-eclampsia
High-RF:
- Pre-existing HTN
- Prev HTN in pregnancy
- AI (e.g. SLE), DM, CKD
Moderate-RF:
- > 40y
- BMI > 35
- > 10y since prev pregnancy
- Multiple pregnancy
- First pregnancy
- FH
Presentation of pre-eclampsia, red flags for HELLP
Triad of: HTN, proteinuria, oedema
- Asyx
- headache
- visual disturbance
- N+V
- frothy urine
- red flags for HELLP: headache, visual disturbance, RUQ pain, breathless
Dx + Ix for Pre-eclampsia
BP >140 systolic or <90mmHg diastolic PLUS one of:
- Proteinuria (urine dip/PCR/ACR)
- Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
- Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
Investigations
- Obs
- Urinedip - assess protein
- bloods: fbc, clotting, ue, lft
- CTG
Management of Pre-eclampsia
(1. ) Aspirin prophylaxis from 12w if: single high RF or >2 moderate RF
(2. ) Antenatal appt: assess BP, syx, urine dip
(3. ) Plan early birth may be necessary if cannot be controlled + steroids if preterm birth
Medical Mx
(1. ) Labetalol (1st line), Nifedipine (2nd line), Methyldopa (3rd line)
(2. ) IV magnesium sulphate - during labour and 24hrs after to prevent seizures
Severe pre-eclapmisa or eclampsia
(1. ) IV hydralazine in critical care
(2. ) Fluid restriction - during labour to avoid fluid overload
WHat is Gestational diabetes? Complications? RF?
- Diabetes caused by reduced insulin sensitivity during pregnancy and resolves after birth.
- Complications: macrosomnia, shoulder dystocia, T2DM, neonatal hypoglycaemia
RF
- Prev GDM
- Prev macrosomic
- BMI > 30
- Ethnic origin (black Caribbean, Middle Eastern and South Asian)
- FH DM
Ix for GDM
(1. ) OGTT at 24-28w
- Indicated in: those with RF, large for dates fetus, polyhydramnios, glucose on urine dipstick
- Performed in morning, pt drinks 75mg glucose, BGL measured before and 2hrs after drink.
- Normal results: Fasting: < 5.6 mmol/l, At 2hrs: < 7.8 mmol/l, If above -> gestational DM
Mx for GDM
(1. ) Healthy diet + exercise
(2. ) Monitor BGL several times a day
(3. ) USS - monitor fetal growth + amniotic fluid
(4. ) Metformin +/- insulin, this can stop after birth
What is Ectopic pregnancy + RF?
Pregnancy implanted outside uterus - most common site is a fallopian tube.
RF:
- Prev ectopic
- Prev surgery to fallopian tube
- Anything that causes pelvic adhesions: Endometriosis, IBD, PID, Chlamydia
- IUD
- Older age
- Smoking (impairs cilia)
Presentation of Ectopic pregnancy
Typically presents 6-8w.
- Missed period
- Constant lower abdo pain (RIF/LIF)
- PV bleeding
O/E
- Adnexal mass
- Lower abdo/pelvic tenderness
- Cervical motion tenderness - pain when moving the cervix during a bimanual examination
- Dizziness or syncope (blood loss)
- Shoulder tip pain (peritonitis)
IX for Ectopic pregnancy
- bHCG
- TV USS: exclude intrauterine pregnancy
Mx of Ectopic pregnancy and indications for mx type.
Indications:
- Expectant: <35mm, unruptured, no pain, no heartbeat, bHCG <1500
- Medical: <35mm, unruptured, not much pain, no heartbeat, bHCG <5000
- Surgery: >35mm, +/-rupture, pain, heartbeat, bHCG >5000
(1. ) Expectant (awaiting natural termination)
- monitor for 48hrs + bHCG. If it rises + syx must intervene
(2.) Medical: IM methotrexate
(3. ) Surgical
- Salpingectomy (removal of fallopian tube with ectopic)
- Salpingotomy (removal of ectopic + no removal of tube, for those at inc risk of infertility)
- Anti-rhesus D prophylaxis is for rhesus negative women
What is a Pregnancy of unknown location (PUL)?
- +ve pregnancy test and no evidence of pregnancy on USS
- ectopic pregnancy cannot be exclude till dx confirmed
- hCG can be tracked over time to monitor pregnancy of unknown location
HCG repeated after 48hrs:
- > 63% hCG rise in 48hrs = intrauterine pregnancy
- <63% hCG rise in 48hrs = ectopic
- > 50% fall hCG in 48hrs = miscarriage
What are the legal requirements for abortion
1967 Abortion Act: abortion can be performed before 24w. Legal requirements for abortion:
- Two registered medical practitioners must sign to agree abortion is indicated
- It must be carried out by a registered medical practitioner in an NHS hospital or approved premise
Mx of TOP
Medical
(1. ) Mifepristone (anti-progestogen)
(2. ) Misoprostol (prostaglandin analogue) 1-2d later
(3. ) Anti-D prophylaxis if >10w + rhesus -ve
Surgical
(1. ) Prior to surgery, cervical priming + dilation with misoprostol, mifepristone or osmotic dilators.
(2. ) <14w: cervical dilatation + suction
(3. ) 14-24w: cervical dilatation + evacuation using forceps
What are the different types of miscarriage and what would you expect to see clinically?
‘Open your I’s’ - open os for inevitable and incomplete miscarriage
(1. ) Threatened = closed os. PV bleeding at 6-9w.
(2. ) Missed = closed os. No syx, fetus not alive.
(3. ) Inevitable = open os. Heavy PV bleeding.
(4. ) Incomplete = open os. Retained products, pain + PV bleeding.
(5. ) Complete = full miscarriage, no products in uterus.
Ix of miscarriage
(1. ) Abdo exam with speculum and bimanual
(2. ) Full set of observations
(3. ) Bloods: FBC, G&S, bHGC, progesterone. If HCG normal and low progesterone = pregnancy is failing
(4. ) TVUS
Mx of miscarriage
(1. ) Expectant management (<6w)
- 1-2w for miscarriage to occur spontaneously
- Repeat pregnancy test to confirm miscarriage.
- Persistent/worsening bleed requires repeat USS, as may indicate an incomplete miscarriage and require additional management.
(2.) Medical: PV/PO Misoprostol
(3. ) Surgical:
- manual vacuum aspiration under local anaesthetic
- electric vacuum aspiration under GA
(4.) Anti-rhesus D prophylaxis is given to rhesus negative
What is Abruption placenta and its RFs?
(1. ) Obstetrics emergency
(2. ) Placental abruption is where placenta separates from uterine wall during pregnancy resulting in antepartum haemorrhage. Bleeding can be concealed within the cavity.
(3. ) Increased risk of PPH after delivery in women with placental abruption.
RF A- prev Abruption B - BP i.e. preeclampsia R - ruptured mb PROM U - uterine injury - DV, surgery P - polyhyrdramino T - twin pregnancies, multiparity I infection e.g. chorioamniotis O - older age N - narcotic use e.g. cocaine, amphetamines, smoking
PResentation of Abruption placenta
(1. ) Sudden + Severe abdo pain
(2. ) PV bleed h/e in some cases haemorrhage may be confined to the uterus (concealed)
(3. ) Shock (hypotension + tachy)
(4. ) CTG abnormalities e.g. reduced FM
O/e:
- ‘woody’ hard abdomen suggesting large haemorrhage
Management of Abruption placenta
It is an emergency.
If mum + fetal unstable: ABCDE
(1. ) Fluids,oxygen
(2. ) EMCS
(3. ) CTG
(4. ) Steroids if 24-34w - to mature fetal lungs
(5. ) Anti D prophylaxis
If mum + foetus table
- Monitor closley
- steroids if <36w
Three causes of antepartum haemorrhage
placenta praevia
placental abruption
vasa praevia
what is placenta praevia? complications? RF?
(1. ) Placenta is lies in lower portion of uterus, normally placenta implants in upper uterus.
- Low-lying placenta = placenta is within 20mm of the internal cervical os
- Placenta praevia = placenta is over the internal cervical os
(2. ) This means it can easily bleed and can occur after 20w
(3. ) It is a cause of antepartum haemorrhage
(4. ) Complications: pre-term delivery, hypoxia, haemorrhage.
(5. ) RF: Prev c-sections, Prev placenta praevia, Older maternal age, Smoking, Structural uterine abnormalities e.g. fibroids
presentation of placenta praevia
(1. ) Asyx
(2. ) Painless bleeding
- After 20w, typically 36w
- Intermittent or continuous
How may you examine + Ix placenta praevia
(1.) Speculum NO bimanual ex
(2. ) Bloods:
- FBC, clotting, G&S, clotting
- Rhesus status
- Kleihauer test: how much of baby’s blood is in mum’s blood
(3. ) 20w USS - allows to visualise where the placenta is lying
(4. ) CTG
Mx of placenta praevia
(1. ) TV USS at 32w, 36w:
- If low-lying placenta/placenta praevia diagnosed early in pregnancy e.g. 20w scan
(2. ) Steroids at 34w + 35+6w
(3. ) Planned c-section at 36 and 37w.
(4. ) If haemorhage: ABCDE + ECS, blood transfusion, intrauterine balloon tamponade.
What is Postpartum haemorrhage (PPH)?
- Significant loss of blood after giving birth and a potential cause of maternal death.
- It is an obstetric emergency.
To be classified as PPH, there needs to be a loss of:
- > 500ml after vaginal delivery
- > 1000ml after c-section delivery
It can also be categorised as:
- Primary PPH: bleeding <24 hours of birth
- Secondary PPH: from 24hrs to 12w after birth usually due to retained products or infection/endometritis
Causes of Postpartum haemorrhage (PPH)?
4T’s
(1. ) Tone = lack of uterine tone (Uterine Atony).
(2. ) Trauma = damage to genital structures e.g. medical instrument - forceps, vacuum extractions, episiotomy.
(3. ) Tissue = retained placenta in uterine cavity
(4. ) Thrombin = bleeding disorder e.g. von Willebrand disease or obstetrics issues e.g. eclampsia, placental abruption
What is Uterine Atony? causes? rx?
- Failure of the uterus to contract after delivery and thus blood vessels are not compressed. This can lead to PPH.
- Lack of uterine tone creates a soft, spongy, boggy uterus which causes slow & steady loss of blood.
Causes
- multiple pregnancies, overstretching from twins/triplets, muscle fatigue from prolonged labour etc.
Rx
- massaging the fundas after birth.
Preventative measures and Management of PPH?
Preventative measures:
(1. ) Treating anaemia during antenatal period
(2. ) Giving birth with an empty bladder (full bladder reduces uterine contraction)
(3. ) IM oxytocin in third stage
(4. ) IV tranexamic acid during c-section in higher-risk patients
ABCDE
- Lie flat, keep warm and communicate
- Bloods: FBC, U&E, clotting, G&S, crossmatch
- IV fluid (warmed) + blood resus
- Severe cases -> activate major haemorrhage protocol
Mechanical
(1. ) Rubbing uterus via abdomen to stimulates a uterine contraction
(2. ) Catheterisation
Medical (‘MOM Ct’)
(1. ) 40unit Oxytocin
(2. ) IV/IM Ergometrine - stimulates contraction
(3. ) IM Carboprost stimulates contraction
(4. ) Misoprostol - prostaglandin analogue + stimulates contraction
(5. ) IV Tranexamic acid - reduces bleeding
Surgical
(1. ) Intrauterine balloon tamponade
(2. ) B-Lynch suture - suture around uterus to compress it
(3. ) Uterine artery ligation
(4. ) Hysterectomy “last resort” but will stop the bleeding and may save the woman’s life
What is Premature rupture of membranes (PROM)
- Premature rupture of mb (PROM) = amniotic sac rupture 1hr before labour
- Preterm premature rupture of mb (PPROM) = amniotic sac rupture before 37w
RF for PROM o Vaginal or cervical infections: UTI/STI/BV o Smoking or drugs during pregnancy o Prev PROM o Polyhydramnios. o Multiple pregnancy. o Cervical insufficiency. o Invasive procedures e.g. amniocentesis.
Presentation of PROM + signs of complication?
(1. ) ‘popping sensation’ or a ‘gush’ with continuous watery liquid draining thereafter. Their underwear or pad may be damp.
(2. ) Signs of ascending infection (chorioamnionitis)
- fetal tachycardia
- mild maternal temp
- PV offensive discharge may be present
- Abdo tenderness
Ix of PROM
(1. ) Sterile Speculum - visualise amniotic fluid pooling into vagina after women has been lying for 30mins
(2. ) If no fluid consider testing vaginal fluid for IGFBP-1, PAMG-1,
(3. ) Sterile swab + microscopy of fluid. Amniotic fluid = Fern pattern* on micro slide
(4. ) Pad check
(5. ) USS - visualise low amniotic fluid
(6. ) If suspect infection:
- HVS
- FBC, CRP
- MSU
- blood cultures
- Fetal monitoring
Mx of PROM
(1. ) Urgent admission + 48hrs observations (monitor for any signs of infections)
(2. ) Erythromycin for 10d or till labour (whatever comes first)
(3. ) >34w = IoL
(4. ) <34w = WW
- Tocolytics to prevent beginning of labour
- Mg sulphate + steroids = allows for mx efficacy of steroids for fetal lungs
- Abx
What is Rh incompatibility and why is it important?
Rh +ve = rhesus-D antigen on RBC
Dx = Coombs test at prenatal
(1. ) Mum and baby have diff blood types + blood do not mix.
(2. ) It is likely at some point blood will mix (senstisation event), this is an issue if mum -ve and baby +ve as:
- Mum will see rh antigen on baby as ‘foreign’ and attack, and thus will produce antibodies to rh antigen. Mum is now sensitised.
(3. ) Sensitisation process does not cause problems during first pregnancy it is subsequent pregnancies as antibodies can cross placenta into fetus and cause haemolytic disease of the newborn.
(4. ) There is no way to reverse the sensitisation process once it has occurred, so prophylaxis is essential.
Management of Rh incompatibility + indications
IM anti-D given to rh -ve mums in the following situations/indications
(1. ) Routinely at 28w, 34w
(2. ) If indicated by kleinhaur test
(3. ) At birth if baby’s cord blood test is rh +ve
(4. ) Where sensitisation may occur (<72hrs)
- Antepartum haemorrhage e.g. placental abruption
- Amniocentesis procedures
- Abdominal trauma
- Miscarriage <12w
- Surgical management of ectopic
Note: anti-D has no effect once sensitisation has already occurred (it is prophylactic only).
What is Dystocia, complications, RF?
- Shoulder dystocia is when anterior shoulder becomes stuck behind pubic symphysis, after head has been delivered.
- It is an obstetric emergency
- Often caused by macrosomia secondary to GDM
Complications:
- Fetal hypoxia (and subsequent cerebral palsy)
- Brachial plexus injury and Erb’s palsy
- Perineal tears
- PPH
RF
- Maternal GDM
- Macrosomia (>4kg)
- Advanced maternal age
- Maternal short stature or small pelvis
- Maternal obesity
- Post-dates pregnancy
Management of Dystocia
Immediate help + managed by experienced midwives and obstetricians
(1.) McRobert’s manoeuvre (1st line): hyperflexion and abduction of mother’s legs tightly to abdomen
(2. ) After delivery
- Assess and monitor mum for PPH, severe perineal tears, trauma
- Assess and examine baby - brachial plexus injury, hypoxic brain damage, humeral or clavicle fractures
What is Gestation trophoblastic disease? RF?
(1. ) Gestational trophoblastic disease (GTD) forms a group of disorders which range from molar pregnancies to malignant conditions such as choriocarcinoma
(2. ) They are chromosomally abnormal pregnancies that have the potential to become malignant
(3. ) RF:
- <16y, >45y
- Prev GTD
- Asian
Gestation trophoblastic disease presentation, IX, Mx
Presentation:
- PV bleed
- hyperemesis
- abnormal uterine enlargement
- hyperthyroidism
- anaemia
- respiratory distress
- pre-eclampsia
Investigations
bHCG, Histology, USS
Management
- suction dilation and evacuation
- hysterectomy
What is Molar pregnancy
(1. ) Type of gestation trophoblastic disease
(2. ) A hydatidiform mole is a type of tumour that grows like a pregnancy inside uterus. This is called a molar pregnancy.
(3. ) There are two types of molar pregnancy
- Complete mole = two sperm cells fertilise an ovum that contains no genetic material.
- Partial mole = two sperm cells fertilise a normal ovum (containing genetic material) at same time and cell now has three sets of chromosomes, divides into a tumour. Some fetal material may form.
Presentation of Molar pregnancy
Molar pregnancy behaves like a normal pregnancy - periods stop and hormonal changes occur.
(1. ) More severe morning sickness
(2. ) PV bleeding
(3. ) Increased uterus enlargement
(4. ) Abnormally high hCG
(5. ) Thyrotoxicosis (hCG can mimic TSH and stimulate thyroid to produce excess T3 and T4)
(6. ) USS: ‘snowstorm appearance’ or ‘grape like cysts’. This gives provisional dx, dx confirmed by histology
Mx of Molar pregnancy
Management
(1. ) Evacuation (suction) of uterus to remove mole
(2. ) Histology: products of conception need to be sent for histological examination to confirm dx.
FU
(3. ) HCG - monitor until return to normal
(4. ) Chemotherapy if mole has metastasised
(5. ) Strongly advised against pregnancy for 1yr
What doe folic acid deficiency cause
- macrocytic, megaloblastic anaemia
- neural tube defects
When is is 5mg folic acid given?
Those at higher risk of NTD
- partner, prev pregnancy with NTD
- AED
- BMI >30
- Coeliac disease
- DM
- Thalassaemia trait
For a women looking to conceive, how much folic acid should be taken and how long for?
- 400mcg
- prior and until 12w pregnancy
What is the definition of infertility?
Unable to become pregnant within one year of unprotected intercourse
Causes and RF for infertility
Causes
(1. ) ovulatory disorders (25%) - PCOS, hypothalamic amenorrhoea (stress related), hypothyrodisim, hyperpolactinoma, low BMI/hypogonadotrophic hypogonadism
(2. ) tubal damage (20%) - sti/pid
(3. ) male infertility (30%)
(4. ) uterine or peritoneal disorders (10%) - fibroids, polyps, adhesions, vaginal septum
(5. ) no identifiable cause (25%)
RF
- smoking, obesity, occupational risks, alcohol, drug.
- Female fertility declines with age.
Investigations for infertility
Investigation indicated if failed to get pregnant after 1 year unless >35y
(1. ) Semen analysis
(2. ) Day 21 progesterone (for 28d cycle) - >30 = indicates ovulation
(3. ) Serum gonadotrophins
- High FSH indicates low ovarian reserve. Ovarian reserve declines with age
- LH: hi levels indicate PCOS
- Androgen
(5. ) TFT
(6. ) prolactin
(7. ) screen for chlamydia
(8. ) USS - look structural problems
(9. ) Hysterosalpingogram + Xray, visualise tube + performed in secondary care.
Treatment for infertility
Medical: induce ovulation
- Clomifene
- Pulsatile gonadotrophin-releasing hormone
Surgery
- Tubal microsurgery
- surgical ablation or resection of endometriosis
Assisted conception
- intrauterine insemination
- IVF
- intracytoplasmic sperm injection
