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YEAR 4 REPRO > Complicated Pregnancy: Pregnancy complications > Flashcards

Complicated Pregnancy: Pregnancy complications Flashcards

Life- threatening complications pre-eclampsia gestational diabetes Obstetric haemorrhage VTE Sepsis Maternal collapse

1
Q

What is obstetric cholestasis?

A

Disorder characterised by maternal pruritus, liver dysfunction in the absence of contributing liver disorders and restricted to pregnancy

Caused by hormonal, genetic and environmental factors

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2
Q

Risk of obstetric cholestasis for the baby?

A

Spontaneous preterm birth
Meconium stained amniotic fluid
Neonatal unit admission
Stillbirth )If the mothers serum bile acids raise > 100micromol/L)

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3
Q

Maternal risks/complications of obstetric cholestasis?

A

Increased risk of gestational diabetes
Pre-eclampsia
Impaired glucose tolerance
Dyslipidaemia

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4
Q

Presentation of patient with Obstetric Cholestasis?

A

Mild jaundice
Pruritus particularly on soles of feet and palms of hands

Fatigue, dark urine, greasy pale stools
No rash present

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5
Q

Investigations for pts with Obstetric Cholestasis?

A

LFTs- raised bilirubin

Do viral screen- Hep A, B, C
EBV and CMV
Liver autoimmune antibodies- chronic hepatitis
Cholesterol- acute fatty liver
RULE ABOVE OUT- if still high LFTs and higher bile acids— this is obstetric cholestasis

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6
Q

RF for obstetric cholestasis?

A

Family hx
Previous hx of obstetric cholestasis
Hx of Hep C infection
Cholelithiasis - when gallstones cause symptoms or complications
Multi-fetal pregnancy

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7
Q

DDx for obstetric cholestasis?

A

Acute viral hep
Fatty liver of pregnancy
Gallstones
Autoimmune hepatitis
HELLP syndrome

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8
Q

Physiology of normal placentation?

A

Trophoblast invades the myometrium and the spiral arteries of the uterus–> destroying the tunica muscularis media

Renders spiral arteries dilated–> unable to constrict–> pregnancy with a high flow and low resistance circulation

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9
Q

Pathophysiology of placentation in pre-eclampsia?

A

Remodelling of spiral arteries=incomplete

High resistance, low flow uteroplacental circulation develops, as the constrictive muscular walls of spiral arteries are maintained–> increased BP

Increased BP with hypoxia and oxidative stress from inadequate uteroplacental perfusion–> systemic inflammatory response and endothelial cell dysfunction

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10
Q

Moderate risk factors for pre-eclampsia?

A

Nuliparity
Maternal age> 40 years
Maternal BMI > 35 at inital presentation
Family hx of pre-eclampsia
Pregnancy interval > 10 years
Multiple pregnancy

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11
Q

High risk factors for Pre-eclampsia?

A

chronic hypertension
HTN, pre-eclampsia or eclampsia in previous pregnancy
Autoimmune disorder
Type 1 or Type 2 DM
CKD

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12
Q

How do you manage the risk of pre-eclampsia?

A

If a pt has one or more high RF or 2 or more moderate RF:
Aspirin 75mg-150mg daily from 12 weeks gestation until the birth

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13
Q

Triad of pre-eclampsia?

A

New onset hypertension
Oedema
Proteinuria

(POOH = Protein, Odema, (new)Onset Hypertension)

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14
Q

What is the definition of pre-eclampsia?

A

New onset BP greater than and equal to 140/90 after 20 weeks
AND, one or more of the following:
Proteinuria
Other organ involvement e.g. renal insufficiency, liver, neuro, haem or uteroplacental dysfunction

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15
Q

Features of Pre-eclampsia

i.e. what can it progress to? Fetal complications? any other organ involvement?

A

May progress to eclampsia: other neuro complications incl altered mental state, blindness, convulsions, severe headaches, clonus, stroke, persistent visual scotomata

Fetal complications (IUGR, prematurity)

Liver involvement

Haemorrhage: placental abruption, intra-abdominal, intra-cerebral, cardiac failure

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16
Q

Features of SEVERE pre-eclampsia?

A

Hypertension ( greater than or equal to 160/110)

Proteinuria: Dipstick ++/+++

Headache

Papilloedema

Visual disturbances

RUQ/epigastric pain

Hyperreflexia

Platelet count < 100 x 106, abnormal liver enzymes or HELLP

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17
Q

Classification of pre-eclampsia?

A

Mild: BP 140/90-149/99 mmHg
Moderate: BP 150/100 – 159/109 mmHg
Severe: BP > 160/110 + proteinuria > 0.5 g/ day
or
BP > 140/90 mmHg + proteinuria + symptoms.

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18
Q

Maternal complications of pre-eclampsia?

A

Eclampsia
AKI
HELLP syndrome
DIC
ARDS
HTN (post partum as well)
Death

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19
Q

Ddx of pre-eclampsia?

A

Chronic HTN
Gestational HTN
Epilepsy
Liver disease

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20
Q

What is HELLP syndrome

A

Complication of pre-eclampsia

Patient has haemolysis, elevated liver enzymes and low platelets

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21
Q

Investigations in pre-eclampsia?

A

Urinalysis- first dipstick and then 24 hour collection ( > or equal to 300mg of protein in 24 hours is diagnostic)
BP

FBC- may see reduced Hb, reduced platelets
U&Es- may see increased urea and creatinine and reduced output due to renal involvement
LFTS- may see elevated enzymes due to hepatic involvement

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22
Q

Management of pre-eclampsia

A

Frequent monitoring via regular blood pressure measurements, urinalysis, blood tests, fetal growth scans and cardiotocography

VTE prevention: most women are managed as an inpatient and given LMWH

Anti-hypertensives: Labetalol first line, Nifedipine is 2nd line (e.g. asthma)

Delivery is the only definite cure:

**Where a woman is less than 35 weeks’ gestation, and delivery is considered, intramuscular steroids should be administered to aid development of the fetal lungs.

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23
Q

Management of eclampsia?

A
  1. DRABCDE
  2. Magnesium sulfate 4g bolus over 10 minutes followed by 1g/hour for 24 hours
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24
Q

What is eclampsia?

A

Eclampsia may be defined as the development of seizures in association pre-eclampsia.

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25
Q
  1. Use of magnesium sulphate in eclampsia?
  2. what should you monitor after giving woman magnesium sulfate?
A
  1. prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop.
  2. monitor reflexes and respiratory rate
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26
Q

How to do you treat eclampsia?

A

Magnesium sulphate should be given as soon as the decision to deliver has been made

IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour

urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment

respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

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27
Q

What is placenta praevia?

A

Placenta fully or partially attached to the lower uterine segment

Cause of antepartum haemorrhage

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28
Q

What is antepartum haemorrhage?

A

Vaginal bleeding from week 24 gestation until delivery

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29
Q

What are the 2 main types of placenta praevia?

A

Minor placenta praevia- placenta is low but does not cover the internal cervical os

Major placenta praevia- placenta lies over the internal cervical os.

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30
Q

What can trigger haemorrhage in placenta praevia?

A

Spontaneous
Mild trauma e.g. vaginal examination
May get damaged as the presenting part of the fetus moves into lower uterine segment

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31
Q

RF for placenta praevia?

A

Multiparity
Multiple pregnancy
Maternal age>40
Previous placenta praevia
Lower segment scar
History of uterine infection (endometriosis)

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32
Q

Clinical features of placenta praevia?

A

Shock in proportion to visible loss
no pain
uterus NOT tender
lie and presentation may be abnormal
Fetal HR usually normal
Coagulation problems rare
Small bleeds before large

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33
Q

When should you be suspicious of ?placenta praevia

A

Any women presenting with painless vaginal bleeding
May be spotting to massive haemorrhage

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34
Q

Questions to ask a woman who presents with antepartum haemorrhage?

A

How much bleeding was there and when did is start?
Was it fresh red or old brown blood, or was it mixed with mucus?
Could the waters have broken (membranes ruptured?)
Was it provoked (post-coital) or not?
Is there any abdominal pain?
Are the fetal movements normal?
Are there any risk factors for abruption? e.g. smoking/drug use/trauma – domestic violence is an important cause.

IF bleed is ongoing or there is a significant vaginal bleed- A-E if the woman is clinically stable proceed to examination

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35
Q

How to exam a woman with antepartum haemorrhage?

A

Pallor, distress, check capillary refill, are peripheries cool?
Is the abdomen tender?
Does the uterus feel ‘woody’ or ‘tense’ (which may indicate placental abruption)?
Are there palpable contractions?
Check the lie and presentation of the fetus/fetuses. Ultrasound can be used to help.
Check fetal wellbeing with a cardiotocograph (CTG) at 26 weeks gestation or above: (otherwise auscultate the fetal heart only).
Read the hand-held pregnancy notes: are there scan reports? This will be helpful in establishing whether there could be placenta praevia

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36
Q

How do you diagnose placenta praevia?

A

Digital vaginal exam should NOT be performed before an USS as it may provoke severe haemorrhage

Often picked up on the 20 week abdominal USS

Use of transvaginal USS improves accuracy and is considered safe

37
Q

Classical grading of placental praevia?

A

I- placenta reached lower segment but not the internal os
II- placenta reaches internal os but doesn’t cover it
III- placenta covers the internal os before dilation but not when dilated
IV (major)- placenta cover the internal os

38
Q

Ddx of placenta praevia?

A

Placental abruption
Vasa praevia
Uterine rupture
Benign or malignant lesions e.g. polyps, carcinoma, cervical ectropion
Infections e.g. candida, BV and chlamydia

39
Q

Investigations of placenta praevia/ any major bleeding?

A

FBC- assess any maternal anaemia
Clotting profile
Kleinbauer test- if women is Rhesus Negative ( to determine the amount of feto-maternal haemorrhage and thus the dose of anti-D required
Group and Save
Crossmatch- if we need to transfuse
U&Es and LFTs to exclude any pre-eclampsia or HELLP syndrome

Assess fatal wellbeing using CTG
Definitive diagnosis is via USS

40
Q

Management of placenta praevia?

A

Usually identified in an asymptomatic patient at their 20 week USS

Placenta praevia minor- repeat scan at 36 weeks is recommended as the placenta is likely to have moved superiorly

Placenta praevia major- repeat scan at 32 weeks is recommended and a plan for delivery should be made at this point

Placenta praevia usually warrants an elective C-section- usually at 38 weeks

41
Q

Management of obstetric cholestasis?

A

Induction of labour at 37-38 weeks
Ursodeoxycholic acid
Vit K supplementation

42
Q

What is placental abruption?

A

Seperation of a normally sited placenta from the uterine wall resulting in maternal haemorrhage into the intervening space

43
Q

Risk factors for placental abruption?

A

Proteinuric hypertension
Cocaine use
Multiparity
Maternal trauma
Increasing maternal age

44
Q

Clincal features of placental abruption?

A
  • Shock out of keeping with visible loss
  • pain constant
  • tender, tense uterus
  • normal lie and presentation
  • fetal heart: absent/distressed
  • coagulation problems
  • BEWARE pre-eclampsia, DIC, anuria
45
Q

Managment of placental abruption?

A

Fetus alive < 36 weeks
* fetal distress: immediate caesarean
* no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation
Fetus alive > 36 weeks
* Fetal distress: immediate caesarean
* no fetal distress: deliver vaginally
Fetus dead
* Induce vaginal delivery
*

46
Q

Complictions of placental abruption?

A

Maternal:
* shock
* DIC
* renal failure
* PPH
Fetal
* IUGR
* hypoxia
* death

47
Q

Prognosis of placental abruption?

A
  • associated with high perinatal mortality rate
  • responsible for 15% of perinatal deaths
48
Q

How may someone with placental abruption present?

A

Painful vaginal bleeding
Woody uterus and painful on palpation

49
Q

Types of Placental abruption?

A
  • Revealed: bleeding tacks down from the site of placental separation and drains through the cervix. This results in vaginal bleeding
  • Concealed: bleeding remains within the uterus and typically forms a clot retroplacentally. This bleeding is not visible but usually enough to cause systemic shock
50
Q

DDx for placental abruption?

A
  • Placenta praevia
  • Marginal placental bleed
  • Vasa praevia
  • Uterine rupture
  • Local genital causes e.g. polyps or infections
51
Q

What is vasa praevia?

A

Where fetal blood vessels run near the internal cervical os.

Triad of:
* vaginal bleeding
* Rupture of membranes
* Fetal compromise

52
Q

What is gestational diabetes?

A

Any degree of glucose intolerance with onset or first recognition during pregnancy

53
Q

Pathophysiology of gestational diabetes?

A

Progressive insulin resistance in pregnancy
Woman with borderline pancreatic reserve is unable to respond to the increased insulin requirements, resulting in transient hyperglycaemia.

54
Q

RF for gestational DM?

A
  • BMI>30kg/m2
  • previous macrosomic baby weighing 4.5kg or above
  • previous gestational DM
  • first degree relative with DM
  • South asian/black caribbean/Middle eastern
55
Q

Clinical features of gestational DM?

A

may be asymptomatic
polyuria
polydipsia
fatigue

56
Q

Fetal complications of gestational DM?

A

Fetus has hyperinsulinaemia due to increased glucose. Insulin is similar structure to growth hormones so:
* Macrosomia-> lead to labour complications e.g. shoulder dsytocia
* Organomegaly
* Erythropoiesis
* Polyhydramnios
* Increased rates of pre-term delivery

After delivery, baby has been used to high glucose, risk of becoming hypoglycaemic- needs regular feeding

High insulin can cause reduction in pulmonary phospholipids–> high risk of transient tachypnoea of the newborn

57
Q

Investigations for gestational diabetes?

A

Oral glucose tolerance test: fasting plasma glucose is measured, then 75g glucose drink is given- with a repeat plasma glucose measurement after 2 hours

Fasting glucose > 5.6mmol/L
2hrs postprandial glucose > 7.8 mmol/L

58
Q

When is the oral glucose tolerance test offered?

A

Booking- if previous gestational diabetes
24-28 weeks gestation- if RF are present, or if previous gestational DM
Any point during pregnancy- if 2+ glycosuria on one occasion, or 1+ on 2 occasions

59
Q

Managemnt of gestation DM?

A
  • newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
  • women should be taught about self-monitoring of blood glucose
  • advice about diet and exercise should be given
    if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
  • if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
  • if glucose targets are still not met insulin should be added to diet/exercise/metformin
  • gestational diabetes is treated with short-acting, not long-acting, insulin
  • if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
  • if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
  • glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
60
Q

What are the self-monitoring glucose targets for women with GDM or DM?

A

Fasting: 5.3mmol/L
1 hour after meals: 7.8 mmol/L
2 hour after meal: 6.4 mmol/L

61
Q

Post-partum management of GDM?

A

All diabetic medication stopped immediately after delivery.
Blood glucose checked and ensured it has returned to normal before discharge
6-13 week post partum, fasting glucose test is recommended, if normal, tests should be offered yearly

62
Q

Why is pregnancy a RF for VTE?

A

As you are hypercoaguable

63
Q

When is pregnant lady considered high risk for VTE?

A

If had previous VTE

64
Q

When is a pregant lady considered intermediate risk of developing VTE?

A

Hospitalisation
Surgery
Co-morbities
Thrombophilia

65
Q

Other RF for VTE?

A

Age > 35
Body mass index > 30
Parity > 3
Smoker
Gross varicose veins
Current pre-eclampsia
Immobility
Family history of unprovoked VTE
Low risk thrombophilia
Multiple pregnancy
IVF pregnancy

66
Q

When do you treat a pregnant lady for VTE?

A

4 or more risk factors: immediate treatment with LMWH until 6 weeks postnatally

3 risk factors LMWH should be initaited from 28 weeks and continued until 6 weeks postnatally

67
Q

Management for a pregnant patient with a DVT?

A

Continue anticoagulation treatment for at least 3 months

68
Q

Clinical features of DVT?

A

Unilateral leg swelling and leg pain
Pyrexia
Pitting oedma
Tenderness
Prominent superficial veins

69
Q

Clincial features of PE?

A

Sudden onset dyspnoea
Pleuritic chest pain
Cough
Haemoptysis

Signs: tachycardia, tachypnoea, pyrexia, raised JVP or pleural rub or pleural effusion

70
Q

DDx DVT

A

Cellulitis
ruptured Baker’s cyst
Superficial vein thrombophlebitis

71
Q

PE Ddx?

A

ACS
Aortic dissection
Pneumonia
Pneumothorax

72
Q

Do you do a D-dimer in a pregnant woman with a suspected DVT?

A

NO! D-dimer will normally be raised in pregnancy

73
Q

Women who are on LMWH due to DVT prophylaxis should stop their dose before induction/c-section. True or false?

A

TRUE- omit the dose 24 hours before any planned induction of labour or C-section.

They should not take their dose if they think they are going into labour

74
Q

How assess bleeding in a pregnant lady?

A

Externally- look at pads

Cusco speculum exam- avoid until placenta praevia has been excluded by USS. Look for whether blood is fresh or dark, how much blood, are they are clots, are there any cervical lesions, is there any cervical dilatation, or any chance have membranes ruptured

Take triple genital swabs to exclude infection if the bleeding is minimal

DVE: contraindicated in PLACENTA PRAEVIA, if excluded- can help to see whether cervix if dilated, avoid if membranes have ruptured

75
Q

Causes of bleeding in 1st trimester of pregnancy?

A

Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole

76
Q

Cause of bleeding 2nd trimester pregnancy?

A

Spontaneous abortion
Hydatidiform mole
Placental abruption

77
Q

Cause of bleeding 3rd trimester

A

Bloody show
Placental abruption
Placenta praevia
Vasa praevia

78
Q

What is hydatiform mole?

A

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

79
Q

How does BP change in pregnancy?

A

BP usually falls during the 1st trimester and continues to fall until 20-24 weeks
After this time the BP usually increases to pre-pregnancy levels by term

80
Q

Prophylaxis for women at risk of developing pre-eclapmsia?

A

75mg aspirin od from 12 weeks until babys birth

81
Q

Criteria for HTN in pregnancy?

A

systolic > 140 mmHg or diastolic > 90 mmHg
or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

82
Q

Mangement of HTN in pregnancy?

A

Oral labetalol
Oral nifedipine and hydralazine (2nd line)

83
Q

HTN in pregnancy vs pre-eclampsia?

A

HTN: hypertension after 20 weeks in pregnancy
Pre-eclampsia: hypertension associated with proteinuria (>0.3g/24 hrs)

84
Q

What is maternal collapse?

A

acute event involving the cardiorespiratory systems and/or central nervous system resulting in a reduced or absent conscious level (and potentially cardiac arrest and death), at any stage in pregnancy and up to 6 weeks after birth

85
Q

Causes of Maternal collapse?

A

5H’s
Hypovolaemia
Hypoxia
Hypo/hyperkalaemia
Hypo/hypernatraemia
Hypothermia

4T’s
Thromboembolism
Toxicity
Tension pneumothorax
Tamponade

Eclampia and pre-eclampsia
Intracranial haemorrhage

86
Q

Mangement of maternal collapse?

A

ABCDE approach
If pt RESPONDS:
2222- obstetric emergency call
Place in left lateral position if TILTED in theatres or if outside this environment, manually and generally displace the uterus to relieve aortocaval compression
Give high flow oxygen- SATS of at least 94%
Commence MEOWS chart if not already in use and escalate appropriately
Assess fetal wellbeing
Check blood glucose level
Insert 16G IV cannula
Take bloods for: FBC, G&S or crossmatch 4 units
U&Es
Clotting studies
ABG/VBG and lactate
Blood cultures should be obtained by separate venous stab as per trust guidelines

NO RESPONSE
2222 Maternal cardiac arrest
Ensure manual uterine displacement in women above 20 weeks gestation or where the
uterus is palpable at or above the level of the umbilicus.

87
Q

When is perimorten c-section (PMCS) indicated in maternal collapse?

A

Interests of maternal survival
In women over 20 weeks gestation, if not response to CPR within 4 mins of maternal collapse or resuscitation is continued beyond this, the PMCS should be undertaken. Should be achieved within 5 mins of collapse

88
Q

Pt with suspected ?PE

A

Baseline bloods- LFTS, U&Es for how LMWH will be metabolised

Treat with LMWH

Arrange imaging- V/Q scan or CTPA

CTPA- increase risk of childhood leukaemia
V/Q- small risk of breast cancer

Counsel pts on risk

89
Q

How does eclampsia impact management of the third stage of labour?

A

In eclamptic patients, management of the third stage of labour should be with oxytocin and not syntometrine/ergometrine because of the risk of increased BP.

quesmed

YEAR 4 REPRO (26 decks)

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