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Obstetrics > Complications during pregnancy > Flashcards

Complications during pregnancy Flashcards

1
Q

What period of gestation is considered to be pre-term?

A

24-37 weeks, greatest risk is at <34 wks

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2
Q

What are complications of preterm delivery?

A

Neonatal ICU admission

Perinatal morbidity

Cerebral Palsy

CLD

Blindness

Maternal infection

Endometritis

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3
Q

What are some risk factors for preterm delivery?

A

Previous History

Lower Socioeconomic Class

Increasing maternal age

Short inter-pregnancy interval

Maternal disease (renal, diabetes, thyroid, pre-eclampsia)

STIs

Vaginal Infection

Multiple Preg

Fibroids

UTI

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4
Q

What are the mechanisms that cause pre-term labour?

A

‘too many defenders’ - multiple, excess liquour, polyhydramnios

fetal survival response - pre-eclampsia, IUGR, Infection, placental abruption

Uterine Abnorm - fibroids, congenital abnorm

Cervical incompetence - dilation/effacement before term

Infection

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5
Q

What are some methods of preterm prevention?

A

Cervix Cerclage - pre-pregnancy
‘rescue suture’ - prevent delivery even with dilation

Progesterone supplementation

Maintenance of good bacteria - e.g. metronidazole gets rid of good bacteria

Fetal reduction - reducing number of multiples

Polyhydramnios - needle aspiration (amnioreduction)

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6
Q

What would you see on presentation of preterm labour?

A

painful contractions

cervical incompetence (painless, dull suprapubic ache)

fever

effaced or dilating cervix confirms diagnosis

Antepartum and fluid loss are common

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7
Q

What investigations would you carry out in suspected preterm labour?

A

Check fetal state - CTG and USS

Likelihood of delivery - if cervix is uneffaced and fetal fibronectin assay is negative = preterm is unlikely
- transvaginal scan of cervical length - >15mm = delivery unlikely

Check for infection - vaginal swabs and CRP

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8
Q

How would you manage preterm delivery?

A

Steroids - given between 24 and 34 weeks

Tocolysis - nifedipine or atosiban (delays labour to allow 24 hrs for steroids to work)

Magnesium Sulphate - neuroprotective

Delivery - vaginal, forceps rather than ventouse if needed

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9
Q

What are some complications of preterm prelabour rupture of membrane?

A

pre-term delivery

infection

prolapse of umbilical cord

pulmonary hypoplasia and postural deformity (absence of liquor)

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10
Q

How would a premature ROM present?

A

Pool of fluid in post.fornix on speculum exam is diagnostic

Chorioamnionitis - contractions, abdo pain, fever, tachycardia, uterine tenderness and coloured or offensive liquor

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11
Q

What investigations would you carry our for premature ROM?

A

commercially available tests available

USS - decreased liquor

Vaginal Swab

Assess fetal well - being CTG

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12
Q

Management of premature ROM?

A

Women admitted and steroids given

maternal signs of infection and fetal surveilance performed

erythromycin prophylaxis

If 36 weeks reached induction performed

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13
Q

What is antepartum hemorrhage?

A

bleeding from gental tract after 24 weeks gestation

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14
Q

What are some causes of antepartum haemorrhage?

A

undetermined

placental abruption

placenta praevia

incidental genital tract pathology

uterine rupture

vasa praevia

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15
Q

What is placenta praevia?

A

When the placenta is implanted in the lower segment of the uterus

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16
Q

How would you class placenta praevia?

A

Marginal - in lower segment of uterus, not covering os

Major - completely or partially covering os

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17
Q

What are some risk factors for placenta pravia?

A

twins

high parity

high age

uterus scarred

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18
Q

What are some complications of placenta praevia?

A

Obstructs engagement of head

Haemorrhage can be severe

Placenta Accreta

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19
Q

How would placenta praevia present?

A

Intermittent painless bleeds which increase in frequency and intensity over weeks

Breech presentation and Transverse lie are common

Fetal head is not engaged and high

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20
Q

What investigation would you carry out in placenta praevia? What is indication that placenta will remian praevia at term?

A

USS - normally second trimester

repeat @ 32 weeks - if <2cm from internal os, likely to remain praevia @ term

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21
Q

How would you manage placenta praevia? What if asymptomatic?

A

Admission > if bleeding stay until delivery

anti-D

IV access maintained

steroids if <34 weeks

If asymp, delay admission until 37 weeks, then elective c-section at 39 weeks. Anticipate placenta accreta

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22
Q

What is placental abruption?

A

When part (or all) of placenta separates before delivery of fetus - maternal bleeding may occur behind it

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23
Q

What are complications of placental abruption?

A

Fetal death (30% of proven abruptions)

DIC

Renal Failure

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24
Q

What are some risk factors of placental abruption?

A

IUGR

Pre-eclampsia

Pre-existing HTN

Maternal Smoking

Previous Abruption

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25
Q

How would you a placental abruption present?

A

Painful bleeding (amount not reflective of severity)

Tachycardia

Uterus soft and contracting

Uterus woody hard and fetus difficult to feel

Fetal heart tones are often abnormal or absent

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26
Q

What are features of a major placental abruption?

A

maternal collapse
coagulopathy
fetal distress
woody hard uterus

poor urine output

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27
Q

How would you manage placental abruption?

A

Admit even without vaginal bleeding, as long as pain and uterine tenderness

IV fluid given and steroids

Opiate analgesia

Anti-D

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28
Q

What would the delivery options be in placental abruption?

A

If fetal distress and <37 weeks - C-section

If fetal distress and >37 weeks - induction with amniotomy

If fetus dead - blood products given and labour induced

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29
Q

What is ruptured vasa praevia?

A

fetal blood vessel runs in membranes in front of presenting part - when membranes rupture . vessels rupture

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30
Q

How does ruptured vasa praevia present?

A

painless vaginal bleeding accompanied by severe fetal distress

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31
Q

How would you define Small For Dates/SGA?

A

Weight of fetus is less than tenth centile for its gestation

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32
Q

What are some caveats for Small for dates/SGA?

A

Most SIMPLY small, having consistent growth and are not compromised

Assessment of fetal weight customized to the individual is better at identifying IUGR

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33
Q

How would you define IUGR?

A

When growth in utero is slowed

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34
Q

What are some prenatal risk factors for IUGR?

A 
Poor past obstetric hx or v.small baby
Maternal disease
Assisted conception
mum too young or too old
heavy smoking
drugs
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35
Q

What are some antenatal risk factors for IUGR?

A

low PAPP-A in the 1st trimester = chromosomal abnorm, IUGR and plaental abrupt

HTN/proteinuria

Vaginal bleeding

SFD baby

prolonged pregancy

multiple pregnancy

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36
Q

What investigation is good at identifying pregnancies at risk of adverse neonatal outcomes due to IUGR?

A

Maternal uterine artery doppler

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37
Q

How would you differentiate healthy small fetus and growth-restricted fetus?

A

Rate of growth - two scans two weeks apart

Pattern of smallness - abdomen will stop enlarging before head

Allowing allowance for ‘customization’ of individual fetal growth

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38
Q

Pathological causes of IUGR?

A

renal disease

pre-eclampsia

multiple preg

smoking

srug use

infection

malnutrition

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39
Q

Complications of IUGR?

A

stillbirth

cerebral palsy

preterm delivery

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40
Q

What would you find on Hostory and Examniation of IUGR fetus?

A

decreased fetal movements

Fundal height decreased or slowed

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41
Q

What investigations would you carry out for IUGR? What would you find out?

A

USS - head sparing

Umbilical artery doppler

oligohydramnios

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42
Q

What is management of IUGR baby?

A

delivered if beyond 36 weeks - induced or c-section

if pre-term - delay delivery until CTG or fetal dopplers abnormal

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43
Q

What is prolonged pregnancy?

A

> /42 weeks

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44
Q

What risks associated with prolonged pregnancy?

A

neonatal illness and encephalopathy

meconium passage

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45
Q

What is management of prolonged pregnancy?

A

41-42 weeks - induce

<41 weeks - sweeping

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46
Q

What is an abnormal lie?

A

Transverse/Oblique

normal lie would be longitudinal (cephalic/breech)

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47
Q

Causes of abnormal lie?

A

Pre-term

Polyhydramnios

Twins

Uterine Abnorm

Placenta Praevia

Pelvic Tumours

48
Q

Complications of abnormal lie?

A

Head can’t engage

Arm or Umbilical cord may prolapse

Uterine rupture

49
Q

What is management of abnormal lie?

A

No action required if less than <37 weeks unless women is in labour

> 37 weeks women admitted and ultrasound to detect polyhydramnios and placenta praevia

-if spontaneous version occurs and persists for 48 hrs then mother is discharged

If persistently abnormal - C-section

50
Q

What are the different types of breech presentation?

A

extended - both legs extended at the knee (70%)

flexed - both legs flexed at the knee (15%)

footling - one or both feet present below buttocks (15%)

51
Q

What are the causes of breech presentation?

A

no cause

previous breech

premature

fetal and uterine abnorm

twin pregnancy

placenta praevia

pelvic tumours

pelvic deform

52
Q

How can breech be diagnosed?

A

Upper abdominal discomfort

Hard head palpable and ballotable @ fundus

USS will confirm diagnosis

53
Q

What are complications of breech presentation?

A

perinatal and long term morbidity and mortality increased

increased long-term neurological handicap

increased risk of cord prolapse

head can get trapped during birth - die

54
Q

What is management of breech presentation?

A

ECV from 37 weeks

55
Q

What is the success rate of ECV? What are some risks associated?

A

50% of which 3% will turn back

placental abruption

uterine rupture

56
Q

When is ECV contraindicated?

A

if fetus is compromised

if vaginal delivery contra-indicated

twins

membranes ruptured

recent APH

57
Q

What are some manourvres that can be used for vaginal breech delivery?

A

Lovset’s

Mauriceau-Swellie-Veit

58
Q

What are two different types of twins? Which is more common?

A

Dizygotic twins 66%

Monozygotic (identical)

59
Q

What determines if monozygotic twins share same placenta/amnion?

A

Time of which division into separate zygotes occur

before day 3 - twins w separate placentas and amnions

days 4-8 (70%) - twins w shared placenta

days 9-13 - twins with shared placenta and amnion
- monochorionic and monoamniotic

60
Q

What is the risk associated with monochorionic monoamniotic twins?

A

have a higher fetal loss rate, particularly before 24 weeks

61
Q

What increases the likelihood of multiple pregnancy?

A

assisted conception (20% IVF are multiple)

genetic factors

increasing maternal age

parity

62
Q

What signs may indicated multiple pregnancy?

A

vomiting worse in early pregnancy

uterus larger than expected

3 or more fetal poles may be felt

63
Q

What complications are associated with multiple pregnancy?

A 
gest. diabetes and pre-eclampsia
anemia
long-term handicap
pre-term delivery
IUGR
late miscarriage more common
64
Q

What is twin-twin transfusion syndrome? What kind of twins is this found in?

A

MCDA twins

Unequal blood distribution. intrauterine blood transfusion from one twin (donor) to another twin (recipient).

65
Q

What is the consequence of twin-twin transfusion syndrome?

A

‘donor’ twin - volume deplted, anemia, IUGR and oligohydramnios

‘recipient’ twin - volume overloaded, polycythaemia, cardiac failure, massive polyhydramnios

66
Q

How would you stage twin-twin transfusion?

A

Quintero staging 1-5

67
Q

What is co-twin death?

A

IF one of an MC twin dies

its drop in BP causes an acute transfusion in blood from the other and causes hypovolaemia which results in death or neurodamage

68
Q

What is a common complication of monoamniotic twins?

A

cords are always entangled and in utero demise is common

69
Q

What can be ascertained from early USS of a multiple pregnancy?

A

screening for abnormality

chorionicity - dichorionic twins (lambda sign), monochorionic (T sign)

nuchal translucency - can predict MC twin complications

70
Q

When can selective reduction be considered in a multiple pregnancy?

A

12 weeks

71
Q

What are disadvantages and advantages of reduction in a multiple pregancy?

A

slight increased risk of early miscarriage

decreased chances of preterm birth

decreased cerebral palsy

72
Q

When is c-section indicated for multiple pregnancy?

A

first fetus is breech/transverse

high order multiples

antepartum complications

monochorionic twins

73
Q

When are the recommended times for delivery of twins?

A

37-38 weeks - DC twins

34-37 weeks - MC twins

after these periods perinatal mortality increases

74
Q

What is hyperemesis gravidarum?

A

Extreme form of ‘nausea and vomiting of pregnancy’ (NVP)

Triad : 5% pre-pregnancy weight loss

dehydration

electrolyte imbalance

75
Q

What is hyperemesis gravidarum associated with?

A

multiple pregnancies

trophoblastic disease

hyperthyroidism

nulliparity

obesity

*smoking decreases incidence

76
Q

What score can be used to assess severity of Hyperemesis gravidarum?

A

Pregnancy-Unique Quantification of Emesis (PUQE)

77
Q

How would you manage Hyperemesis Gravidarum?

A

Antihistamines (promethazine)

Ondansetron and metoclopramide 2nd

admission for IV hydration

78
Q

What complications are associated with Hyperemesis Gravidarum?

A

Wernicke’s Encephalopathy

Mallory-Weiss tear

Acite tubular necrosis

IUGR and pre term birth

79
Q

What is hydatidiform mole?

A

trophoblastic tissues, which is part of the blastocyst that normally invades the endometrium and proliferates in a more aggressive way than normal

80
Q

What are the different types of hydatidiform mole?

A

Complete mole - entirely paternal in origin, when sperm fertilized an empty oocyte - diploid 46 XX

Partial mole - triploid > 2 sperms fertilize one oocyte

81
Q

What is it called when hydatidiform mole is only in the uterus? and when it metastasizes?

A

invasive mole

choriocarcinoma

82
Q

What are the 3 Gestational trophoblastic disorders

?

A

complete hydatidiform mole
partial hydatidiform mole
choriocarcinoma

83
Q

What are the risk factors for gestational trophoblastic disorders?

A

extremes of age

asian

84
Q

Presentation of gestational trophoblastic disorders?

A

uterus large for dates

early pre-eclampsia

exaggerated symptoms of pregnancy e.g. hyperemesis

very high serum levels of human chorionic gonadotropin (hCG)

hypertension

hyperthyroidism (hCG can mimick TSH)

85
Q

What would you do to investigate gestational trophoblastic disorders?

A

USS - snowstorm - swollen villi with complete moles

serum hCG increase

86
Q

How would you manage gestational trophoblastic disorder?

A

suction curettage - evacuation of retained products of conception

87
Q

What will tubal damage cause?

A

tubal implantation

ectopic pregnancy

88
Q

When does the zygote enter the uterus? At what stage?

A

day 4

multicellular morula stage

89
Q

How does the morula become a blastocyst? Which layer becomes the placenta?

A

by developing a fluid-filled cavity within

the outer layer becomes trophoblast and then becomes the placenta

90
Q

When does implantation occur?

A

Blastocyst invades the endometrium around the 6th to 12th day to achieve implantation

91
Q

What produces hCG?

A

trophoblast

92
Q

When is placental morphology complete? When is the fetal heart beat established?

A

12 weeks

16-17 weeks for FHR

93
Q

What are the types of spontaneous miscarriage?

A

Threathened

Inevitable

Incomplete

Complete

Septic

Missed

Isolated non-recurring

94
Q

What is a threathened miscarriage?

A

bleeding but fetus still alive

uterus size as expected from dates

OS closed

25% will miscarry

95
Q

What is an inevitable miscarriage?

A

Heavy bleeding

fetus may be alive but cervical os open

miscarriage about to occur

96
Q

What is an incomplete miscarriage?

A

some fetal parts passed

os usually open

97
Q

What is a complete miscarriage?

A

all fetal tissue has passed

bleeding diminished

uterus no longer enlarged and cervical OS closed

98
Q

What is a septic miscarriage?

A

Contents of uterus are infected - endometritis

vaginal loss usually offensive

uterus is tender

fever can be absent

99
Q

What is a missed miscarriage?

A

fetus not developed or died - not recognized until bleeding or USS

uterus smaller than dates

OS is closed

100
Q

How would you investigate a miscarriage?

A

increase of more than 66% in 48 hrs of hCG with a viable intrauterine pregnancy

differentiates from an ectopic

101
Q

How would you manage a miscarriage?

A

admit

resus

speculum - rempre products of conception in cervical os

ergometrine - reduce bleeding

swabs

anti- D

102
Q

How would you manage a non-viable intrauterine pregnancy?

A

continue as long as woman willing and no infection

prostaglandin and oral anti-progesterone (mifepristone)

ERPC - examine tissue to exclude molar

103
Q

What is defined as recurrent miscarriage?

A

3 or more miscarriages in succession

104
Q

What are some causes of recurrent miscarriages?

A

antiphospholid syndrome

chromosomal defects

infection

anatomical factors

obesity

smoking

PCOS

increasing maternal age

105
Q

How would you investigate recurrent miscarriages?

A

antiphospholipid antibody screen

karyotyping both parents

pelvic USS

106
Q

When can you terminate a pregnancy?

A

<24 weeks

two registered medical practitioners must sign a legal document (in an emergency only one is needed)

only a registered medical practitioner can perform an abortion, which must be in a NHS hospital or licensed premise

107
Q

What conditions must be met for a pregnancy to be terminated past 24 weeks?

A

injury to the physical or mental health of the pregnant woman or any existing children of her family

to prevent grave permanent injury to the physical or mental health of the pregnant woman

involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated

substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped.

108
Q

What tests should be done before termination?

A

Hb

blood group

rhesus status

testing for haemoglobinopathies

if rhesus -ve, receive anti-D within 72 hrs

109
Q

How would you terminate a pregnancy?

A

mifepristone + prostaglandin (36-48 hrs later) <9 weeks

suction and curettage <13 weeks

dilation and evacuation (>15 weeks)

if very late >22 weels - KCL into umbilical vein

110
Q

What are complications associated with termination?

A

haemorrhage

infection

uterine perforation

cervical trauma

failure

111
Q

What are some sites for ectopic?

A

Fallopian tube 95%

cornual

abdo

cervical

ovarian

112
Q

What are some causes for ectopic pregnancy?

A

increasing maternal age

PID

STI

assisted contraception

surgery

previous ectopic

smoker

IUD - exclude in anyone with copper IUD but still preg

113
Q

How does an ectopic present?

A

‘classic’ - collapse with abdo pain

abnormal vaginal bleeding

abdo pain

collapse

shoulder-tip pain - intraperitoneal blood

114
Q

What would you see on examination of someone with ectopic pregnancy?

A

tachycardia

hypotension

collapse

abdominal and often rebound tenderness

movement of uterus might cause pain

smaller uterus than expected

cervical os closed

115
Q

How would you investigate an ectopic pregnancy?

A

pregnancy test, if positive >

USS- doesn’t always visualize ectopic, if not detected intrauterine (gestation too early, complete miscarriage, pregnancy elsewhere)

serum hCG - >1000 IU/mL = either visible to transvaginal USS

If lower than 1000 IU/mL but rises more than 66% in 48 hrs, an earlier but intrauterine preg is likely

declining or slower rising = ectopic

LAPAROSCOPY is best

116
Q

How would you manage a ectopic?

A

admit

IV access

anti-D

laparoscopy + salpingostomy/salpingectomy

hCG < 3000 - single dose MTX

Obstetrics (5 decks)

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