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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
How would you a placental abruption present?
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
26
What are features of a major placental abruption?
maternal collapse coagulopathy fetal distress woody hard uterus poor urine output
27
How would you manage placental abruption?
Admit even without vaginal bleeding, as long as pain and uterine tenderness IV fluid given and steroids Opiate analgesia Anti-D
28
What would the delivery options be in placental abruption?
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
29
What is ruptured vasa praevia?
fetal blood vessel runs in membranes in front of presenting part - when membranes rupture . vessels rupture
30
How does ruptured vasa praevia present?
painless vaginal bleeding accompanied by severe fetal distress
31
How would you define Small For Dates/SGA?
Weight of fetus is less than tenth centile for its gestation
32
What are some caveats for Small for dates/SGA?
Most SIMPLY small, having consistent growth and are not compromised Assessment of fetal weight customized to the individual is better at identifying IUGR
33
How would you define IUGR?
When growth in utero is slowed
34
What are some prenatal risk factors for IUGR?
``` Poor past obstetric hx or v.small baby Maternal disease Assisted conception mum too young or too old heavy smoking drugs ```
35
What are some antenatal risk factors for IUGR?
low PAPP-A in the 1st trimester = chromosomal abnorm, IUGR and plaental abrupt HTN/proteinuria Vaginal bleeding SFD baby prolonged pregancy multiple pregnancy
36
What investigation is good at identifying pregnancies at risk of adverse neonatal outcomes due to IUGR?
Maternal uterine artery doppler
37
How would you differentiate healthy small fetus and growth-restricted fetus?
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
38
Pathological causes of IUGR?
renal disease pre-eclampsia multiple preg smoking srug use infection malnutrition
39
Complications of IUGR?
stillbirth cerebral palsy preterm delivery
40
What would you find on Hostory and Examniation of IUGR fetus?
decreased fetal movements Fundal height decreased or slowed
41
What investigations would you carry out for IUGR? What would you find out?
USS - head sparing Umbilical artery doppler oligohydramnios
42
What is management of IUGR baby?
delivered if beyond 36 weeks - induced or c-section if pre-term - delay delivery until CTG or fetal dopplers abnormal
43
What is prolonged pregnancy?
>/42 weeks
44
What risks associated with prolonged pregnancy?
neonatal illness and encephalopathy meconium passage
45
What is management of prolonged pregnancy?
41-42 weeks - induce <41 weeks - sweeping
46
What is an abnormal lie?
Transverse/Oblique normal lie would be longitudinal (cephalic/breech)
47
Causes of abnormal lie?
Pre-term Polyhydramnios Twins Uterine Abnorm Placenta Praevia Pelvic Tumours
48
Complications of abnormal lie?
Head can't engage Arm or Umbilical cord may prolapse Uterine rupture
49
What is management of abnormal lie?
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
What are the different types of breech presentation?
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
What are the causes of breech presentation?
no cause previous breech premature fetal and uterine abnorm twin pregnancy placenta praevia pelvic tumours pelvic deform
52
How can breech be diagnosed?
Upper abdominal discomfort Hard head palpable and ballotable @ fundus USS will confirm diagnosis
53
What are complications of breech presentation?
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
What is management of breech presentation?
ECV from 37 weeks
55
What is the success rate of ECV? What are some risks associated?
50% of which 3% will turn back placental abruption uterine rupture
56
When is ECV contraindicated?
if fetus is compromised if vaginal delivery contra-indicated twins membranes ruptured recent APH
57
What are some manourvres that can be used for vaginal breech delivery?
Lovset's Mauriceau-Swellie-Veit
58
What are two different types of twins? Which is more common?
Dizygotic twins 66% Monozygotic (identical)
59
What determines if monozygotic twins share same placenta/amnion?
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
What is the risk associated with monochorionic monoamniotic twins?
have a higher fetal loss rate, particularly before 24 weeks
61
What increases the likelihood of multiple pregnancy?
assisted conception (20% IVF are multiple) genetic factors increasing maternal age parity
62
What signs may indicated multiple pregnancy?
vomiting worse in early pregnancy uterus larger than expected 3 or more fetal poles may be felt
63
What complications are associated with multiple pregnancy?
``` gest. diabetes and pre-eclampsia anemia long-term handicap pre-term delivery IUGR late miscarriage more common ```
64
What is twin-twin transfusion syndrome? What kind of twins is this found in?
MCDA twins Unequal blood distribution. intrauterine blood transfusion from one twin (donor) to another twin (recipient).
65
What is the consequence of twin-twin transfusion syndrome?
'donor' twin - volume deplted, anemia, IUGR and oligohydramnios 'recipient' twin - volume overloaded, polycythaemia, cardiac failure, massive polyhydramnios
66
How would you stage twin-twin transfusion?
Quintero staging 1-5
67
What is co-twin death?
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
What is a common complication of monoamniotic twins?
cords are always entangled and in utero demise is common
69
What can be ascertained from early USS of a multiple pregnancy?
screening for abnormality chorionicity - dichorionic twins (lambda sign), monochorionic (T sign) nuchal translucency - can predict MC twin complications
70
When can selective reduction be considered in a multiple pregnancy?
12 weeks
71
What are disadvantages and advantages of reduction in a multiple pregancy?
slight increased risk of early miscarriage decreased chances of preterm birth decreased cerebral palsy
72
When is c-section indicated for multiple pregnancy?
first fetus is breech/transverse high order multiples antepartum complications monochorionic twins
73
When are the recommended times for delivery of twins?
37-38 weeks - DC twins 34-37 weeks - MC twins after these periods perinatal mortality increases
74
What is hyperemesis gravidarum?
Extreme form of 'nausea and vomiting of pregnancy' (NVP) Triad : 5% pre-pregnancy weight loss dehydration electrolyte imbalance
75
What is hyperemesis gravidarum associated with?
multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity *smoking decreases incidence
76
What score can be used to assess severity of Hyperemesis gravidarum?
Pregnancy-Unique Quantification of Emesis (PUQE)
77
How would you manage Hyperemesis Gravidarum?
Antihistamines (promethazine) Ondansetron and metoclopramide 2nd admission for IV hydration
78
What complications are associated with Hyperemesis Gravidarum?
Wernicke's Encephalopathy Mallory-Weiss tear Acite tubular necrosis IUGR and pre term birth
79
What is hydatidiform mole?
trophoblastic tissues, which is part of the blastocyst that normally invades the endometrium and proliferates in a more aggressive way than normal
80
What are the different types of hydatidiform mole?
Complete mole - entirely paternal in origin, when sperm fertilized an empty oocyte - diploid 46 XX Partial mole - triploid > 2 sperms fertilize one oocyte
81
What is it called when hydatidiform mole is only in the uterus? and when it metastasizes?
invasive mole choriocarcinoma
82
What are the 3 Gestational trophoblastic disorders | ?
complete hydatidiform mole partial hydatidiform mole choriocarcinoma
83
What are the risk factors for gestational trophoblastic disorders?
extremes of age asian
84
Presentation of gestational trophoblastic disorders?
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
What would you do to investigate gestational trophoblastic disorders?
USS - snowstorm - swollen villi with complete moles serum hCG increase
86
How would you manage gestational trophoblastic disorder?
suction curettage - evacuation of retained products of conception
87
What will tubal damage cause?
tubal implantation ectopic pregnancy
88
When does the zygote enter the uterus? At what stage?
day 4 multicellular morula stage
89
How does the morula become a blastocyst? Which layer becomes the placenta?
by developing a fluid-filled cavity within the outer layer becomes trophoblast and then becomes the placenta
90
When does implantation occur?
Blastocyst invades the endometrium around the 6th to 12th day to achieve implantation
91
What produces hCG?
trophoblast
92
When is placental morphology complete? When is the fetal heart beat established?
12 weeks 16-17 weeks for FHR
93
What are the types of spontaneous miscarriage?
Threathened Inevitable Incomplete Complete Septic Missed Isolated non-recurring
94
What is a threathened miscarriage?
bleeding but fetus still alive uterus size as expected from dates OS closed 25% will miscarry
95
What is an inevitable miscarriage?
Heavy bleeding fetus may be alive but cervical os open miscarriage about to occur
96
What is an incomplete miscarriage?
some fetal parts passed os usually open
97
What is a complete miscarriage?
all fetal tissue has passed bleeding diminished uterus no longer enlarged and cervical OS closed
98
What is a septic miscarriage?
Contents of uterus are infected - endometritis vaginal loss usually offensive uterus is tender fever can be absent
99
What is a missed miscarriage?
fetus not developed or died - not recognized until bleeding or USS uterus smaller than dates OS is closed
100
How would you investigate a miscarriage?
increase of more than 66% in 48 hrs of hCG with a viable intrauterine pregnancy differentiates from an ectopic
101
How would you manage a miscarriage?
admit resus speculum - rempre products of conception in cervical os ergometrine - reduce bleeding swabs anti- D
102
How would you manage a non-viable intrauterine pregnancy?
continue as long as woman willing and no infection prostaglandin and oral anti-progesterone (mifepristone) ERPC - examine tissue to exclude molar
103
What is defined as recurrent miscarriage?
3 or more miscarriages in succession
104
What are some causes of recurrent miscarriages?
antiphospholid syndrome chromosomal defects infection anatomical factors obesity smoking PCOS increasing maternal age
105
How would you investigate recurrent miscarriages?
antiphospholipid antibody screen karyotyping both parents pelvic USS
106
When can you terminate a pregnancy?
<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
What conditions must be met for a pregnancy to be terminated past 24 weeks?
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
What tests should be done before termination?
Hb blood group rhesus status testing for haemoglobinopathies if rhesus -ve, receive anti-D within 72 hrs
109
How would you terminate a pregnancy?
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
What are complications associated with termination?
haemorrhage infection uterine perforation cervical trauma failure
111
What are some sites for ectopic?
Fallopian tube 95% cornual abdo cervical ovarian
112
What are some causes for ectopic pregnancy?
increasing maternal age PID STI assisted contraception surgery previous ectopic smoker IUD - exclude in anyone with copper IUD but still preg
113
How does an ectopic present?
'classic' - collapse with abdo pain abnormal vaginal bleeding abdo pain collapse shoulder-tip pain - intraperitoneal blood
114
What would you see on examination of someone with ectopic pregnancy?
tachycardia hypotension collapse abdominal and often rebound tenderness movement of uterus might cause pain smaller uterus than expected cervical os closed
115
How would you investigate an ectopic pregnancy?
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
How would you manage a ectopic?
admit IV access anti-D laparoscopy + salpingostomy/salpingectomy hCG < 3000 - single dose MTX

Obstetrics (5 decks)

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