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Year 4k: Obs and Gynae > Complications Encountered in Pregnancy 2 > Flashcards

Complications Encountered in Pregnancy 2 Flashcards

1
Q

What are causes of jaundice in pregnancy?

A
  • Intrahepatic cholestasis of pregnancy (also known as obstetric cholestasis)
  • Acute fatty liver of pregnancy
  • Gilbert’s exarcebation during pregnancy
  • Dubin-Johnson syndrome exarcebation during pregnancy
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2
Q

What are features of obstetric cholestasis?

A
  • Generally seen in 3rd trimester and most common liver disease of pregnancy.
  • Affects 1% of all pregnancies
  • Recurrence rate of 45-90% in subsequent pregnancies
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3
Q

What are signs and symptoms of Obstetric Cholestasis?

A
  • Pruritus often in palms, soles and abdomen which is intense at night resulting in insomnia and malaise
  • No rash (although skin changes may be seen due to scratching)
    • If there is rash then consider pemphigoids gestation
  • Clinically detectable jaundice occurs in around 20% of patients
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4
Q

What are investigations for Obstetric Cholestasis?

A
  • LFT and bile acids: Elevated transaminases, Alkaline phosphatase raised, Raised gamma-GT, Raised bilirubin (90%), Raised bile acids
  • Viral screen: hep A, B and C, Epstein Barr virus and cytomegalovirus
  • Liver autoimmune screen
    • Chronic active hepatitis and primary biliary cirrhosis
    • Anti-smooth muscle and antimitochondrial antibodies
  • USS abdomen – liver and gallstones
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5
Q

What is the management of Obstetric Cholestasis?

A
  • Symptomatic Relief: Ursodeoxycholic acid.
    • Antihistamine and calamine can also be tried.
  • Weekly liver function tests and foetal surveillance
  • Delivery at foetal maturity and typically induced at 37 weeks
  • Vitamin K supplementation for neonate and mother
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6
Q

What are complications of Obstetric Cholestasis?

A

Foetal

  • Increased rate of stillbirth
  • Foetal distress
  • Perinatal mortality increased
  • Meconium
  • Preterm labour
  • Intracranial haemorrhage

Maternal

  • Vitamin K deficiency
  • Increased risk of PPH
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7
Q

What are features of Acute Fatty Liver of Pregnancy?

A
  • Occurs in 3rd trimester or period immediately following delivery
  • Severe disease may result in pre-eclampsia
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8
Q

What are signs and symptoms of Acute Fatty Liver of Pregnancy?

A

Symptoms

  • Abdominal pain
  • Nausea & vomiting
  • Headache

Signs

  • Hypoglycaemia
  • Jaundice
  • Elevated ALT
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9
Q

What is the management of patients with acute fatty liver of pregnancy?

A
  • Management: Supportive care. Once stabilised delivery is definitive management
  • Complications: Increased rate of stillbirth
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10
Q

What is Placenta Praevia?

A
  • Describes a placenta lying wholly or partly in the lower uterine segment covering the cervical os
  • 5% have low lying placenta when scanned at 6-20 weeks. Incidence at delivery is only 0.5% there most placenta rise away from cervix
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11
Q

What is Placenta Praevia associated with?

A
  • Multiparity
  • Multiple pregnancy
  • Embryo more likely to implant in lower segment scar from previous C-section
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12
Q

What are clinical features of Placenta Praevia?

A
  • Shock in proportion to visible loss
  • No pain
  • Uterus not tender
  • Lie and presentation may be abnormal
  • Foetal heart usually normal
  • Coagulation problems rare
  • Small bleeds occur before large
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13
Q

Why should vaginal examinations be avoided in Placenta Praevia?

A
  • Vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - women with placenta praevia may haemorrhage
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14
Q

What are investigations for Placenta Praevia?

A

Often picked up on routine 20-week abdominal ultrasound

  • Use of transvaginal ultrasound can improve accuracy of placental localisation and is considered safe
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15
Q

What is the classical grading of Placenta Praevia?

A
  • Type I: placenta reaches lower segment but not the internal os
  • Type II: placenta reaches internal os but doesn’t cover it
  • Type III: placenta covers the internal os before dilation but not when dilated
  • Type IV: placenta completely covers the internal os
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16
Q

How is Placenta Praevia managed?

A

If low-lying placenta at 16-20 week scan:

  • Rescan at 34 weeks. If still present at 34 and grade 1/2 then scan every 2 weeks
  • No need to limit activity or intercourse unless they bleed
  • If high presenting part or abnormal lie at 37 weeks, then C-section
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17
Q

How is Placenta Praevia with bleeding managed?

A
  • Admit and treat shock
  • Cross match blood
  • Final ultrasound at 36-37 weeks determines method of delivery.
    • C-section for grade 3/4 between 37-38 weeks. If grade 1 then vaginal delivery
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18
Q

What are complications of Placenta Praevia?

A
  • Placenta Accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
  • Placenta Increta: chorionic villi invade into the myometrium
  • Placenta Perceta: chorionic villi invade through the perimetrium like the bladder for example
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19
Q

What is Vasa Praevia?

A
  • Rupture of membranes followed immediately by vaginal bleeding.
  • Fetal bradycardia is classically seen
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20
Q

What is the definition of Placental Abruption?

A
  • Separation of normally sited placenta from uterine wall resulting in maternal haemorrhage into the intervening space
  • Associated with high perinatal mortality rate and responsible for 15% of perinatal deaths
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21
Q

What are risk factors for Placental disease?

A
  • Previous Caesarean Section
  • Placenta Praevia
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22
Q

What are risk factors for Placental Abruption?

A
  • Proteinuric Hypertension
  • Cocaine and tobacco use
  • Multiparity
  • Maternal Trauma
  • Increasing maternal age
  • Uterine overdistention
  • Previous placental abruption
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23
Q

What are signs and symptoms of Placental Abruption?

A

Symptoms

  • Shock out of keeping with visible loss
  • Sudden constant abdominal pain in the third trimester
  • Normal lie and presentation
  • Fetal heart: absent/distressed
  • Bleeding (80%) but absence does not rule it out

Signs

  • Mother can be seen in extreme pain and cold touch
  • Tender, tense uterus
  • Coagulation problems
24
Q

What is mangement of Placental Abruption?

A

Foetus alive and <36 weeks:

  • Foetal distress: immediate caesarean
  • No Foetal Distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Foetus alive and >36 weeks:

  • Foetal distress: immediate caesarean
  • No Foetal Distress: deliver vaginally

Foetus Dead:

  • Induce Vaginal Delivery
25
Q

What are complications of Placental Abruption?

A

Maternal

  • Shock
  • DIC
  • Renal Failure
  • Post-partum haemorrhage

Foetal

  • Intrauterine growth restriction
  • Hypoxia
  • Death
26
Q

What is Hyperemesis Gravidum?

A
  • Extreme form of nausea and vomiting of pregnancy (NVP).
  • Occurs in around 1% of pregnancies and may be related to raised bhCG levels. Common between 6 and 12 weeks and may persist for 20 weeks
  • Smoking associated with decrease incidence of hyperemesis

Diagnosis of exclusion: infections, metabolic, drugs, tumours need reviewing

27
Q

What are possible causes of Hyperemesis Gravidum?

A
  • Elevate hCG: More common in twin/molar pregnancies. Same alpha subunit TSH
  • Elevated oestrogen and progesterone: Decrease gut motility, increase enzyme and decreased cardiac sphincter pressure
  • Helicobacter pylori: Subclinical infection active by altered immunity in pregnancy
  • Psychosocial
28
Q

What is Hyperemesis Gravidum associated with?

A
  • Multiple pregnancies
  • Trophoblastic disease
  • Hyperthyroidism
  • Nulliparity
  • Obesity
29
Q

What are symptoms of True Hyperemesis Gravidum?

A
  • Severe dehydration
  • Deranged blood
  • Marked ketosis
  • Weight loss
  • Nutritional deficiency
30
Q

What are investigations for Hyperemesis Gravidum?

A
  • Urine: PT/ketonuria/UTI
  • Bloods: LFTs, Amylase, U&Es (especially potassium), TFTs (hCG can confuse), FBC (haematocrit levels)
  • USS: exclude GTD/Multiple pregnancy
31
Q

What is the criteria for diagnosis of Hyperemesis Gravidum?

A

Triad

  • 5% pre-pregnancy weight loss
  • Dehydration
  • Electrolyte imbalance
32
Q

What is used to score Hyperemesis Gravidum?

A

Pregnancy-Unique Quantification of Emesis (PUQE) score can be used to classify the severity of NVP.

33
Q

How is Hyperemesis Gravidum managed medically?

A

Symptomatic

  • 1st Line: Antihistamines (promethazine or cyclizine)
  • 2nd Line: Ondansetron and Metoclopramide
  • Ginger and P6 acupressure can be tried but little evidence of benefit

Other management options

  • Give thiamine replacement and folic acid if required
  • Consider thromboprophylaxis and ranitidine (particularly if Mallory Weiss tear)
  • Rarely steroids, TPN/JEG (gastroenterologist assessment required). Termination considered
34
Q

When is admission required for Hyperemesis Gravidum?

A

Consider admission for IV hydration if:

  • Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics
  • Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
  • A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection)

Lower threshold for admitting to hospital if the woman has a co-existing condition adversely affected by N&V.

35
Q

What are complications of Hyperemesis Gravidum?

A
  • Wernicke’s encephalopathy
  • Mallory-Weiss tear
  • Central pontine myelinolysis
  • Acute tubular necrosis
  • Foetal: small for gestational age, pre-term birth
36
Q

What is the definition of Oligohydramnios?

A
  • Reduced amniotic fluid.
  • Definitions vary but include less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile.
37
Q

What are causes of Oligohydramnios?

A
  • Premature rupture of membranes
  • Foetal renal problems e.g. renal agenesis
  • Intrauterine growth restriction
  • Post-term gestation
  • Pre-eclampsia
38
Q

When is foetal growth assessed?

A
  • Foetal growth is assessed routinely during antenatal growth. This is done after 24 weeks gestation as growth assessment before 24 weeks rarely provides clinically useful information.
  • Rate of growth and crude measurements assessed
39
Q

What are ‘Small for Dates’ and ‘Large for Dates’?

A
  • ‘Small for Dates’ describes anthropometric variables below the 10th population centile for gestational age
  • ‘Large for Dates’ describes anthropometric variables above the 95th population centile for gestational age
40
Q

What are methods of assessing foetal growth?

A
  1. Two clinical examination methods used are (mainly used as screening tools)
  • Abnormal palpation of fundal height (20-30% sensitivity)
  • Symphysis-fundal height measure using measuring tape (20-40% sensitivity)
  1. Ultrasound Assessment
    1. In high-risk or in low-risk patient where growth issue is suspected based on clinical examination, this can be used for more accurate assessment (90-95% sensitivity)
  3. Key anthropometric measurement assessed at
    • Head circumference (and biparietal diameter)
    • Abdominal circumference
    • Femur length
41
Q

What parameters are used in Ultrasound measurement of foetal growth?

A

Key anthropometric measurement assessed at

  • Head circumference (and biparietal diameter)
  • Abdominal circumference
  • Femur length
42
Q

What are conerns of ‘Small for Dates’ Foetus?

A
  • Contribute disproportionally to perinatal morbidity and mortality.
  • Main contributor to this association is foetal growth restriction rather than SFD
  • Increased morbidity and mortality is result of intrauterine hypoxia, acidaemia, prematurity (often iatrogenic) and neonatal complications
43
Q

What is a Growth Restricted Foetus?

A

One that has failed to reach its genetic growth potential

44
Q

What are risk factors of Growth Restricted Foetuses?

A
  • AGE
  • BMI
  • SMOKING
  • ALCOHOL
  • SUBSTANCE ABUSE
  • DOMESTIC VIOLENCE
  • PRECRISTION AND OTC DRUG
  • HIGH ALTITUDE
  • PREVIOUS FGR
  • RECURRENT FOEEATAL LOSS
  • PREVIOUS UNEXPLAINED STILIRTH
  • RAISED AFP
  • INFECTION
  • PLACENTAL PATHOLOGY
  • HYPERTENSION
  • HAEMAGLOBINOPATHIES
  • ANTIPHPHOLIPID SYNDROME
  • COLLAGEN VASCULAR DISEASE
  • RENAL DISEASE
45
Q

What is the approach to ‘Small for Dates’ referrals?

A
  • Is foetus really small? (confirm diagnosis)
    • Confirm dates, Assess growth by USS, review measurements
  • Why is the foetus small? (establish cause)
  • How to monitor pregnancy with small foetus (management plan)
  • Timing and mode of delivery (weigh up risk and benefits)
46
Q

Why are foetuses small?

A
  • Normal small: constitutionally small, healthy baby
  • Abnormal small: chromosomal abnormalities, syndrome, congenital malformations
  • Infected small: Infection during pregnancy (commonly CMV, rubella)
  • Starved small: Placental FGR, Poor placentation, Smoking, Maternal disease affecting placenta, multiple pregnancy etc
  • Wrong small: Incorrect dates or measurements
47
Q

What are signs of a normal small foetus?

A
  • Normal UMA doppler,
  • Normal amniotic fluid
  • Normal velocity and symmetrical growth
48
Q

What are signs of Starved small foetuses?

A
  • Centile position: 1st centile more likely to be small
  • Asymmetrical growth due to compensation for lack of resources. Growth of the abdomen largely determined by size of liver and size of liver by the amount of glycogen storage. Growth of abdomen therefore will be reduced if lacking in glucose supply compared to head in centiles
  • Reduced Liquor volume: due to less blood supply to kidneys so less urine to amniotic fluid
  • Umbilical artery doppler: tells how much resistance in the system.
  • Reduced Growth velocity: when compared to centiles
49
Q

What is involved in maternal monitoring of small foetuses?

A
  • Assess for any modifiable factors (smoking)
  • Assess for maternal disease
  • Continue monitoring for pre-eclampsia with regular blood pressure and urine check in regular intervals
50
Q

What is involved in foetal monitoring of small foetuses?

A
  • Serial growth measurement (every 2-4 weeks)
  • Foetal wellbeing surveillance (maternal perception of foetal movement, foetal doppler, amniotic volume measure, biophysical profile)
  • Use of Doppler
51
Q

How can doppler be used to monitor small for date foetuses?

A
  • Uterine artery doppler: Useful for screening where notching identifies high risk patient
  • Umbilical artery doppler: essential in surveillance of FGR
  • Middle cerebral artery doppler: useful for shunting and surveillance
  • Venous Doppler: information about pump and useful for surveillance
52
Q

How is Delivery timed in Foetal Growth Restriction?

A

Mode of delivery depends on gestation, presentation, foetal condition and maternal factors

  • When umbilical artery doppler is normal, delay delivery until at least 37 weeks (if normal in other assessment)
  • With AREDF (Absence or reversal of end diastolic flow) consider delivery if gestation >34/40 even in presence of normal additional assessment
  • With AREDF, deliver before 34/40 if CTG abnormal, BPP abnormal or other doppler parameters are abnormal (MCA, umbilical vein)
53
Q

What are complicatiion post delivery in Small for Date foetuses?

A

Increased need for resuscitation. Higher risk of:

  • Hypothermia
  • Hypoglycaemia
  • RDS
  • Necrotising enterocolitis
  • Neurodevelopmental disability
  • Cerebral palsy and adult disease
54
Q

How is a ‘large for date’ foetus assessed?

A
  • Establish correct dates
  • If the diagnosis was suspected based on clinical assessment, an ULTRASOUND measure is important as there can be other causes for increased symphysis fundal height in a singleton pregnancy
    • Uterine fibroids
    • Pelvic mass pushing up uterus
    • Polyhydramnios
    • Maternal obesity
55
Q

What causes ‘Large for Dates’ foetus?

A

Foetus first palpable through abdomen at 12 weeks

  • Large for date in 1st trimester could be due to constitutionally large foetus, adnexal mass, multiple gestation, inaccurate menstrual history
  • Maternal factors: diabetes, obesity, increased maternal age, multiparity, large status
  • Foetal factors: constitutional, male gender, post-maturity, genetic disorders (beckwith wiedeman)
56
Q

What are risks assocaited with Macrosomic babies?

A

Maternal risk:

  • Prolonged labour
  • Operative delivery
  • Postpartum haemorrhage
  • Genital tract trauma

Foetal/neonatal/childhood risk:

  • Birth injury
  • Perinatal asphyxia from difficult delivery
  • Shoulder dystocia/Erb’s palsy
  • Hypoglycaemia
  • Childhood obesity
  • Metabolic syndrome
57
Q

What is done for ‘Large for Dates’ babies?

A
  • Exclude maternal diabetes
  • In absence of polyhydramnios, treat pregnancy as normal
  • No benefit of induction of labour or caesarean section in absence of maternal diabetes. If maternal diabetes is present in addition to macrosomia, then offer caesarean section
  • Early recourse to intervention where there is delay in labour
  • Anticipate shoulder dystocia
  • Monitor for hypoglycaemia in neonatal period

Year 4k: Obs and Gynae (19 decks)

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