Complications in pregnancy 1 Flashcards by Vikram Shivakumar

Abortion

* Voluntary termination of foetus

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Miscarriage

Spontaneous loss of pregnancy before 24 weeks gestation

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Categories of spontaneous miscarriage

* Threatened
* Inevitable
* Incomplete
* Complete
* Septic
* Missed

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Aetiology of spontaneous miscarriage

* Abnormal conceptus: chromosomal, genetic, structure
* Uterine abnormality: congenital, fibroids
* Cervical weakness: primary or secondary
* Maternal factors: increasing age, diabetes, SLE
* Unknown

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Threatened miscarriage

* Vaginal bleeding +/- pain
* Viable pregnancy Closed cervix on speculum examination
*

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Inevitable miscarriage

* Viable pregnancy
* Open cervix with heavy bleeding (+/- clots)

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Missed miscarriage (early fatal demise)

* Asymptomatic
* Sometimes bleeding/ brown loss from vagina
* Gestational sac on scan
* No clear foetus/ foetal pole without foetal heartbeat

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Incomplete miscarriage

* Majority of products of conception (POC) expelled, some retained
* Open cervix, vaginal bleeding (maybe heavy)

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Complete miscarriage

* All products of conception passed
* Cervix is closed
* Bleeding has stopped

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Septic miscarriage

* Incomplete miscarriage caused by ascending infection

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Management of spontaneous miscarriage

* Threatened → conservative, ‘wait and see’
* Inevitable → heavy bleeding may require evacuationMissed
* Conservative
* Medical → prostaglandins (misoprostol)
* Surgical → surgical management of miscarriage
* Septic → antibiotics and uterine evacuation

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Definition of pre-term labour

Onset of labour before 37 weeks gestation (259 days)
* Can be spontaneous or induced 3 categories
* Mildly preterm
* Very preterm
* Extremely preterm

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Aetiological factors in pre-term labour

Idiopathic (majority)
* Multigravidity
* Polyhydramnios
* APH
* Pre-eclampsia Infection (UTI)
* Prelabour premature rupture of membranes (PPRM)

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Diagnosis for pre-term labour

* Vaginal examination → contractions with evidence of cervical changes Test → fetal fibrinoectin Consider possible cause

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Management of preterm labour

* Tocolytics (allows steroids and transfer to NICU)
* Steroids unless contraindicated
* Transfer to NICU
* An aim for vaginal delivery

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Complications of prematurity

* Respiratory distress syndrome
* Intraventricular haemorrhage
* Cerebral palsy
* Nutrition needs
* Temperature control requirements
* Jaundice
* Infection
* Visual impairment
* Hearing loss

Tocolysis

* Medications used to inhibit uterine contractions
* Used in pre-term labour

Definition of ectopic pregnancy

* Pregnancy implanted outside the uterine cavity
* Commonly found Fallopian tube, fimbriae, cervix

Risk factors for ectopic pregnancy

* Pelvic inflammatory disease
* Previous tubal surgery
* Previous ectopic
* Assisted conception (IVF)

Management of antepartum haemorrhage

Maternal shock, collapse
Fetal distress → death
Maternal DIC (disseminated intravascular coagulation) → renal failure
Post-partum haemorrhage → ‘couvelaires sign’

Presentation of placental abruption

Pain
* Vaginal bleeding (minimal)
* Increasing uterine tone

Definition of Placental abruption

* Haemorrhage due to early separation of the placenta before birth of baby
* Very rare

Classification of Placental abruption

* Revealed (visibility of a lot of blood)
* Concealed (bleeding inside but can’t see)
* Mixed (concealed and revealed)

Couvelaire’s uterus

Placental abruption causing bleeding to penetrate deep into myometrium and eventually peritoneal cavity

Factors associated with Placental abruption

\* Pre-eclampsia/ chronic hypertension \* Multigravidity \* Polyhydramnios \* Smoking, increasing age parity \* Previous abruption \* Cocaine use

Definition of placenta praevia

\* All or part of the placenta implants into the lower segment of uterus (near internal os)

Presentation of placenta praevia

* **Painless PV (per vaginum) bleeding** * Malpresentation of foetus * Soft, no-tender uterus * Incidental finding

Risk factors for placenta praevia

* Multiparous women * Multiple pregnancies * Previous Caesarean section

Classification of placenta praevia

* Low lying → less than 20mm from internal loss * Placenta praevia → covering os entirely

Investigation for placenta praevia

\* Ultrasound (gold standard)More difficulty to locate posterior placenta praevia

Management of placenta praevia

* Depends on severity and gestational age * Conservative → reach gestational maturity * Elective Caesarean section * *Watch for postpartum haemorrhage*

Definition of antepartum haemorrhage

Haemorrhage from the genital tract after 24 weeks gestation but before delivery of baby

Aetiology of antepartum haemorrhage

\* Placenta praaevia \* Placental abruption \* APH of unknown origin \* Local lesion of genital tract \* Vasa praevia (rare)

Definition of postpartum haemorrhage

\* Bleeding after delivery more than 500mls

Management of postpartum haemorrhage

* Medical: oxytocin, ergometrine, carboprost, tranexemic acid * Ballon tamponade * Surgical: B Lynch suture, ligaton of uterine. iliac arteries, hysterectomy

Presentation of ectopic pregnancy

Period of amenorrhea (+/- urine pregnancy test) \* Vaginal bleeding \* Abdominal pain \* GI/ urinary symptoms

Investigations for ectopic pregnancy

\* Ultrasound scan → no intrauterine gestational sac, adnexal mass, fluid in pouch of Douglas \* Serum b-hCG levels → high

Management of ectopic pregnancy

\* Medical → IV methotrexate \* Surgical → laparoscopy salpingectomy, salpingostomy \* Conservative → to those haemodynamically stable + low serum b-hCG