Complications in pregnancy 1 Flashcards by Isla Anderson

miscarriage

spontaneous loss of pregnancy before 24 weeks gestation

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abortion

voluntary termination

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threatened miscarriage signs

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

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inevitable miscarriage signs

Viable pregnancy
Open cervix with bleeding
that could be heavy (+/-clots)

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missed miscarriage (early foetal demise) signs

No symptoms, or could have bleeding/ brown loss vaginally
Gestational sac seen on scan
No clear fetus (empty gestational sac) or a fetal pole with no fetal heart seen in the gestational sac

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incomplete miscarriage signs

No symptoms, or could have bleeding/ brown loss vaginally
Gestational sac seen on scan
No clear fetus (empty gestational sac) or a fetal pole with no fetal heart seen in the gestational sac

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complete miscarriage signs

– passed all products of conception (POC), cervix closed and bleeding has stopped (should ideally have confirmed the POC or should have had a scan previously that confirmed an intrauterine pregnancy)

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when are septic miscarriages most commonly seen

especially in cases of an incomplete miscarriage

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aetiology of a spontaneous miscarriage

Abnormal conceptus
chromosomal, genetic, structural

Uterine abnormality
congenital, fibroids

Cervical weakness
Primary, secondary

Maternal
increasing age, diabetes

Unknown

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management of a threatened miscarriage

conservative, “just wait” – most stop bleeding and are okay

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management of inevitable miscarriage

If bleeding heavy may need evacuation

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missed miscarriage management

conservative
- medical – prostaglandins (misoprostol)
- surgical – SMM (surgical management of miscarriage)

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management of septic miscarriage

antibiotics and evacuate uterus

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ectopic pregnancy

pregnancy outside the uterus cavity

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incidence ectopic pregnancy

around 1:90 pregnancies

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risk factors ectopic pregnancy

Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic
Assisted conception

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presentation ectopic pregnancy

Period of ammenorhoea (with +ve urine pregnancy test)
+/_ Vaginal bleeding
+/_ Pain abdomen
+/_ GI or urinary symptoms

what investigations are done for an ectopic pregnancy

Scan – no intrauterine gestational sac, may see adnexal mass, fluid in Pouch of Douglas

Serum BHCG levels – may need to serially track levels over 48 hour intervals- if a normal early intrauterine pregnancy HCG levels will increase by at least 66%ish

management for ectopic pregnancy

Medical – Methotrexate

Surgical –
(mostly laparoscopy– Salpingectomy, Salpingotomy for few indications)

Conservative

what is an antepartum haemorrhage

haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby.

what are causes of antepartum haemorrhage

Placenta praevia

Placental abruption

APH of unknown origin

Local lesions of the genital tract

Vasa praevia (very rare)

what is Placenta praevia

All or part of the placenta implants in the lower uterine segment

Incidence
1/200 pregnancies

More common in
Multiparous women
multiple pregnancies
previous caesaren section

old classification of Placenta praevia

Grade I Placenta encroaching on the lower segment but not the internal cervical os

Grade II Placenta reaches the internal os

Grade III Placenta eccentrically covers the os

Grade IV Central placenta praevia

RCOG classification
Placenta Praevia

Low lying- placenta is less than 20 mm from internal os

Placenta previa – covering the os

presentation placenta Praevia

Painless PV bleeding Malpresentation of the fetus Incidental

clinical features placenta Praevia

Maternal condition correlates with amount of bleeding PV Soft, non tender uterus +/- fetal malpresentation

diagnosis placenta Praevia

Ultrasound scan to locate placental site VAGINAL EXAMINATION MUST NOT BE DONE WITH SUSPECED PLACENTA PRAEVIA

management placenta Praevia

Gestation Severity Caesarean section, watch for PPH

management PHH

Medical management – oxytocin, ergometrine, carboprost, tranexemic acid Balloon tamponade Surgical – B Lynch cutre, ligation of uterine, iliac vessels, hystrectomy

Placental abruption

Haemorrhage resulting from premature separation of the placenta before the birth of the baby Incidence 0.6% of all pregnancies

Factors associated with Placental Abruption

Pre-eclampsia/ chronic hypertension Multiple pregnancy Polyhydramnios Smoking, increasing age, parity Previous abruption Cocaine use

clinical types Placental abruption

Revealed (see the blood) Concealed (bleeding but inside so can’t see!) Mixed (concealed and revealed)

presentation placental abruption

Pain Vaginal bleeding (may be minimal bleeding) Increased uterine activity

General management of APH

Management will vary from expectant treatment to attempting a vaginal delivery to immediate Caesarean section depending on Amount of bleeding General condition of mother and baby Gestation

Complications of placental abruption

Maternal shock, collapse (may be disproportionate to the amount of bleeding seen) Fetal distress then death Maternal DIC, renal failure Postpartum haemorrhage ‘couvelaire uterus’

what is preterm labour

Onset of labour before 37 completed weeks gestation (259 days) 32-36 wks mildly preterm 28-32 wks very preterm 24-28 wks extremely preterm Spontaneous or induced (iatrogenic)

what is the incidence of preterm labour

Around 5- 7% in singletons 30 - 40% multiple pregnancy

what are predisposing factors to preterm labour

Multiple pregnancy Polyhydramnios APH Pre-eclampsia Infection eg UTI Prelabour premature rupture of membranes Majority no cause (idiopathic)

how is preterm delivery managed

Contractions with evidence of cervical change on VE Test- Fetal fibronectin Consider possible cause abruption, infection

management preterm delivery

<24-26 weeks Generally regarded as very poor prognosis decisions made in discussion with parents and neonatologists All cases considered viable Consider tocolysis to allow steroids/ transfer Steroids unless contraindicated Transfer to unit with NICU facilities Aim for vaginal delivery

Neonatal Morbidity resulting from Prematurity

respiratory distress syndrome intraventricular haemorrhage cerebral palsy nutrition temperature control jaundice infections visual impairment hearing loss