Complications in pregnancy 1 Flashcards
miscarriage
spontaneous loss of pregnancy before 24 weeks gestation
abortion
voluntary termination
threatened miscarriage signs
Vaginal bleeding+/- pain
Viable pregnancy
Closed cervix on speculum examination
inevitable miscarriage signs
Viable pregnancy
Open cervix with bleeding
that could be heavy (+/-clots)
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
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
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)
when are septic miscarriages most commonly seen
especially in cases of an incomplete miscarriage
aetiology of a spontaneous miscarriage
Abnormal conceptus
chromosomal, genetic, structural
Uterine abnormality
congenital, fibroids
Cervical weakness
Primary, secondary
Maternal
increasing age, diabetes
Unknown
management of a threatened miscarriage
conservative, “just wait” – most stop bleeding and are okay
management of inevitable miscarriage
If bleeding heavy may need evacuation
missed miscarriage management
conservative
- medical – prostaglandins (misoprostol)
- surgical – SMM (surgical management of miscarriage)
management of septic miscarriage
antibiotics and evacuate uterus
ectopic pregnancy
pregnancy outside the uterus cavity
incidence ectopic pregnancy
around 1:90 pregnancies
risk factors ectopic pregnancy
Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic
Assisted conception
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
