Complications in Pregnancy 1 Flashcards
define a miscarriage
spontaneous loss of pregnancy before 24 weeks gestation
what does a threatened miscarriage refer to?
A threatened miscarriage refers to bleeding from the gravid uterus before 24 weeks gestation when there is a viable fetus and no evidence of cervical dilatation.
miscarriage becomes inevitable if?
the cervic has already begun to dilate
what does a missed miscarriage refer to?
a pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception
clinical features of a threatened miscarriage
- vaginal bleeding +/- pain
- viable pregnancy
- closed cervix on speculum exam
clinical features of inevitable miscarriage
- viable pregnancy
- open cervix with bleeding that could be heavy (+/- clots)
clinical features of missed miscarriage (early fetal demise)
- no symptoms, or could have bleeding/brown loss vaginally
- gestational sac seen on scan
- no clear fetus (empty gestational sac) or fetal pole with no fetal heart seen in the gestational sac
define a complete miscarriage
- passed all products of conception (POC), cervix closed and bleeding has stopped (should ideally have confirmed the POC or should have had a scan previouslt rhat confirmed and intrauterine pregnancy
List some causes of spontaneous miscarriage
- abnormal conceptus: chromosomal, genetic, structural
- uterine abnormality: congenital, fibroids
- cervical weakness: primary, secondary
- materanl: increasing age, diabetes
- unknown
outline the management of different types of miscarriage
threatened, inevitable, missed, septic
Threatened - conservative, ‘just wait’, most stop bleeding and are okay
Inevitable - if bleeding heavy may need evacutation
Missed - conservative, medical: prostaglandins (misoprostol), surgical: SMM
Septic: antibiotics and evacuate uterus
what are the most common sites of ectopic pregnancy?
ectopic pregnancy incidence
1:90 pregnancies
ectopic pregnancy risk factors
- pelvic inflammatory disease
- previous tubal surgery
- previous ectopic
- assisted conception
ectopic pregnancy clinical presentation
- period of ammenorrhoea (with +ve urine pregnancy test)
- +/- vaginal bleeding
- +/- abdomen pain
- +/- GI or urinary symptoms
ectopic pregnancy investigations
- scan - no uterine gestational sac, may see adnexal mass, fluid in Pouch of Douglas
- serum BHCG levels - may need to serially track levels over 48hr intervals, if a normal intrauterine pregnancy HCG levels will increase by at least 66%
ectopic pregnancy management
- medical: methotrexate
- surgical: mostly laparoscopy - Salpingectomy (remove the tube), Salpingotomy (leave a damaged tube, remove the embryo) for few indications
- conservative
define antepartum haemorrhage (APH)
- haemorrhage from the genital tract after the 24th week of pregnancy but before the delivery of the baby
list some caused of antepartum haemorrhage (APH)
- placental praevia - where the placenta is attached to lower segment of uterus
- placental abruption
- APH of unknown origin
- local lesion of the genital tract
- Vasa praevia (very rare) - rupture of fetal vessel, can be catastrophic for fetus
what is placenta praevia
- all or part of the placenta implants in the lower uterine segment
- a cause of APH
- incidence 1/200 pregnancies
- more common in multiparous women, multiple pregnancies, previous c-section
RCOG classification placenta previa
- low-lying - placenta is less than 20mm from internal os
- placenta previa - covering the os
placenta praevia presentation
- painless PV bleeding
- soft, non-tender uterus +/- malpresentation of fetus on US
- incidental
placenta praevia diagnossi
Ultrasound scan to locate placental site
VAGINAL EXAMINATION MUST NOT BE DONE WITH SUSPECED PLACENTA PRAEVIA
placenta praevia management
- gestation
- severity
- c-section, watch for post-partum haemorrhage
management of post-partum haemorrhage (PPH)
- medical: oxytocin, ergometrine, carboprost
- balloon tamponade
- surgical: B lynch suture, ligation of uterine, iliac vessels, hysterectomy.
what is placental abruption?
- Placental abruption causes haemorrhage from premature separation of the placenta before the birth of the baby and is associated with a retroplacental clot.
- The incidence of placental abrution will depend on maternal age, parity and social status but it is estimated to occur in approx 0.6% of all pregnancies
which risk factors are associated with placental abruption?
- pre-eclampsia/chronic hypertension
- multiple pregnancy
- polyhydramnios
- smoking, increasing age, parity
- previous abruption
- cocaine use
what are the clinical types of placental abruption?
- revealed (see the blood)
- concealed (bleeding but inside so can’t see)
- mix of above
placental abruption presentation
- pain
- vaginal bleeding (may be minimal)
- increased uterine activity
placental abruption complications
- maternal shock, collapse
- fetal distress then death
- maternal DIC, renal failure
- postpartum haemorrhage ‘couvelaire uterus’
define preterm labour
- onset of labour before 37 completed weeks gestation (259 days)
- 32-36 wks mildy preterm
- 28-32 wks very preterm
- 24-28 wks extremely preterm
- spontaneous or induced (iatrogenic)
preterm labour risk factors
- multiple pregnancy
- polyhydramnios
- APH
- pre-eclampsia
- infection e.g. UTI
- prelabour premature rupture of membranes
- majority idiopathic
preterm labour diagnosis
- contractions with evidence of cervical change on VE
- test fetal fibronectin
Preterm delivery management
< 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 morbidities resulting from prematurity
- respiratory distress syndrome
- intraventricular haemorrhage
- cerebral palsy
- nutrition
- temperature control
- jaundice
- infections
- visual impairment
- hearing loss
