Complications In Pregnancy 1 Flashcards
Abortion or Spontaneous Miscarriage
Termination/ loss of pregnancy before 24 weeks gestation
Incidence of spontaneous miscarriage
Around 15%
Threatened miscarriage
- Vaginal bleeding +/- pain
- Viable pregnancy
- Closed cervix on speculum examination
Inevitable miscarriage
- Viable pregnancy
- Open cervix with bleeding that could be heavy (+/-clots)
Missed Miscarriage
- No symptoms, or could have bleeding/ brown loss vaginally
- Gestational sac seen on scan
- No clear foetus or a foetal pole with no foetal heart seen in the gestational sac
Incomplete Miscarriage
- most of pregnancy expelled out, some products of pregnancy remaining in the uterus
- open cervix, vaginal bleeding (may be heavy)
Complete miscarriage
passed all products of conception (POC), cervix closed and bleeding has stopped
Aetiology of Spontaneous Miscarriage
- abnormal conceptus - chromosomal, genetic, structural
- uterine abnormality - congenital, fibroids
- cervical incompetence - Primary, secondary
- maternal increasing age, diabetes
- unknown
Management of Threatened Miscarriage
Conservative
Management of Inevitable Miscarriage
if bleeding heavy may need evacuation
Management of Missed Miscarriage
- conservative
- medical - prostaglandins (Misoprostol)
- surgical - SMM (surgical managemtnt of miscarriage)
Management of Septic Miscarriage
antibiotics and evacuate uterus
Ectopic pregnancy
Pregnancy implanted outside the uterine cavity
Incidence of ectopic pregnancy
Around 1:90 pregnancies
Risk factors for ectopic pregnancy
- Pelvic inflammatory disease
- Previous tubal surgery
- Previous ectopic
- Assisted conception
Ectopic pregnancy presentation
- Period of ammenorhoea (with +ve urine pregnancy test)
- +/- Vaginal bleeding
- +/- Pain abdomen
- +/- GI or urinary symptoms
Ectopic pregnancy investigations
- 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 -
- Serum Progesterone levels – with viable IU pregnancy high levels > 25ng/ml
Ectopic pregnancy management
- Conservative
- Medical - Methotrexate
- Surgical - (mostly laparosciopic - Salpingectomy, Salpingotomy for few indications)
Antepartum Haemorrhage (APH)
haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby.
Causes of Antepartum Haemorrhage
- Placenta praevia (common)
- Placental abruption (common)
- APH of unknown origin
- Local lesions of the genital tract
- Vasa praevia (very rare)
Placenta praevia
All or part of the placenta implants in the lower uterine segment
Placenta praevia Incidence
1/200 pregnancies
Placenta praevia more common in:
- multiparous women
- multiple pregnancies
- previous caesaren section
Placenta praevia classification
- Grade I Placenta encroaching on the lower segment but not the internal cervical os
- Grade II Placenta reaches the internal os
- Grade III Placenta partially covers the os
- Grade IV Central placenta praevia
Placenta praevia presentation
- Painless PV bleeding
- Malpresentation of the fetus
- Incidental
Placenta Praevia Clinical features
- Maternal condition correlates with amount of bleeding PV
- Soft, non tender uterus +/- foetal malpresentation
Placenta Praevia Investigations
- Ultrasound scan to locate placental site
- Vaginal exam must not be done
Placenta Praevia Management
- depends on gestation and severity
- caesarean section, watch for PPH
Placental abruption
Haemorrhage resulting from premature separation of the placenta before the birth of the baby
Incidence of placental abruption
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
Placental abruption presentation
- Pain
- Vaginal bleeding (may be minimal bleeding)
- Increased uterine activity
Management of placental abruption
Management will vary from expectant treatment to attempting a vaginal delivery to immediate caesarean section
Complications of placental abruption
- Maternal shock, collapse (may be disproportionate to the amount of bleeding seen)
- Foetal death
- Maternal DIC, renal failure
- Postpartum haemorrhage ‘couvelaire uterus’
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
Incidence of preterm labour
- Around 5- 7% in singletons
- 30 - 40% multiple pregnancy
Predisposing factors for preterm labour
- Muliple pregnancy
- Polyhydramnios
- APH
- Pre-eclampsia
- Infection eg UTI
- Prelabour premature rupture of membranes
- Majority idiopathic
Diagnosis of preterm delivery
Contractions with evidence of cervical change on VE
Management of preterm delivery
- 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
- temperature control
- jaundice
- infections
- visual impairment
- hearing loss
Primary post partum haemorrhage
Primary post-partum haemorrhage is the loss of >500 ml of blood per-vagina within 24 hours of delivery.
It can be classified into two main types:
- Minor PPH – 500-1000ml of blood loss
- Major PPH – >1000ml of blood loss
Causes of primary post partum haemorhage
-
Tone
- ‘Tone’ refers to uterine atony, which is the most common cause of primary post-partum haemorrhage. This is where the uterus fails to contract adequately following delivery, due to a lack of tone in the uterine muscle.
- The risk factors for uterine atony include:
- Maternal profile: Age >40, BMI > 35, Asian ethnicity.
- Uterine over-distension – multiple pregnancy, polyhydramnios, fetal macrosomia.
- Labour – induction, prolonged (>12 hours).
- Placental problems – placenta praevia, placental abruption, previous PPH.
-
Tissue
- ‘Tissue’ refers to retention of placental tissue – which prevents the uterus from contracting. It is the second most common cause of 1° PPH
-
Trauma
- This refers to damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical tears). Risk factors include:
- Instrumental vaginal deliveries (forceps or ventouse)
- Episiotomy
- C-section
- This refers to damage sustained to the reproductive tract during delivery (e.g. vaginal tears, cervical tears). Risk factors include:
-
Thrombin
- ‘Thrombin’ refers to coagulopathies and vascular abnormalities which increase the risk of primary post-partum haemorrhage:
- Vascular – Placental abruption, hypertension, pre-eclampsia.
- Coagulopathies – von Willebrand’s disease, haemophilia A/B, ITP or acquired coagulopathy i.e. DIC, HELLP.
- ‘Thrombin’ refers to coagulopathies and vascular abnormalities which increase the risk of primary post-partum haemorrhage:
Managment of uterine atony
- Bimanual compression to stimulate uterine contraction – insert a gloved hand into the vagina, then form a fist insider the anterior fornix to compress the anterior uterine wall and the other hand applies pressure on the abdomen at the posterior aspect of the uterus (ensure the bladder is emptied by catheterisation).
- Pharmacological measures – act to increase uterine myometrial contraction.
- Surgical measures
- intrauterine balloon tamponade,
- B-lynch suture
- bilateral uterine or internal iliac artery ligation
- hysterectomy (as a last resort)
Pharmacological managment of primary post partum haemorrhage
- Syntocinon (synthetic oxytocin)
- Ergometrine
- Carboprost (prostaglandin analogue)
- Misoprolol (prostaglandin analogue)
Preventative measures to reduce risk and consequence of post partum haemorrhage
- Treating anaemia during the antenatal period
- Giving birth with an empty bladder (a full bladder reduces uterine contraction)
- Active management of the third stage (with intramuscular oxytocin in the third stage)
- Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients
Secondary post partum haemorrhage
Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum.
This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).
Investigations for secondary post partum haemorrhage
- Ultrasound for retained products of conception
- Endocervical and high vaginal swabs for infection
Managment of secondary post partum haemorrhage
- Surgical evaluation of retained products of conception
- Antibiotics for infection
