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Complications in Pregnancy 1 Flashcards

Miscarriage Ectopic Pregnancy Antepartum Haemorrhage Preterm Labour

1
Q

Define Abortion and Spontaneous Miscarriage

A

Termination/loss of pregnancy before 24 weeks gestation with no evidence of life

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2
Q

What is the incidence of spontaneous miscarriage?

A

15%

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3
Q

What are the 6 categories of spontaneous miscarriage?

A
  1. Threatened
  2. Inevitable
  3. Incomplete
  4. Complete
  5. Septic
  6. Missed
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4
Q

What constitutes a ‘threatened’ miscarriage?

A

Bleeding from gravid uterus before 24 weeks gestation +/- pain
Foetus viable
No evidence of cervical dilatation

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5
Q

What constitutes an ‘inevitable’ miscarriage?

A

Cervix has already begun to dilate

Open cervix with bleeding (may be heavy) +/- clots

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6
Q

What constitutes an ‘incomplete’ miscarriage?

A

Only partial expulsion of products of conception
Open cervix
Vaginal bleeding

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7
Q

What constitutes a ‘septic’ miscarriage?

A

Risk of ascending infection into uterus and spread through pelvis

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8
Q

What constitutes a ‘missed’ miscarriage?

A

Fetus has died
No attempt by uterus to expel products

Could have bleeding/brown loss vaginally

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9
Q

Describe findings on ultrasound in missed miscarriage

A

Gestational sac visible

No fetus - empty sac or foetal pole with no foetal heartbeat

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10
Q

What constitutes a ‘complete’ miscarriage?

A

All products expelled
Cervix closed
Bleeding stopped

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11
Q

What investigations are helpful in confirming complete miscarriage?

A

Confirmed products of conception expelled

Witnessed scan of intrauterine pregnancy

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12
Q

What cases of miscarriage are at higher risk of sepsis occuring?

A

Incomplete

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13
Q

8 factors that could lead to Spontaneous miscarriage

A 
Abnormal conceptus
Uterine abnormality
Cervical incompetence
Maternal factors - age, diabetes
Hormonal imbalances
SLE, Thyroid Disease
Acute maternal infection
UNKNOWN - general risk is quite high
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14
Q

3 elements of Abnormal conceptus

A

Chromosomal
Genetic
Structural

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15
Q

Why are causes of structural issues in conceptus difficult to identify?

A

Changes in fetal tissue after death changes chromosomal analysis

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16
Q

Name 2 uterine abnormalities that could contribute to spontaneous miscarriage occurring

A

Congenital - double uterus

Fibroids - distorts uterine cavity (submucus)

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17
Q

How do congenital abnormalities occur in the uterus?

A

Failure of normal fusion of mullerian ducts

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18
Q

At which stage of pregnancy is cervical incompetence prevalent?

A

2nd trimester

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19
Q

3 ways in which cervical incompetence may occur

A

Premature opening of cervix without uterine activity - pregnancy expelled
Primary or secondary weakness (disease, surgery, smears)
Trauma - dilatation, biopsy

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20
Q

Which hormone is found to be at lower levels in women who experience threatened miscarriages and inevitable abortions compared to those who continue with healthy pregnancy?

A

Progesterone

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21
Q

What is essential during the first 8 weeks of pregnancy and if removed will induce abortion within 7 days?

A

Corpus luteum

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22
Q

Why is corpus luteum essential in early pregnancy?

A

Pumps out progesterone - thickens uterine lining, decidualization and maintenance of endometrium keeps pregnancy viable

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23
Q

Name examples of maternal infection that can lead to loss of pregnancy

A

Appendicitis

Pyelitis

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24
Q

How can acute infection lead to the loss of a pregnancy?

A

Mother will experience general toxic illness, high temperature
This can stimulate uterine activity and loss

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25
How is a threatened miscarriage managed?
Conservatively | Bleeding will settle
26
How is an inevitable miscarriage managed?
Evacuation if heavy bleeding
27
How is a missed miscarriage managed?
Conservative management
28
Describe medical and surgical management in miscarriage
Medical - prostaglandins | Surgical - Surgical Management of Miscarriage (SMM) - Short GA, dilate cervix, evacuate uterus
29
How is a septic miscarriage managed?
Antibiotics Evacuation of uterus Prevent spread to tubes
30
Define an ectopic pregnancy
Implantation outwith the uterine cavity
31
Most common site of ectopic pregnancy
Ampullary Second- isthmus Tubal 95-97%
32
Rate of ectopic pregnancies
1 in 90
33
Risk factors for ectopic pregnancy
Pelvic inflammatory disease Previous ectopic Previous tubal surgery - sterilisation; ask for reverse Assisted conception -IVF
34
Why might IVF treatment increase the risk of ectopic pregnancy?
How the embryo is implanted | Underlying fertility issues that are present in IVF patients
35
Presentation of Ectopic Pregnancy
Period of amenorrhea with positive urine pregnancy test Vaginal bleeding Pain in abdomen GI or urinary symptoms
36
What GI or urinary symptoms may present in ectopic pregnancy?
Increased micturition | Increased bowel movement
37
Investigations for ectopic pregnancy
Ultrasound Scan - no gestational sac, adnexal mass, fluid in pouch of douglas Serum bHCG Serum progesterone - should be high, over 25 ng/ml
38
Management of ectopic pregnancy
Medical - Methotrexate - shrink tissue Surgical - Laprascopical salpingectomy, salpingotomy (tube spared) Conservative - if asymptomatic
39
Define Antepartum Haemorrhage
Bleeding from genital tract after 24th week but before delivery of baby
40
5 Causes of Antepartum Haemorrhage
``` Placenta Praevia Placental abruption APH of unknown origin Local lesions of genital tract Vasa praevia - rare ```
41
Examples of local lesions in genital tract
Cervical erosions or polyps Cervical cancers Trichomonas or thrush - bleeding, blood-stained discharge
42
Vasa praevia is the rupture of which vessels?
Rupture of foetal vessels in membranes | Blood loss is foetal, not maternal blood loss
43
Where in the uterus does all or part of the placenta implant to cause placenta praevia?
Lower uterine segment
44
What 3 factors can increase likelihood of placenta praevia?
Multiparous women Multiple pregnancies Previous Caesarean Section
45
Describe Grades I to IV in the classification of Placenta Praevia
Grade I - Placenta encroaching on lower segment not the internal cervical os Grade II - Placenta reaches internal os Grade III- Placenta eccentrically covers internal os Grade IV - Central placenta praevia
46
Presentation of placenta praevia
Painless bleeding per vaginam Malpresentation of foetus - oblique/transverse Incidental
47
Why does bleeding occur with placenta praevia?
Placenta separates as lower segment is formed and cervix effaces Blood loss from venous sinuses in lower segment
48
Clinical features of placenta praevia
Maternal condition will correlate with amount of PV bleeding (unlike abruption) Soft, non-tender uterus Fetal malpresentation
49
Diagnosis of Placenta Praevia
Ultrasound
50
Which type of placenta praevia is harder to identify on ultrasound?
Posterior
51
What organ is a landmark for the anterior part of the lower uterine segment?
Bladder
52
Management of placenta praevia
Confirm diagnosis by US Cross match blood and transfuse if necessary Conservative approach to prolong pregnancy to foetal maturity Caesarean - risk of Post Partum Haemorrhage Medical Balloon Tamponade Surgical
53
Describe medical management of placenta praevia
Oxytocin Ergometrin Carbaprost Tranexamic acid
54
Describe surgical management of placenta praevia
B lynch suture Ligation of uterine and iliac vessels Hysterectomy *Post partum bleed severe, placenta adherent*
55
What is placental abruption?
Haemorrhage due to premature separation of placenta before birth of baby Associated with large retroplacental clot
56
What is associated with placental abruption?
Large retroplacental clot
57
What factors may predispose a mother to placental abruption?
``` Pre-eclampsia/Chronic hypertension Multiple pregnancies Polyhydramnios Smoking Increasing age Parity Previous abruption Cocaine use ```
58
Three Clinical Types of Placental Abruption
Revealed - apparent, bood through cervical os Concealed- haemorrhage between placental and uterine wall Mixed
59
2 Clinical signs of a concealed placental abruption
Increased pain - tender/irritable on examination | Fundal height greater than consistent for gestation
60
Signs and symptoms of placental abruption
Severe abdominal pain and APH Longitudinal lie with presenting part fixed in pelvis Uterine tone increased - may be contracting
61
Management of Placental Abruption
Expectant Treatment Vaginal delivery Immediate Caesarean Section
62
What determines the management of placental abruption
Amount of bleeding Condition of mother and baby Gestation
63
Complications of placental abruption
``` Maternal shock Fetal death Maternal DIC - will bleed when line inserted Renal failure PPH Couvelaire Uterus ```
64
What is Couvelaire uterus?
Uterus appears bruised | Blood penetrates the uterine wall and seeps into myometrium
65
Define preterm labour
Onset of labour prior to 37 weeks gestation 32-36 mildly preterm 28-32 very preterm 24-28 extremely preterm
66
Predisposing factors to preterm labour
``` Multiple pregnancies Polyhydramnios APH Pre-eclampsia Infection eg UTI Pre-labour premature rupture of membranes ```
67
Diagnosis of Preterm labour
Contractions | Evidence of cervical change on vaginal exam
68
Vaginal exam must not be carried out in which condition?
Suspected placenta praevia
69
Management of preterm labour
Tocolysis - slows contractions to allow steroid admin/transfer of mother Steroids Transfer to NICU Aim for vaginal delivery
70
In which cases are steroids contraindicated in management of preterm labour?
Fetal immaturity If help needed with breathing 2 doses maximum
71
Examples of neonatal morbidity resulting from prematurity
``` Respiratory Distress Syndrome Intraventricular Haemorrhage Cerebral palsy Nutrition Temperature control Jaundice Infections Visual impairments Hearing loss ```

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