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Year 3 - Repro and Anaesthetics > Complications in Pregnancy 1 > Flashcards

Complications in Pregnancy 1 Flashcards

1
Q

topic covered:

  • Miscarriage
  • Ectopic Pregnancy
  • Antepartum haemorrhage
  • Preterm labour
A
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2
Q

what is the difference between miscarrige and abortion?

A
  • Miscarriage : spontaneous loss of pregnancy before 24 weeks gestation (before the fetus reaches viability. The term therefore includes all pregnancy losses from the time of conception until 24 weeks of gestation)
  • Abortion: voluntary termination
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3
Q

Incidence of spontaneous miscarriage is around 15%, maybe higher

what are the diffeent categories?

A
  • Threatened - bleeding from the gravid uterus before 24 weeks gestation when there is a viable fetus and no evidence of cervical dilatation
  • Inevitable - the cervix has already begun to dilate
  • Incomplete -When there is only partial expulsion of the products of conception this is referred to as an incomplete miscarriage
  • Complete - complete expulsion of the products of conception is referred to as a complete miscarriage
  • Septic - Following an incomplete miscarriage there is always a risk of ascending infection into the uterus which can spread throughout the pelvis and this is known as a septic abortion
  • Missed - Missed miscarriage describes a pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception
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4
Q
A
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5
Q

what is shown here?

A

Threatened miscarriage:

Vaginal bleeding+/- pain

Viable pregnancy

Closed cervix on speculum examination

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6
Q

what is shown here

A

Inevitable miscarriage:

Viable pregnancy

Open cervix with bleeding

that could be heavy (+/-clots)

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7
Q

when is a msised misscarrige (Early Fetal Demise) diagnosed?

A

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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8
Q

what happens in incomplete misscarrige?

A

Most of pregnancy expelled out, some products of pregnancy remaining in the uterus

open cervix, vaginal bleeding (may be heavy)

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9
Q

what happens in a complete misscarrige?

A

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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10
Q

when does a septic misscarrige happen?

A

especially in cases of an incomplete miscarriage

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11
Q

what is the aetiology of a spontaneous misscarrige?

A
  • Abnormal conceptus - chromosomal, genetic, structural
  • Uterine abnormality - congenital, fibroids
  • Cervical weakness - Primary, secondary
  • Maternal - increasing age, diabetes

Unknown

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12
Q

what are some Abnormal conceptus cause sof spontaneous misscarrige?

A

chromosomal

genetic

structure

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13
Q

what are some uterine abnormality causes of spontaneous misscarrige?

A

congenital

fibroids

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14
Q

what are some cervical weakness causes of spontaneous misscarrige?

A

primary

secondary

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15
Q

what is the management of a threatened misscarrige?

A

Threatened - conservative, “just wait” – most stop bleeding and are okay (pregnancy is okay)

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16
Q

what is the management of an inevitable misscarrige?

A

if bleeding heavy may need evacuation

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17
Q

what is the treatment of a missed misscarrige?

A
  • conservative
  • medical – prostaglandins (misoprostol)
  • surgical – SMM (surgical management of miscarriage)
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18
Q

what is the treatment of a septic misscarrige?

A

antibiotics and evacuate uterus

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19
Q

what is an ectopic pregnancy?

A

Pregnancy implanted outside the uterine cavity

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20
Q

what is the most common place for an ectopic pregnnacy?

A

ampulla of fallopian tube

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21
Q

what is the incidence of ectopic pregnancies?

A

Around 1:90 pregnancies

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22
Q

what are the risk factors of ectopic prengnacy?

A

Pelvic inflammatory disease

Previous tubal surgery

Previous ectopic

Assisted conception

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23
Q

what is the presentation of ectopic pregnancy?

A

Period of ammenorhoea (with +ve urine pregnancy test)

+/_ Vaginal bleeding

+/_ Pain abdomen

+/_ GI or urinary symptoms

24
Q

what is the investigation of ectpoic pregnancy?

A

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

25
Q

what is the management of ectopic pregnancy?

A

Medical – Methotrexate

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

Conservative

26
Q

ultraosund images of ectopic pregnancy

A
27
Q

laproscopic image of ectpoic pregnancy

red arrows = ectopic pregnancy

blue arrows = uterus which is empty

see some free blood in the pouch of douglus which is the area behind the uterus

A

Medical management by methotrexate or surgical by:

Salopingectomy = remove the tube

Salpingotomy = leave a damaged tube, remove the embryo

28
Q

what is antepartum haemorrhage?

A

•APH - haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby

APH is one of the gravest obstetric emergencies and is associated with significant maternal and neonatal morbidity and mortality

29
Q

what are the causes of antepartum haemorrhage?

A
  • Placenta praevia (where the placenta is attached to the lower part of the uterus)
  • Placental abruption (placenta has started to separate from the uterine wall before birth)
  • APH of unknown origin
  • Local lesions of the genital tract
  • Vasa praevia (very rare) - blood loss is small and is due to rupture of a fetal vessel within the fetal membranes, loss of foetal blood not materal
30
Q

what is placenta praevia?

A
  • All or part of the placenta implants in the lower uterine segment and lies infront of the presenting part of the foetus
  • Incidence 1/200 pregnancies
31
Q

who is placenta praevia more common in?

A
  • Multiparous women
  • multiple pregnancies
  • previous caesaren section
32
Q

what is the old classification of placenta praevia?

A

depends on how close the placenta is to the cervix

  • 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
33
Q

RCOG (royale collage) classification is what?

A
  • Low lying- placenta is less than 20 mm from internal os
  • Placenta previa – covering the os
34
Q

picture hsowing the varying degrees of placenta praevia

A
35
Q

what is the presentation of placenta praevia?

A
  • Painless PV bleeding
  • Malpresentation of the fetus
  • Incidental

diagnosis usually by US

bleeding is due to separation of the placenta as the lower uterine segment forms and the cervix effaces

36
Q

what are the clinical features of placenta praevia?

A
  • Maternal condition correlates with amount of bleeding PV
  • Soft, non tender uterus +/- fetal malpresentation
37
Q

what is the diagnosis of placenta praevia?

A

• Ultrasound scan to locate placental site

VAGINAL EXAMINATION MUST NOT BE DONE WITH SUSPECED PLACENTA PRAEVIA

38
Q

what is the management of placenta praevia?

A
  • Gestation
  • Severity

Caesarean section, watch for PPH - C section as cervix dilatation will cause bleeding

39
Q

what is the management of postpartum haemorrhage? (any bleeding afterdelivery over 500ml) (PPH)

A

Medical management – oxytocin, ergometrine, carboprost, tranexemic acid

Balloon tamponade (balloon fille diwth fluid)

Surgical – B Lynch cutre, ligation of uterine, iliac vessels, hystrectomy

40
Q

This is a pathology specimen of a uterus with a grade IV placneta praevia completely covering the internal cervical os. The baby was delivered by elective Caesarean sectioon but due to postpartum haemorrhage following delivery of the baby a Caesarean hysterectomy had to be performed to control the haemorrhage.

A
41
Q

what is Placental abruption?

A

Haemorrhage resulting from premature separation of the placenta before the birth of the baby

42
Q

what is the incidence of placental abruption?

A

The incidence of placental abrution will depend on maternal age, parity and social status but it in estimated to occur in approx 0.6% of all pregnancies

43
Q

what are factors associated with placental abruption?

A
  • Pre-eclampsia/ chronic hypertension
  • Multiple pregnancy
  • Polyhydramnios
  • Smoking, increasing age, parity
  • Previous abruption
  • Cocaine use
44
Q

what are the different types of placental abruption?

A
  • Revealed (see the blood)
  • Concealed (bleeding but inside so can’t see!)
  • Mixed (concealed and revealed)
45
Q

what is the presentation of placental abruption?

A
  • Pain
  • Vaginal bleeding (may be minimal bleeding)
  • Increased uterine activity
46
Q

general manaement of APH - Management will vary from expectant treatment to attempting a vaginal delivery to immediate Caesarean section depending on what?

A
  • Amount of bleeding
  • General condition of mother and baby
  • Gestation
47
Q

what are some complciaitons of placental abruption?

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

‘couvelaire uterus’

48
Q

what is pre term labour?

A

•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)

Babies resuscitated after 22 weeks now

49
Q

what is the incidenc eof preterm labour?

A
  • Around 5- 7% in singletons
  • 30 - 40% multiple pregnancy
50
Q

what are some predisposing factors to preterm labour?

A
  • Multiple pregnancy
  • Polyhydramnios
  • APH
  • Pre-eclampsia
  • Infection eg UTI
  • Prelabour premature rupture of membranes

Majority no cause (idiopathic)

51
Q

what doe spreterm delivery cause?

A
  • Major cause of perinatal mortality and mobidity
  • Gestation dependent
52
Q

what is the management of preterm delivery?

A
  • Diagnosis - Contractions with evidence of cervical change on vaginal exmaination, Test- Fetal fibronectin (test to predict preterm labour)
  • Consider possible cause - abruption, infection
53
Q

what is the management of preterm dleivery if it is before 24-26 weeks?

A
  • Generally regarded as very poor prognosis
  • decisions made in discussion with parents and neonatologists
54
Q

what is the management of preterm dleivery in cases that are considered viable?

A
  • Consider tocolysis (drugs preventing uterine contractions, labour suppressants) to allow steroids/ transfer
  • Steroids unless contraindicated
  • Transfer to unit with NICU facilities
  • Aim for vaginal delivery
55
Q

Survival and handicap rates in the very preterm infant

improves with increasing gestation?

A
56
Q

what is the neonatal morbidity resulting from prematurity?

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

Year 3 - Repro and Anaesthetics (50 decks)

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