Complications in Pregnancy 1 Flashcards
What is the definition of a miscarriage?
Spontaneous loss of pregnancy before 24 weeks gestation
What is the definition of an abortion?
Voluntary termination
What is the incidence of spontaneous miscarriage?
Around 15%
What are the 6 categories of spontaneous miscarriage?
- Threatened
- Inevitable
- Incomplete
- Complete
- Septic
- Missed
What is a threatened miscarriage?
Bleeding from the gravid uterus before 24 weeks gestation when there is a viable fetus and no evidence of cervical dilatation
What is an inevitable miscarriage?
Miscarriage become inevitable if the cervix has already begun to dilate
What is an incomplete miscarriage?
Only partial expulsion of the products of conception
What is a complete miscarriage?
Complete expulsion of the products of conception
What is a septic miscarriage?
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
What is a missed miscarriage?
Missed miscarriage describes a pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception
How is an early viable pregnancy imaged?
- Ultrasound scan
* Transvaginal probe into vagina
What are the features of a threatened miscarriage?
- Vaginal bleeding +/- pain
- Viable pregnancy
- Closed cervix on speculum examination
What are the features of an inevitable miscarriage?
- Viable pregnancy
* Open cervix with bleeding that could be heavy +/- clots
What are the features of a missed miscarriage (early foetal demise)?
- 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
What are the features of an incomplete miscarriage?
- Most of pregnancy expelled out, some products of pregnancy remaining in the uterus
- Open cervix
- Vaginal bleeding (may be heavy)
What are the features of 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 previously that confirmed an intrauterine pregnancy)
What are the features of a septic miscarriage?
•More common in cases of an incomplete miscarriage
What are the causes of spontaneous miscarriage?
- Abnormal conceptus
- Uterine abnormality
- Cervical weakness
- Maternal
- Unknown
How might the conceptus be abnormal?
- Chromosomal
- Genetic
- Structural
What are possible uterine abnormalities?
- Congenital - failure of normal fusion of the Mullerian ducts
- Fibroids - in particular submucous fibroids due to distortion of the uterine cavity
What are the 2 types of cervical weakness?
- Primary
* Secondary
How might hormones be involved in miscarriage?
It has been shown that progesterone levels are lower in women with threatened miscarriage who proceed to have inevital abortions compared to the levels in those whose pregnancies continue (corpus lute vital)
How is a threatened miscarriage treated?
- Conservative
* Most stop bleeding and are okay
How is an inevitable miscarriage treated?
•If bleeding heavy may need evacuation
How is a missed miscarriage treated?
- Conservative
- Medical – prostaglandins (misoprostol)
- Surgical – SMM (surgical management of miscarriage)
How is a septic miscarriage treated?
Antibiotics and evacuate uterus
What is an ectopic pregnancy?
Pregnancy implanted outside the uterine cavity
What are the risk factors for ectopic pregnancy?
•Pelvic inflammatory disease •Previous tubal surgery •Previous ectopic •Assisted conception (1:90 pregnancies)
How does an ectopic pregnancy present?
- Period of ammenorhoea (with +ve urine pregnancy test)
- +/_ Vaginal bleeding
- +/_ Pain abdomen
- +/_ GI or urinary symptoms
What are the investigations 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
How is an ectopic pregnancy managed?
- Medical – Methotrexate (stops growth of child)
- Surgical – mostly laparoscopy– Salpingectomy, Salpingostomy (only embryo is removed) 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 the causes of APH?
- Placenta praevia
- Placental abruption
- APH of unknown origin - when all other causes have been excluded
- Local lesions of the genital tract
- Vasa praevia (very rare)
What is placenta praevia?
- When all or part of the placenta implants in the lower segment of the uterus
- 1/200
What is a placenta abruption?
- When the placenta has started to separate from the uterine wall before the birth of the baby and is associated with a retroplacental clot
- 0.6% of pregnancies
Which local lesions of the genital tract may cause APH?
- Cervical erosions and polyps may cause an APH
- Occasionally cervical Ca may present with an APH
- Trichomonas or thrush infections within the vaginal can occasionally cause a blood-stained discharge
What is vasa praevia?
- Rare but serious
- Usually the blood loss is small and is due to rupture of a fetal vessel within the fetal membranes
- The blood loss is fetal and not maternal and the effect on the fetus can be catastrophic
What increases chance on placenta praevia?
- Multiparous women
- Multiple pregnancies
- Previous caesarean section
What is the old classification for 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
What is the RCOG classification for placenta praevia?
- Low lying - placenta is less than 20 mm from internal os
* Placenta previa – covering the os
How does placenta praevia present?
- Painless PV bleeding (APH)
- Soft, non-tender uterus +/- malpresentation of the foetus
- Incidental
- USS - diagnosis
- MRI if USS is inconclusive
- NO VAGINAL EXAM IF SUSPICION
What causes bleeding in placenta praevia?
Separation of the placenta as the lower uterine segment forms and the cervix effaces
How is placenta praevia managed?
- Depends on gestation and severity
- C section as cervix dilatation will cause bleeding
- Watch out for PPH
How is a PPH managed?
- Medical management – oxytocin, ergometrine, carboprost, tranexemic acid
- Balloon tamponade
- Surgical – B Lynch cutre, ligation of uterine, iliac vessels, hystrectomy
What factors are associated with placental abruption?
- Pre-eclampsia/chronic hypertension
- Multiple pregnancy
- Polyhydramnios
- Smoking, increasing age, parity
- Previous abruption
- Cocaine use
N.B. very similar to causes of pre-term labour
What are the clinical types of placental abruption?
- Revealed (see the blood)
- Concealed (bleeding but inside so can’t see!) - Couvelaire uterus
- Mixed (concealed and revealed)
How does placental abruption present?
- Pain!!
- Vaginal bleeding (may be minimal bleeding)
- Increased uterine activity
How is APH managed?
•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
What are the complications placental abruption?
- Maternal shock, collapse (may be disproportionate to the amount of bleeding seen)
- Foetal 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)
- Babies resuscitated after 22 weeks now
What is the incidence of preterm labour?
- Around 5- 7% in singletons
* 30 - 40% multiple pregnancy
What are the predisposing factors of preterm labour?
- Multiple pregnancy
- Polyhydramnios
- APH
- Pre-eclampsia
- Infection eg UTI
- Pre-labour premature rupture of membranes
- Majority no cause (idiopathic)
How is a preterm labour diagnosed?
- Contractions with evidence of cervical change on VE
* Test- Fetal fibronectin
What are possible causes of preterm labour?
- Abruption
* Infection
How is preterm delivery managed?
•<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
What are the neotnatal morbidities caused by prematurity?
- Respiratory distress syndrome
- Intraventricular haemorrhage
- Cerebral palsy
- Nutrition
- Temperature control
- Jaundice
- Infections
- Visual impairment
- Hearing loss
