Complications in pregnancy 1 Flashcards
How are miscarriages classified?
- Threatened - a woman with a viable pregnancy has symptoms suggestive of miscarriage but there has been no loss of pregnancy yet
- Inevitable - cervix is open and there is bleeding (could be heavy +/- clots)
- Incomplete - only partial expulsion of products of conception, open cervix, vaginal bleeding
- Complete - complete expulsion, cervix closed, bleeding has stopped
- Septic - incomplete or missed miscarriage where the products of conception (tissues etc) are not expelled can result in infection which can spread throughout the pelvis and elsewhere.
- Missed - death of embryo/foetus in the uterus but the body does not expell the products of conception.
What modality of imaging is used to check for early viable pregnancy?
USS using transvaginal probe
What is a threatened miscarriage?
- A threatened miscarriage is when there is bleeding from the gravid (pregnant) uterus before <24 weeks.
- There is a viable foetus
- And no sign of cervical dilatation on speculum examination
What is an Inevitable miscarriage?
- A miscarriage becomes inevitable if the cervix has dilated.
- There is a viable pregnancy and there could be heavy bleeding.
Typical case study for inevitable miscarriage:
- A women presents with vaginal bleeding and lower crampy abdominal pain at approximately 9 weeks gestation.
- Her observations are stable.
- Speculum examination reveals blood and small clots coming through the open cervical os
What is a Missed Miscarriage?
- A pregnancy in which the foetus has died but the uterus has made no attempt to expel the products of conception
- Could have no symptoms or bleeding/brown loss vaginally
- No clear foetus (empty gestational sac) or a foetal pole with no foetal heart seen in the gestational sac
What is a Septic Miscarriage?
Incomplete miscarriage + infection
Following incomplete miscarriage there is a risk of ascending infection into the uterus which can then spread throughout the pelvis
What are some causes of miscarriage?
- Abnormal conceptus (egg, embryo or foetus) - chromosomal, genetic or structural
- Uterine abnormality - congenital or fibroids
- Cervical weakness - primary or secondary - the cervix opens prematurely with absent or minimal uterine activity and the pregnancy is expelled.
- Maternal - age, diabetes
- Unknown
What is the management of threatened miscarriage?
Conservative
In most cases the bleeding will stop and the pregnancy will be okay
Ectopic pregnancy:
- What is the incidence?
- Risk factors?
- Presentation?
- Around 1:90 pregnancies
- Risk factors: Pelvic inflammatory disease, previoius tubal surgery, previous ectopic and assited conception i.e IVF or IUI
- Presentation = A period of amenorhoea with a positive urine pregnancy test +/- vaginal bleeding, pain in abdomen or GI/urinary symptoms
What 2 key investigations are done for a suspected ectopic pregnancy?
- Transvaginal Ultrasound Scan - no intrauterine gestational sac, fluid in Pouch of Douglas (may come about from a ruptured or leaking ectopic pregnancy and/or from a ruptured corpus luteum)
-
Serum BHCG levels
- May need to serially track levels over 48 hour intervals.
- In a normal pregnancy, the first-trimester β-hCG concentration rapidly increases, doubling about every 2 days. An increase over 48 hours of at least 66% has been used as a cutoff point for viability.
- Ectopic pregnancy may present with rising, falling or plateau β-hCG levels; thus, serial measurement is most useful to confirm fetal viability rather than to identify ectopic pregnancy.
How is an ectopic pregnancy managed?
Ectopic pregnancy may be managed surgically, medically or conservatively depending on the individual patient.
- Medical - Methotrexate injection and follow up with serum B-HCG test - Methotrexate works by stopping the growth of the fertilized egg before a rupture occurs.
- Surgical - mostly laparoscopy - Salpingectomy (remove fallopian tube) or Salpingotomy (leave damaged tube but remove embryo)
What is antepartum haemorrhage?
Haemorrhage from the genital tract after 24 weeks but before delivery of the baby.
It is one of the gravest obstetric emergencies and is associated with significant maternal and neonatal morbidity and mortality.
What are some causes of Antepartum Haemorrhage? (5)
- Placenta praevia - where the placenta is attached to the lower segment of the uterus, covering the cervical os
- Placental abruption - placenta has started to separate from the uterine wall before the birth of the baby and is associated with a retroplacental clot.
- APH of unknown origin
- Local lesions of the genital tract - i.e cervical erosions and polyps
- Vasa praevia (very rare) - usually due to rupture of a foetal vessel within the foetal membranes. The blood loss if foetal and not maternal and the effect on the foetus can be catastrophic
Placenta praevia
The placenta is said to be praevia when all or part of it implants in the lower uterine segment and lies in front of the presenting part of the fetus (covering the cervical os)
It occurs in about 1% of all pregnancies and is more common in:
- Multiparous women
- Multiple pregnancies where the placenta mass is increased
- In women with previous c-sections.
Low-lying placenta vs placenta praevia
Why does placental abruption cause bleeding?
It causes haemorrhage from premature separation of the placenta from the uterine wall before the birth of the baby and is associated with a retroplacental clot.
The incidence of placental abruption will depend on maternal age, parity and social status but it is estimated to occur in approx 0.6% of all pregnancies
