Complications in Pregnancy 1 Flashcards
How is miscarriage defined?
Spontaneous loss of pregnancy before 24 weeks gestation
What is a threatened miscarriage? What are some features of a threatened miscarriage?
Bleeding from the uterus before 24 weeks gestation when there is a viable fetus and no evidence of cervical dilatation
- Vaginal bleeding +/- pain
- Viable pregnancy
- Closed cervix on speculum exam
What is an inevitable miscarriage? What are some features of an inevitable miscarriage?
Miscarriage once the cervix has begun to dilate
- Viable pregnancy
- Open cervix with bleeding that may be heavy (+/- clots)
What is an incomplete miscarriage? Complete?
Incomplete - only partial expulsion of the products of conception.
Complete - complete expulsion of the products of conception
What is a septic miscarriage?
After an incomplete abortion an ascending infection invades the uterus and may spread to the pelvis
What is a missed miscarriage? What are some features of a missed miscarriage?
A pregnancy in which the fetus has died but the uterus has made no effort to expel the products of conception
- No symptoms, or could have bleeding / brown expulsion vaginally
- Gestational sac seen on scan
- No clear fetus / fetal pole with no heartbeat on scan
What are some features of an incomplete miscarriage?
- Open cervix
- Vaginal bleeding that may be heavy
- Expulsion of some of the products of conception
What are some features of a complete miscarriage?
- Cervix closed and bleeding stopped
- Complete expulsion of the products of conception
- Should have previously had a scan that confirmed intrauterine pregnancy
What are some of the possible causes of spontaneous miscarriage?
Fetal abnormality - chromosomes / genetics
Uterine abnormality
Cervical weakness - cervix opens with minimal uterine activity and pregnancy is expelled
Hormonal abnormalities - corpus luteum dysfunction
Maternal disease
How is a threatened miscarriage managed?
Conservative, just wait for bleeding to stop
Most stop bleeding and require no further intervention
How is an inevitable miscarriage managed?
If bleeding is heavy may require surgical evacuation
How is a Missed miscarriage managed?
Either:
- Conservative
- Prostaglandins (initiate labour)
- Surgical: SMM, surgical management of miscarriage
Where do ectopic pregnancies tend to occur?
Ampullary - most common
Isthmus - second most common
Interstitial - 2-5%
Ovary - 0.5 - 1%
Cervical - 0.1%
Fimbrial - very rare
How common are ectopic pregnancies? What are some risk factors?
Incidence - 1:90 pregnancies
- pelvic inflammatory disease
- Previous tubal surgery
- Previous ectopic
- Assisted conception
How does an ectopic pregnancy tend to present?
- Period of amenorhoea (with positive urine preg test)
+/- vaginal bleeding
+/- abdominal pain
+/- GI or urinary symptoms
Investigations for ectopic pregnancy?
USS - no intrauterine gestational sac, fluid in pouch of Douglas, possible adnexal mass
serum BHCG levels - increase slower than intrauterine pregnancy
Management of ectopic pregnancy?
Methotrexate - blocks folate metabolism which stops pregnancy advancing
Surgery - laparoscopic salpingectomy / salpingotomy
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 some of the possible causes of antepartum haemorrhage?
- Placenta praevia
- Placental abruption
- Uknown origin
- Local lesions of the genital tract (eg. vaginal tear)
- Vasa praevia
What is placenta praevia? What are some risk factors?
all or part of the placenta presents in the lower uterus
- Being multiparous
- Multiple pregnancies
- Previous caesarean section
What is haemorrhage due to placenta praevia caused by? How does it present?
Caused by the detachment of the placenta from the uterine wall as it presents near the cervix
- Soft, non-tender uterus
+/- fetal malpresentation
Diagnosis and management of placenta praevia?
Ultrasound scan
DO NOT do vaginal examination on suspected placenta praevia
management:
- Blood transfusion + conservative management
- Delivery by caesarean after conservative extension of gestation period
What is a common complication associated with placenta praevia?
Post partum haemorrhage
What is a placental abruption? Risk factors?
premature separation of the placenta before birth of the baby
- Pre-eclampsia / chronic hypertension
- Multiple pregnancy
- Polyhydramnios
- Smoking, old age, parity, cocaine
- Previous abruption
What are the types of placental abruption?
Revealed - haemorrhage is apparent externally
Concealed - bleeding confined to haematoma between placenta and uterine wall
Mixed - mixture of both
How does a placental abruption tend to present?
Pain
vaginal bleeding (amount depends on type of abruption)
Increased uterine activity
Management of placental abruption?
Depends on:
- amount of bleeding, condition of mother and baby, gestation
Options:
- Vaginal delivery
- |Immediate Caesarean
What are some common complications of placental abruption?
Maternal shock / collapse
Fetal distress progressing to death
Maternal DIC / renal failure
Postpartum haemorrhage
Couvelaire uterus - bleeding penetrates the myometrium and then the peritoneal cavity
What is preterm labour? How are preterm babies classified according to gestation period?
Onset of labour before 37 weeks gestation
32-36 weeks - mildly preterm
28-32 weeks - very preterm
24-28 weeks - extremely preterm
What are some predisposing factors for preterm labour?
Multiple pregnancy (occurs in 30-40%) Polyhydramnios Antepartum haemorrhage pre-eclampsia - Infection - Prelabour premature rupture of membranes
Diagnosis of preterm labour?
Contractions with evidence of cervical change on vaginal exam
Fetal fibronectin - signals detachment of amniotic sac from uterus
Management of preterm delivery?
Consider tocolysis to allow steroids / transfer (drugs preventing uterine contractions)
Steroids - increase baby’s lung function
Aim for vaginal delivery
How dangerous is preterm delivery?
At 26 weeks only 48% survive, 26% of which are disabled
At 24 weeks only 26% survive, 38% of which are disabled
