Complications in Pregnancy Flashcards
What is abortion or spontaneous miscarriage?
Termination/loss of pregnancy before 24weeks gestation with no evidence of life.
What is a threatened miscarriage?
Bleeding from the gravid uterus before 24 weeks gestation when there is a viable foetus an no evidence of cervical dilation.
What is incomplete miscarriage?
When there is only partial expulsion of the products of conception.
What is a complete abortion?
When there is complete expulsion of the products of conception.
What is a septic abortion?
Following an incomplete abortion there is risk of ascending infection into the uterus which can spread throughout pelvis.
What is a missed abortion?
A pregnancy in which the foetus has died but the uterus has made no attempt to expel the products of conception.
What are some symptoms of a threatened miscarriage?
Vaginal Bleeding
Sometimes Pain
Viable pregnancy
Closed cervix
What are some symptoms of inevitable miscarriage?
Viable pregnancy
Open cervix
Vaginal bleeding - could be quite heavy
Potential clots
What are some symptoms of missed miscarriage?
Asymptomatic
Vaginal bleeding
Brown sludgy loss
Empty gestational sac seen on scan or a foetal pole with no foetal heart seen.
What are some causes of spontaneous miscarriage?
- Abnormal chormosomal, genetic or structural make-up of foetus
- Congenital uterine abnormalities
- Fibroids
- Cervical incompetence
- Maternal problems
- Idiopathic
What are some examples of maternal diseases that may be associated with increasing the risk of spontaneous miscarriage?
Systemic Lupus Erythematosus (SLE)
Thyroid disease
Acute maternal infection e.g pyelitis, appendicitis
What is the management method for the various types of miscarriage/abortion?
Threatened - conservative
Inevitable - evacuation if heavy bleeding.
Missed - conservative, medical = prostaglandins (misoprostol), surgical
Septic - antibiotics and evacuate uterus
What is 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
What is the incidence of ectopic pregnancies?
Around 1:90 pregnancies
How does an ectopic pregnancy present?
Period of ammenorhoea Positive urine pregnancy test Possible Vaginal bleeding Possible painful abdomen Possible GI or urinary symptoms
What investigations would you carry out for a suspected ectopic pregnancy?
USS - no intrauterine gestational sac, fluid in pouch of Douglas, may see adnexal mass.
Serum BhCG levels - may need to track over 48hrs.
Serum progesterone level - viable intrauterine pregnancies are high >25ng/ml
What is the management for an ectopic pregnancy?
Medical - methotrexate
Surgical - mostly done laporscopically; salpingectomy, salpingotomy
Conservative
What is Antepartum Haemorrhage (APH)?
Haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby.
What are some causes of Antepartum Haemorrhage?
Placenta praevia Placental abruption Idiopathic Local lesions of genital tract Vasa praevia
What is Placenta Praevia?
All or part of the placenta implants in the lower uterine segment.
Can lie in front of the presenting part of foetus.
Incidence is 1:200 pregnancies.
When in Placenta Praevia more common
Multiparous women
Multiple pregnancies
Previous Caesarean section
What is the classification system for Placenta Praevia?
Grade 1 - Placenta encroaching on the lower segment but not the internal cervical os.
Grade 2 - Placenta reaches the internal os.
Grade 3 - Placenta eccentrically covers the os.
Grade 4 - Central placenta praevia.
How does Placenta Praevia present?
Painless Vaginal bleeding Malpresentation of the foetus Incidental Maternal condition correlates with amount of PV bleeding Soft, non tender uterus
What is the management for Placenta praaevia?
Depends on severity of blood loss and gestation.
May just be conservative to prolong pregnancy to gain foetal maturity before delivering c-section.
Blood transfusion
What is Placental abruption?
Haemorrhage resulting from premature separation of the placenta before the birth of the baby.
Associated with retro-placental clot.
What are some factors associated with placental abruption?
Pre-eclampsia Chronic Hypertension Multiple pregnancy Polyhydramnios (excess amniotic fluid) Smoking Increasing Age Parity Previous Abruption Cocaine use
What is revealed placental abruption?
The major haemorrhage is apparent externally because the blood released from the placenta escapes through the cervical os.
What is concealed placental abruption?
The haemorrhage occurs between the placenta and the uterine wall. The uterine contents then expands and the fundal height is larger than what would be consistent for gestation. Sometimes the blood penetrates the uterine wall so it appears bruised.
What is a mixed placental abruption?
There is both revealed and concealed haemorrhage.
How does placental abruption present?
Pain (severe abdominal)
Vaginal bleeding (may minimal)
Increased uterine activity
Patient ay be having contractions.
What is the management of Antepartum Haemorrhage?
Varies from expectant treatment to attempting vaginal delivery to immediate c-section depending on:
Amount of bleeding
General condition of mum/baby
Gestation
What are some complications of Placental abruption?
Maternal shock Collapse Foetal death Maternal DIC Renal failure Postpartum Haemorrhage
What is preterm labour?
Onset of labour before 37 completed weeks gestation.
32-36wks mild preterm
28-32 wks very preterm
24-28 wks extremely preterm
What are some predisposing factors for preterm labour?
Multiple pregnancy Polyhydramnios APH Pre-eclampsia Infection e.g UTI Prelabour premature rupture of membranes Idiopathic
What is the management of preterm delivery?
<24-26 wks very poor prognosis, decisions made in discussion with parents and neonatalogists.
All cases considered viable then consider tocolysis (drug that delay premature uterine activity) to allow steroids and mum to be transferred to correct unit.
Steroids
Transfer to unit with NICU facilities
Aim of vaginal delivery.
What are some neonatal conditions that may develop due to prematurity?
Respiratory distress syndrome Intraventricular haemorrhage Cerebral palsy Nutrition Temperature control Jaundice Infections Visual impairment Hearing loss
What are the different classifications of hypertension ?
Mild Hypertension = diastolic 90-99, systolic 140-149
Moderate Hypertension = diastolic 100-109 systolic 150-159
Severe Hypertension = diastolic >110 systolic >160
What is gestational hypertension?
New hypertension that develops after 20 weeks of pregnancy.
What is pre-eclampsia?
New hypertension >20 weeks in association with significant proteinuria.
What is meant by significant proteinuria?
Protein strip urine > 1+
Spot urinary protein: creatinine ratio >30mg/mmol
24hrs urine protein collection > 300mg/day
How is chronic hypertension in pregnancy managed?
Aim to keep BP <150/100 - uses labetolol, nifedipine, methyldopa.
Monitor for superimposed pre-eclampsia
Monitor foetal growth
Be cautious of placental abruption.
What is the pathophysiology of pre-eclampsia?
Secondary invasion of maternal spiral arterioles by trophoblasts, become impaired and leads to reduced placental perfusion.
Imbalance between vasodilators and vasoconstrictors in pregnancy (prostocyclin/thromboxane).
What are the risk factor for developing pre-eclampsia?
First pregnancy Extremes of maternal age Pre-eclampsia in a previous pregnancy Pregnancy interval > 10years Family history Multiple pregnancy Underlying medical disorders - chronic hypertension, pre-existing renal disease, pre-existing diabetes, autoimmune disorders
What are the maternal and foetal complications of pre-eclampsia?
Eclampsia Seizures Cerebral haemorrhage Stroke HELLP (haemolysis, elevated liver enzymes, low platelets) DIC (disseminated intravascular coagulation) Renal failure Pulmonary oedema Cardiac failure
Impaired placental perfusion
What are the symptoms of severe pre-eclampsia?
Headache Blurred vision Epigastric pain Pain below ribs Vomitng Sudden swelling face, hands, legs. Clonus Brisk reflexes Papillodema Reducing urine output Convulsions > 3+ proteinuria raised liver enzymes, urea and creatinine, urate. Low platelets, haemoglobin
What is the management of pre-eclampsia?
Only cure is delivery of baby & placenta.
Close observations
Anti-hypertensives
Steroids for foetal lung maturity if gestation < 36 weeks.
Consider induction of labour if maternal or foetal condition deteriorates, irrespective of gestation.
Close monitoring in puerperium as symptoms may persist.
How are PET seizures treated?
Magnesium sulphate bolus + IV infusion Control BP (IV labetolol, hydralazine if >160/110) Avoid fluid overload - aim for 80mls/hour fluid intake.
What is the prophylaxis for pre-eclampsia in subsequent pregnancies?
Low dose Aspirin from 12 weeks till delivery.
Why do the insulin requirements of the mother increase if she has pre-existing diabetes in pregnancy?
Human placental lactogen, Progesterone, Human Chorionic gonadotrophin and Cortisol from the placenta are all anti-insulin in their action.
What does foetal hyperinsulinaemia cause?
Macrosomia (large baby)
What is the management for Diabetes in pregnancy?
Better glycemic control - ideally blood sugars should be around 4-7 mol/l pre-conception and HbA1c < 6.5% (< 48mmol/mol).
Folic acid 5mg
Dietary advice
Retinal and renal assessment
How is diabetes managed during labour?
Observe for PET
Labour induced 38-40 weeks or earlier if concerns
Maintain blood sugar with insulin - dextrose infusion,
Continuous CTG foetal monitoring in labour.
Early feeding of baby to reduce neonatal hypoglycaemia.
Pre-pregnancy regimen of insulin post delivery.
What are the risk factors for gestational diabetes?
Increased BMI > 30 Previous macrocosmic baby > 4.5 kg Previous GDM Family Hx Asian origin Polyhydramnios Recurrent glycosuria
Why is venous thrombosis-embolism increased in pregnancy?
Pregnancy is a hypercoagulable state - increased fibrinogen, factor VIII, VW factor, platelets
- decrease in natural anticoagulants (antithrombin II) - increase in fibrinolysis
Increased stasis - progesterone, effects of enlarging uterus.
May be vascular damage at delivery.
What factors increase the risk of Venous thrombosis-embolism?
Increasing Age Increasing Parity Increased BMI Smokers PET IV drug users Dehydration Infections Decreased mobility Haemorrhage >2L Previous VTE Sickle cell disease Thrombophilia Family Hx
What is the prophylaxis for VTE in pregnancy?
TED stockings
Advice to increase mobility and hydration
Prophylactic anti-coagulation with 3 or more risk factors and may need to continue it 6 weeks postpartum.
What are the signs and symptoms of VTE?
Claudication Increased girth of affected leg Calf muscle tenderness SOB Cough Tachycardia Hypoxia Pleural rub Dyspnea
