Complications in pregnancy Flashcards
What is spontaneous miscarriage?
Loss of pregnancy before 24 weeks gestation
What are 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 missed abortion?
A pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of the pregnancy
What are clinical features of threatened miscarriage?
Vaginal bleeding +/- pain
Viable pregnancy
Closed cervix on speculum examination
What are clinical features of inevitable miscarriage?
Viable pregnancy with open cervix with bleeding
What are clinical features of missed miscarriage?
Bleeding or no symptoms
Gestational sac seen on scan
No clear fetus
What are clinical features of incomplete miscarriage?
Most of the pregnancy has been expelled out with some products of pregnancy remaining in the uterus
Open cervix with vaginal bleeding
What is septic miscarriage?
Infection in the uterus as a result of miscarriage
What is the aetiology of spontaneous miscarriage?
Abnormal conceptus
Uterine abnormality
Cervical incompetence
Maternal illness
How is threatened miscarriage managed?
Conservative management
How is inevitable miscarriage managed?
If bleeding is heavy may require evacuation
How is septic miscarriage managed?
Antibiotics and evacuation of uterus
What is an ectopic pregnancy?
Implantation outside of the uterine cavity
What are risk factors of ectopic pregnancy?
Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic
Assisted conception
How does ectopic pregnancy present?
Period of ammenorrhoea
May have vaginal bleeding, abominal pain, or GI/urinary symptoms
What investigations are done if ectopic pregnancy is suspected?
Scan - no intrauterine gestational sac
Serum Beta human chorionic hormone - normal intrauterine pregnancy will see raised levels
Serum progesterone - viable pregnancy levels will be >25ng/ml
How is ectopic pregnancy managed?
Methotrexate
Laparoscopic salpingectomy or salpingotomy
Why is methotrexate given in ectopic pregnancy?
It prevents further growth of the fetus
What is antepartum haemorrhage?
Haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby
What are causes of antepartum haemorrhage?
Placenta praevia Placental abruption APH of unknown origin Local lesions of the genital tract Vasa praevia
What is placenta praevia?
Where the placenta is attached to the lower segment of the uterus
What is Placental abruption?
Placenta detaches from the uterine wall before the birth of the baby
Who is more at risk of placenta praevia?
Multiparous women
Multiple pregnancies
Previous caesarean
What are classifications of placenta praevia?
Grade I - placenta encroaching on the lower segment but not the internal os
Grade II - Placenta reaches the internal os
Grade III - Placenta partially covers the os
Grade IV - Central placenta praevia
How does placenta praevia present?
Painless PV bleeding
Malpresentation of the fetus
Incidental
How is placenta praevia diagnosed?
Ultrasound scan to locate the placental site
How is placenta praevia managed?
Cesearean section
What are factors associated with placental abruption?
Pre-eclampsia/chronic hypertension Multiple pregnancy Polyhydraminos Smoking Increasing age Parity Previous abruption Cocaine use
How does placental abruption present?
Pain
Vaginal bleeding
Increased uterine activity
What are complications of placental abruption?
Maternal shock
Fetal death
Maternal renal failure
Postpartum haemorrhage
What is preterm labour?
Onset of labour befroe 37 weeks gestation or 259 days
How is preterm labour graded?
Mildly preterm - 32-36 weeks
Very preterm - 28-32 weeks
Extremely preterm - 24-28 weeks
What are predisposing factors for preterm labour?
Multiple pregnancy Polyhydramnios APH Pre-eclampsia Infection Prelabour premature rupture of membranes
What is gestational hypertension?
Hypertension that develops after 20 weeks of gestation
What is pre-eclampsia?
Hypertension after week 20 associated with significant proteinuria
How is significant proteinuria defined for pre-eclampsia?
Urine dipstick >1+
Spot urinary Protein:creatinine ratio >30mg/mmol
24 hours urine protein collection >300mg/day
What actions should be taken in pregnancies with maternal hypertension?
Change anti-hypertensive drugs if indicated ie teratogenic/fetotoxic drugs such as ACEinhibitors
Aim to keep BP <150/100
Monitor for superimposed pre-eclampsia
Monitor fetal growth
May have a higher incidence of placental abruption so be aware
How is pre-eclampsia diagnostically defined?
Mild hypertension on two occassions more than 4 hours apart or moderate to severe hypertension
AND
Proteinuria of >300mgs/24 hours
What is pathophisiology of pre-eclampsia?
Immunological
Genetic predisposition - secondary invasion of maternal spiral arterioles by trophoblasts impaired, imbalance between vasodilators/vasoconstrictors in pregnancy
What are risk factors for developing pre-eclampsia?
First pregnancy
Extremes of maternal age
Pre-eclampsia in previous pregnancyPregnancy interval >10 years
BMI>35
Family history
Underlying disorders - hypertension, diabetes, renal disease, autoimmune disorders
What organs are affected by pre-eclampsia?
Kidneys Liver Vasculation Brain Lungs
What are maternal complications of pre-eclampsia?
Eclampsia - seizures
Severe hypertension leading to cerebral haemorrhage or stroke
HELLP - Hemolysis, Elevated Liver enzymes, Low Platelets
Disseminated intravascular coagulation
Renal failure
Pulmonary oedema, cardiac failure
What are fetal complications of pre-eclampsia?
Impaired placental perfusion leading to Intrauterine Growth Restriction, fetal distress, prematurity, increased perinatal mortality
What are signs and symptoms of severe pre-eclampsia?
Headache, blurred vision, epigastric pain/tenderness, pain below ribs, vomiting, swelling of hands, face, legs Severe hypertension Clonus, brisk reflexes, papillodoema Reduced urine output Convulsions
What are biochemical abnormalities of severe pre-eclampsia?
Raised liver enzymes/bilirubin
Raised urea and creatinine, raised urate
What are haematological abnormalities of severe pre-eclampsia?
Low platelets
Low haemoglobin
Features of disseminated intravascular coagulation
How shoud pre-eclampsia be managed?
Frequent blood pressure checks/urine protein Check symptoms Check for hyperreflexia Check for tenderness over the liver Bloods - FBC for hemolysis/platelets Liver function tests Renal function tests Cardiotocography (CTG)
What is the only ‘cure’ for pre-eclampsia?
Delivery of the baby and placenta
How should eclamptic seizures be managed?
Magnesium sulphate bolus
Control of blood pressure
Avoid fluid overload
What is gestational diabetes?
Diabetes first presenting in pregnancy which returns to normal after delivery
Is someone who develops gestational diabetes at increased risk of developing type 2 diabetes in later life?
Yes
What causes insulin requirements of the mother to increase?
Human placental lactogen, progesterone, human chorionic gonadotrophin, and cortisol from placenta are all anti-insulin
What is fetal macrosomia?
Abnormally large baby weighing over 4000 grams at any gestation
What are potential complications of diabetes in pregnancy?
Fetal congenital abnormalities Miscarriage Fetal macrosmia Polyhydramnios Shoulder dystocia during delivery Stillbirth Increase risk of pre-eclampsia Worsening maternal nephropathy, retinopathy Infections Impaired neonatal lung maturity, neonatal hypoglycaemia, jaundice
What is polyhydramnios?
Excess of amniotic fluid in the amniotic sac
How is diabetes managed before pregnancy
Better glycemic control
Folic acid 5mg
Dietary advice
Retinal and renal assessment
How is gestational diabetes managed?
Optimise glucose control, insulin requirements increase
Could continue oral agents such as metformin but may need to change to insulin for tighter control
Provide glucagon injections/concentrated glucose solution in case of hypo
Watch for ketonuria
How should diabetes be managed during labour?
Induce labour 38-40 weeks or earlier if fetal or maternal concerns
Consider caesarean if significant fetal macrosomia
Maintain blood sugar with insulin
Continous CTG
Early feeding of baby to reduce neonatal hypoglycaemia
What are risk factors for gestational diabetes?
Increased BMI>30
Previous macrosomic baby
Previous gestational diabetes
Family history of diabetes
High risk groups eg Asian origin
Polyhydramnios or big baby in current pregnancy
Recurrent glycosuria in current pregnancy
How is gestational diabetes screened?
Offer HbA1C if risk factor present, if >43mmol/mol OGTT to be done, if normal repeat at 24-28 weeks
What is Virchow’s triad of venous thromboembolism?
Stasis
Vessel wall injury
Hypercoagulability
Why is risk of thromboembolism increased in pregnancy?
Hypercoagulable state to protect mother against bleeding post delivery - increase in fibrinogen, factor VIII, VW factor, platelets - decrease in natural anticoagulants
Increased staiss
May be vascular damage at delivery
What are risk factors for VTE in pregnancy?
Older mothers, increasing parity Increased BMI Smokers IVDU Pre-eclampsic Dehydration Decreased mobility Infection Operative delivery Haemorrhage Previous VTE Sickle cell disease
How is VTE managed in pregnancy?
TED stockings
Advise increased mobility, hydration
What are signs/symptoms of VTE?
Pain in calf Increased girth of affected leg Calf muscle tenderness Breathlessness Pain on breathing Cough Tachycardia Hypoxic Pleural rub
What investigations can be done if VTE is suspected?
ECG
Blood gases
Doppler
Ventilation perfusion (V/Q)
How is preterm labour diagnosed?
Contractions with evidence of cervical change on vaginal examination
What neonatal morbidity results from prematurity?
Respiratory distress syndrome Intraventricular haemorrhage Cerebral palsy Nutrition Temperature control Jaundice Infections Visual impairment Hearing loss
