Complications in Pregnancy Flashcards
What is a threatened miscarriage?
Vaginal bleeding +/- pain, viable pregnancy and closed cervix on speculum examination
What is an inevitable miscarriage?
- Viable pregnancy
- Open cervix with bleeding that could be heavy (+/- clots)
What is a missed miscarriage?
- No symptoms (could have bleeding/brown loss vaginally)
- Gestational sac seen on scan
- No clear fetus or a fetal pole with no fetal heart seen in the gestational sac
What is an incomplete miscarriage?
- Most of the pregnancy expelled out but some products of pregnancy remaining in the uterus
- Open cervix with vaginal bleeding (may be heavy)
What is a complete miscarriage?
- Passed all products of conception
- Cervix is closed and all bleeding has stopped
- Ideally should have confirmed the POC or had a scan previously that confirmed an intrauterine pregnancy
When is a septic miscarriage more common?
In the case of an incomplete miscarriage - infection
What are the causes of spontaneous miscarriage?
Abnormal conceptus, uterine abnormality, cervical incompetence, maternal (increasing age, diabetes etc.) and unknown causes
What is the management of miscarriage?
- Threatened: conservative
- Inevitable: evacuation if bleeding is heavy
- Missed: conservative, medical (misoprostol) and surgical
- Septic: antibiotics and evacuate uterus
What are the risk factors for an ectopic pregnancy?
Pelvic inflamm. disease, previous tubal surgery, previous ectopic and assisted conception
What is the presentation of ectopic pregnancies?
Ammenorhoea (+ positive pregnancy test), vaginal bleeding, abdominal pain and GI/urinary symptoms
What investigations are used to diagnose ectopic pregnancies?
USS, serum BhCG and serum progesterone
What are the management options for ectopic pregnancies?
Medical (methotrexate), surgical and 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 antepartum haemorrhage?
Placenta praevia, placental abruption, APH of unknown origin, local lesions of the genital tract and vasa praevia (rare)
What is the presentation of placenta praevia?
Painless PV bleeding, malpresentation of the fetus, soft non tender uterus and incidental findings
How is placenta praevia diagnosed and how is it managed?
- USS (cannot do vaginal examination)
- Depends on gestation and severity
- C section
What is the management of PPH?
Medical: oxytocin, ergometrine, carbaprost and tranexemic acid
Balloon tamponade
Surgical: B lynch suture, ligation of uterine , iliac vessels and hysterectomy
What is placental abruption?
Haemorrhage resulting from premature separation of the placenta before the birth of the baby
Which factors are associated with placental abruption?
Pre-eclampsia/chronic hypertension, multiple pregnancy, polyhydramnios, smoking, increasing age, parity, previous abruption and cocaine use
What is the presentation of placental abruption?
Pain, vaginal bleeding and increased uterine activity
What is the general management of APH?
Varies from expectant treatment to vaginal delivery to C section depending on the amount of bleeding, condition of mother and baby and gestation
What are the complications of placental abruption?
Maternal shock/collapse, fetal death, maternal DIC/renal failure and postpartum haemorrhage
What is the classification of preterm labour?
Onset of labour before 37 completed weeks
What are the predisposing factors for preterm labour?
Multiple pregnancy, polyhydramnios, APH, pre-eclampsia, infection e.g. UTI and prelabour premature rupture of membranes
How is preterm delivery managed?
- Diagnosis
- Consider possible cause
- Steroids unless contraindicated, transfer to unit with NICU and aim for vaginal delivery
Which neonatal morbidities are associated with prematurity?
Resp. distress syndrome, intraventricular haemorrhage, cerebral palsy, nutrition, temp. control, jaundice, infections, visual impairment and hearing loss
How is placenta praevia classified?
- Grade 1: placenta encroaching on the lower segment
- Grade 2: placenta reaches the internal os
- Grade 3: placenta eccentrically covers the os
- Grade 4: central placenta praevia
What are the types of placental abruption?
- Revealed
- Concealed
- Mixed
Describe how chronic hypertension is classified
- Mild: Diastolic 90-99 and systolic 140-49
- Moderate: Diastolic 100-109 and systolic 150-159
- Severe: Diastolic >110 and systolic >160
What is gestational hypertension?
New hypertension which develops after 20 weeks
What is pre-eclampsia?
New hypertension > 20 weeks in association with significant proteinuria
What is classed as significant proteinuria>
- Reagent strip estimation > 1+
- Spot urinary protein: creatinine ratio > 30mg/mmol
- 24hrs urine protein collection > 300mg/day
How should essential hypertension be managed during pregnancy?
- Change anti-hypertensives if indicated
- Aim to keep BP <150/100
- Monitor for superimposed pre-eclampsia
- Monitor fetal growth
- May have higher incidence of placental abruption
What is the definition of pre-eclampsia?
-Mild HT on two occassions or moderate/severe HT
Plus
-Proteinuria of more than 300mgms/24hrs
What are the risk factors for developing pre-eclampsia?
- First pregnancy
- Extremes of maternal age
- Pre-eclampsia in a previous pregnancy
- Pregnancy interval > 10yrs
- FH
- Multiple pregnancy
- Underlying medical conditions: chronic hypertension, renal disease, diabetes and autoimmune disorders
What are the potential complications of pre-eclampsia?
- Seizures
- Cerebral haemorrhage or stroke
- Haemolysis, elevated liver enzymes and low platelets
- DIC
- Renal failure
- Pulmonary oedema and cardiac failure
- Impaired placental perfusion
How does severe pre-eclampsia present?
- Headache, blurred vision, epigastric pain, pain below ribs, vomiting and sudden swelling of hands, face and legs
- Severe hypertension and proteinuria
- Clonus, brisk reflexes
- Reducing urine output
- Convulsions
- Raised liver enzymes and bilirubin
- Raised urea, creatinine and urate
- Low platelets
- Low haemoglobin and signs of haemolysis
- Features of DIC
How can severe pre-eclampsia be managed?
- Frequent BP and urine protein checks
- Check symptomatology
- FBC, LFTs, U&Es and coagulation tests
- Scan for fetal growth and cardiotocography
- Anti-hypertensives (labetolol, methyldopa and nifedipine)
- Steroids for fetal lung maturity if <36wks
- Consider induction of labour or C section if maternal or fetal condition deteriorates
How can seizures be treated in eclampsia?
- Magnesium sulphate
- Control of blood pressure
- Avoid fluid overload
How can pre-ecampsia be avoided in subsequent pregnancy?
Low dose aspirin from 12 weeks to delivery
What is gestational diabetes?
- Carbohydrate intolerance with onset in pregnancy
- Abnormal glucose tolerance that reverts to normal after delivery
What happens to pre-existing diabetes in pregnancy?
- Insulin requirements of the mother increase
- Fetal hyper-insulinemia (maternal glucose crosses the placenta and induces increased insulin production in the fetus)
- Post delivery: more risk of neonatal hypoglycaemia and increased risk of respiratory disease
What are the risks of diabetes in pregnancy?
- Fetal congenital abnormalities
- Miscarriage
- Fetal macrosomia and polyhydramnios
- Operative delivery and shoulder dystocia
- Stillbirth and increased perinatal mortality
- Increased risk of pre-eclampsia
- Worsening of maternal nephropathy, retinopathy and hypoglycaemia (+ reduced awareness)
- Infections
- Impaired neonatal lung maturity, neonatal hypoglycaemia and jaundice
How can diabetes be managed prior to conception?
- Better glycaemic control
- Folic acid
- Dietary advice
- Retinal and renal assessment
How should diabetes be managed during pregnancy?
- Optimise glucose control
- Can continue oral anti-diabetic meds but may need to switch to insulin for better control
- Risk of hypoglycaemia: provide glucagon injections/conc. glucose solution
- Watch for ketouria/infections
- Repeat retinal assessments at 28 and 34 wks
- Watch fetal growth
- Observe for pre-eclampsia
- Labour usually induced earlier
- Consider elective C section if significant fetal macrosomia
- Maintain blood sugar during labour
- Continuous CTG fetal monitoring in labour
- Early feeding of baby
What are the risk factors for developing gestational diabetes?
- Increased BMI
- Previous macrosomic baby
- Previous GDM
- FH of diabetes
- High risk groups e.g. Asian origin
- Polyhydramnios or big baby
- Recurrent glycouria in current pregnancy
How can GDM be screened for (if risk factors present)?
- HbA1C estimation
- OGTT
- If OGTT is normal then repeat at 24-38 weeks
How can GDM be managed?
- Control blood sugars: diet and metformin/insulin
- Post delivery: check OGTT 6-8 weeks post delivery
- Yearly HbA1c/ blood sugar check
Why is there a higher risk of venous thrombo-embolism in pregnancy?
- Hypercoagulable state (to protect mother against bleeding post delivery)
- Increased stasis
- May be vascular damage at delivery/C-section
Which risk factors increase the risk of a VTE in pregnancy?
- Older mothers, increasing parity
- Increased BMI
- Smoking
- IVDA
- Pre-eclampsia
- Dehydration
- Decreased mobility
- Infections
- Operative delivery and prolonged delivery
- Haemorrhage
- Previous VTE
- Strong FH of VTE
- Sickle cell disease
How can VTE risk be managed prophylactically in pregnancy?
- TED stockings
- Advise increased mobility and hydration
- Prophylactic anti-coagulation with 3 or more risk factors
How should a suspected VTE be investigated and how is it treated?
- ECG, blood gases, doppler, V/Q scan and CTPA
- Anticoagulants
