Complications in pregnancy Flashcards
1
Q
Pregnancy related conditions (14)
A
- Asthma
- Depression
- Diabetes
- Eating disorders
- Epilepsy
- Hypertension
- HIV
- Obesity
- Sexually Transmitted Infections (STIs)
- Uterine fibroids
- GI symptoms
- Musculoskeletal problems
- Vascular symptoms
- GU symptoms
2
Q
Pregnancy complications
A
- Anaemia
- APH
- Depression
- Ectopic pregnancy
- Foetal problems
- Gestational diabetes
- Hypertension
- Hyperemesis gravidarum
- Miscarriage
- Placenta previa
- Placental abruption
- Pre-eclampsia
- Eclampsia
- Preterm labour
3
Q
Infections during pregnancy
A
- Bacterial vaginosis (BV)
- Cytomegalovirus
- Group B Strep (GBS)
- Hepatitis B virus (HBV)
- Influenza (flu)
- Listeriosis
- Parovirus B19
- Sexually transmitted infection (STI)
- Toxoplasmosis
- Urinary tract infection (UTI)
- Yeast infection
- Rubella (German measles)
- Measles
- Varicella (chicken pox)
- Herpes simplex
- Malaria
- Group A streptococcus
4
Q
Uterine STIMULANTS (5)
A
- Endothelin
- Prostin
- Misoprostol
- Oxytocin
- Ergometrine
5
Q
Uterine RELAXANTS: (7)
A
- Nitirc oxide
- Relaxin
- Atosiban
- Nifedipine
- Indomethacin
- Terbutaline
- Magnesium
6
Q
What are the signs of magnesium toxicity? (3)
A
- Loss of tendon reflexes (due to neuromuscular blockade)
- Respiratory depression
- Cardiac arrest
7
Q
Uterine STIMULANTS: Endothelin
A
Constricts blood vessels and raises blood pressure.
8
Q
Uterine STIMULANTS: Prostin
A
Used in labor induction, bleeding after delivery, termination of pregnancy, and in newborn babies to keep the ductus arteriosus open.
9
Q
Uterine STIMULANTS: Misoprostol
A
A medication used to prevent and treat stomach ulcers, start labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus.
10
Q
Uterine STIMULANTS: Oxytocin
A
Plays a role in social bonding, sexual reproduction, childbirth, and the period after childbirth.
11
Q
Uterine STIMULANTS: Ergometrine
A
A medication used to cause contractions of the uterus to treat heavy vaginal bleeding after childbirth.
12
Q
Uterine RELAXANTS: Nitric oxide
A
Most important function is vasodilation, meaning it relaxes the inner muscles of the blood vessels, causing them to widen and increase circulation.
13
Q
Uterine RELAXANTS: Relaxin
A
A hormone secreted by the placenta that causes the cervix to dilate and prepares the uterus for the action of oxytocin during labour.
14
Q
Uterine RELAXANTS: Atosiban
A
An inhibitor of the hormones oxytocin and vasopressin. It is used as an intravenous medication as a labour repressant to halt premature labor.
15
Q
Uterine RELAXANTS: Nifedipine
A
Is a medication used to manage angina, high blood pressure, Raynaud’s phenomenon, and premature labor. It is one of the treatments of choice for Prinzmetal angina. It may be used to treat severe high blood pressure in pregnancy.
16
Q
Uterine RELAXANTS: Indomethacin
A
A nonsteroidal anti-inflammatory drug commonly used as a prescription medication to reduce fever, pain, stiffness, and swelling from inflammation. It works by inhibiting the production of prostaglandins, endogenous signaling molecules known to cause these symptoms.
17
Q
Uterine RELAXANTS: Terbutaline
A
A β2 adrenergic receptor agonist, used as a “reliever” inhaler in the management of asthma symptoms and as a tocolytic (anti-contraction medication) to delay preterm labor for up to 48 hours.
18
Q
Uterine RELAXANTS: Magnesium
A
A nutrient that the body needs to stay healthy. Magnesium is important for many processes in the body, including regulating muscle and nerve function, blood sugar levels, and blood pressure and making protein, bone, and DNA.
19
Q
Normal haematological values in pregnancy
A
- Maternal plasma volume increases by around 50%.
- Red cell mass only increases by 25-30%.
- This results in a fall in Hb concentration.
- ‘Physiological anaemia of pregnancy’
- Many coagulation factors are increased in normal pregnancy.
- Pregnancy = hypercoagulable state.
- Some anticoagulant factors are reduced.
- This contributes to the risk of thrombotic complications in pregnancy.
20
Q
Hypertensive disorders in pregnancy (3)
A
- Pre-existing hypertension: pre-pregnancy/early pregnancy
- Pregnancy induced hypertension: hypertension > 20 weeks, without proteinuria
- Pre-eclampsia: hypertension > 20 weeks, with proteinuria
21
Q
Small for Gestational Age (SGA)
A
A foetus that is born with a birth weight of less than the 10th centile.
22
Q
Fetal Growth Restriction (FGR)
A
Failure of the foetus to reach it’s pre-determined growth potential due to pathology.
23
Q
SGA vs. FGR
A
What are the differences between FGR and being born SGA?
FGR describes a reduction of the fetal growth rate but is not defined by the subsequent birth weight, whereas birth weight is used to define SGA. FGR babies may not be SGA and vice versa.
24
Q
Types of FGR:
- Symmetrical
- Asymmetrical
A
- Symmetrical: Head and abdomen are equally small.
- Asymmetrical: Foetus responds to inadequate nutrition by redirecting blood flow to head/brain and heart - therefore abdominal fat stores are reduced.
25
Risk factors for FGR:
- Minor (7)
- Major (10)
- Minor:
- Maternal age >35
- IVF pregnancy
- Nulliparity
- BMI (<20 or 25-34.9)
- Smoker (1-10 PD)
- Previous PET
- Pregnancy interval <6m or >60m
Major:
- Maternal age >40
- Smoker (>11 PD)
- Paternal or maternal SGA
- Cocaine use
- Previous SGA or stillbirth
- Chronic HTN
- Diabetes with vascular disease
- Renal impairment
- Anti-phospholipid Syndrome (APS)
- Low PAPP-A-
26
Aetiology of Growth restriction:
- Problem with mother (3)
- Problem with foetus (2)
Problem with mother: (↓ gas exchange + nutrient delivery)
1. Impaired maternal oxygen carrying
- (heart disease, smoking, haemoglobinopathies)
2. Impaired oxygen delivery
- (due to maternal vascular disease, HTN, diabetes, autoimmune disease)
3. Placental damage
- (smoking, thrombophilia, PET, autoimmune disease)
Problem with foetus:
1. Chromosomal/congenital abnormalities
2. Intrauterine infections
27
FGR: Implications for foetus
- Short term (5)
- Long term (7)
Short term:
- Premature birth (necrotising enterocolitis, HIE, chronic lung disease, NICU stay)
- Low APGAR's
- Hypoglycaemia/hypocalcaemia
- Hypothermia
- Polycythaemia and hyperbilirubinaemia
Long term:
- Learning difficulties
- Short stature
- Failure to thrive
- Cerebral palsy
- HTN
- T2DM
- Heart disease
28
FGR: Screening
- All women are screened for risk factors @ booking.
- If risk factors present: extra surveillance carried out.
- If no risk factors: they are screened with SFH throughout pregnancy at each antenatal visit.
- If SFG < 10 centile/reduced velecity/static growth: referred for growth scan.
29
FGR: Diagnosis
USS biometry:
- Abdominal circumference (AC)
- Head circumference (HC)
- Femur length (FL)
These are combined using the Hadlock calculation to give Estimated Fetal Weight (EFW).
30
Umbilical Artery Doppler: Definition
Measure of the resistance to blood flow in the umbilical artery (and therefore placenta).
In a normal pregnancy there should be no resistance to blood flow in the UA.
In FGR, the placenta does not function correctly and there is increased resistance to blood flow coming from the UA.
This results in decreased flow in the UA (↓ end diastolic flow - EDF).
As this worsens, the resistance becomes so great there is no flow in the UA (absent EDF).
Eventually, resistance is so great it reverses the blood flow in the UA (reversed EDF).
31
FGR: Management
- Early onset (4)
- Late onset (3)
Early onset (<32 wks)):
- Detailed USS
- Amniocentesis
- Steroids
- Intensive monitoring
Late onset (>32 wks):
- Surveillance
- Delivery if evidence of foetal compromise
- Steroids if <36 wks
32
FGR: Prevention (3)
- Smoking cessation
- Aspirin for women @ risk of PET
- Appropriate screening
33
Analgesia for labour: Key points
- Many different techniques available.
- Regional and non-regional.
- Non-regional techniques = most frequently used.
- Most commonly used opioid: meperidine (pethidine).
- Inhalation of nitrous oxide relieves pain.
- Epidural analgesia provides superior analgesia for labour.
- There is no association between epidural anaesthesia + ↑ risk of c-section or post-partum backache.
34
Analgesia for labour: Non-pharmacological methods (7)
- TENS
- Relaxation/breathing techniques
- Temperature modulation
- Hypnosis
- Massage
- Acupuncture
- Aromatherapy
35
Analgesia for labour: Summary
- Regional (3)
- Non-regional (2)
Regional:
- Spinal
- Epidural
- Combined
Non-regional
- Pharmacological
- Non-pharmacological (inhalation, systemic)
36
Analgesia for labour: TENS
- Electrodes placed about 2cm over the T10-L1 dermatomes.
- On either side of the spinous processes.
- Provide analgesia for the 1st stage of labour.
- 2nd set of electrodes is placed over the S2-S4 dermatomes for 2nd stage pain relief.
37
Analgesia for labour: Inhalational methods - ENTONOX
- Advantages (4)
- Disadvantages (2)
- Nitrous oxide has been used in practice for over a century.
- Entonox (50% nitrous oxide in oxygen) provides analgesia within 20-30 seconds of inhalation, with a maximum effect after about 45 seconds.
ADVANTAGES:
- Ease of use
- No requirement for physician support
- Minimal accumulation with intermittent use
- Self-administration provides some control
DISADVANTAGES:
- Drowsiness, disorientation, nausea may occur (including brief loss of consciousness)
- Does not provide complete analgesia
38
Analgesia for labour: Systemic analgesia
- Meperidine (Pethidine)
- Morphine
- Diamorphine
- Fentanyl
39
Analgesia for labour: Systemic analgesia - PETHIDINE
Meperidine (Pethidine):
- Synthetic phenylpiperidine derivative
- Commonly administered IM.
- Like other opioids, it delays gastric emptying + increases gastric volumes in labour.
- It also causes sedation, dose-dependent respiratory depression and it's active metabolite (normeperidine) has convulsant properties.
- It also crosses the placenta.
40
Analgesia for labour: Systemic analgesia - MORPHINE
- Shares many of the side effects meperidine.
| - It rapidly crosses the placenta, however its metabolites do not have anticonvulsant effects.
41
Analgesia for labour: Systemic analgesia - DIAMORPHINE
- More potent drug than meperidine.
| - Increasingly used for labour analgesia in the UK.
42
Analgesia for labour: Systemic analgesia - FENTANYL
- Highly potent phenylpiperidine derivative.
- It has a rapid onset of action.
- It has a longer terminal half life than both meperidine and morphine.
- Advantages include absence of active metabolites and rapid onset of actions.
43
Patient controlled analgesia (PCA) (2)
- Fentanyl
- Remifentanil
- Alfentanil
44
Analgesia for labour: Epidural drugs (4)
- Bupivacaine
- Ropivacaine
- Levobupivacaine
- Chlorprocaine
45
Techniques for maintenance of epidural anaesthesia (3)
- Single shot administration
- Intermittent top ups
- Continuous epidural infusion
46
APGAR score
```
A - Appearance
P - Pulse
G - Grimace (reflex irritability)
A - Activity (muscle tone)
R - Respiration
```
47
Minor symptoms of pregnancy: GI
- Nausea + vomiting
- Gastro-oesophageal reflux (heartburn)
- Constipation
48
Minor symptoms of pregnancy: Musculoskeletal + vascular
- Symphysis pubis dysfunction (SPD)
- Pelvic girdle pain (PGP)
- Backache
- Sciatica
- Carpel tunnel syndrome
- Haemorrhoids
49
Minor symptoms of pregnancy: GU
- Urinary symptoms (frequency, incontinence)
- Vaginal discharge
- Itching/rashes
50
Other common minor symptoms of pregnancy
- Breast enlargement + pain
- Mild breathlessness on exertion
- Headaches
- Tiredness
- Insomnia
- Stretch marks
- Labile mood
- Calf cramps
- Braxton Hicks contractions
51
Pregnancy: Abnormal bleeding patterns
Miscarriage:
- Bleeding from conception - 24 weeks.
- Early: <12 weeks
- Late: >12 weeks
Antepartum haemorrhage:
- Bleeding from 24 weeks - onset of labour
Intrapartum haemorrhage:
- Bleeding from onset of labour - end of 2nd stage
Postpartum haemorrhage:
- Primary: within 24 hr
- Secondary: from 24 hr - 6 weeks
52
Abnormal periods:
- Amenorrhoea
- Oligomenorrhoea
- Dysmenorrhoea
- Dysfunctional Uterine Bleeding (DUB)
- Amenorrhoea: no periods:
- Oligomenorrhoea: infreuqent periods
- Dysmenorrhoea: painful periods
- DUB: diagnosis of exclusion
53
Antepartum haemorrhage: CAUSES (3)
- Unexplained (97%)
- Placenta praevia (1%)
- Placental abruption (1%)
- Other (1%)
54
Vasa praevia: Definition + Risk Factors (4)
- A condition in which fetal blood vessels cross/run near the internal opening of the uterus.
- Presenting symptom: PV bleeding after rupture of foetal membranes followed by rapid foetal distress.
Risk factors include:
- Low-lying placenta
- Multiple pregnancy
- IVF pregnancy
- Bilobed + succenturiate lobed placentas
55
Antepartum haemorrhage: Definition + Initial assessment
Definition: Bleeding from 24 weeks - onset of labour
Initial assessment: Rapid assessment of maternal + foetal condition is a vital step as it may prove to be an obstetric emergency
56
Antepartum haemorrhage: Hx
- Gestational age
- Amount of bleeding
- Associated/initiating factors (coitus/trauma)
- Abbominal pain
- Foetal movements
- Date of last smear
- Previous episodes of PV bleeding (in this pregnancy)
- Leakage of fluid PV
- Previous uterine surgery (including CS)
- Smoking + use of illegal drugs (esp. cocaine)
- Blood group + rhesus status (will she need anti-D?)
- Previous Obs hx (placental abruption/IUGR)
- Position of placenta (if known from previous scan)
57
Antepartum haemorrhage: Maternal assessment
- BP
- Pulse
- Haemodynamic compromise? (peripheral vasoconstriction, central cyanosis)
- Uterine palpation for size, tenderness, fetal lie, presenting part)
58
Antepartum haemorrhage: Fetal assessment
- Check foetal HR
| - Ensure it is foetal and not maternal
59
Placenta praevia:
- Definition
- Types
- Diagnosis
- Management
Definition: when the placenta is inserted wholly or in part in to the lower segment of the uterus.
Types:
- Major: placenta lies over the cervical os.
- Minor: placenta lies in the lower segment, close to or encroaching on the cervical os.
Diagnosis:
- Transvaginal USS = safe (+ more accurate than Transabdominal USS)
Management:
- Delivery is likely to be by CS if the placental edge is <2cm from the internal os, especially if it is posterior or thick.
N.B. Remember never perform a vaginal examination (VE) in presence of PV bleeding without first excluding a placenta praevia ('No PV until no PP')
Once a placenta praevia is excluded, a speculum examination should be undertaken to assess degree of bleeding and possible local causes of bleeding (trauma, polyps, ectropion) and to determine if membranes are ruptured.
60
Cervical effacement: Definition
Definition: Cervical effacement (also called cervical ripening) refers to a thinning of the cervix. It is a component of the Bishop score. It can be expressed as a %. Prior to effacement, the cervix is usually about 4cm in length.
61
Antepartum haemorrhage: Following assessment
Following assessment women will fall into one of the following categories:
- Bleeding heavy + continuing
- Bleeding minor, or settling
62
Antepartum haemorrhage: Maternal management (4)
- FBC
- Kleihauer testing
- Group and save serum
- Coagulation screen
63
Antepartum haemorrhage: Foetal management (2)
- Ultrasound to establish foetal well-being
| - Umbilical artery doppler measurement
64
Kleihauer-Betke test: Definition
A blood test used to measure the amount of foetal haemoglobin transferred from a foetus to mothers bloodstream.
65
Placental abruption: Definition
Placenta separates partly or completely from uterus before delivery of foetus. Blood accumulates behind placenta in uterine cavity or is lost through cervix.
66
Placental abruption: Types (2)
- Concealed: no external bleeding evident (<20%)
| - Revealed: vaginal bleeding
67
Placental abruption: Presentation
- Abdominal pain
- Severe backache
- Uterine activity (tender + hard)
- Onset of labour
- Bleeding
- Maternal signs of shock
- Foetal distress = common
68
Placenta praevia vs. Placental abruption
Placenta praevia: painless bleeding (APH), affects the mother more than the baby
Placental abruption: tends to be concealed bleeding, presents with painful contractions
69
Placental abruption: Diagnosis
- Made clinically
| - USS: used to confirm foetal wellbeing + exclude placenta praevia.
70
Placental abruption: Management
- Admit all women with PV bleeding/unexplained abdo pain
- CTG - establish foetal wellbeing
- Arrange USS ASAP
- Access + bloods
- Foetal distress/maternal compromise: resuscitate + deliver
- No foetal distress/bleeding + pain cease: consider delivery by term
71
Blood pressure in pregnancy: PHYSIOLOGY
BP is directly related to:
- Systemic vascular resistance
- Cardiac output
It follows a distinct course during pregnancy:
- ↓ in early pregnancy due to ↓ in vascular resistance
- ↑ after 24 wks until delivery via ↑ in stroke volume
- ↓ after delivery but may peak again 3-4 days post-partum.
Most women book in 1st or 2nd trimester. Be aware of the pregnant women with a high booking BP, who may have previously undetected chronic hypertension - especially important in pregnant older women.
72
Blood pressure in pregnancy: MEASUREMENT
- BP must be measured correctly.
- BP should be measured in sitting or supine position.
- Use the correct cuff size.
73
Blood pressure in pregnancy: HYPERTENSION types (4)
- Pre-eclampsia
- Pregnancy-induced hypertension (PIH)
- Chronic hypertension
- Post-partum hypertension
74
Blood pressure in pregnancy: ANTI-HYPERTENSIVE medications (6)
- Labetalol
- Nifedipine
- Methyldopa
- Hydralazine
- Atenolol
- ACE inhibitors
75
Hypertension in pregnancy: Treatment principles
- Normal blood pressure: 140/90
- Treatment of BP is urgently required for maternal safety at level >160/110.
- Escalation of treatment is required until levels are below this.
- Treatment should aim for BP levels not <120/80.
- Treatment of BP protects women from the adverse effects of ↑ but does not alter the course of pre-eclampsia.
76
Pre-eclampsia: Definition
Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy induced hypertension in association with proteinuria.
Due to its heterogenous nature, it can be difficult to define clinically, it is usually defined as:
- BP > 140/90
- > 300 mg proteinuria/24 hrs
77
Pre-eclampsia: Incidence
- Affects about 5% of pre-eclampsia.
| - Severe pre-eclampsia affects 1% of pregnancies.
78
Pre-eclampsia: Prediction (3)
- History
- Blood tests
- Ultrasound
79
Pre-eclampsia: Prevention
Women who have had severe early-onset pre-eclampsia in a previous pregnancy should be offered:
- Low dose aspirin (75 mg PO od)
(before 16 wks)
This may reduce the incidence of severe pre-eclampsia by 20%.
80
Pre-eclampsia:
- Secondary causes of hypertension (3)
- Risks from chronic hypertension (3)
Secondary causes of hypertension:
- Renal disease
- Cardiac disease (coarctation of the aorta)
- Endocrine causes (Cushing's, Conn's, phaeochromocytoma)
Women with chronic hypertension are at risk of:
- Superimposed pre-eclampsia
- Fetal growth restriction
- Placental abruption
81
Pre-eclampsia: Risk factors (10)
- Previous severe/early onset pre-eclampsia
- Age >40 or teenager
- Family hx (mother/sister)
- Obesitiy (BMI >30)
- Primiparity
- Multiple pregnancy
- Long birth interval (>10 years)
- Fetal hydrops
- Hydatidiform mole
- Pre-exisiting medical conditions
- Hypertension
- Renal disease
- Diabetes
- Antiphospholipid antibodies
- Thrombopihlias
- Connective tissue disease
82
Fetal hydrops (Hydrops fetalis): DEFINITION
A serious fetal condition defined as an abnormal accumulation of fluid in 2 or more fetal compartments, including ascites, pleural effusion, pericardial effusion and skin oedema.
In some patients it may also be associated with polyhydraminos + placental oedema.
83
Molar pregnancy: DEFINITION
A molar pregnancy is where a foetus doesn't form properly in the womb and a baby doesn't develop. A lump of abnormal cells grows in the womb instead of a health foetus. This is called a 'hydatidiform mole', which can be either:
- A complete mole: where there's a mass of abnormal cells in the womb and no foetus develops.
- A partial mole: where an abnormal foetus starts to form, but it can't survive/develop into a baby.
84
Pre-eclampsia: SYMPTOMS (5)
- Headache
- Visual disturbances
- Epigastric/RUQ pain
- Nausea + vomiting
- Rapid oedema (esp. face)
85
Pre-eclampsia: SIGNS (8)
- Hypertension (>140/90)
- Proteinuria
- Facial oedema
- Epigastric/RUQ tenderness (liver involvement/capsule distention)
- Confusion
- Hyperreflexia and/or clonus (cerebral irritability)
- Uterine tenderness/vaginal bleeding
- Fetal growth restriction
86
Pre-eclampsia: Lab INVESTIGATIONS (3)
- FBC
- Coagulation profile
- Biochemistry
87
Pre-eclampsia: COMPLICATIONS (6)
- Eclampsia
- HELP
- Cerebral haemorrhage
- IUGR/fetal compromise
- Renal failure
- Placental abruption
88
Pre-eclampsia: MANAGMENT
- Conservative (4)
- Medical (1)
- Surgical (1)
Conservative:
- BP review
- Urine analysis
- Fetal assessment (CTG/USS)
- FBC
Medical:
- Anti-hypertensive medication
Surgical:
- Delivery
89
Severe pre-eclampsia: DEFINITION
Defined as the occurrence of BP > 160/110 of the presence of significant proteinuria (>1g/24hrs) or if maternal complications occur.
90
Severe pre-eclampsia: Indication for immediate delivery (5)
- Worsening thrombocyotpaenia/coagulopathy
- Worsening liver/renal function
- Severe maternal symptoms
- HELLP syndrome/eclampsia
- Fetal reasons (CTG/USS abnormalities)
91
Eclampsia: DEFINITION
Eclampsia is defined as the occurrence of a tonic-clonic seizure in association with a diagnosis of pre-eclampsia.
Eclampsia is an obstetric emergency. Every hospital in the UK should have an eclampsia protocol and eclampsia box with all the drugs for treatment.
Eclampsia is a sign of severe disease; most women who die with pre-eclampsia or eclampsia do so from other complications, such as blood loss, intracranial haemorrhage of HELLP.
92
HELLP syndrome:
- Definition
- Symptoms
- Signs
This is a serious complication regarding by most as a variant of severe pre-eclampsia, which manifests with:
(H) - Haemolysis
(EL) - Elevated liver enzymes
(LP) - Low platelets
Symptoms:
- Epigastric/RUQ pain
- Nausea + vomting
- Tea coloured urine - due to haemolysis
Signs:
- RUQ tenderness
- ↑ BP
