Complications in Pregnancy Flashcards
What is meant by miscarriage / abortion?
Termination / loss of pregnancy before 24 weeks gestation.
What is a spontaneous miscarriage?
Threatened = bleeding from gravid when there is a viable fetus and no evidence of cervical dilatation. OR vaginal bleeding and pain, closed cervix on speculum. Management = Conservative.
What is an inevitable miscarriage?
Abortion if the cervix has already begun to dilate. Open cervix with bleeding.
Management = if bleeding heavy may need evacuation.
What is incomplete miscarriage?
Partial expulsion of products of conception. Products remaining in the uterus, open cervix, vaginal bleeding.
What is a complete miscarriage?
Compete expulsion of the products of conception - complete abortion. Cervix closed and bleeding stopped.
What is septic abortion?
Following incomplete always a risk of ascending infection into the uterus which can spread throughout pelvis - septic abortion.
Management = antibiotics and evacuate uterus.
What is missed miscariage?
Fetus has died but the uterus has made no attempt to expel the products. No symptoms, could have bleeding or brown loss vaginally. Gestational sac seen on scan.
No clear fetus or fetal pole.
Managment = conservative, medical - prostaglandins, surgical.
What causes spontaneous miscarriage?
Abnormal conceptus = chromosomal, genetic, structural.
Uterine abnormality - congenital, fibroids.
Cervical incompetence - primary, secondary.
Maternal - Increasing age, diabetes.
What is an ectopic pregnancy?
Pregnancy implanted outside the uterine cavity. Ampulla is most common place followed by the isthmus. 1:90 pregnancies.
What are the risk factors for ectopic pregnancy?
Pelvic inflammatory disease, previous tubal surgery, previous ectopic, assisted conception.
How does an ectopic pregnancy present?
Period of ammenorhoea (with +ve pregnancy rest) +/- vaginal bleeding, +/- pain in abdomen, +/- GI or urinary symptoms.
What investigations take place for ectopic pregnancy?
Scan - no intrauterine gestational sac, may see adnexal mass, fluid in pouch of douglas.
Serum BHCG levels.
Serum progesterone.
What is the management for ectopic pregnancy?
Medical - methotrexate
Surgical - Mostly laproscopical - Salpingectomy.
Conservative.
What is Antepartum Haemorrhage?
Haemorrhage from the genital tract after 24th week of pregnancy but before delivery of the baby.
What causes Antepartum haemorrhage?
Placenta praevia.
Mulitparous women, multiple pregnancies, previous caesarean section.
Presentation of Antepartum haemorrhage
Painless PV bleeding. Malpresentation of fetus. Risk of PPH.
What is placenta praevia?
Placenta is attached to lower segment of uterus - 1/200 pregnancies.
What are the 4 grades of Placenta Praevia?
1 - encroaching lower segment but not the internal cervical os.
2 - Placenta reaches the internal os.
3- Placenta eccentrically covers the os.
4- Central placenta praevia.
How does Placenta Praevia present?
Maternal condition correlates with amount of bleeding PV. Soft non tender uterus =/- fetal malpresentation.
How is placenta praevia diagnosed?
USS locate placental site. Vaginal exam if suspected.
What is placenta praevia management?
Gestation, severity, caesarean section, watch for PPH.
Medical management = oxytocin, ergometetrine, balloon tamponade.
Surgical management = Blynch suture, ligation of uterine, iliac vessels, hysterectomy.
What is Placental abruption?
Placenta starts to separate from the uterine wall before birth of baby.
Antepartum haemorrhage of unknown origin. Resulting from premature separation of the placenta.
Associated with retroplacental clot.
What can cause it?
Pre-eclampsia
Multiple pregnancies
Trauma
What is vasa praevia?
Very rare - due to rupture of fetal vessel within fetal membranes, blood loss is fetal and not maternal and effect on fetus can be catastrophic.
What factors are associated with vasa praevia?
Pre-eclampsia / chronic hypertension. Multiple pregnancies. Polyhydraminos. Smoking, increasing age, parity, previous abruption, cocaine use.
Presentation of pre-eclampsia
Pain
Vaginal bleeding, increased uterine acivity.
Pre-eclampsia management
Vary expectant treatment to attempt vaginal delivery to immediate caesarean section depending on amount of bleeding, general condition of mother and baby and gestation.
Complications of pre-eclampsia?
Maternal shock, collapse, fetal death, maternal DIC, renal failure, postpartum haemorrhage.
What is meant by pre term labour?
Onset of labour before 37 weeks gestation. Spontaneous or induced.
How is pre term classified in terms of weeks gestation
32-36 - mild
28-32 - very preterm
24-28 - extremely pre-term with poor prognosis.
What are the predisposing factors to pre term?
Multiple pregnancy, polyhydraminos, APH, Pre-eclampsia, Infection e.g. UTI.
Majority no cause.
Management for pre-term pregnancy
Diagnosis = contractions with evidence of cervical change on VE. Consider possible cause (abruption, infection).
Major cause of perinatal mortality and morbidity.
What causes neonatal morbidity in prematurity?
Resp distress syndrome. Intraventricular haeamorrhage Cerebral palsy. Nutrition Temperature control jaundice Infections Visual impairment Hearing loss
What are key signs of pre-eclampsia?
New hypertension > 20 weeks in association with significant proteinuria.
Why might we change anti-hypertensive drugs during pregnancy?
Ace inhibitors can cause birth defects, imparied growth.
Monitor to keep BP <150/100.
May have higher incidence of placental abruption.
What is pre-eclampsia toxinaemia?
Mild Hypertension on 2 occasions more than 4 hours apart. Moderate to severe HT. Proteinuria of more than 300mgrms / 24hrs.
What are risk factors of PET?
First pregnancy, extremes of maternal age. Pre-eclampsia in previous pregnancy. BMI >35, Fam history. Underlying medical disorders e.g. autoimmune, pre-existing diabetes/renal disease.
complications of pre-eclampsia?
Maternal - eclampsia seizures. Severe hypertertension - cerebral haemorrhage / stroke. haemolysis, elevated liver enzymes, low platelets.
Renal failure, cardiac failure, pulmonary oedema.
Fetal - Impaired placental perfusion - fetal distress.
How does severe PET present?
Headache, blurring of vision, epigastric pain, pain below ribs, vomitting, sudden swelling of hands face legs. Severe hypertension > 3 + urine proteinuria. Clonus / brisk reflexes; papilloedema, epigastric tenderness. Reducing urine output. Convulsions.
What is management for pre-eclampsia?
Frequent BP checks, urine protein. Check symptoms. Check hyperreflexia (clonus), tenderness over liver.
Blood investigations - FBC, LFTs, Renal function tests - serum urea, creatinine.
Fetal investiagstions - scan for growth, cardiotocography.
Delivery of baby and placenta. Induction of labour. Treat seizures - Mg sulphate bolus + IV infusion.
Control BP, avoid fluid overload.
Prophylaxis for PET in subsequent pregnancy - low dose aspirin from 12 weeks till delivery.
What happens when a mother has pre-existing diabetes?
Insulin requirement increases - human placental lactogen have anti-insulin action.
Fetal hyper-insulineamia occurs.
Maternal glucose crosses the placenta and induced increased insulin production in the fetus.
What are the effects of Diabetes on the baby?
Risk of neonatal hypoglycaemia. Increases risk of respiratory distress. Increased risk of fetal congenital abnormalities.
Shoulder dystocia.
Stillbirth.
What effects can diabetes have on the mother?
Increased risk of pre-eclampsia.
Worsening maternal nephropathy, retinopathy, infections, miscarriage.
What is the management for diabetes in pregnancy?
Better glycemic control, ideally blood sugar about 4-7mmol. Folic acid, dietary advice, retinal and renal assessment.
Optimise glucose control. Watch for ketouria.
Switch metformin to insulin. Observe for PET. Early feeding of baby to reduce hypoglycaemia.
What are risk factors for gestational diabetes?
RF/screening - increased BMI >30.
Previous macrosomic baby >4.5kg
Previous GDM. FH diabetes. Asian. Recurrent glycosuria in current pregnancy.
Offer Hb1AC.
How is gestational diabetes managed?
Control blood sugars - diet, metformin/ insulin if sugars remain high.
How do we monitor and treat Venous thrombo-embolism in pregnant women?
Hypercoaguable state to protect mother against bleeding post delivery. Increases fibrinogen, platelts, decreased natural anti-coagulants. Increased stasis.
Prophylaxis in pregnancy = TED stockings, advice increased mobility, hydration.
What are signs of Thrombosis and what tests are done?
Pain in calf, increased girth, calf muscle tenderness, breathlessness, pain on breathing, cough,tachycardia.
ECG, blood gases, doppler, ventilation perfusion scan. CTPA.
