complications in pregnancy Flashcards
spontaenous miscarriagee
Termination/loss of pregnancy before 24 weeks’ gestation
threatened miscarriage
• Threatened miscarriage
- Bleeding from the gravid uterus before 24 weeks’ gestation
- Viable fetus
- No cervical dilatation (closed cervix)
inevitable
- Bleeding from uterus
- Viable fetus
- Cervix dilatation (open cervix)
incomplete
partial
complete
Passed all products of conception (POC), cervix closed and bleeding has stopped
septic
there is always a risk of ascending infection into the uterus which can spread throughout the pelvis and this is known as a septic abortion
missed
o Describes a pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception
o Gestational sac seen with no clear fetus (empty gestational sac) or a fetal pole with no fetal heart seen in the gestational sac
aetiology
abnormal conceptus
uterine abnormality
eg bicornuate uterus
fibroids
most frequently seen tumour
♣ Firm, compact tumours which are made of smooth muscle cells and fibrous connective tissue that develop in the uterus.
influence of oestrogen.
Women approaching menopause are at greatest risk of developing fibroids due to the long exposure to high levels of oestrogen
Sub-mucous fibroids, in particular, are associated with miscarriage due to distortion of the uterine cavity
cervical incompetence
maternal-
increasing age
hormonal imbalance
o Various maternal medical conditions are known to be associated with an increased risk of spontaneous miscarriage
♣ Diabetes, SLE, thyroid disease.
♣ Acute maternal infection e.g. pyelitis, appendicitis, by causing a general toxic illness with high temperature can stimulate uterine activity and loss of pregnancy.
management
-conservative
-medical -prostaglandins
surgical
ectopic
1 in 90 pregnancies risk factors -damaged tubes which can result from: PID Previous tubal surgery previos ectopic assisted conception
presentation
• Period of amenorrhoea (with +ve urine pregnancy test)
• +/- Vaginal bleeding (usually mild)
• +/- Painful abdomen
• +/- GI or urinary symptoms (if bleeding into the pelvis)
Note: Ectopic pregnancies commonly present in an atypical way, so consider the possibility in women of reproductive age. Consider the need for a pregnancy test even in women with nonspecific signs.
Scan
no intrauterine gestational sac, fluid in pouch of douglas, adnexal mass
• Serum BHCG levels – may need to serially track levels
o As it doesn’t show the same pattern as a normal pregnancy – increases less
• Serum Progesterone levels
management
Medical – Single dose Methotrexate, abdo pain
Contraception should be used for 3-6 months, as methotrexate is teratogenic
• Surgical
o Mostly laparosciopical – Salpingectomy, Salpingotomy for few indications
♣ Salpingotomy preserves tube(s) – predisposes woman to another ectopic
antepartum haemorrhage
Haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby.
-gravest obstetric emergencies, significant maternal and neonatal morbidity
causes of APH
• Placenta praevia • Placental abruption • APH of unknown origin • Local lesions of the genital tract Vasa praevia (very rare)
Placenta praevia
All or part of the placenta implants in the lower uterine segment and lies in front of the presenting part of the fetus
o More common in:
♣ Multiparous women (>1 child borne previously)
♣ multiple pregnancies
previous caesarean section
classification
o Grade I: Placenta encroaching on the lower segment but not the internal cervical os
o Grade II: Placenta reaches the internal os
o Grade III: Placenta eccentrically covers the os
o Grade IV: Central placenta praevia completely covering the os
presentation: PAINLESS PV bleeding
- mal presentation of fetus
- non tender
diagnosis: ultrasound
blood is cross matched and blood transfused depending on the maternal condition. The mother is kept in hospital and provided the maternal and fetal condition permit a conservative approach is adopted to prolong the pregnancy to gain fetal maturity and then deliver by Caesarean section. There is a risk of PPH with PP.
placenta abruption
premature separation of the placenta before the birth of the baby
• retroplacental clot
• Factors associated with placental abruption
o Pre-eclampsia/ chronic hypertension
o Excessive expansion of uterus
♣ Multiple pregnancy
♣ Polyhydramnios – the excessive accumulation of amniotic fluid
o Smoking, increasing age, parity
o Previous abruption
o Cocaine use
Clinical types:
revealed
concealed-occurs between the placenta and the uterine wall. The uterine contents increase in volume and the fundal height is larger than would be consistent for gestation
blood penetrates the uterine wall and the uterus appears bruised and this is known as a Couvelaire uterus
presentation of placental abruption
o Pain – differentiates it from praevia
o Vaginal bleeding (may be minimal bleeding because much of the bleeding may be concealed)
o Increased uterine activity
Typically, the patient presents with severe abdominal pain and usually an APH from small to severe haemorrhage. The fetal lies, unlike with placental praevia, longitudinally with the presenting part fixed in the pelvis
o Caesarean section depending on:
♣ Amount of bleeding
• In small abruptions, it may resolve by itself
♣ General condition of mother and baby – pain, foetal distress
♣ Gestation
o Complications of placental abruption:
♣ Maternal shock, collapse (may be disproportionate to the amount of bleeding seen)
♣ Fetal death
♣ Maternal DIC, renal failure
♣ Postpartum haemorrhage
• ‘Couvelaire uterus’
Vasa praevia
• condition in which babies’ blood vessels cross or run near the internal opening of the uterus. These vessels are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue.
risk factors
o Velamentous insertion of the umbilical cord, accessory placental lobes (succenturiate or bilobate placenta), multiple gestation, IVF pregnancy.
o Velamentous insertion of the umbilical cord the umbilical cord inserts into the fetal membranes (choriamniotic membranes), then travels within the membranes to the placenta (between the amnion and the chorion).
delivered by elective caesarean prior to rupture of the membranes.
preterm give steroids
preterm
• 32-36 wks: mildly preterm • 28-32 wks: very preterm • 24-28 wks: extremely preterm Predisposing factors: • Overstretching of uterus: o Multiple pregnancies o Polyhydramnios • APH • Pre-eclampsia • Infection e.g. UTI • Pre-labour premature rupture of membranes • Majority are idiopathic
• Consider obtaining a vaginal fetal fibronectin (FFN) sample before pelvic examination
o fFN is a protein that’s believed to help keep the amniotic sac “glued” to the lining of the uterus.
o When the fFN test is positive, it is an inconclusive result.
o When the fFN test is negative, the result is a better predictor. A negative result means that there is little possibility of preterm labour within the next 7 to 10 days.
negative means unlikely to deliver
-NICU facilities aim for vaginal delivery • Neonatal morbidity resulting from prematurity: o o respiratory distress syndrome o intraventricular haemorrhage o cerebral palsy o nutrition o temperature control o jaundice o infections o visual impairment o hearing loss
Gestational hypertension
Hypertension developed after 20 weeks’ gestation
Chronic hypertension: Hypertension either pre-pregnancy or at booking (≤ 20 weeks’ gestation)
-change in antihypertensives
o ACE inhibitors (Ramipril / Enalopril cause birth defects, impaired growth)
o Angiotensin receptor blockers (losartan, Candesartan)
o Diuretics should be avoided as they can reduce blood flow in the placenta
-lower dietary sodium
aim keep BP < 150/100 mm Hg
labetalol, nifedipine, methyldopa
- monitor for proteinuria
- increased risk of complications
pre eclampsia
mild HT on two occasions more than 4 hours apart or moderate severe HT
proteinuria of more than 300mg/24hrs + protein creatinine ratio> 30 mg /mmol
-suboptimal uteroplacental perfusion
riskfactors
o First pregnancy o Extremes of maternal age o Pre-eclampsia in a previous pregnancy (esp. severe PET, delivery <34 weeks, IUGR baby, IUD, abruption) o Pregnancy interval >10 years o BMI > 35 o Family history of PET o Multiple pregnancy o Underlying medical disorders ♣ chronic hypertension ♣ pre-existing renal disease ♣ pre-existing diabetes ♣ autoimmune disorders – e.g. antiphospholipid antibodies, SLE • Complications (multi-system disorder) o Maternal ♣ eclampsia (seizures) ♣ severe hypertension – cerebral haemorrhage, stroke ♣ HELLP (haemolysis, elevated liver enzymes, low platelets) ♣ DIC (disseminated intravascular coagulation) ♣ renal failure ♣ pulmonary oedema, cardiac failure
fetal- IUGR, fetal distress, prematurity, increased mortality severe PET clonus/brisk reflexes epigastric tenderness reducing urine output -low platelet features of DIC
• Management
o Frequent BP checks, Urine protein
o Check symptomatology – headaches, epigastric pain, visual disturbances
o Check for hyper-reflexia (clonus), tenderness over the liver
o Blood investigations
♣ Full Blood Count (for haemolysis, platelets)
♣ Liver Function Tests
♣ Renal Function Tests – serum urea, creatinine, urate
♣ Coagulation tests if indicated
o Fetal investigations
♣ scan for growth
♣ cardiotocography (CTG)
• 5-8% of pregnant women have PET
• 0.5% women have severe PET & 0.05% have eclamptic seizures
38% of seizures occur antepartum, 18% intrapartum, 44% postpartum
• Prophylaxis for PET in subsequent delivery
o Low dose Aspirin from 12 weeks till delivery
gestational diabetes
o Carbohydrate intolerance with onset (or first recognised) in pregnancy
♣ abnormal glucose tolerance that reverts to normal after delivery
♣ Increased risk of developing type II diabetes later in life
- increased insulin requirements of mother
-fetal hyperinsulinaemia
• Effects of diabetes on mother, fetus & neonate
o Fetal congenital abnormalities (especially if blood sugars high peri-conception)
♣ E.g. cardioagenesis
o Miscarriage
o Pre-eclampsia
o Fetal macrosomia, polyhydramnios
o Operative delivery, shoulder dystocia
o Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
o Infections
o Stillbirth, increased perinatal mortality
o neonatal - Impaired lung maturity, neonatal hypoglycaemia, jaundice
risk factors of GDM
o increased BMI >30
o Previous macrosomic baby > 4.5kg
o Previous GDM
o Family history of diabetes
o Polyhydramnios or big baby in current pregnancy
o Recurrent glycosuria in current pregnancy
