complications in pregnancy

Question 1

spontaenous miscarriagee

Answer 1

Termination/loss of pregnancy before 24 weeks’ gestation

Question 2

threatened miscarriage

Answer 2

• Threatened miscarriage

1. Bleeding from the gravid uterus before 24 weeks’ gestation
2. Viable fetus
3. No cervical dilatation (closed cervix)

Question 3

inevitable

Answer 3

1. Bleeding from uterus
2. Viable fetus
3. Cervix dilatation (open cervix)

Question 4

incomplete

Answer 4

partial

Question 5

complete

Answer 5

Passed all products of conception (POC), cervix closed and bleeding has stopped

Question 6

septic

Answer 6

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

Question 7

missed

Answer 7

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

Question 8

aetiology

Answer 8

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.

Question 9

management

Answer 9

-conservative
-medical -prostaglandins
surgical

Question 10

ectopic

Answer 10

1 in 90 pregnancies
risk factors
-damaged tubes which can result from:
PID
Previous tubal surgery
previos ectopic
assisted conception

Question 11

presentation

Answer 11

• 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.

Question 12

Scan

Answer 12

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

Question 13

management

Answer 13

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

Question 14

antepartum haemorrhage

Answer 14

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

Question 15

causes of APH

Answer 15

•	Placenta praevia
•	Placental abruption
•	APH of unknown origin
•	Local lesions of the genital tract
Vasa praevia (very rare)

Question 16

Placenta praevia

Answer 16

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.

Question 17

placenta abruption

Answer 17

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

Question 18

presentation of placental abruption

Answer 18

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’

Question 19

Vasa praevia

Answer 19

• 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

Question 20

preterm

Answer 20

•	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

Question 21

Gestational hypertension

Answer 21

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

Question 22

pre eclampsia

Answer 22

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

Question 23

riskfactors

Answer 23

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

Question 24

gestational diabetes

Answer 24

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

Question 25

Venous thromboembolism

Answer 25

o pregnancy a hypercoagulable state (to protect mother against bleeding post delivery)
o increase in fibrinogen, factor VIII, VW factor, platelets
o decrease in natural anticoagulants – anti-thrombin III
increase in fibrinolysis
risk of VTE
o Older mothers, increasing parity
o Increased BMI, smokers
o IV drug users
o PET
o Dehydration – hyperemesis (can reduce mobility)
o Decreased mobility
o Infections
o Operative delivery, prolonged labour
o Haemorrhage, blood loss > 2L
-sickle cell

Question 26

Prophylaxis

Answer 26

o TED stockings
o Advice increased mobility
o Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk factor if significant risk), may need to continue 6 weeks postpartum

Question 27

VTE signs and symptoms

Answer 27

pain in calf, breathlessness, pain on breathing,

Question 28

Multiple pregnancies

Answer 28

MZ 1:285
dizygotic twins
♣	F/H
♣	Ethnicity, Race
♣	Maternal age, Parity
♣	Fertility treatment

Question 29

chorionicity & zygosity

Answer 29

o Two separate placenta and two sacs - Dichorionic Diamniotic (DCDA)
♣ ‘Lambda’ sign - dichorionic
o One sac and one placenta – Monochorionic Monoamniotic (MCMA)
♣ ‘T’ sign - monochorionic
o Two sacs and one placenta – Monochorionic Diamniotic (MCDA)

complications: twin to twin transfusion syndrome
♣ Bigger baby receives too much blood, causing polyhydramnios to develop; and tends to develop heart failure.
♣ The other baby much smaller, develops oligohydramnios

o Maternal complications
♣ 2x risk of gestational hypertension & pre-eclampsia
♣ More than 2x risk of anaemia
♣ PPH – increased risk of PPH due to large placental area and over-distended uterus

Question 30

delivery

Answer 30

o	In theatre
o	CTG monitoring
o	Cord clamping
o	Scan 2nd twin for presentation
o	Stabilise lie / ECV
o	Oxytocin – if contractions stop after first baby is out 
o	Vaginal assisted / C-section
o	Emergency CS indications:
♣	placental abruption, cord prolapse, 2nd baby in distress

Question 31

obstetric emergencies

Answer 31

shoulder dystocia

Question 32

shoulder dystocia

Answer 32

Management: 
H – Call for Help
E – Evaluate for Episiotomy
L – Legs (McRoberts Position)
P – Suprapubic Pressure
E – Enter Manoeuvres (Internal Rotation)
R – Remove the Posterior Arm
R – Roll the Patient (Onto all Fours)

dangers: umbilical cord entrapment
brain damage due to hypoxia
brachial plexus damage- erbs palsy

Question 33

PPH

Answer 33

Management of PPH: 
•	Call for help!
•	ABCDE
•	Empty Bladder
•	Rub up fundus
•	Drugs:
o	Oxytocin 5iu slow iv injection
o	Ergometrine 0.5mg slow iv injection (not in HTN)
o	Oxytocin infusion
o	Carboprost 0.25mg im (max 8 doses)
o	Misoprostol 800 micrograms
•	Surgical:
o	Intrauterine Balloon tamponade
o	Interventional Radiology
o	B-Lynch Suture
o	Hysterectomy

Question 34

Cord prolapse

Answer 34

• the descent of the umbilical cord through the cervix alongside (occult) or past (overt) the presenting part in the presence of ruptured membrane.
higher in breech
• Management of cord prolapse
o Call for Help!
o Replace cord into vagina (not uterus)
o Perform digital elevation of the presenting part
♣ Gloved hand to lift foetus upward & off cord
o Catheterise and fill bladder to elevate presenting part.
o Encourage mother to adopt knee-chest or left lateral position with raised hips
♣ Uses gravity to shift foetus out of pelvis
♣ Woman’s thighs should be at right angles to the bed and her chest flat on the bed OR
Hips elevated with 2 pillows & head down
o Consider tocolysis
o Arrange for a Category 1 C-Section