Complications in pregnancy Flashcards
What is a spontaneous miscarriage?
Spontaneous termination of pregnancy before 24 weeks gestation
What are the types of miscarriage?
Threatened Inevitable Incomplete Complete Septic Missed
What is a threatened miscarriage?
Bleeding from gravid uterus before 24 weeks when there is a viable foetus
No evidence of cervical dilatation
What are the clinical features of a threatened miscarriage?
Vaginal bleeding +/- pain
Viable pregnancy
Closed cervix
What is the management of a threatened miscarriage?
Conservative
What is an inevitable miscarriage?
Cervix starts to dilate
What are the clinical features of an inevitable miscarriage?
Viable pregnancy
Open cervix with heavy bleeding +/- clots
What is the management of an inevitable miscarriage?
Evacuation for heavy bleeding
What is an incomplete miscarriage?
Partial expulsion of products of conception
What is a complete miscarriage?
Complete expulsion of products of conception
What is a septic miscarriage?
Ascending inflammation into the uterus which can spread through the pelvis
When is septic miscarriage most common?
In cases of incomplete miscarriage
What is the management of a septic miscarriage?
Antibiotics
Evacuate uterus
What is a missed miscarriage?
Foetus has died, but uterus has made no attempt to expel
What are the clinical features of a missed miscarriage?
Normally no symptoms
May have bleeding/brown discharge
Gestational sac seen on scan
No clear foetus or foetal pole with no heartbeat
What is the management of a missed miscarriage?
Conservative
Prostaglandins
Surgical evacuation
What are the categories of causes of miscarriage?
Abnormal conceptus Uterine abnormality Cervical imcompetence MAternal factors Unknown
What maternal factor can increase the risk of miscarriage?
Increasing age
Diabetes
What is an ectopic pregnancy?
Pregnancy implanted outside of uterine cavity
Where is the most common location for an ectopic to implant?
Fallopian tube
What are the risk factors for an ectopic pregnancy?
PID
Previous ectopic
Previous tubal surgery
Assisted conception
What are the clinical features of an ectopic?
Period of amenorrhoea and + urine pregnancy test
May have- vaginal bleeding, abdominal pain, GI/urinary symptoms from pressure, shoulder tip referred pain
What investigations are done for an ectopic?
US
Serum betaHCG levels
Serum progesterone
What are the findings on US in an ectopic?
No intrauterine gestational sac
May have adnexal mass or fluid in pouch of Douglas
What is the medical treatment of an ectopic?
Methotrexate
What are the surgical options for an ectopic?
Salpingectomy
Salpingotomy
When is surgical management of an ectopic used?
If woman is unstable, or ectopic close to rupture
When is a salpingostomy used in an ectopic
If other tube already removed
When is conservative management of an ectopic used?
Woman is stable
What is the conservative management of an ectopic?
Monitor for rupture and allow to pass normally
What is an antepartum haemorrhage?
Haemorrhage from genital tract after 24th week of pregnancy but before delivery of baby
What are the causes of antepartum haemorrhage?
Placenta praaevia Placental abruption Unknown Local lesions of genital tract Vasa praevia
What is placenta praaevia?
Placenta attached to lower segment of uterus
Who is placenta praaevia most common in?
Multiparous women
Previous C section
Multiple pregnancies
What is the classification of placenta praaevia?
Grade I- placenta encroaching on lower segment
Grade II- placenta reached internal os
Grade III- placenta eccentrically covers os
Grace IV- Central placenta praevia
What are the clinical features of placenta praaevia?
Painless PV bleeding
Malpresentation of foetus, normally oblique
Soft, non tender uterus
What investigations are done for placenta praaevia?
US
NEVER do a vaginal exam if you suspect placenta praevia
What is the management of placenta praaevia?
Dependent on severity and gestation
C section and monitor for PPH
What is placenta abruption?
Placenta begins to separate from uterine wall before birth
What are the risk factors for placental abruption?
Pre-eclampsia Chronic hypertension Multiple pregnancy Parity Previous abruption Polyhydramnios Smoking Cocaine use Increasing age
What are the types of placental abruption?
Revealed- major haemorrhage apparent externally
Concealed- haemorrhage between placenta and uterine wall
What are the clinical features of Placental abruption?
Pain
Vaginal bleeding
Increased uterine activity
What is the management of less severe placental abruption?
Monitor baby and mother
What is the management of more severe placental abruption?
Induction or c section
What are the complications of Placental abruption?
Maternal shock, collapse- may be disproportionate to amount of blood
Foetal death
Maternal DIC, renal failure
PPH
What is vasa praevia?
Rupture of foetal vessel within foetal membranes
What is the management of an antenatal haemorrhage?
Varies massively depending on severity and gestation
Up to and including c section
What is the management of PPH?
Medical- oxytocin, ergometrine, carbaprost, tranexemic acid
Balloon tamponade
Surgical
What is preterm labour?
Onset of labour before 37 weeks
What are the grades of preterm labour?
Mild- 32-36 weeks
Very- 28-32 weeks
Extremely- 24-28 weeks
What are the risk factors for preterm labour?
Multiple pregnancy Polyhydramnios APH Pre-eclampsia Infection Prelabour premature rupture of membranes
How is preterm labour diagnosed?
Contractions with evidence of cervical changes on vaginal examination
What is the management of preterm labour?
Labour suppressants
Steroids unless contraindicated
Transfer to unit with NICU
Aim for vaginal delivery
What are the neonatal morbidities resulting from prematurity?
Respiratory distress syndrome Intraventricular haemorrhage Cerebral palsy Jaundice Infections Visual impairment Hearing loss
What is chronic hypertension in pregnancy?
Hypertension from pre pregnancy or developing before 20 weeks
What is mild hypertension?
140-149/90-99
What is moderate hypertension?
150-159/100-109
What is severe hypertension?
> 160/>110
What is the management of hypertension in pregnancy?
Ideally should have pre pregnancy care- change if necessary
Pharm- labetolol, nifedipine or methyldopa
Aim to keep BP <150/100
Monitor for foetal growth and pre-eclampsia
What is pre-eclampsia?
Mild hypertension on two occasions or moderate to severe hypertension once with proteinuria
What is the pathophysiology of pre-eclampsia?
Immunological
Genetic predisposition- imbalance between vasodilators and vasocontristors
What are the risk factors for pre-eclampsia?
First pregnancy Extrenes of maternal age Previous pre-eclampsia Pregnancy interval >10 years FH Multiple pregnancy Underlying medical disorders
What are the signs and symptoms of pre-eclampsia?
Headache Blurred vision Epugastric pain Pain below ribs Vomiting Sudden Stellung of hands, face, legs Clonus/brisk reflexes Reduced urine output
What are the findings on biochemistry with pre-eclampsia?
Raised liver enzymes
Raised urea, creatinine and urate
What are the findings on haematology with pre-eclampsia?
Low platelets
Low haemoglobin, signs of haemolytic
Features of DIC
What is the management of pre-eclampsia?
Frequent BP checks
Urine protein monitoring
Foetal monitoring- growth, CTG
Antihypertensives- labetolol, methyldopa, nifedipine
Steroids if <36 weeks gestation
Anticonvulsants
Induction of labour/c section if situation deteriorates
What is done for prophylaxis of pre-eclampsia?
Low dose aspirin form 12 weeks until delivery
What are the maternal complications of pre-eclampsia?
Seizures Cerebral haemorrhage Stroke HAemolysis, elevated liver enzymes, low platelets DIC Renal failure Pulmonary oedema Cardiac failure
What are the foetal complications of pre-eclampsia?
Impaired [lacental function- IUGR, foetal distress, prematurity, increased perinatal mortality
What changes about diabetes in pregnancy?
Insulin requirements increase due to anti-insulin properties of hormones
What is the effect of maternal diabetes on the foetus?
Maternal glucose crosses placenta and induces insulin production- causing macrosomnia
What is the management of diabetes pre-conception?
optimise glycemic control
5mg folic acid
Dietary advice
Retinal and renal assessment
What is the management of diabetes during pregnancy?
Optimise glycemic control
Change drugs/add insulin
Monitor for hypo/hyper, ketonuria, infections
Monitor foetal growth
Induce labour at 38-40 weeks and consider section
What is the treatment of diabetes in labour?
Dextrose insulin infusion
COntinuous CTG
Early feeding of baby
What is gestational diabetes?
Abnormal glucose intolerance that reverts to normal after delivery
What ar the risk factors fir gestational diabetes?
BMI >30 Previous baby >4.5kg Previous gestational diabetes FH Polyhydramnios or big baby
How is gestational diabetes screened for?
Offer HbA1C at booking if any risk factors
Offer OGTT at 16 and 28 weeks if any risk factors
Wha is the management of gestational diabetes?
Diet
Metformin and insulin
Check OGTT 6-8 weeks postnatally
Yearly check of HbA1C and blood sugar annually
What does diabetes during pregnancy increase the risk of?
Foetal congenital abnormalities Miscarriage Foetal macrosomnia Polyhydramnios Operative delivery Shoulder dystocia Stillbirth Pre-eclampsia Infections Neonatal- impaired lung maturity, neonatal hypo, jaundice
What are the factors in Virchow’s triad?
Stasis
Vessel wall injury
Hypercoagulability
Why is pregnancy a risk with VTE?
Hyercoaguable state
Increased stasis due to progesterone
What are the risk factors for VTE in pregnancy?
Older mothers Parity High BMI Smokers IV drug use Dehydration Decreased mobility Infections Haemorrhage Previpus VTE Sickle cell disease
What are the signs and symptoms of a VTE?
Pain in calf Swelling and erythema of affected leg Breatlessness PAin breathing Cough Tachycardia Hypoxic Pleura; rub
What investigations are done for VTE?
ECG
ABG
Soppler V/Q lung scan
CTPA
What is done for prophylaxis of VTE?
TED stockings
Advice on mobility and hydration
Prophylactic anticoagulation of >3 risk factors
