Complications in pregnancy Flashcards
Common complications in pregnancy (4)
Miscarriage
Ectopic Pregnancy
Antepartum haemorrhage
Preterm labour
What is the difference between abortion and miscarriage?
Miscarriage : spontaneous loss of pregnancy before 24 weeks gestation
Abortion: voluntary termination
Spontaneous Miscarriage - what are the 6 different types you can get
Incidence of spontaneous miscarriage is around 15%,
maybe higher
Threatened Inevitable Incomplete Complete Septic Missed
Threatened miscarriage - 3 features
Vaginal bleeding+/- pain
Viable pregnancy
Closed cervix on speculum examination
Inevitable miscarriage features -2
- Viable pregnancy
– Open cervix with bleeding
that could be heavy (+/-clots
Missed Miscarriage (Early Fetal Demise - features 3
- No symptoms, or could have bleeding/ brown loss vaginally
- Gestational sac seen on scan
- No clear fetus (empty gestational sac) or a fetal pole with no fetal heart seen in the gestational sac
Incomplete Miscarriage- features
Most of pregnancy expelled out, some products of pregnancy remaining in the uterus
open cervix, vaginal bleeding (may be heavy)
Complete miscarriage & Septic miscarriage features
Complete miscarriage
– passed all products of conception (POC), cervix closed and bleeding has stopped (should ideally have confirmed the POC or should have had a scan previously that confirmed an intrauterine pregnancy)
Septic Miscarriage
especially in cases of an incomplete miscarriage
Aetiology of Spontaneous Miscarriage - 5 types
chromosomal, genetic, structural
Uterine abnormality
- congenital, fibroids
Cervical weakness
- Primary, secondary
Maternal
- increasing age, diabetes
Unknown
Management of Miscarriage
- 4 types
Threatened - conservative, “just wait” – most stop bleeding and are okay
Inevitable - if bleeding heavy may need evacuation
Missed - conservative
- medical – prostaglandins (misoprostol) - surgical – SMM (surgical management of miscarriage
Septic - antibiotics and evacuate uterus
What is a Ectopic pregnancy?
Pregnancy implanted outside the uterine cavity
1 in 20
Risk factors for ectopic pregnancies? (4)
Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic
Assisted conception
Presentation of ectopic pregnancies ? (4)
Period of ammenorhoea (with +ve urine pregnancy test)
+/_ Vaginal bleeding
+/_ Pain abdomen
+/_ GI or urinary symptoms
Investigations for ectopic pregnancies
Scan – no intrauterine gestational sac, may see adnexal mass, fluid in Pouch of Douglas
Serum BHCG levels – may need to serially track levels over 48 hour intervals- if a normal early intrauterine pregnancy HCG levels will increase by at least 66%ish
Management for ectopic pregnancies (3)
Medical – Methotrexate
Surgical – (mostly laparoscopy– Salpingectomy, = remove the tube
Salpingotomy for few indications) - leave damaged tube and take embryo
Conservative
Antepartum Haemorrhage (APH) is?
APH - haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby.
Causes of Antepartum Haemorrhage? (5)
Placenta praevia
Placental abruption
APH of unknown origin
Local lesions of the genital tract
Vasa praevia (very rare)
Placenta praevia- what is it? - incidence? where is it more commonly seen in
All or part of the placenta implants in the lower uterine segment
Incidence
1/200 pregnancies
More common in
Multiparous women
multiple pregnancies
previous caesaren section
Placenta praevia – old classification 1-5 - describe them
Grade I Placenta encroaching on the lower segment but not the internal cervical os
Grade II Placenta reaches the internal os
Grade III Placenta eccentrically covers the os
Grade IV Central placenta praevia
RCOG classification
Low lying- placenta is less than 20 mm from internal os
Placenta previa – covering the os
Placenta praevia presentation (3)
Painless PV bleeding
Malpresentation of the fetus
Incidental
why are you likely to do a cs for Placenta praevia ?
cervix dilatation will cause bleeding
Clinical features for Placenta praevia?
Clinical features
Maternal condition correlates with amount of bleeding PV
Soft, non tender uterus +/- fetal malpresentation
Diagnosis for Placenta praevia?
Ultrasound scan to locate placental site
- VAGINAL EXAMINATION MUST NOT BE DONE WITH SUSPECED PLACENTA PRAEVIA
Management for Placenta praevia?
Gestation
Severity
Caesarean
Management of PPH? - medical and surgical
Medical management – oxytocin, ergometrine, carboprost, tranexemic acid
Balloon tamponade Surgical – B Lynch cutre, ligation of uterine, iliac vessels , hysterectomy
What is Placental abruption (2)
Haemorrhage resulting from premature separation of the placenta before the birth of the baby
Incidence 0.6% of all pregnancies
Factors associated with Placental Abruption include? (6)
Pre-eclampsia/ chronic hypertension Multiple pregnancy Polyhydramnios Smoking, increasing age, parity Previous abruption Cocaine use
Clinical types and presentation of placental abruption?
Placental abruption
Revealed (see the blood)
Concealed (bleeding but inside so can’t see!)
Mixed (concealed and revealed)
Presentation of placental abruption?
Pain
Vaginal bleeding (may be minimal bleeding)
Increased uterine activity
General management of APH? depends on what 3 things?
Management will vary from expectant treatment to attempting a vaginal delivery to immediate Caesarean section depending on
Amount of bleeding
General condition of mother and baby
Gestation
Complications of placental abruption (4)
- Maternal shock, collapse (may be disproportionate to the amount of bleeding seen)
- Fetal distress then death
- Maternal DIC, renal failure
- Postpartum haemorrhage
‘couvelaire uterus’
Preterm Labour - when is this?
Onset of labour before 37 completed weeks gestation (259 days)
How is the timing of a preterm baby defined?
32-36 wks mildly preterm
28-32 wks very preterm
24-28 wks extremely preterm
Spontaneous or induced (iatrogenic
Babies are resuscitated after how many weeks old?
22 weeks
Reasons for preterm babies ?
– pre eclampsia, infection, PPH, placental praevia
preterm labour is more common in?
30 - 40% multiple pregnancy
Predisposing factors of pre term labour?
Multiple pregnancy Polyhydramnios APH Pre-eclampsia Infection eg UTI Prelabour premature rupture of membranes Majority no cause (idiopathic
Preterm Delivery is a major cause of?
perinatal mortality and mobidity
Gestation dependent
Management of Preterm Delivery? -how to diagnose it properly
- what should you make sure you consider?
Diagnosis
Contractions with evidence of cervical change on VE
Test- Fetal fibronectin
Consider possible cause
abruption, infection
Management Preterm Delivery? 24-26 weeks
Generally regarded as very poor prognosis
decisions made in discussion with parentsand neonatologists
All cases of preterm delivery are regarded as viable - what should you consider?
Consider tocolysis to allow steroids/ transfer
Steroids unless contraindicated
Transfer to unit with NICU facilities
Aim for vaginal delivery
What are tocolysis?
drugs preventing uterine contractions, labour suppressants
Neonatal Morbidity resulting from Prematurity - what conditions
respiratory distress syndrome intraventricular haemorrhage cerebral palsy nutrition temperature control jaundice infections visual impairment hearing loss
