complications in pregnancy Flashcards
misscarriage
spontaneous loss of pregnancy before foetus reaches viability
all pregnancy losses from time of conception until 24wks gestation
classifications of spontaneous miscarriages
threatened inevitable incomplete complete septic missed
threatened misscarriage
refers to bleeding from gravid uterus before 24wks gestation when there is a viable foetus and no evidence of cervical dilatation
vaginal bleeding +/-pain
viable pregnancy
closed cervix on speculum exam
inevitable misscarriage
cervix has already begun to dilate
viable pregnancy
open cervix with bleeding that could be heavy (+/- clots)
incomplete misscarriage
only partial expulsion of products of conception
most of pregnancy expelled, some products of pregnancy remaining in uterus
open cervix, vaginal bleeding (may be heavy)
complete misscarriage
complete expulsion of products of conception
passed all products of conception (POC), cervix closed and bleeding stopped
should ideally confirm POC or scan that has prev confirmed a intrauterine pregancy
septic miscarriage
following incomplete miscarriage there is risk of ascending infection into uterus which can spread throughout pelvis
missed miscarriage (early fetal demise)
fetus has died but uterus hasn’t made attempt to expel POC
no symptoms, could have bleeding/brown loss vaginally
gestational sac on scan
no clear foetus (empty sac) or foetal pole with no heart
aetiology of spontaneous miscarriage: abnormal conceptus
chromosomal, genetic, structural
abnormal fetal development
aetiology of spontaneous miscarriage: uterine abnormality
congenital fibroids
aetiology of spontaneous miscarriage: cervical weakness
primary, secondary
cervix opens prematurely with absent/minimal uterine activity and pregnancy expelled
aetiology of spontaneous miscarriage: maternal
inc age, diabetes
SLE
thyroid disease
acute maternal infection - pyelitis, appendicitis
management of miscarriage: threatened
conservative
‘just wait’ - most stop bleeding and are okay
management of miscarriage: inevitable
if bleeding heavy may need evacuation
management of miscarriage: missed
conservative
medical: prostaglandins (misoprostol )
surgical - SMM (surgical management of miscarriage)
management of miscarriage: septic
antibiotics and evacuate uterus
ectopic pregnany
pregnancy implanted outside uterus
most commonly found in fallopian tube esp ampullary area
risk factors of ectopic pregnancy
pelvic inflammatory disease
previous tubal surgery
previous ectopic
assisted conception
presentation of ectopic pregnancy
period of amenorrhoea (with +ive urine pregnancy test)
+/- vaginal bleeding
+/- pain abdomen
+/- GI or urinary symptoms
ectopic pregnancy investigations
scan: no intrauterine gestational sac, may see adnexal mass, fluid in pouch of douglas
serum B-HCG levels
management of ectopic pregnancy
methotrexate
surgery - salpingectomy, salpingotomy
salpingectomy
remove fallopian tube
salpingotomy
leave damaged tube, remove embryo
antepartum haemorrhage
haemorrhage from genital tract after 24th week of pregnancy and before birth of baby
causes antepartum heamorrhage
placenta praevia placental abruption APH unknown origin local lesions of genitla tract vase praevia
placental abruption
placenta started to separate from uterine wall before birth
assoc with a retroplacental clot
placenta praevia
all or part of placenta implants in lower uterine segment and lies infront of the presenting part of the fetus
placenta praevia is more common in…
multiparous women
multiple pregnancies where placenta mass increased
woman with previous C sec
placenta praevia presentation
painless PV bleeding
soft, non-tender uterus +/- fetal malpresentation
malpresentation USS
what is bleeding in placenta praevia due to
separation of placenta as lower uterine segment forms and the cervix effaces
blood loss occurs from venous sinuses in lower segment
diagnosis of placenta praevia
USS
*vaginal examination must not be done with suspected placenta praevia
factors associated with placental abruption
pre-eclampsia chronic HTN multiple pregnancy polyhydramnios smoking inc age parity previous abruption cocaine use
types of placental abruption
revealed
concealed
mixed (revealed and concealed)
revealed placental abruption
can see the blood
major haemorrhage is apparent externally because the blood released from placenta escaped through cervical os
concealed placental abruption
bleeding inside so cant see it
haemorrhage occurs between placenta and uterine wall.
presentation of placental abruption
pain - severe abdominal
vaginal bleeding
increased uterine activity
fetal lie longitudinally with presenting part fixed in pelvis
uterine tone increased and pt may be having contractions
general management of antepartum haemorrhage
management will vary from expectant treatment to attempting vaginal delivery to immediate C section depending on
- amount of bleeding
- general condition of mother and baby
- gestation
complications of placental abruption
maternal shock, collapse
fetal distress then death
maternal DIC, renal failure
PPH
preterm labour
onset of labout before 37wks gestation
mildly preterm
32-36wks
very preterm
28-32wks
extremely preterm
24-28wks
preterm reasons
pre-eclampsia
infection
PPH
placental praevia
predisposing factors to preterm labour
multiple pregnancy polyhydramnios APH pre-eclampsia infection e.g. uti prelabout premature rupture membranes majority idiopathic
diagnosis of preterm delivery
contractions with evidence of cervical changes on VE
test: foetal fibronectin
management of preterm delivery
consider tocolysis to allow steroids/transfer
steroids
tranfser to unit with NICU
aim for vaginal delivery
tocolysis
drugs preventing uterine contractions
labour suppressants
neonatal morbidity resulting from prematurity
respiratory distress syndrome intraventricular haemorrhage cerebral palsy nutrition temp control jaundice infections visual impairment hearing loss
chronic hypertension in pregnancy
hypertension either pre-pregnancy or at booking 20wks gestation or less
chronic hypertension in pregnancy: mild HT
diastolic 90-99
systolic 140-149
chronic hypertension in pregnancy: moderate HT
diastolic: 100-109
systolic 150-159
chronic hypertension in pregnancy: severe Ht
diastolic 110+
systolic 160+
gestational hypertension
pregnancy induced hypertension
new htn - develops after 20wks
pre-eclampsia
new hypertension >20wks in association with significant proteinuria
significant proteinuria
automated reagent strip urine protein estimation >1+
spot urinary protein: creatinine ratio >30mg/mol
24hr urine protein collection >300mg/day
essential/chronic hypertension management
change anti-htn drugs if indicated
aim to keep BP<150/100, labetolol, nifedipine, methyldopa can be used
monitor for superimposed pre-eclampsia
monitor fetal growth
definition of pre-eclampsia (PET)
mild HT on 2 occasions more than 4hrs apart (>140/90)
+ proteinuria of more that 300mg/24hrs and protein:creatinine ratio >30mg/mmol
pathophysiology of PET
immunological
genetic predisposition
secondary invasion of maternal spiral arterioles by trophoblasts impaired –> reduced placental perfusion
imbalance between vasodilators/vascoconstrictors in pregnancy (prostocylin/thromboxane)
risk factors for developing PET
1st pregnancy extremes of maternal age PET in prev pregnancy pregnancy interval >10yrs BMI>35 FHx PET multiple pregnancy
underlying medical conditions: chronic htn, pre-existing renal disease, pre-existing diabetes
maternal complications of PET
eclampsia: seizures severe htn - cerebeal haemorrhage, stroke HELLP DIC renal failure pulm oedema cardiac failure
fetal complications of PET
impaired placental perfusion --> IUGR fetal distress prematurity increased PN mortality
symptoms/signs severe PET
headache, blurred vision, epigastric pain, pain below ribs, vomiting, swelling hands face legs
severe htn, 3+ proteinuria
clonus/brisk reflexes, papillodema
reduced urine output
convulsions (eclampsia)
biochemical abnormalities of severe PET
raised liver enzymes + bilirubin if HELLP present
raised urea + creatinine, raised urate
haematological abnormalities of severe PET
low platelets
low haemoglobin
signs haemolysis
features DIC
management of PET
frequent BP + urine protein checks
check symptomatology
check for hyper-reflexia
bloods: FBC, LFTs, U&Es
fetal investigations: scan for growth, CTG
only ‘cure’ for PET
delivery of baby and placenta
when to consider induction of labour/c section
if maternal or fetal condition deteriorates, irrespective of gestation
treatment of seizures/impending seizures (PET)
obstetric emergency ABD approch
magnesium sulphate bolus + IV infusion
control BP: IV labetol, hydralazine
avoid fluid overload
how does magnesium sulphate bolus + IV infusion work
causes cerebral dilation and completely blocks calcium at synaptic nerve endins
antidote is calcium gluconate
pre-existing diabetes in pregnancy
insulin requirements of mum increase
fetal hyper-insulinemia occurs
why does insulin requirements of pre-existing diabetic mum increase
human placental lactogen, progesterone, human chorionic gonadotropin and cortisol from placenta all have anti-insulin action
why does fetal-insulinemia occur in pre-existing diabetes
maternal glc crosses placenta and induces increased insulin production in the foetus
fetal hyperinsulinema cuases macrosomis
effects of pre-existing diabetes on mum and baby - increased risks off..
fetal congenital abnormalities miscarriage fetal macrosomia, polyhydramnios still birth inc perinatal mortality inc risk PET
preconception management of pre-existing diabetes
better glycemic control
blood sugars ~4.7mmol/l pre conception
HbA1c < 48mmol/mol
folic acid 5mg
dietary advice
retinal and renal assessment
risk factors for developing gestational diabetes
increased BMI>30
prev macrosomic baby >4.5kg
previous GDM
FHx diabetes
polyhydramnios or big baby in current pregnancy
recurrent glycosuria in current pregnancy
screening for GDM
if risk factor present, offer HbA1c estimation at booking
if >43mmol/mol then OGTT needs to be done, if this is normal repeat it at 24-28wks
can also offer OGTT at 16 and 28wks if sig risk factors (e.g. prev GDM)
management of GDM
control blood sugars: diet, metformin/insulin
post-delivery check OGTT 6-8wks PN
yrly check on HbA1c/blood sugars as higher risk developing overt diabetes
virchow’s triad
stasis
vessel wall injury
hypercoaguabillity
why is risk of thrombo-embolism inc in pregnancy
pregnancy hypercoaguable state - to protect mum bleeding after giving birth
increased stasis - progesterone, effects enlarging fetus
may be vascular damage at delivery/CS
what further increased risk thrombo-embolism in pregnancy
older mothers, inc parity inc BMI, smokers IV drug users PET dehydration - hyperemesis decr mobility op delivery, prolonged labout haemorrhage blood loss >2l previous VTE those w thrombophilia strong FHx VTE sickle cell
VTE prophylaxis in pregnancy
TED stockings
advice inc mobility, hydration
prophylactic anti-coag with 3+ risk factors
signs/symptoms VTE
pain in calf, inc girth affected leg, calf muscle tenderness
SOB, pain breathing, cough, tachycardic, hypoxic, pleural rub
investigations if sus VTE
ECG blood gases doppler V/Q lung scan CTPA
