complications in pregnancy Flashcards

1
Q

misscarriage

A

spontaneous loss of pregnancy before foetus reaches viability

all pregnancy losses from time of conception until 24wks gestation

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2
Q

classifications of spontaneous miscarriages

A
threatened
inevitable 
incomplete
complete
septic 
missed
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3
Q

threatened misscarriage

A

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

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4
Q

inevitable misscarriage

A

cervix has already begun to dilate

viable pregnancy
open cervix with bleeding that could be heavy (+/- clots)

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5
Q

incomplete misscarriage

A

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)

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6
Q

complete misscarriage

A

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

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7
Q

septic miscarriage

A

following incomplete miscarriage there is risk of ascending infection into uterus which can spread throughout pelvis

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8
Q

missed miscarriage (early fetal demise)

A

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

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9
Q

aetiology of spontaneous miscarriage: abnormal conceptus

A

chromosomal, genetic, structural

abnormal fetal development

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10
Q

aetiology of spontaneous miscarriage: uterine abnormality

A

congenital fibroids

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11
Q

aetiology of spontaneous miscarriage: cervical weakness

A

primary, secondary

cervix opens prematurely with absent/minimal uterine activity and pregnancy expelled

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12
Q

aetiology of spontaneous miscarriage: maternal

A

inc age, diabetes
SLE
thyroid disease
acute maternal infection - pyelitis, appendicitis

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13
Q

management of miscarriage: threatened

A

conservative

‘just wait’ - most stop bleeding and are okay

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14
Q

management of miscarriage: inevitable

A

if bleeding heavy may need evacuation

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15
Q

management of miscarriage: missed

A

conservative
medical: prostaglandins (misoprostol )
surgical - SMM (surgical management of miscarriage)

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16
Q

management of miscarriage: septic

A

antibiotics and evacuate uterus

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17
Q

ectopic pregnany

A

pregnancy implanted outside uterus

most commonly found in fallopian tube esp ampullary area

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18
Q

risk factors of ectopic pregnancy

A

pelvic inflammatory disease
previous tubal surgery
previous ectopic
assisted conception

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19
Q

presentation of ectopic pregnancy

A

period of amenorrhoea (with +ive urine pregnancy test)

+/- vaginal bleeding
+/- pain abdomen
+/- GI or urinary symptoms

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20
Q

ectopic pregnancy investigations

A

scan: no intrauterine gestational sac, may see adnexal mass, fluid in pouch of douglas

serum B-HCG levels

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21
Q

management of ectopic pregnancy

A

methotrexate

surgery - salpingectomy, salpingotomy

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22
Q

salpingectomy

A

remove fallopian tube

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23
Q

salpingotomy

A

leave damaged tube, remove embryo

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24
Q

antepartum haemorrhage

A

haemorrhage from genital tract after 24th week of pregnancy and before birth of baby

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25
Q

causes antepartum heamorrhage

A
placenta praevia 
placental abruption 
APH unknown origin 
local lesions of genitla tract
vase praevia
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26
Q

placental abruption

A

placenta started to separate from uterine wall before birth

assoc with a retroplacental clot

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27
Q

placenta praevia

A

all or part of placenta implants in lower uterine segment and lies infront of the presenting part of the fetus

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28
Q

placenta praevia is more common in…

A

multiparous women
multiple pregnancies where placenta mass increased
woman with previous C sec

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29
Q

placenta praevia presentation

A

painless PV bleeding
soft, non-tender uterus +/- fetal malpresentation
malpresentation USS

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30
Q

what is bleeding in placenta praevia due to

A

separation of placenta as lower uterine segment forms and the cervix effaces

blood loss occurs from venous sinuses in lower segment

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31
Q

diagnosis of placenta praevia

A

USS

*vaginal examination must not be done with suspected placenta praevia

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32
Q

factors associated with placental abruption

A
pre-eclampsia 
chronic HTN 
multiple pregnancy
polyhydramnios
smoking
inc age 
parity 
previous abruption 
cocaine use
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33
Q

types of placental abruption

A

revealed
concealed
mixed (revealed and concealed)

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34
Q

revealed placental abruption

A

can see the blood

major haemorrhage is apparent externally because the blood released from placenta escaped through cervical os

35
Q

concealed placental abruption

A

bleeding inside so cant see it

haemorrhage occurs between placenta and uterine wall.

36
Q

presentation of placental abruption

A

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

37
Q

general management of antepartum haemorrhage

A

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
38
Q

complications of placental abruption

A

maternal shock, collapse
fetal distress then death
maternal DIC, renal failure
PPH

39
Q

preterm labour

A

onset of labout before 37wks gestation

40
Q

mildly preterm

A

32-36wks

41
Q

very preterm

A

28-32wks

42
Q

extremely preterm

A

24-28wks

43
Q

preterm reasons

A

pre-eclampsia
infection
PPH
placental praevia

44
Q

predisposing factors to preterm labour

A
multiple pregnancy
polyhydramnios 
APH 
pre-eclampsia
infection e.g. uti 
prelabout premature rupture membranes
majority idiopathic
45
Q

diagnosis of preterm delivery

A

contractions with evidence of cervical changes on VE

test: foetal fibronectin

46
Q

management of preterm delivery

A

consider tocolysis to allow steroids/transfer

steroids
tranfser to unit with NICU
aim for vaginal delivery

47
Q

tocolysis

A

drugs preventing uterine contractions

labour suppressants

48
Q

neonatal morbidity resulting from prematurity

A
respiratory distress syndrome 
intraventricular haemorrhage
cerebral palsy
nutrition 
temp control 
jaundice
infections
visual impairment
hearing loss
49
Q

chronic hypertension in pregnancy

A

hypertension either pre-pregnancy or at booking 20wks gestation or less

50
Q

chronic hypertension in pregnancy: mild HT

A

diastolic 90-99

systolic 140-149

51
Q

chronic hypertension in pregnancy: moderate HT

A

diastolic: 100-109

systolic 150-159

52
Q

chronic hypertension in pregnancy: severe Ht

A

diastolic 110+

systolic 160+

53
Q

gestational hypertension

A

pregnancy induced hypertension

new htn - develops after 20wks

54
Q

pre-eclampsia

A

new hypertension >20wks in association with significant proteinuria

55
Q

significant proteinuria

A

automated reagent strip urine protein estimation >1+

spot urinary protein: creatinine ratio >30mg/mol

24hr urine protein collection >300mg/day

56
Q

essential/chronic hypertension management

A

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

57
Q

definition of pre-eclampsia (PET)

A

mild HT on 2 occasions more than 4hrs apart (>140/90)

+ proteinuria of more that 300mg/24hrs and protein:creatinine ratio >30mg/mmol

58
Q

pathophysiology of PET

A

immunological
genetic predisposition

secondary invasion of maternal spiral arterioles by trophoblasts impaired –> reduced placental perfusion

imbalance between vasodilators/vascoconstrictors in pregnancy (prostocylin/thromboxane)

59
Q

risk factors for developing PET

A
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

60
Q

maternal complications of PET

A
eclampsia: seizures
severe htn - cerebeal haemorrhage, stroke 
HELLP
DIC
renal failure 
pulm oedema 
cardiac failure
61
Q

fetal complications of PET

A
impaired placental perfusion -->
IUGR
fetal distress
prematurity 
increased PN mortality
62
Q

symptoms/signs severe PET

A

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)

63
Q

biochemical abnormalities of severe PET

A

raised liver enzymes + bilirubin if HELLP present

raised urea + creatinine, raised urate

64
Q

haematological abnormalities of severe PET

A

low platelets
low haemoglobin
signs haemolysis
features DIC

65
Q

management of PET

A

frequent BP + urine protein checks
check symptomatology
check for hyper-reflexia
bloods: FBC, LFTs, U&Es

fetal investigations: scan for growth, CTG

66
Q

only ‘cure’ for PET

A

delivery of baby and placenta

67
Q

when to consider induction of labour/c section

A

if maternal or fetal condition deteriorates, irrespective of gestation

68
Q

treatment of seizures/impending seizures (PET)

A

obstetric emergency ABD approch

magnesium sulphate bolus + IV infusion

control BP: IV labetol, hydralazine

avoid fluid overload

69
Q

how does magnesium sulphate bolus + IV infusion work

A

causes cerebral dilation and completely blocks calcium at synaptic nerve endins

antidote is calcium gluconate

70
Q

pre-existing diabetes in pregnancy

A

insulin requirements of mum increase

fetal hyper-insulinemia occurs

71
Q

why does insulin requirements of pre-existing diabetic mum increase

A

human placental lactogen, progesterone, human chorionic gonadotropin and cortisol from placenta all have anti-insulin action

72
Q

why does fetal-insulinemia occur in pre-existing diabetes

A

maternal glc crosses placenta and induces increased insulin production in the foetus

fetal hyperinsulinema cuases macrosomis

73
Q

effects of pre-existing diabetes on mum and baby - increased risks off..

A
fetal congenital abnormalities
miscarriage
fetal macrosomia, polyhydramnios
still birth 
inc perinatal mortality 
inc risk PET
74
Q

preconception management of pre-existing diabetes

A

better glycemic control
blood sugars ~4.7mmol/l pre conception
HbA1c < 48mmol/mol

folic acid 5mg
dietary advice
retinal and renal assessment

75
Q

risk factors for developing gestational diabetes

A

increased BMI>30
prev macrosomic baby >4.5kg
previous GDM
FHx diabetes
polyhydramnios or big baby in current pregnancy
recurrent glycosuria in current pregnancy

76
Q

screening for GDM

A

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)

77
Q

management of GDM

A

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

78
Q

virchow’s triad

A

stasis
vessel wall injury
hypercoaguabillity

79
Q

why is risk of thrombo-embolism inc in pregnancy

A

pregnancy hypercoaguable state - to protect mum bleeding after giving birth

increased stasis - progesterone, effects enlarging fetus

may be vascular damage at delivery/CS

80
Q

what further increased risk thrombo-embolism in pregnancy

A
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
81
Q

VTE prophylaxis in pregnancy

A

TED stockings
advice inc mobility, hydration
prophylactic anti-coag with 3+ risk factors

82
Q

signs/symptoms VTE

A

pain in calf, inc girth affected leg, calf muscle tenderness

SOB, pain breathing, cough, tachycardic, hypoxic, pleural rub

83
Q

investigations if sus VTE

A
ECG 
blood gases
doppler
V/Q lung scan 
CTPA