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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
causes antepartum heamorrhage
``` placenta praevia placental abruption APH unknown origin local lesions of genitla tract vase praevia ```
26
placental abruption
placenta started to separate from uterine wall before birth assoc with a retroplacental clot
27
placenta praevia
all or part of placenta implants in lower uterine segment and lies infront of the presenting part of the fetus
28
placenta praevia is more common in...
multiparous women multiple pregnancies where placenta mass increased woman with previous C sec
29
placenta praevia presentation
painless PV bleeding soft, non-tender uterus +/- fetal malpresentation malpresentation USS
30
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
31
diagnosis of placenta praevia
USS *vaginal examination must not be done with suspected placenta praevia
32
factors associated with placental abruption
``` pre-eclampsia chronic HTN multiple pregnancy polyhydramnios smoking inc age parity previous abruption cocaine use ```
33
types of placental abruption
revealed concealed mixed (revealed and concealed)
34
revealed placental abruption
can see the blood major haemorrhage is apparent externally because the blood released from placenta escaped through cervical os
35
concealed placental abruption
bleeding inside so cant see it haemorrhage occurs between placenta and uterine wall.
36
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
37
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
38
complications of placental abruption
maternal shock, collapse fetal distress then death maternal DIC, renal failure PPH
39
preterm labour
onset of labout before 37wks gestation
40
mildly preterm
32-36wks
41
very preterm
28-32wks
42
extremely preterm
24-28wks
43
preterm reasons
pre-eclampsia infection PPH placental praevia
44
predisposing factors to preterm labour
``` multiple pregnancy polyhydramnios APH pre-eclampsia infection e.g. uti prelabout premature rupture membranes majority idiopathic ```
45
diagnosis of preterm delivery
contractions with evidence of cervical changes on VE test: foetal fibronectin
46
management of preterm delivery
consider tocolysis to allow steroids/transfer steroids tranfser to unit with NICU aim for vaginal delivery
47
tocolysis
drugs preventing uterine contractions | labour suppressants
48
neonatal morbidity resulting from prematurity
``` respiratory distress syndrome intraventricular haemorrhage cerebral palsy nutrition temp control jaundice infections visual impairment hearing loss ```
49
chronic hypertension in pregnancy
hypertension either pre-pregnancy or at booking 20wks gestation or less
50
chronic hypertension in pregnancy: mild HT
diastolic 90-99 | systolic 140-149
51
chronic hypertension in pregnancy: moderate HT
diastolic: 100-109 | systolic 150-159
52
chronic hypertension in pregnancy: severe Ht
diastolic 110+ | systolic 160+
53
gestational hypertension
pregnancy induced hypertension new htn - develops after 20wks
54
pre-eclampsia
new hypertension >20wks in association with significant proteinuria
55
significant proteinuria
automated reagent strip urine protein estimation >1+ spot urinary protein: creatinine ratio >30mg/mol 24hr urine protein collection >300mg/day
56
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
57
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
58
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)
59
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
60
maternal complications of PET
``` eclampsia: seizures severe htn - cerebeal haemorrhage, stroke HELLP DIC renal failure pulm oedema cardiac failure ```
61
fetal complications of PET
``` impaired placental perfusion --> IUGR fetal distress prematurity increased PN mortality ```
62
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)
63
biochemical abnormalities of severe PET
raised liver enzymes + bilirubin if HELLP present raised urea + creatinine, raised urate
64
haematological abnormalities of severe PET
low platelets low haemoglobin signs haemolysis features DIC
65
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
66
only 'cure' for PET
delivery of baby and placenta
67
when to consider induction of labour/c section
if maternal or fetal condition deteriorates, irrespective of gestation
68
treatment of seizures/impending seizures (PET)
obstetric emergency ABD approch magnesium sulphate bolus + IV infusion control BP: IV labetol, hydralazine avoid fluid overload
69
how does magnesium sulphate bolus + IV infusion work
causes cerebral dilation and completely blocks calcium at synaptic nerve endins antidote is calcium gluconate
70
pre-existing diabetes in pregnancy
insulin requirements of mum increase fetal hyper-insulinemia occurs
71
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
72
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
73
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 ```
74
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
75
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
76
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)
77
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
78
virchow's triad
stasis vessel wall injury hypercoaguabillity
79
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
80
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 ```
81
VTE prophylaxis in pregnancy
TED stockings advice inc mobility, hydration prophylactic anti-coag with 3+ risk factors
82
signs/symptoms VTE
pain in calf, inc girth affected leg, calf muscle tenderness SOB, pain breathing, cough, tachycardic, hypoxic, pleural rub
83
investigations if sus VTE
``` ECG blood gases doppler V/Q lung scan CTPA ```

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