Complications of Pregnancy 1 Flashcards
Define spontaneous miscarriage/abortion
Termination/loss of pregnancy before 24 weeks
Define still birth
Loss of pregnancy after 24 weeks
What are the categories of miscarriage?
Threatened Inevitable Partial Complete Missed Septic
What is a threatened miscarriage?
Bleeding from gravid uterus before 24 weeks with closed cervix and viable pregnancy
What is the typical presentation of threatened miscarriage?
Vaginal bleeding and pain
Viable pregnancy
Closed cervix
Spontaneous abortion can be prevented
What is an inevitable miscarriage?
PV bleeding + open cervix
What is the typical presentation of inevitable miscarriage?
Bleeding (may be heavy, may get clots), viable pregnancy and open os
What is an incomplete miscarriage?
Some production of conception are retained
What is the typical presentation of incomplete miscarriage?
PV bleeding, open cervix
What is a complete miscarriage?
Complete expulsion of products of conception
What is the typical presentation of complete miscarriage?
Cervix closed and bleeding stopped
What is a septic miscarriage?
Ascending infection after incomplete miscarriage
Infection can spread throughout pelvis
What is a missed miscarriage?
Foetal death but no expulsion of PoC
What will you see on Ex/USS if there is a missed miscarriage?
No symptoms/brown/bloody discharge, closed cervix
USS - empty gestational sac/no fetal heart seen
What are the aetiologies of miscarriages?
Abnormal conceptus - chromosomal/structural/genetic abnormalities (50%)
Uterine abnormalities - submucosal fibroids, fusion failure of Mullerian ducts
Cervical impotence
Maternal factors - DM, increased age, SLE, thyroid disease, acute maternal infection
Unknown - hormonal imbalances
Which type of fibroids distort the uterine cavity the worst?
Submucosal
What occurs in cervical impotence that leads to miscarriage?
Cervix opens prematurely with absent/minimal uterine activity and pregnancy is expelled
What factors are linked to cervical impotence?
Trauma to cervix, e.g. following dilatation of cervix or cone biopsy treatment
How can hormonal imbalances lead to miscarriage?
CL essential for survival in first 8 weeks of pregnancy
If CL removed –> abortion within 7 days
?Lower progesterone levels assoc with higher risk of miscarriage
How can acute maternal infection lead to miscarriage?
General toxic illness with high temperature can stimulate uterine activity –> loss of pregnancy
E.g. appendicitis
What is the management of threatened miscarriage?
Watch and weight, avoid strenuous exercise, weakly pelvic USS
What is the management of inevitable miscarriage?
May req. evacuation
What is the management of missed miscarriage?
Prostaglandins/misoprostol to induce cervical ripening
Surgical miscarriage
What is the management of septic miscarriage?
Antibiotics and removal of PoC
Define ectopic pregnancy
When an embryo implants in somewhere other than the uterine cavity (mostly fallopian ampulla)
What are the risk factors for ectopic pregnancy?
Alteration of the fallopian tubes, e.g. prev. ectopic in tubes, PID affecting tubes, surgery to tubes
Assisted conception
What is the presentation of ectopic pregnancy?
Amenorrhoea, +ve preg test, and other signs of pregnancy
Vaginal bleeding, GI/urinary signs, abdominal pain/tenderness over ectopic
What is the presentation of tubal rupture in ectopics?
Acute onset severe abdominal and shoulder tip pain
Signs of haemorrhagic shock (tachycardia, hypotension, syncope)
Why do you get shoulder pain in ruptured ectopics?
Blood irritates the diaphragm which is supplied by same nerve that supplies shoulder
(Referred pain)
What investigations should you do for ectopic pregnancies?
TUVS (thickened endometrium with no gestational sac in the uterus, fluid in pouch of douglas)
Serum beta-hCG, progesterone
How can you manage ectopic pregnancy?
Methotrexate (interfers with folate dependent steps in making DNA in rapidly diving ectopic)
Surgical - salphingectomy (removal of tubes), salphinotomy (removal of pregnancy - assoc. with higher risk of recurrence)
Conservative if haemodynamically stable & uncomplicated as may resolve itself
Define antepartum haemorrhage
Haemorrhage from the genital tract after the 24th week up until birth
What are the causes of APH?
Placenta praevia Vasa praevia Placental abruption APH of unknown origin Local lesion of the genital tract
What local lesions of the genital tract may lead to APH?
Cervical erosions, polyps, cancer
What STI may lead to blood discharge?
Trichomonas
What is placenta praevia?
Placenta lying in lower uterine segment
What are RFs for placenta praevia?
Previous C-section, multiparous woman, multiple pregnancy
What is the classification of placenta praevia?
1 - lying in lower uterine segment, but not touching internal os
2 - reaches internal os
3 - eccentrically covers os
4 - central placenta praevia
What is the presentation of placenta praevia?
Painless PV
Soft, non-tender uterus
Malpresentation of foetus
Why do you get bleeding in placenta praevia?
Separation of placenta as lower uterine segment forms the cervical effaces
How do you diagnose placenta praevia?
USS
Bladder is good landmark for the lower uterine segment
MRI better but not widely available
How do you manage placenta praevia?
DO not do vaginal Ex
Cross match and transfuse if req.
Conservative approach to allow foetal maturity
C-section delivery
How do you manage PPH?
Oxytocin, ergometrine, carbaprost, tranexamic acid
Balloon tamponade
B lynch suture, ligation of uterine/iliac vessels/hysterectomy
Define placental abruption
Placenta has started to separate from uterine wall
Assoc. with retroplacental clot
In placental abruption which vessels are bleeding?
Mothers and foetal
What are the RFs for placental abruption?
Cocaine Smoking, increased age, parity Multiple pregnancy Pre-eclampsia/HTN Polyhydramnios Previous abruption
What are the types of placental abruption?
Revealed
Concealed
Mixed
What is the presentation of the revealed placental abruption?
Major haemorrhage apparent as blood leaks down from os
What is the presentation of concealed placental abruption?
Haemorrhage occurs between placenta and uterine wall
Increase in fungal height
May get couvelaire uterus
What is a couvelaire uterus?
Blood leaks into uterine wall and gives it bruised appearance
What is the presentation of placental abruption?
Pain - abdominal, severe and tenderness
Vaginal bleeding
Increased uterine activity (may go into premature labour)
Foetal distress
How do you diagnose placental abruption?
USS
How do you manage placental abruption?
Attempt vaginal delivery or C-section
What are complications of placental abruption?
Maternal shock, collapse, DIC
PPH
Couvelaire uterus
Define vasa praevia
Foetal vessels located in membranes near internal os of cervix, putting them at risk when membranes rupture
Where is the blood loss from in vasa praevia?
Foetal blood
Hence is catastrophic to the foetus
What are RF for vasa praevia?
Placental abnormalities, placenta praevia, IVF
What are the clinical features of placenta praevia?
Painless PV bleeding, occurring after rupture of membranes, foetal distress
What is the management of vasa praevia?
Emergency C-section if foetal distress
Define pre-term labour
Labour before 37 weeks
Define mild, very and extremely preterm
Mild - 32-26wks
Very - 28-32wks
Extremely - 24-28wks
What are the factors predisposing to premature labour?
Polyhydramnios Multiple pregnancy APH Pre-eclampsia Infection, UTI, STI Premature rupture of membranes Idiopathic
<24-26wks premature labour is associated with what prognosis?
Very poor prognosis
What is the management of premature labour?
Tocolysis (anti-contraction meds) to allow steroids/transfer
NICU
Steroids to improve lung maturity/surfactant production
Aim for vaginal deliver
What are the neonatal complications assoc. with premature delivery?
IRDS (surfactant deficiency disorder –> alveolar collapse –> tachycardia, tachypnoea, increased resp effort, cyanosis)
Intraventricular haemorrhage
Cerebral palsy
Others: nutrition, temp control, jaundice, infections, visual/hearing impairment
What is cerebral palsy?
Group of disorders affecting muscle tone/development of movement/posture
What causes cerebral palsy?
Damage to the foetal brain in utero/brain during infancy
What symptoms are caused by cerebral palsy?
Spasticity/apraxia/dysarthria etc.
