Complications of pregnancy 1 Flashcards
definition of abortion or spontaneous miscarriage
(abortion is termination) miscarriage is spontaneous loss of pregnancy before 24 weeks gestation
what is the incidence of psontaneous miscarriage?
15%
what is a threatened miscarriage ?
bleeding from the gravid uterus before 24 weeks gestation, when there is still a viable fetus but no evidecne of cervical dilatation
what is an inevitable miscarriage?
there is a open cervix with bleeding however the fetus is still viable
what is septic miscarriage?
following an incomplete abortion there is a risk of ascending infection into the uterus which can spread throughout the pelvis
what is an incomplete miscarriage?
When there is only partial expulsion of the products of conception, there is an open cervix and vaginal bleeding
what is a missed miscarriage?
when the fetus has died but the uterushas made no attempt to expel the products of conception, gestation sac seen in scan but there is no clear fetus
what is a complete miscarriage?
all products of conception are passed, the cervix is closed and bleeding has stopped
Aetiology of a spontaneous miscarriage
abnormal conceptus (chromosomal, genetic or structural), uterine abnormality (congenital, fibroids), cervical incompetence (1 or 2dary), maternal (age, DM). PCOS, hypothyroidism, SLE, protein s and c deficiency, anti-phospholipid syndrome, fibroids etc…
what are the ways the fetal development may be abnormal?
chromosomal, genetic or structural
name 2 diseases (maternal) which increase the risk of miscarriage
SLE (systemic lupus erythematous) and thyroid disease. PCOS, hypothyroidism, SLE, protein s and c deficiency, anti-phospholipid syndrome, fibroids etc…
name 2 acute infections which may cause miscarriage?
pyelitis and appendicitis, by causing a general toxic illness with high temperature can stimulate uterine activity and loss of pregnancy.
Ix for misscarriage?
FSH, LH, TFT, Prolactin, testosterone, protein c and s, coag studies. USS, hysteroscopy, karyotype.
Mx of a missed miscarriage
prostaglandins, surgical and conservative
Mx of a septic miscarriage
Abx and evacuation of the uterus
advice for pre-pregnency
don’t travel post 24 weeks, folic acid 3 months prior to conception an during pregnancy, avoid cats (toxoplasmosis), smoking cessation, alcohol avoidance, use of unsfe medications, optimism control of DM.
common case seen –>
Recurrent spontaneous miscarriages - loss of 3 or more foetuses under 500g in weight, Case: 34f, vaginal bleeding and abdo pain, 22wks pregnant, 3 previous miscarriages.
Define - ECTOPIC PREGNANCY
pregnancy implanted outside the uterine cavity
what is the most common site of an ectopic pregnancy (list in order of most to least common)
Amupllary, isthmus, interstitial, ovary, cervical, fimbrial (very rare)
what is the incidence of a ectopic pregnancy?
1 in 90
RF of an ectopic pregnancy
(PID) pelvic inflamatory disease, previous tubal surgery, endometriosis, previous ectopic, assisted contraception, failed sterilisaiton.
DDX for ectopic pregnancy…
appendicitis, ovarian cyst rupture, misscarriage, late period, PID, PCOS
Presentation?
Lower abdomen pain, period of ammenhorhoaea, with a positive pregnancy test, vagincal bleeding, GI or urinary symptoms
what does a presentation of pain in the shoulder mean?
Ruptured ectopic pregnancy!
Ix?
Scan, serum Beta human chorionic gonadotropin (BHCG) levels, serum progesterone levels. Bloods - crp, fbc, u and e, serum beta HCG. Urinary pregnancy test.
wha is seen on the scan in an ectopic pregnancy?
no intrauterine sac, may see adnexal mass, fluid in rectouterine pouch (pouch of douglas)
what is a BHCG test?
Abeta HCGtest is a blood test used to diagnose pregnancy, and usually becomes positive around the time of the first missed period (it is produced by the placenta)
Mx?
Methotrexate, surgical excision (salpingectomy laproscopically) or conservative. Prepare for surgery: iv fluids, roiutine bloods to group and save, keep NBM, obtian consent.
what does methotrexate do?
shrinks the pregnancy tissue
Define ANTEPARTUM HAEMORRHAGE (APH)
haemorrhage from the genital tract after the 24th week of pregnancy but before the delivery of the baby
list the causes of APH
placenta previa, placental abruption, APH of unknown origin, local lesions of the genital tract, vasa previa
Urgent Mx of APH
ABC then iv access and fluids, blood bank for urgent blood, take to theatre for an urgent caesarean and possible hysterectomy.
define PLACENTA PREVIA
where the placenta is implanted into the lower segment of the uterus and lies infront of the presenting part of the fetus
in what cases is placental previa most common? RF’s…
Previous placenta previa, multiparous women, multiple pregnancies, previous caesarian section. (1 in 200 incidence)
3 types of PP are
lateral, marginal central
Classify Grade 1 (MARGINAL)
placenta encroaches on the lower segment but not the internal cervical os
Classify Grade 2 (LATERAL)
placenta reaches the internal os
Classify Grade 3 (CENTRAL)
placenta eccentrically/ slightly covers the os
Classify Grade 4 (CENTRAL)
central placent praevia
Px of placenta praevia?
painless vaginal bleeding, malpresentation of the uterus, incidental finding
clincical features of placenta praevia
soft, non tender uterus with or without fetal malpresentation
what Ix are done?
USS
what Ix must you not do if there is suspected placenta praevia?
A Vaginal exam
Mx of placenta praevia?
Caesarian section, also watch for PPH. Mx is dependent of the gestaiton and severity.
Define PPH (POSTPARTUM HAEMORRHAGE)
PPH is classified as a genital blood loss of above 500ml within the first 24 hours of giving birth. This may come from the uterus, cervix, vagina or labia
cause of PPH
Poor contraction of the uterus following childbirth. Not all of the placenta being delivered, a tear of the uterus, or poor blood clotting are other possible causes. It occurs more commonly in those who: already have a low amount of red blood, are Asian, with bigger or more than one baby, are obese or are older than 40 years of age
CAUSES OF PPH… THE 4 T’S
Tone - prolonged labour, multiple pregnancy
Trauma - Cesarean, instrumental delivery, episiotomy
Tissue - retained placenta, placenta accretta
Thrombin - coagulopathies (secondary to pre-eclampsia/sepsis/anticoagulants)
what is the Mx of PPH?
OXYTOCIN, ERGOTAMINE, carboprost, balloon tamponade, blood transfusions, surgical (B lynch suture, ligation of uterine or iliac vessels or a hysterectomy)
Define PLACENTLA ABRUPTION
Haemorrhage resulting from premature separation of the placenta before the birth of the baby (incididence of 0.6% of all pregnancies), where the placenta has started to separate from the uterine wall before the birth of the baby and is associated with a retroplacental clot.
What are the factors associated with placental abruption?
pre-eclampsia, multiple pregnancy, polyhydramnios (excessive accumulation of amniotic fluid), smoking, age, parity (number of pregnancies), previous abruption, cocaine use
types of placental abruption
revealed, concealed, mixed
Px of placental abruption
Abdominal pain, vaginal bleeding, increased uterine activity
Complications of placental abruption
maternal shock, fetal death, Maternal DIC (Disseminated intravascular coagulation is a condition in which blood clots form throughout the body, blocking small blood vessels), renal failure, PPH.
Define PRETERM LABOUR
onset of labour before 37 completed weeks gestation, 24-28 extremely preterm, 28-32 is very preterm, 32-36 weeks is mildly preterm, this may be spontaneous or induced
what are the predisposing factors to preterm labour?
multiple pregnancy, polyhdramnios, APH, pre-eclampsia, maternal febrile ilness, infection e.g. UTI or genital tract infection (GROUP B STREP), premature rupture of membranes, (PROM), HOWEVER this is mainly idiopathic.
Low socio-economic status, extremes of maternal age, stressful work, smoking, substance abuse, cervical incompetance,
how is preterm labour diagnosed?
contractions with evidence of cervial change on Vaginal exam, also consider abruption and infection
what drugs may be used to postpone the onset of labour?
Beta Agonists, CCB’s, GTN.
What is the Mx of preterm labour?
Tocolysis (anticontraction medicsation) to allow steroids, transfer to NICU and aim for a vaginal delivery. If before 26 weeks then there is a very poor prognosis so discuss with parents and neonatologists.
what morbitities are a result of prematurity?
Rresp distress syndrome, intraventricular haemorrhage, cerebral palsy, temoerature control, jaundice, infections, visual impairment, hearing loss.
when considering giving the mother steriods, after how many weeks is it acceptable to give steroids?
After 28-34 weeks.
why are steroids given for preterm labour?
fetal lung maturation.
If untreated with iv benzylpenicillin, what complicaitons can group b strep cause in neonates?
chest infections, speticaemia, meningitis (all within 3 months of age).
