Complications of pregnancy 1 Flashcards
What is a miscarriage?
the spontaneous loss of pregnancy before the fetus reaches viability
This includes all pregnancy losses from the time of conception until 24 weeks gestation
What are the categories of miscarriage?
Threatened
Inevitable
Incomplete
Complete
Septic
Missed
What is a ‘threatened’ miscarriage?
What features will it have?
A threatened miscarriage refers to bleeding from the gravid uterus before 24 weeks gestation when there is a viable fetus and no evidence of cervical dilatation
What is an ‘inevitable’ miscarriage?
Miscarriage becomes inevitable if the cervix has already begun to dilate
Ie - bleeding from gravid uterus with cervical dilation, <24 weeks
What is the difference between a complete and incomplete miscarriage?
When there is only partial expulsion of the products of conception this is referred to as an incomplete miscarriage whilst complete expulsion of the products of conception is referred to as a complete miscarriage
What is a septic miscarriage?
Following an incomplete miscarriage there is always a risk of ascending infection into the uterus which can spread throughout the pelvis and this is known as a septic abortion.
What is a ‘missed’ miscarriage?
Missed miscarriage describes a pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception.
What are the clinical features of a threatened miscarriage?
Vaginal bleeding +/- pain
Viable pregnancy
Closed cervix on speculum examination
What are the features of an inevitable miscarriage?
Viable pregnancy
Open cervix with bleeding (can be heavy)
May also be clots
What are the features of a missed miscarriage?
No symptoms or vaginal bleeding/brown discharge
Gestational sac seen on scan
No clear fetus (empty gestational sac) or a fetal pole with no fetal heart seen in the gestational sa
What are the features of an incomplete miscarriage?
Most of pregnancy expelled out, some products of pregnancy remaining in the uterus (on scan)
Open cervix, vaginal bleeding (may be heavy)
What are the features of a complete miscarriage?
Passed out all products of conception (POC)
Closed cervix
Bleeding stopped
What are the causes & risk factors for miscarriages?
Abnormal conceptus:
- Chromosomal (50% all miscarriages)
- Genetic
- Structural
Uterine abnormality:
- Congenital
- Fibroids
Cervical weakness:
- Primary or secondary
Maternal:
- Increasing age
- Diabetes
How is a threatened miscarriage managed?
Conseratively - ‘just wait’, most stop bleeding and are okay
How is an inevitable miscarriage managed?
If bleeding is heavy may need evacuation
How is a missed miscarriage managed?
Conservatively
Medically:
- Prostaglandins (misoprostol)
Surgically:
- SMM (surgical management of miscarriage)
How is a septic miscarriage managed?
Antibiotics and evacuate uterus
Ectopic pregnancies happen when implantation occurs outside the uterus
Where can this happen?
How likely^
Tubal (fallopian tube):
- Ampullary (most common)
- Isthmus (also common)
Cornual (interstitial) (rare)
Cervical (rare)
Ovary (rare)
What are risk factors for an ectopic pregnancy?
What is the incidence of ectopic pregnancies?
Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic pregnancy
Assisted conception
Incidence 1:90 pregnancies
How do ectopic pregnancies present?
Period of ammenorhoea (with +ve urine pregnancy test)
+/- Vaginal bleeding
+/- Abdo pain
+/- GI or urinary symptoms
How is an ectopic pregnancy investigated?
US Scan:
- No intrauterine gestational mass
- May see adexnal mass (outside of uterus)
- Fluid in pouch of douglas (rectouterine pouch)
Serum BHCG levels:
- may need to serially track levels over 48 hour intervals- if a normal early intrauterine pregnancy HCG levels will increase by at least 66%ish
- Ectopic miscarriage = BHCG drops
How is an ectopic pregnancy managed?
Medical:
- Methotrexate injection
- Follow up with serum BHCG measurement
Surgical:
- Salpingectomy - take out tube
- Salpingotomy - take out embryo, leave tube
Conservative:
- If patient’s BhCG levels low and are haemodynamically stable
What is an antepartum haemorrhage?
haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby
associated with significant maternal and neonatal morbidity and mortality
What are the causes of antepartum haemorrhage?
Placenta praevia
Placental abruption
APH of unknown origin
Local lesions of the genital tract
Vasa praevia (very rare)
What is placenta praevia?
What are risk factors for it?
When all or part of the placenta implants in the lower uterine segment and lies in front of the presenting part of the fetus
Risk factors:
- Multiparous women / multiple pregnancies
- Previous C-section
How would placenta praevia present?
Painless bleeding (APH)
Soft, non-tender uterus
Malpresentation of fetus
Often incidentally found prior to APH (USS)
How is placenta praevia investigated/diagnosed?
What must you never do to a patient with suspected PP?
Transvaginal ultrasound scan - best
Often picked up incidentally at 20 week antenatal abdo US though
NEVER DO VAGINAL EXAMINATION ON SUSPECTED PLACENTA PRAEVIA
How is placenta praevia managed?
depends on many factors including the gestation at presentation and the severity of the blood loss
Management of blood loss (if APH etc):
- Blood is cross matched and blood transfused depending on the maternal condition
C-section for delivery, watch for PPH
How is postpartum haemorrhage dealth with?
Medical management:
- Oxytocin
- Ergometrine
- Carboprost
- Tranexemic acid
Surgical options may be needed:
- Balloon tamponade (not surgery but shut up)
- B-lynch cutre
- Ligation of uterine, iliac vessels
- Hysterectomy
What factors are associated with placental abruption?
Pre-eclampsia/hypertension
Multiple pregnancies
Polyhydramnios
Smoking
Increasing age, parity
Previous abruption
Cocaine
How does a patient with placental abruption present?
Severe abdominal pain
APH - can be mild to heavy bleeding (‘revealed’), can also be absent* (‘concealed’)
Increased uterine tone +/- contractions
*in concealed abruption - haemorrhage occurs between placenta & uterine wall so will not pass through vagina
What are the complications of placental abruption
Maternal shock, collapse
Fetal distress & death
Maternal DIC, renal failure
Postpartum haemorrhage
Couvelaire uterus
What is a Couvelaire uterus?
Complication of placental abruption
Trapped blood between the placenta & uterus penetrates the uterus giving it a bruised (couvelaire) appearance
Define what pre-term labour is
What are the different categories of preterm-ness
Onset of labour < 37 completed weeks…
- 32-36 weeks = mildly preterm
- 28-32 weeks = very preterm
- 24-28 weeks = extremely preterm
From when in gestation can a baby be resuscitated
22 weeks onward
What are risk factors for a preterm labour?
Multiple pregnancies
Polyhydramnios
Abruption
APH
Pre-eclampsia
Infection - eg UTI
Prelabour premature rupture of membranes
Iatrogenic
Usually idiopathic
How is preterm labour diagnosed?
Contractions with evidence of cervical dilatation on VE
Fetal fibronectin test
How is preterm labour managed?
Tocolysis (prevents uterine contractions)
Steroids unless contraindicated
Transfer to NICU facilities
Aim for vaginal delivery
The more preterm the delivery - the higher the risk of morbidity and mortality in the beby
What morbidity can result from preterm delivery for the neonate
Respiratory distress syndrome
Intraventricular haemorrhage
Cerebral palsy
Problems with:
- Nutrition
- Temperature control
- Infections
- Jaundice
- Visual impairments
- Hearing loss
