Complications of pregnancy 1 Flashcards by Michael Alcorn

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

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What are the categories of miscarriage?

Threatened

Inevitable

Incomplete

Complete

Septic

Missed

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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

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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

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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

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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.

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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.

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What are the clinical features of a threatened miscarriage?

Vaginal bleeding +/- pain

Viable pregnancy

Closed cervix on speculum examination

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What are the features of an inevitable miscarriage?

Viable pregnancy

Open cervix with bleeding (can be heavy)

May also be clots

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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

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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)

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What are the features of a complete miscarriage?

Passed out all products of conception (POC)

Closed cervix

Bleeding stopped

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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

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How is a threatened miscarriage managed?

Conseratively - ‘just wait’, most stop bleeding and are okay

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How is an inevitable miscarriage managed?

If bleeding is heavy may need evacuation

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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