Complications of Pregnancy Flashcards
what is miscarriage?
spontaneous loss of pregnancy before 24 weeks gestation
what is abortion?
voluntary termination
What is the incidence of spontaneous miscarriage?
15%
what are the types of spontaneous miscarriage
threatened: vaginal bleeding +/- pain, viable pregnancy, closed cervix
inevitable: vaginal bleeding (heavy +/- clots), open cervix
missed: asymptomatic, (brown) vaginal bleeding, empty gestational sac/foetal pole with no foetal heart
incomplete: products of pregnancy remain, vaginal bleeding (heavy), open cervix
complete: passed out all POC, bleeding stopped, cervix closed
septic: cases of incomplete miscarriage
What is the aetiology of spontaneous miscarriage?
- abnormal conceptus (chromosomal, genetic, structural)
- uterine abnormality (congenital, fibroids)
- cervical incompetence (primary (congenital), secondary (iatrogenic))
- maternal (increasing age, diabetes)
- unknown
what is the management of miscarriages?
threatened: conservative
inevitable: if heavy bleeding then evacuation of retained products
missed: conservative, medical (prostaglandins), surgical
septic: antibiotics, evacuate uterus
What is an ectopic pregnancy?
pregnancy implanted outside the uterine cavity
~1%
Give examples of sites of miscarriage?
- ampulla of fallopian tube (most common)
- isthmus of fallopian tube
- interstium of fallopian tube
- ovary (rare)
What are the risk factors for ectopic pregnancy?
- pelvic inflammatory disease
- previous tubal surgery
- previous ectopic surgery
- assisted conception
How do ectopic pregnancies present?
period of ammenorhoea (with +ve urine pregnancy test)
+/- Vaginal bleeding
+/- Pain abdomen
+/- GI or urinary symptoms
How are ectopic pregnancies investigated?
scan
- no intrauterine gestational sac
- may see adnexal mass
- fluid in Pouch of Douglas
serum BHCG
- track levels over 48 hour intervals
- if normal early intrauterine pregnancy, HCG levels will increase by at least 66%
How are ectopic pregnancies managed?
- medical: methotrexate
- surgical: laproscopy - salpingectomy or salpingotomy
- conservative
What is an antepartum haemorrhage?
haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby
What are some 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?
all or part of the placenta implants in the lower uterine segment
What is the incidence of placenta praevia?
1 in 200 pregnancies
Who is placenta praevia more common in?
- multiparous women
- multiple pregnancies
- previous C section
What are the classifications of placenta praevia?
Grade I: Placenta encroaching on the lower segment but not the internal cervical os
Grade II: Placenta reaches the internal os
Grade III: Placenta eccentrically covers the os
Grade IV: Central placenta praevia
How does placenta praevia present?
- painless PV bleed
- malpresentation of the foetus
- incidental on US
What are the clinical features of placenta praevia?
- maternal condition correlates with amount of bleeding PV
- soft, non tender uterus +/- fetal malpresentation
How is placenta praevia diagnosed?
-USS
VAGINAL EXAMINATION MUST NOT BE DONE
How is placenta praevia managed?
- depends on severity and gestation
- mother admitted to hospital and attempts made to allow for maturation of the foetus
- delivered by C section
- mother may require blood transfusion
What is there a risk of following delivery with placenta praevia?
PPH
How is PPH managed?
medical
- oxytocin, ergometrine, carbaprost, tranexamic acid
balloon tamponade
Surgical
- b lynch cutre, ligation of the uterine and iliac vessels, hyserterectomy
What is placental abruption?
Haemorrhage resulting from premature separation of the placenta before the birth of the baby
What factors are associated with placental abruption?
- pre-eclampsia/ chronic hypertension
- multiple pregnancy
- polyhydramnios
- smoking, increasing age, parity
- previous abruption
- cocaine use
What are the clinical types of placental abruption?
- revealed (can see blood)
- concealed (bleeding inside so can’t see)
- mixed
How does a placental abruption present?
- pain
- vaginal bleeding (may be minimal)
- increased uterine activity
What does management of APH depend on?
either:
- expectant treatment
- vaginal delivery
- immediate Caesarean section
depends on:
- amount of bleeding
- general condition of mother and baby
- gestation
What are the possible complications of placental abruption?
- maternal shock, collapse (may be disproportionate to the amount of bleeding seen)
- foetal distress & death
- maternal DIC, renal failure
- postpartum haemorrhage ‘couvelaire uterus’
What is preterm labour?
onset of labour before 37 completed weeks of gestation (259 days)
- 32-36 wks mildly preterm
- 28-32 wks very preterm
- 24-28 wks extremely preterm
spontaneous or induced
What is the incidence of preterm labour?
- 5- 7% in singletons
- 30 - 40% multiple pregnancy
What are some predisposing factors for preterm labour?
- multiple pregnancy
- polyhydramnios
- APH
- Pre-eclampsia
- infection eg UTI
- prelabour premature rupture of membranes
- idiopathic
How is preterm labour diagnosed?
- contractions with evidence of cervical change
- test: foetal fibronectin
consider possible cause: abruption, infection
How are preterm deliveries managed in all cases considered viable?
- consider tocolysis to allow steroids/ transfer
- steroids unless contraindicated
- transfer to unit with NICU facilities
- aim for vaginal delivery
What are the percentage of very preterm delivery survivors with severe disability?
<24 weeks: 65
24 weeks: 38
25 weeks: 31
26 weeks: 26
What neonatal morbidity may result from prematurity?
- respiratory distress syndrome
- intraventricular haemorrhage
- cerebral palsy
- nutrition
- temperature control
- jaundice
- infections
- visual impairment
- hearing loss
Give examples of hypertensive disorders in pregnancy.
- chronic hypertension
- gestational hypertension
- pre-eclampsia
What is considered significant proteinuria?
- automated reagent strip urine protein estimation > 1+
- spot urinary protein: creatinine Ratio > 30 mg/mmol
- 24 hours urine protein collection > 300mg/ day
Who is chronic hypertension commoner in?
Older mothers
How should chronic hypertension in pregnancy be managed?
- pre-pregnancy care
- keep BP < 150/100
- monitor for superimposed pre-eclampsia and foetal growth
higher incidence of placental abruption
Give examples of antihypertensives that are safe to use in pregnancy.
- labetolol
- methyldopa
- nifedipine
describe pre-eclampsia
mild HT on two occasions more than 4 hours apart OR moderate to severe HT
PLUS proteinuria of more than 300 mgms/ 24 hours
describe pathophysiology of pre-eclampsia?
Immunological
Genetic
- secondary invasion of maternal spiral arterioles by trophoblasts impaired leading to reduced placental perfusion
- imbalance between vasodilators and vasoconstrictors in pregnancy (prostacyclin/thromboxane)
What are the risk factors for PET?
- first pregnancy
- extremes of maternal age
- previous PET
- pregnancy interval >10 years
- BMI >35
- FMH
- multiple pregnancy
- underlying medical conditions (HT, renal disease, DM, autoimmune disorders)
What are the possible complications of PET?
maternal
- eclampsia (seizures)
- severe HT (stroke)
- HELLP (haemolysis, elevated liver enzymes, low platelets)
- DIC
- renal failure
- pulmonary oedema and cardiac failure
foetal
- impaired placental perfusion –> IUGR, foetal distress, prematurity, increased PN mortality
What are the signs and symptoms of severe PET?
- headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands face legs
- severe Hypertension; > 3+ of urine proteinuria
- clonus/brisk reflexes; papillodema, epigastric tenderness
- reducing urine output
- convulsions (Eclampsia)
What biochemical abnormalities can occur in severe PET?
- raised liver enzymes, bilirubin if HELLP present
- raised urea an creatinine, raised urate
What haematological abnormalities can occur in severe PET?
- low platelets
- low haemoglobin, signs of haemolysis
- features of DIC
What is the management for PET?
- frequent BP checks and urine protein
- check for symptoms: headaches, epigastric pain, visual disturbances
- check for hyper-reflexia and tenderness over liver
- bloods: FBC, LFTs, U+Es, coagulation
- foetal investigations including scans and CTG
What is the only cure for PET?
Delivery of the baby and placenta
What is the conservative approach for PET?
- close observation of clinical signs & investigations
- anti-hypertensives (labetolol, methyldopa, nifedipine)
- steroids for fetal lung maturity if gestation < 36wks
consider induction of labour/CS if maternal or fetal condition deteriorates, irrespective of gestation
risks of PET may persist into the puerperium therefore monitoring must be continued post delivery
What is the epidemiology of PET and eclampsia?
- 5-8% of pregnant women have PET
- 0.5% women have severe PET & 0.05% have eclamptic seizures
- 38% of seizures occur antepartum, 18% intrapartum, 44% postpartum
How are eclamptic seizures and impending seizures treated?
- magnesium sulphate bolus + IV infusion
- control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
- avoid fluid overload – aim for 80mls/hour fluid intake
What is the prophylaxis for PET in further pregnancies?
- low dose aspirin from 12 weeks to delivery
increased risk to develop hypertension in later life
What is gestational diabetes?
- carbohydrate intolerance with onset (or first recognised) in pregnancy
- abnormal glucose tolerance that reverts to normal after delivery
- however, more at risk of developing type II diabetes later in life
What effect does pre-existing diabetes have on pregnancy?
- insulin requirements of the mother increase
- foetal hyper-insulinaemia occurs
Why do insulin requirements increase in pregnancy?
- human placental lactogen
- progesterone
- human chorionic gonadotrophin
- cortisol
from placenta have anti-insulin action
Why does foetal hyper-insulinaemia occur?
maternal glucose crosses the placenta and induces increased insulin production in the foetus.
foetal hyperinsulinemia causes macrosomia
What are neonates of diabetic mothers at increased risk of?
- neonatal hypoglycaemia
- respiratory distress
What are the increased risks of diabetes in pregnancy?
- foetal congenital abnormalities (cardiac abnormalities, sacral agenesis)
- miscarriage
- foetal macrosomia, polyhydramnios
- operative delivery, shoulder dystocia
- stillbirth, increased perinatal mortality
What are the possible complications of diabetes in pregnancy?
- increased risk of pre-eclampsia
- worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
- infections
- neonatal: impaired lung maturity, neonatal hypoglycaemia, jaundice
What is the management for diabetes and pregnancy preconception?
- folic acid 5mg
- dietary advice
- retinal and renal assessment
- better glycemic control, ideally blood sugars should be
4 - 7mmo/l and HbA1c <6.5% (<48mmol/mol)
What is the management for diabetes during pregnancy?
- optimise glucose control
- continue oral agents but may need to change to insulin
- be aware of hypoglycaemia risk
- watch for ketonuria/infections
- repeat retinal assessments at 28 and 34 weeks
- watch foetal growth
What blood sugars are optimal during pregnancy?
<5.3mmol/l Fasting
<7.8mmol/l 1 hour postprandial
<6.4mmol/l 2 hours postprandial
<6mmol/l Before bedtime
What is the management of diabetes regarding birth?
- observe for PET
- labour induced 38-40 weeks or earlier
- consider C section if macrosomnia
- maintain blood sugar with insulin and dextrose insulin solution
- CTG monitoring
- early feeding of new-born to prevent hypoglycaemia
- pre-pregnancy insulin regime post delivery
What are the risk factors for gestation diabetes mellitus?
- BMI >30
- previous macrosomic baby > 4.5kg
- previous GDM
- FMH of diabetes
- women from high risk groups for developing diabetes – eg. Asian origin
- polyhydramnios or big baby in current pregnancy
- recurrent glycosuria in current pregnancy
What is GDM associated with?
increase in maternal complications (eg PET) and fetal complications (macrosomia) but much less than with type I or II diabetes
When is GDM screened for?
If risk factor present, offer HbA1C estimation at booking:
- If > 6% (43 mmol/mol), 75gms OGTT to be done.
- If OGTT normal, repeat OGTT at 24 -28 weeks
Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (eg. Previous GDM) present
How is GDM managed?
- control blood sugars through metformin and diet (insulin may be required)
- post delivery: check OFTT 6-8 weeks PN
- yearly check on Hb1AC/blood sugars as at higher risk of developing overt diabetes
What are the components of Virchow’s triad?
- stasis
- hypercoaguability
- vessel wall injury
Why is the risk of VTE increased in pregnancy?
- Pregnancy is a Hypercoaguable state (protect mother against bleeding post delivery)
- Increased stasis due to progesterone and effects of enlarged uterus
- May be vascular damage at delivery/ C section
What is the physiology of the Hypercoaguable state of pregnancy?
- increase in fibrinogen, factor VIII, VW factor, platelets
- decrease in natural anticoagulants – antithrombin III
- increase in fibrinolysis
What are the risk factors for VTE in pregnancy?
- Older mothers with increased parity
- High BMI, smokers
- IVDU
- PET
- Dehydration
- Decreased mobility
- Infection
- Operative delivery, long labour
- Haemorrhage or blood loss >2L
- Previous VTE, FMH, thrombophilia
- Sickle cell disease
What is the prophylaxis fro VTE in pregnancy?
- TED stockings
- Advice increased mobility, hydration
Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk factor if significant risk), may need to continue 6 weeks postpartum
What are the signs and symptoms of VTE?
- Pain in calf
- Increase girth of affected leg
- Calf muscle tenderness
- Breathlessness
- Pain on breathing
- Cough
- Tachycardia
- Hypoxic
- Pleural rub
How is VTE investigated in pregnancy?
- ECG
- Blood gases
- Doppler
- V/Q lung scan
- CT pulmonary angiogram
How is VTE treated in pregnancy?
Appropriate anticoagulation
