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Clinical OBS/GYN > Complications of Pregnancy > Flashcards

Complications of Pregnancy Flashcards

1
Q

Incidence and Common Sites of Ectopic Pregnancies?

A

1/60

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2
Q

Risk Factors for Ectopic Pregnancies?

A

History of PID (particularly Chlamydia)

History of infertility or assisted conception (especially IVF)

Endometriosis

Pelvic or tubal surgery

Previous ectopic pregnancy (recurrence risk is 10-20%)

IUCD in situ (prevents intrauterine pregnancy)

Smoking

Maternal age >40 years

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3
Q

Investigations for Ectopic Pregnancy?

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4
Q

Management of Ectopic Pregnancy?

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5
Q

Definition of Miscarriage?

A

Pregnancy loss before 24 weeks of gestation (at a stage when fetus would be incapable of independent survival and weighing less than 500g)

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6
Q

Epidemiology of Miscarriages?

A

Miscarriage occurs in 10-15% of clinically recognised pregnancies, up to 40% of conceptions

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7
Q

Risk Factors for Miscarriage?

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8
Q

Primary cause of Miscarriage?

A

Chromosomal abnormalities account for 50% of all miscarriages

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9
Q

Miscarriage in which cervical os is closed, and the fetus is present with cardiac activity?

A

Threatened miscarriage

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10
Q

Miscarriage in which cervical os is open, and the fetus is present?

A

Inevitable Miscarriage

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11
Q

Miscarriage in which fetus has passed, some placental tissue remains, the cervical os is open?

A

Incomplete Miscarriage

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12
Q

Miscarriage in which the fetus and placenta have passed, the cervical os is closed?

A

Complete Miscarriage

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13
Q

Classification of Miscarriage?

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14
Q

Management of Miscarriage?

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15
Q

Severe form of Nausea and vomiting in pregnancy (NVP)?

What contributes to it?

A

Hyperemesis Gravidarum: Persistent and intractable vomiting; inability to keep food and fluid down

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16
Q

Associations with Hyperemesis Gravidarum?

A

● Multiple pregnancy

● Trophoblastic disease (molar pregnancy)

● Hyperthyroidism (HG is associated with gestational thyrotoxicosis because HCG is structurally similar to TSH)

● Nulliparity

● Obesity

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17
Q

Timing of Hyperemesis Gravidarum?

A

Presents in the first trimester (most commonly between 8-12 weeks)

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18
Q

Complications of Hyperemesis Gravidarum?

A

Electrolyte imbalances (common)– hypokalaemia, hyponatremia, hypochloraemia, metabolic alkalosis

Mallory Weiss tear

Wernicke encephalopathy (rare; due to thiamine deficiency)

Acute tubular necrosis

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19
Q

Diagnosis of Hyperemesis Gravidarum?

A

Consider also other causes of nausea, vomiting including urinary tract infections, gastroenteritis, small bowel tumors, adhesions, etc

Triad of:

  • 5% weight loss
  • Dehydration
  • Electrolyte imbalance
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20
Q

Staging of Hyperemesis Gravidarum?

A

Pregnancy Unique Quantification of Emesis (PUQE) Score: quantifies frequency of nausea, vomiting and dry retching, and impact on quality of life

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21
Q

Investigations for Hyperemesis Gravidarum?

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22
Q

Management of Hyperemesis Gravidarum?

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23
Q

Physiologic changes during pregnancy that favour a state of insulin resistance?

A

Increased caloric intake and reduced exercise

Placental lactogen and progesterone

Increased cortisol and growth hormone

These changes support the fetus – the resulting maternal hyperglycemia and hyperinsulinemia provides glucose to the fetus and stimulate fetal insulin production

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24
Q

Risk Factors for Gestational Diabetes Mellitus?

A

Maternal age >40 years

PCOS

Previous unexplained stillbirth

Obesity (BMI >30kg/m2)

Previous macrosomic baby (>4.5kg)

History of gestational diabetes

Family history of diabetes

Ethnic predisposition to diabetes (South Asian, black Caribbean, and Middle Eastern)

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25
Complications of Gestational Diabetes?
**Maternal Complications**: - Shoulder Dystocia - Pregnancy Induced Hypertension - Pre-Eclampsia **Fetal Complications** - Macrosomia (may cause Pre-Term Labor) - Polyhydramnios (buildup of increased amniotic fluid) - Intrauterine growth restriction - Intrauterine Death **Neonatal Complications** - Hypoglycemia - Polycythemia (May cause jaundice) - Birth Trauma (Fractures Brachial Plexus Injury, Asphyxia, respiratory Distress Syndrome)
26
Investigations for Gestational Diabetes?
Oral glucose tolerance test (OGTT) or Glucose Challenge test followed by GTT (two-step) *Note that HbA1c measurements are not useful for GDM* If DM is diagnosed in the first trimester, suspect undiagnosed pre-existing DM
27
Management of Gestational Diabetes?
28
Definition of Antepartum haemorrhage?
Bleeding from the genital tract during pregnancy at >24 weeks gestation, and before the onset of labor (Note that bleeding prior to 24 weeks is known as threatened miscarriage) Complicates 3-5% of pregnancies
29
Causes of Antepartum Haemorrhage?
30
Investigations for Antepartum Hemorrhage? (Maternal/Fetal)
Maternal - FBC - Crossmatch - Keilhauer Test (determine the amount of fetal haemoglobin that has been transferred from a fetus to the mother’s bloodstream; it is useful to determine if a higher dose of anti-D is required) - Clotting Screen (abruption suspected) Fetal - Ausclate Fetal HR - CTG - Fetal Growth and Wellbeing
31
Management of Antepartum Hemorrage?
Admission (minimum 24 hrs) Corticosteroids (from 24 weeks if risk of pre-term delivery) Anti-D Immunoglobulin (all rhesus negative women given at least 500 IU, more if determined by Kailhauer Test)
32
Complications of Antepartum Hemorrhage? (Maternal/Fetal)
33
What is Placenta Previa? Classifications?
Placenta that is inserted, wholly or in part, into the lower segment of the uterus; more recently diagnosed as placental edge within 2cm of the internal cervical os (.5% of pregnancies)
34
Assessment of Placenta Previa?
35
Management of Placenta Previa? - Asymptomatic - w/ Hemmorage - Delivery
36
Placental villi adhere superficially to the myometrium but do not invade it?
Placenta Accreta
37
Placental villi deeply penetrate the myometrium down to the serosa
Placenta Increta
38
Placental villi penetrate through the uterine wall and may involve other pelvic organs
Placenta Percreta
39
Risk Factors for Placenta Accreta?
40
Clinical Features of Placenta Accreta?
Consider PAS in presence of **anterior** low lying placenta or placenta praevia in patient with previous caesarean
41
Assessment of Placenta Accreta?
42
Management of Placenta Accreta?
43
Complications of Placenta Accreta? (Maternal/Fetal)
44
Separation of the placenta, partially or completely, from the uterus before delivery
Placental Abruption
45
Risk Factors for Placental Abruption
Hypertension Trauma History of Abruption Smoking/Cocaine Use
46
Pathogenesis of Pre-Eclamsia?
47
Risk Factors for Pre-Eclamsia?
● Aged <20 or >40 years ● History of pre-eclampsia (7x) ● Multiple pregnancy (5x) ● Family history (4x) ● Primiparity (2-3x) ● Pregnancy interval >10 years (2-3x) ● Obesity (2x) ● Maternal disease – hypertension, diabetes, renal disease, autoimmune disease, thrombophilia ● Fetal hydrops ● Hydatidiform mole
48
Prevention of Pre-Eclampsia
49
Diagnosis of Pre-Eclamsia?
**Hypertension** (>140/90mmHg) on more than one occasion **Proteinuria** (>300mg/24h or PCR of 30mg/mmol or urine dipstick protein of ≥2+), in the absence of UTI The diagnosis of pre-eclampsia should also be made in case of: - sustained systolic blood pressure > 160 mmHg - rise in creatinine, alanine transaminases - fall in platelets - symptoms of severe pre-eclampsia such as pulmonary edema
50
Clinical Features of Pre-Eclampsia
Hypertension Protinuria Edema Abdominal Pain (Subcapsular Hemorages of Liver)
51
Mild pre-eclampsia?
BP >140/90mmHg Absent or low proteinuria (<300mg/24h or 1+ on dipstick) No maternal complications
52
Moderate pre-eclampsia?
BP >140/90mmHg Significant proteinuria (>300mg/24h or 2+) No maternal complications
53
Severe Pre-Eclampsi?
BP >160/110mmHg Significant proteinuria (>1g/24h or >2+) Maternal complications have occurred
54
Maternal Complications of Pre-Eclampsia
Presence of ANY of the Following Defines Severe Pre-Eclampsia: - **BP**: SBP >160mmHg or DBP >110mmHg - **Proteinuria**: 1g/24h or ≥3+ protein on urine dipstick - **Renal insufficiency** – creatinine >90micromol/L - **Haematologic** – thrombocytopenia (platelets <100,000), haemolysis, DIC, haemorrhage (abruption, stroke, etc.) - **Hepatic** – raised serum transaminases, severe epigastric or RUQ pain or tenderness, nausea and vomiting - **Neurologic** – eclampsia, confusion, hyperreflexia, clonus, persistent new headache, visual disturbance, stroke - **Respiratory** – pulmonary oedema (dyspnoea)
55
Timing of Eclampsia?
40% Before Delivery 20% During Delivery 40% After Delivery
56
HELLP Syndrome?
57
Fetal Complications of Pre-Eclampsia?
IUGR (40% of cases) Prematurity (iatrogenic) Intrauterine death
58
Investigations for Pre-Eclampsia
59
Management of Severe Pre-Eclampsia?
Admission to a high-dependency unit (HDU) **Monitoring** - BP and HR (every 15-30 minutes) - urine output - oxygen saturations - fluid balance - neurologic assessment (reflexes, GCAESAREAN, AVPU) - fetal wellbeing (CTG, US) **Magnesium sulphate** – indicated for the management or prevention of seizures **Antihypertensives**: Methyl Dopa, Hydralizine, Leabtetalol Delivery – delivery of the placenta is usually curative (though complications may occur postnatally) ▪ **Delivery** is usually curative
60
Indications for immediate delivery?
Indications for immediate delivery: - eclampsia - HELLP syndrome - worsening thrombocytopenia or coagulopathy or liver or renal function - severe symptoms (especially epigastric pain) - reversed umbilical artery end-diastolic flow
61
Management of Mild/Moderate Pre-Eclampsia?
62
Production of antibodies against antigens that are foreign to the individual but native to another individual of the same species?
Isoimmunization
63
Abnormal accumulation of fluid in two or more fetal compartments (fetal ascites, pleural effusion, pericardial effusion or skin oedema)
Hydrops
64
Pathophysiology of Rhesus Disease?
65
Prevention of Rhesus Disease?
Check Fetal Rhesus after 11 weeks’ gestation in all Rhesus negative women (blood test in the mother) Anti-D immunoglobulin – anti-D (1500IU) is given to all Rhesus negative women with Rhesus positive fetuses (or unknown fetal Rhesus status) routinely at 28 weeks, within 72h of any potentially sensitizing event, and after delivery
66
What is the Keilhauer test?
If a large fetomaternal haemorrhage is suspected, the standard dose of anti-D may not be sufficient; in this case, the Keilhauer test can be performed to determine if more anti-D immunoglobulin is required
67
Investigations and Management of Rheusus Disease Antenatally?
68
Postnatal Management of Rhesus Disease?
69
Causes/Risk Factors of Pre-Term Labor?
Causes: - Idiopathic - Iatrogenic - Cervical weakness - Ascending infection - Uterine stretch (abruption, polyhydramnios, MP) Risk Factors - History of Pre-term birth - Mulitple pregnancy - Cervical Surgery - Renal Disease - Pre-Eclampsia - IUGR
70
Management of Pre-Term Labor
● **Steroids** – 12mg betamethasone IM, two doses 24h apart ● **Tocolysis** – tocolytic agents (nifedipine, oxytocin receptor antagonists) may be used to delay delivery until steroids have been administered; do not use tocolysis for >24h; contraindicated if infection is suspected or if membranes are ruptured ● **Magnesium sulphate** - fetal neuroprotection, offer up to 30 weeks’ gestation ● **Intrapartum IV antibiotics** are indicated only if features of infection are present
71
Indications/Screening Procedure for Pre-Term Labor
72
Prevention of Pre-term Labor?
73
PROM vs. PPROM
**Prelabour rupture of membranes at term (PROM)** is defined as leakage of amniotic fluid in the absence of uterine activity after 37 completed weeks of gestation (8% of pregnancies) **Preterm prelabour rupture of membranes (PPROM)** – membranes rupture before the onset of labour and before 37 weeks of gestation
74
Causes of PROM?
75
Assessment of Patient w/ PPROM?
76
Complications of PPROM?
Maternal risks – chorioamnionitis, sepsis, placental abruption Fetal risks – prematurity, infection, cord prolapse, pulmonary hypoplasia, limb contractures, intrauterine death
77
Signs/Symptoms of Chorioamnionitis?
78
Management of PPROM?
**24-34 weeks** – admission, daily review for signs of infection, steroids, antibiotics (erythromycin 250mg QDS PO for 10 days or until established labour) *Intrapartum antibiotic prophylaxis for all pre-term deliveries, irrespective of GBS status* - Aim for induction of labour at 37 weeks if no signs of infection - May consider induction of labour from 34 weeks if significant risk factors for infection (e.g. known GBS carriage) **Evidence of infection** – admission, steroids, IV antibiotics, induction of labour (indicated regardless of gestational age), Broad-spectrum antibiotic coverage (benzylpenicillin and gentamicin and metronidazole)
78
Management of PROM?
79
Risk Factors for PPROM?
80
Antenatal Steroids - Indicaitons - Administration - Benefits - Cautions
81
Classification of Breechn Presentations
82
Breech Presenation occures in ______% of pregnancies at term; More common preterm (_____% at 28 weeks)
Breech presentation occurs in 3-4% of pregnancies at term; More common preterm (50% at 28 weeks)
83
Causes and Associations for Breech Presentation
84
Complications of Breech Presentation
85
Features of breech presentation?
longitudinal lie the head is palpable in the fundus the presenting part is not hard the fetal heart is best auscultated high up in the uterus
85
Management of Breech Presentation?
86
What is ECV and how is it Performed? - Timing - Pre/Post Procedure - Complications? - Contraindications?
87
Causes of Abnormal Lie?
88
Management of Abdnomarl Lie?

Clinical OBS/GYN (13 decks)

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