Complications of Pregnancy Flashcards
Abortion?
Voluntary termination of pregnancy
Miscarriage?
Spontaneous loss of pregnancy before 24wks gestation
There are many categories of miscarriage.
What happens in a threatened miscarriage?
Bleeding from uterus before 24wks gestation in a viable pregnancy
There are many categories of miscarriage.
What happens in an inevitable miscarriage?
Cervix already began to dilate in a viable pregnancy
There are many categories of miscarriage.
What happens in an incomplete miscarriage?
Only partial expulsion of the products of conception
There are many categories of miscarriage.
What happens in a complete miscarriage?
Complete expulsion of the products
What is he risks following an incomplete miscarriage?
Risk of ascending infection into the uterus which can then spread throughout the pelvis
->this is known as septic miscarriage
There are many categories of miscarriage.
What happens in a missed miscarriage?
Foetus has died but uterus makes no attempts to expel the products on conception
When is a missed miscarriage diagnosed?
No symptoms/could have bleeding or brown loss vaginally
Gestational sac seen on scan
No clear foetus, no foetal heart
What are some of the causes of spontaneous miscarriage?
Abnormal conceptus- chromosomal, genetic, structural
Uterine abnormality- congenital, fibroids
Cervical weakness
Maternal- increasing age, diabetes
->usually difficult to identify the underlying factor
What are some maternal health conditions which are known to increases risks of spontaneous miscarriage?
SLE- lupus
Thyroid conditions
Diabetes
Infections e.g. pyelitis, appendicitis
Management of threatened miscarriage?
Conservative management
Just wait, most cases, bleeding stops
Management of inevitable miscarriage?
If bleeding is heavy, may need evacuation
Management of missed miscarriage?
Conservative
Medical- prostaglandins
Surgical- suction evacuation
Management of septic miscarriage?
Antibiotics and evacuate uterus
Ectopic pregnancy?
Pregnancy implanted outwith the uterine cavity
Where is the most common location of ectopic pregnancy?
Fallopian tube, especially in the ampullary region
Risk factors of ectopic pregnancy?
Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic pregnancy
Assisted conception
Presentation of ectopic pregnancy?
Period of amenorrhoea (with +ve urine pregnancy test)
+/- vaginal bleeding
+/- abdominal pain
+/- GI or urinary symptoms
Investigations done to investigate a potential ectopic pregnancy?
Scan- no intrauterine gestational sac.
Serum BHCG levels
Medical management of ectopic pregnancy?
Methotrexate injection
Surgical management of ectopic pregnancy?
Most laparoscopy- salpingectomy, salpingotomy for few indications)
Where is the pouch of Douglas?
Behind the uterus
Antepartum haemorrhage?
Haemorrhage from the genital tract after the 24th week of pregnancy but before the delivery of the baby
->one of the greatest obstetric emergencies
Causes of Antepartum haemrrohage?
Placenta praevia
Placental abruption
Local lesions of genital tract
Vasa praevia (v rare)
Placenta praevia?
Placenta is attached to the lower segment of the uterus
Placental abruption?
Placenta has started to sperate from the uterine wall
When is placenta praevia more common?
Multiparous women (women who have given birth one or more times in the past)
Multiple pregnancies
Previous C-section
Presentation of placenta praevia?
Painless PV bleeding
Malpresentation of the foetus on US
->may be incidental upon US of foetus for another reason
How is diagnosis of placenta praevia usually made?
Via ultrasound
Management of placenta praevia?
Depends on gestation and severity of blood loss
Patient admitted to hospital, diagnosis made by ultrasound and blood transfusion may be required.
Deliver baby via C-section, watch for postpartum haemorrhage
->note that vaginal examination is contraindicated
Postpartum haemorrhage>
Any bleeding after delivery >500mls
How can postpartum haemorrhage be managed medically?
Oxytocin
Ergometrine
Carboprost
Tranexamic acid
What are some of the other forms of management of postpartum haemorrhage?
Balloon tamponade
Surgical
List some of the factors associated with placental abruption.
Pre-eclampsia/ chronic hypertension
Multiple pregnancy
Polyhydramnios
Smoking
Increasing age
Previous abruption
Cocaine use
Three types of placental abruption?
Revealed
Concealed
Mixed
->in revealed, see blood. In concealed, don’t see blood as inside
Presentation of placenta abruptuon?
Severe abdominal pain
Vaginal bleeding
Increased uterine activity
->note bleeding may be minimal
Management of antepartum haemorrhage?
Depends on amount of bleeding and the general condition of mother and baby, as well as the gestation.
However, may attempt vaginal delivery or go to an immediate C-section.
Complications of placental abruption?
Maternal shock/collapse
Foetal distress, then potentially death
Maternal DIC
Renal failure
Postpartum haemorrhage
Preterm labour?
Onset of labour before 37wks gestation
Predisposing factors to preterm labour?
Multiple pregnancy
Polyhydramnios
APH- antepartum haemorrhage
Pre-eclampsia
Infection e.g. UTI
Prelabour premature rupture of membranes
->majority are idiopathic
How is a diagnosis of preterm labour made?
Contractions with evidence of cervical change on vaginal examination
Test- foetal fibronectin
Management of preterm delivery?
Consider tocolysis to allow steroids/transfer
Steroids unless contraindicated
Transfer to unit with NICU facilities
Aim for vaginal delivery
List some of the potential neonatal morbidities resulting from prematurity.
Respiratory distress syndrome
Intraventricular haemorrhage
Cerebral palsy
Nutrition
Temperature control
Jaundice
Infections
Visual impairment
Gearing loss
Hypertension can be common in pregnancy.
What are the systolic and diastolic cutoffs for mild HT in pregnancy?
140/90
Diastolic- 90-99
Systolic- 140-49
Hypertension can be common in pregnancy.
What are the systolic and diastolic cutoffs for moderate HT in pregnancy?
150/100
Diastolic- 100-109
Systolic- 150-159
Hypertension can be common in pregnancy.
What are the systolic and diastolic cutoffs for severe HT in pregnancy?
> 160/110
What is meant by chronic hypertension in pregnancy?
Hypertension either pre-pregnancy or at booking (<20wks gestation)
What is meant by gestational hypertension in pregnancy?
New hypertension which has developed in pregnancy, usually develops after 20wks
What is the difference between gestational hypertension and pre-eclampsia?
Pre-eclampsia is new hypertension >20wks gestation AND significant proteinuria
When in chronic hypertension in pregnancy more common?
In increased maternal age
->this makes sense as hypertension often occurs in older age anyways
Describe the changes to anti-hypertensive drugs in pregnancy.
Women with pre-existing hypertension need to switch meds.
Stop ACEi, ARB’s, anti-diuretics
Aim to keep BP <150/100 using labetalol, nifedipine, methyldopa
What needs to be monitored in women with chronic hypertension in pregnancy?
Monitor for superimposed pre-eclampsia
Monitor foetal growth
->bear in mind there is a higher risk of placental abruption
As mentioned, pre-eclampsia is when there is hypertension and proteinuria.
Quantify this though.
HT on two occasions more than 4hrs apart
Proteinuria more than 300mgs/24hrs
Risk factors for pre-eclampsia?
First pregnancy
Extremes of maternal age
Pre-eclampsia in previous pregnancy
Pregnancy interval >10yrs
FH of pre-eclampsia
Underlying medical disorders: chronic hypertension, renal disease, diabetes, autoimmune conditions
Pre-eclampsia has mutisystem involvement. Which systems does it affect?
Renal
Liver
Vascular
Cerebral
Pulmonary
Maternal complications of pre-eclampsia?
Eclampsia- seizures
Severe hypertension increasing risks of strokes or cerebral haemorrhage
Renal failure
Pulmonary oedema
Cardiac failure
Foetal complications of pre-eclampsia?
Impaired placental perfusion which can lead to prematurity, foetal distress
Symptoms/signs of severe pre-eclampsia?
Headache, blurring of vision
Severe hypertension and proteinuria
Reduced urine output
Convulsions (eclampsia)
Clonus/brisk reflexes
Biochemical/haematological abnormalities in severe pre-eclampsia?
Raised LFTs
Raised urea, creatinine, urate
Low platelets
Low haemoglobin
Management of pre-eclampsia?
Frequent BP checks and urinalysis
Check symptoms
Check for hyper-reflexia and tenderness over liver
Bloods
Foetal investigations- scan for growth, cardiotocography
What is the only cure for pre-eclampsia?
Delivery of baby
->conservative management can be given if aiming for increased foetal maturity before delivery
Although delivery of the baby is the only cure for pre-eclampsia, what needs to still be monitored after?
Monitoring of pre-eclampsia must continue after delivery as risks still continue and could still develop into eclampsia
Treatment of seizures/impending seizures of eclampsia?
Magnesium sulphate bolus + IV infusion
Control of BP
Avoid fluid overload
What is used for prophylaxis for pre-eclampsia in subsequent pregnancies?
Low does aspirin
Given from 12wks to delivery
What are women with pre-eclampsia at increased risk of developing in later life?
Hypertension
Gestational diabetes?
Diabetes in pregnancy- carbohydrate intolerance or abnormal glucose tolerance that reverts to normal after delivery
What are mother’s with gestational diabetes at increased risks of developing in later life?
Type II diabetes
What is the management of pre-existing diabetes in a pregnant mother?
Insulin requirements increases
Foetal hyper-insulinemia occurs
What are some of the risks to the foetus after delivery to a mother with pre-existing diabetes?
Increased risk of neonatal hypoglycaemia
Increased risk of respiratory distress
What effect does diabetes have on the foetus?
Increased risks of foetal congenital abnormalities e.g. cardiac abnormality, sacral agenesis
Impaired lung maturity
Neonatal hypoglycaemia
Jaundice
->especially if blood sugards high peri-conception
What are some of the increased risks on the mother if she has diabetes in pregnancy?
Miscarriage
Foetal macrosomia
Shoulder dystocia
Stillbirth
Pre-eclampsia
Infections
What are some pre-existing maternal issues which can worsen if there is diabetes in pregnancy?
Nephropathy
Retinopathy
Hypoglycaemia
What makes up the preconception management of diabetes if the mother is wanting to become pregnant?
Better glycaemic control
Folic acid 5mg
Dietary advice
Retinal and renal assessment
What is the management of diabetes during pregnancy?
Optimise glucose control- insulin requirements will increase
Can continue oral anti-diabetic meds e.g. metformin but may need to add insulin for tighter glucose control
Watch foetal growth
Watch for ketonuria/infections
Why may Csection be considered in mothers with diabetes?
Baby may be bigger- macrosomia
What are other aspects of management which need to be carried out in delivery of a baby when the mother has diabates?
Induction of pregnancy
Maintain blood sugar in labour with insulin-dextrose infusion
Continuous CTG foetal monitoring
Early feeding of baby to reduce neonatal hypoglycaemia
->mother can go back to pre-pregnancy regimen of insulin post delivery
Risk factors for gestational diabetes?
Increased BMI > 30
Previous macrosomic baby (>4.5kg)
Previous GDM
FH of diabetes
Management of gestational diabetes?
Control blood sugars- by diet, but metformin/insulin if sugars remain high
Annual check of HbA1C as higher risk of developing overt diabetes
Venous thromboembolism is a lot more common in pregnancy because of Virchow’s triad. What makes up this?
Stasis of blood
Hypercoagulability
Vessel wall injury
->all of which occur in pregnancy
What are some of the factors which increased risk of a thromboembolism in pregnancy?
Older mothers
Increased BMI
Smokers
IVDU
Pre-eclampsia
Dehydration
Decreased mobility
Infections
Prolonged delivery
Haemorrhage
Previous VTE
Sickle cell disease
What can be used as prophylaxis for VTE in pregnancy?
TED stockings
Advise increased mobility, hydration
Prophylactic anti-coagulation with three or more risk factors
Signs/symptoms of VTE?
Pain in calf
Swelling
Heat
Calf muscle tenderness
Breathlessness
Pain on breathing
Cough
Tachycardia
Hypoxic
Pleural rub
Investigations if suspect VTE?
ECG
Blood gases
Doppler V/Q lung scam
CTPA- CT pulmonary angiogram
Treatment of VTE?
Appropriate anticoagulation
