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Reproductive System > Complications of Pregnancy > Flashcards

Complications of Pregnancy Flashcards

1
Q

What is an abortion or spontaneous miscarriage?

A

Termination/loss of pregnancy before 24 weeks

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2
Q

What is a threatened miscarriage?

A
  • vaginal bleeding +/- pain
  • viable pregnancy
  • closed cervix on speculum examination
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3
Q

What is an inevitable miscarriage?

A
  • viable pregnancy
  • open cervix with bleeding, could be heavy +/- clots
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4
Q

What is a missed miscarriage?

A
  • no symptoms, or bleeding/brown loss vaginally
  • gestational sac seen on screen
  • no clear fetus (empty gestational sac) or a fetal pole with no fetal heart
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5
Q

What is an incomplete miscarriage?

A
  • most of pregnancy expelled
  • some products still remain in the uterus
  • open cervix, vaginal bleeding- may be heavy
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6
Q

What is a complete miscarriage?

A
  • passed out all products of contraception (POC)
  • cervix closed + bleeding stopped
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7
Q

What is a septic miscarriage?

A
  • sepsis, common with incomplete miscarriage
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8
Q

What is the aetiology of spontaneous miscarriage?

A
  • abnormal conceptus
  • chromosomal, genetic, structural
  • uterine abnormality
  • congenital, fibroids
  • cervical incompetence
  • primary, secondary
  • maternal
  • inc. age, diabetes
  • unknown
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9
Q

What is the management for a miscarriage?

A
  • threatened- conservative
  • inevitable- if heavy bleeding, may need evacuation
  • missed- conservative
  • medical- prostaglandins (misoprostol)
  • surgical- Surgical Management of Miscarriage (SMM)
  • septic- antibiotics + evacuate uterus
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10
Q

What is an ectopic pregnancy?

A

Pregnancy implanted outside the uterine cavity

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11
Q

What is the incidence and risk factors for an ectopic pregnancy?

A
  • around 1/90 pregnancies
  • pelvic inflammatory disease
  • previous tubal surgery
  • previous ectopic
  • assisted conception
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12
Q

What is the presentation of an ectopic pregnancy?

A
  • ammenorhoea (+ve urine pregnancy test)
  • +/- vaginal bleeding
  • +/- abdominal pain
  • +/- GI or urinary symptoms
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13
Q

What are the investigations for an ectopic pregnancy?

A
  • scan
  • no intrauterine gestational sac
  • may see adnexal mass
  • fluid in rectouterine pouch
  • serum B-hCG
  • may need to track over 48 hr intervals
  • if normal pregnancy inc. by at least 66%
  • serum progesterone
  • viable pregnancy, high levels > 25ng/ml
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14
Q

What is the management for an ectopic pregnancy?

A
  • medical- methotrexate
  • surgical- salpingectomy, salpingotomy (mostly laparoscopic)
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15
Q

What is an Antepartum Haemorrhage (APH)?

A

Haemorrhage from the genital tract, after 24 weeks but before delivery of baby

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16
Q

What are some causes of an antepartum haemorrage (APH)?

A
  • placenta praevia
  • placental abruption
  • local lesions of genital tract
  • vasa praevia (very rare)
  • unknown
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17
Q

What is the general management of Antepartum Haemorrhage (APH)?

A
  • expectant treatment/vaginal delivery/immediate C-section
  • depends on; amount of bleeding, general condition of mother and baby, gestation
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18
Q

What is a placenta praevia and what are the different classifications?

A
  • all/part of placenta implants in lower segment of uterus
  • 1/200 pregnancies
  • common if; multiparous women, multiple pregnancies, previous C-section
  • grade I- placenta enroached on lower segment but not internal cervical os
  • grade II- placenta reaches internal os
  • grade III- placent eccentrically covers os
  • grade IV- central placenta praevia
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19
Q

What is the presentation of a placenta praevia?

A
  • painless PV bleeding
  • malpresentation of fetus
  • incidental
  • maternal condition correlates with amount of PV bleeding
  • soft, non-tender uterus
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20
Q

What is the investigation for a placenta praevia?

A
  • US scan- to locate placental site

*MUST NOT perform vaginal examination with suspected placenta praevia*

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21
Q

What is the management for a placenta praevia?

A
  • medical- oxytocin, ergometrine, carbaprost, tranexemic acid
  • surgical- B Lynch suture, ligation of uterine iliac vessels, hysterectomy, C-section
  • balloon tamponade
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22
Q

What is a placental abruption?

A
  • haemorrhage resulting from premature separation of placenta before birth
  • 0.6% of pregnancies
23
Q

What are risk factors for placental abruption?

A
  • pre-eclampsia/chronic hypertension
  • multiple pregnancy
  • polyhydramnios
  • smoking, inc. age, parity
  • previous abruption
  • cocaine use
24
Q

What is the presentation of a placental abruption and its different clinical types?

A
  • pain
  • vaginal bleeding (may be little)
  • increased uterine activity
  • revealed
  • concealed
  • mixed (revealed + concealed)
25
Q

What are some complications of placental abruption?

A
  • maternal shock, collapse (may be disproportional to amount of bleeding seen)
  • fetal death
  • maternal DIC, renal failure
  • postpartum haemorrhage
  • “couvelaire uterus”
26
Q

What is preterm labour?

A
  • onset of labour before 37 completed weeks of gestation
  • 32-36 weeks- mildly preterm
  • 28-32 weeks- very preterm
  • 24-28 weeks- extremely preterm
  • spontaneous or induced (iatrogenic)
  • 5-7% in singletons, 30-40% in multiple pregnancies
27
Q

What are some risk factors for preterm labour?

A
  • multiple pregnancy
  • polyhydramnios
  • APH
  • pre-eclampsia
  • infection e.g. UTI
  • prelabour premature rupture of membranes

* majority idiopathic

28
Q

What is the diagnosis for preterm labour?

A

Contractions with evidence of cervical change on vaginal examination

29
Q

What is the management for preterm delivery?

A
  • < 24-26 weeks:
  • prognosis very poor
  • decisions made with parents and neonatologists
  • all viable cases:
  • tocolysis to allow steroids/transfer
  • steroids
  • transfer to unit with NICU facilities
  • aim for vaginal delivery
30
Q

What are some neonatal morbidities that result from prematurity?

A
  • respiratory distress syndrome
  • intraventricular haemorrhage
  • cerebral palsy
  • nutrition
  • temp. control
  • jaundice
  • infections
  • visual impairment
  • hearing loss
31
Q

What is chronic hypertension + gestational hypertension?

A
  • chronic- hypertension pre-pregnancy/at booking (≤ 20 weeks)
  • gestational- new hypertension (after 20 weeks)
  • mild- diastolic 90-99, systolic 140-149
  • moderate- diastolic 100-109, systolic 150-159
  • severe- diastolic ≥ 110, systolic ≥ 160

*commoner in older patients

32
Q

What is the management for essential/chronic hypertension?

A
  • ideally have pre-pregnancy care
  • change certain antihypertensive drugs; ACE inhibitors (birth defects, impaire growth), angiotensin receptor blockers, diuretics, lower dietary sodium
  • aim to keep BP < 150/100 (labetolol, nifedipine, methyldopa)
  • monitor for superimposed pre-eclampsia
  • monitor fetal growth

* may have higher incidence of placental abruption

33
Q

What is pre-eclampsia?

A
  • new hypertension (after 20 weeks)
  • mild HT on 2 occasions > 4hrs apart
  • OR moderate/severe HT
  • significant proteinuria
  • automated reagent strip urine protein estimation > 1+
  • spot urine protein:creatinine > 30mg/mmol
  • 24 hr urine protein collection > 300mg/day
34
Q

What is the pathophysiology for pre-eclampsia?

A
  • immunological
  • genetic predisposition
  • secondary invasion of maternal spiral arterioles by trophoblasts impaire -> reduced placental perfusion
  • imbalance between vasodilators/vasoconstrictors in pregnancy (prostocyclin/thromboxane)
35
Q

What are the risk factors for pre-eclampsia?

A
  • first pregnancy
  • extremes of maternal age
  • pre-eclampsia in previous pregnancy
  • pregnancy interval > 10 years
  • BMI > 35
  • family history of PET
  • multiple pregnancy
  • underlying health condition (chronic HT, pre-existing renal disease, pre-existing diabetes, autoimmune disorders)
36
Q

What are the complications of pre-eclampsia?

A
  • multisystem multiorgan disorder- renal, liver, vascular, cerebral, pulmonary
  • maternal
  • eclampsia- seizures
  • severe HT- cerebral haemorrhage, stroke
  • HELLP (haemolysis, elevated liver enzymes, low platelets)
  • DIC (disseminated intravascular coagulation)
  • renal failure
  • pulmonary oedema, cardiac failure
  • fetal
  • impaired placental perfusion (IUGR, fetal distress, prematurity, inc. PN mortality)
37
Q

What are the symptoms/signs of pre-eclampsia?

A
  • haedache, blurred vision, epigastric/below rib pain, vomiting, sudden hands face legs swelling
  • severe HT- proteinuria > 3+
  • clonus/brisk reflexes, papilloedema
  • reduced urine output
38
Q

What is the management of pre-eclampsia?

A
  • frequent BP checks, urine protein
  • check for symptoms
  • check for hyperreflexia, liver tenderness
  • bloods (FBC, LFTs, RFTs, coagulation)
  • fetal investigations (growth, CTG)
  • anti-hypertensives (labetolol, methyldopa, nifedipine)
  • steroids (fetal lung maturity) if > 36 weeks
  • induction of labour of condition deteriorates
  • delivery of baby + placenta only ‘cure’
  • monitor puerperium
39
Q

What is prophylaxis for PET in subsequent pregnancy?

A
  • low dose aspirin from 12 weeks till delivery
40
Q

What is the treatment for (impending) seizures of pre-eclampsia?

A
  • MgSO4 bolus + IV infusion
  • control of BP- IV labetolol, hydrallazine (if > 160/110)
  • avoid fluid overload- aim for 80mls/hr
41
Q

Why does maternal insulin requirement increase during pregnancy for pre-existing diabetes?

A

Human placental lactogen, progesterone, human chorionic gonadotrophin + cortisol from placenta all have anti-insulin action

42
Q

What are the risk of diabetes during pregnancy?

A
  • fetal congenital abnormalities (cardiac, sacral agenesis)
  • miscarriage
  • fetal marcosomia, polyhydramnios
  • opertative delivery, shoulder dystocia
  • stillbirth, inc. perinatal mortality
43
Q

What are the complications of diabetes during pregnancy?

A
  • inc. risk of pre-eclampsia
  • worseing of; maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
  • infections
  • neonatal- impaired lung maturity, neonatal hypoglycaemia, jaundice
44
Q

What is the management of diabetes preconception?

A
  • better glycaemic control
  • BG 4-7mmol/L
  • HbA1c < 6.5% (< 48mmol/L)
  • folic acid 5mg
  • dietary advice
  • retinal + renal assessment
45
Q

What is the management of diabetes during pregnancy?

A
  • optimise glc control- insulin requirement inc.
  • < 5.3mmol/L fasting
  • < 7.8mmol/L 1hr postprandial
  • < 6.4mmol/L 2hrs postprandial
  • < 6mmol/L before bedtime
  • could continue with oral anti-diabetic agents (metformin), bbut may need to switch to insulin
  • should be aware of the risk of hypoglycaemia
  • watch for ketonuria/infections
  • repeat retinal assessment 28 + 34 weeks
  • watch fetal growth
  • observe for PET
  • labour usually induced (38-40 weeks)
  • consider elective caesarean
  • maintain BG in labbour with insulin-dextrose infusion
  • continuous CTG fetal monintoring in labour
  • early feeding of baby- reduce neonatal hypoglycaemia
46
Q

What is gestational diabetes?

A
  • carbohydrate intolerance with onset in pregnancy
  • abnormal glc tolerance- reverts to normal after delivery

* more at risk of developing type II later in life

47
Q

What are the risk factors for gestational diabetes?

A
  • BMI > 30
  • previous macrosomic baby > 4.5kg
  • previous GDM
  • family history diabetes
  • high risk groups (e.g. asian origin)
  • polyhydramnios or big baby in current pregnancy
  • recurrent glucosuria in curret pregnancy
48
Q

What is the screening for gestational diabetes?

A
  • HbA1c at booking
  • OGTT (if HbA1c > 6% (43mmol/mol))
  • if OGTT normal- repeat at 24-28 weeks, or also at 16 weeks- if strong risk factors
49
Q

What is the management for gestational diabetes?

A
  • control blood sugars
  • diet
  • metformin/insulin
  • OGTT post deliver- 6-8 weeks PN
  • yearly check HbA1c/blood sugars of at high risk of developing overt diabetes
50
Q

Why does the risk of thrombo-embolism increase during pregnancy?

A
  • hypercoagulable state during pregnancy (protect mother from bleeding PN)
  • inc. fribrinogen, factor VIII, VW factors, platelets
  • inc. fibrinolysis
  • dec. natural anticoagulants (antithrombin III)
  • inc. stasis
  • progesterone
  • effects of enlarging uterus
  • may be vascular damage at delivery
51
Q

What additional factors increase the risk of thrombo-embolism?

A
  • older age, inc. parity
  • inc. BMI, smokers, IV drug use
  • PET, infections
  • dehydration
  • decreased mobility
  • operative delivery, prolonged labour
  • haemorrhage > 2L
  • previous VTE, thrombophilia, family history
  • sickle cell disease
52
Q

What is the prophylaxis for VTE in pregnancy?

A
  • TED stockings
  • inc. mobility
  • hydration
  • prophylactic anticoagulation (if ≥ 3 risk factors), may need to continue up to 6 weeks PN
53
Q

What are the signs + symptoms of VTE?

A
  • pain in calf
  • calf muscle tenderness
  • inc. girth of affected leg
  • breathlessness
  • pain on breathing
  • cough
  • tachycardia
  • hypoxia
  • plural rub
54
Q

What are the investigations for suspected VTE?

A
  • V/Q (ventilation perfusion) lung scan
  • CTPA (computed tomography pulmonary angiogram)

Reproductive System (22 decks)

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