Complications of Pregnancy Flashcards
1
Q
What is an abortion or spontaneous miscarriage?
A
Termination/loss of pregnancy before 24 weeks
2
Q
What is a threatened miscarriage?
A
- vaginal bleeding +/- pain
- viable pregnancy
- closed cervix on speculum examination
3
Q
What is an inevitable miscarriage?
A
- viable pregnancy
- open cervix with bleeding, could be heavy +/- clots
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
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
6
Q
What is a complete miscarriage?
A
- passed out all products of contraception (POC)
- cervix closed + bleeding stopped
7
Q
What is a septic miscarriage?
A
- sepsis, common with incomplete miscarriage
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
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
10
Q
What is an ectopic pregnancy?
A
Pregnancy implanted outside the uterine cavity
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
12
Q
What is the presentation of an ectopic pregnancy?
A
- ammenorhoea (+ve urine pregnancy test)
- +/- vaginal bleeding
- +/- abdominal pain
- +/- GI or urinary symptoms
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
14
Q
What is the management for an ectopic pregnancy?
A
- medical- methotrexate
- surgical- salpingectomy, salpingotomy (mostly laparoscopic)
15
Q
What is an Antepartum Haemorrhage (APH)?
A
Haemorrhage from the genital tract, after 24 weeks but before delivery of baby
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
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
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
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
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*
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
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
What are some complications of placental abruption?
* maternal shock, collapse (may be disproportional to amount of bleeding seen)
* fetal death
* maternal DIC, renal failure
* postpartum haemorrhage
* "couvelaire uterus"
26
What is preterm labour?
* 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
What are some risk factors for preterm labour?
* multiple pregnancy
* polyhydramnios
* APH
* pre-eclampsia
* infection e.g. UTI
* prelabour premature rupture of membranes
\* majority idiopathic
28
What is the diagnosis for preterm labour?
Contractions with evidence of cervical change on vaginal examination
29
What is the management for preterm delivery?
* \< 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
What are some neonatal morbidities that result from prematurity?
* respiratory distress syndrome
* intraventricular haemorrhage
* cerebral palsy
* nutrition
* temp. control
* jaundice
* infections
* visual impairment
* hearing loss
31
What is chronic hypertension + gestational hypertension?
* 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
What is the management for essential/chronic hypertension?
* 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
What is pre-eclampsia?
* 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
What is the pathophysiology for pre-eclampsia?
* immunological
* genetic predisposition
- secondary invasion of maternal spiral arterioles by trophoblasts impaire -\> reduced placental perfusion
- imbalance between vasodilators/vasoconstrictors in pregnancy (prostocyclin/thromboxane)
35
What are the risk factors for pre-eclampsia?
* 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
What are the complications of pre-eclampsia?
* 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
What are the symptoms/signs of pre-eclampsia?
* 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
What is the management of pre-eclampsia?
* 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
What is prophylaxis for PET in subsequent pregnancy?
* low dose aspirin from 12 weeks till delivery
40
What is the treatment for (impending) seizures of pre-eclampsia?
* MgSO4 bolus + IV infusion
* control of BP- IV labetolol, hydrallazine (if \> 160/110)
* avoid fluid overload- aim for 80mls/hr
41
Why does maternal insulin requirement increase during pregnancy for pre-existing diabetes?
Human placental lactogen, progesterone, human chorionic gonadotrophin + cortisol from placenta all have anti-insulin action
42
What are the risk of diabetes during pregnancy?
* fetal congenital abnormalities (cardiac, sacral agenesis)
* miscarriage
* fetal marcosomia, polyhydramnios
* opertative delivery, shoulder dystocia
* stillbirth, inc. perinatal mortality
43
What are the complications of diabetes during pregnancy?
* inc. risk of pre-eclampsia
* worseing of; maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
* infections
* neonatal- impaired lung maturity, neonatal hypoglycaemia, jaundice
44
What is the management of diabetes preconception?
* better glycaemic control
- BG 4-7mmol/L
- HbA1c \< 6.5% (\< 48mmol/L)
* folic acid 5mg
* dietary advice
* retinal + renal assessment
45
What is the management of diabetes during pregnancy?
* 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
What is gestational diabetes?
* 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
What are the risk factors for gestational diabetes?
* 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
What is the screening for gestational diabetes?
* 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
What is the management for gestational diabetes?
* 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
Why does the risk of thrombo-embolism increase during pregnancy?
* 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
What additional factors increase the risk of thrombo-embolism?
* 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
What is the prophylaxis for VTE in pregnancy?
* TED stockings
* inc. mobility
* hydration
* prophylactic anticoagulation (if ≥ 3 risk factors), may need to continue up to 6 weeks PN
53
What are the signs + symptoms of VTE?
* pain in calf
* calf muscle tenderness
* inc. girth of affected leg
* breathlessness
* pain on breathing
* cough
* tachycardia
* hypoxia
* plural rub
54
What are the investigations for suspected VTE?
* V/Q (ventilation perfusion) lung scan
* CTPA (computed tomography pulmonary angiogram)
