Complications of Pregnancy Flashcards
What is an abortion or spontaneous miscarriage?
Termination/loss of pregnancy before 24 weeks
What is a threatened miscarriage?
- vaginal bleeding +/- pain
- viable pregnancy
- closed cervix on speculum examination
What is an inevitable miscarriage?
- viable pregnancy
- open cervix with bleeding, could be heavy +/- clots
What is a missed miscarriage?
- 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
What is an incomplete miscarriage?
- most of pregnancy expelled
- some products still remain in the uterus
- open cervix, vaginal bleeding- may be heavy
What is a complete miscarriage?
- passed out all products of contraception (POC)
- cervix closed + bleeding stopped
What is a septic miscarriage?
- sepsis, common with incomplete miscarriage
What is the aetiology of spontaneous miscarriage?
- abnormal conceptus
- chromosomal, genetic, structural
- uterine abnormality
- congenital, fibroids
- cervical incompetence
- primary, secondary
- maternal
- inc. age, diabetes
- unknown
What is the management for a miscarriage?
- threatened- conservative
- inevitable- if heavy bleeding, may need evacuation
- missed- conservative
- medical- prostaglandins (misoprostol)
- surgical- Surgical Management of Miscarriage (SMM)
- septic- antibiotics + evacuate uterus
What is an ectopic pregnancy?
Pregnancy implanted outside the uterine cavity
What is the incidence and risk factors for an ectopic pregnancy?
- around 1/90 pregnancies
- pelvic inflammatory disease
- previous tubal surgery
- previous ectopic
- assisted conception
What is the presentation of an ectopic pregnancy?
- ammenorhoea (+ve urine pregnancy test)
- +/- vaginal bleeding
- +/- abdominal pain
- +/- GI or urinary symptoms
What are the investigations for an ectopic pregnancy?
- 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
What is the management for an ectopic pregnancy?
- medical- methotrexate
- surgical- salpingectomy, salpingotomy (mostly laparoscopic)
What is an Antepartum Haemorrhage (APH)?
Haemorrhage from the genital tract, after 24 weeks but before delivery of baby
What are some causes of an antepartum haemorrage (APH)?
- placenta praevia
- placental abruption
- local lesions of genital tract
- vasa praevia (very rare)
- unknown
What is the general management of Antepartum Haemorrhage (APH)?
- expectant treatment/vaginal delivery/immediate C-section
- depends on; amount of bleeding, general condition of mother and baby, gestation
What is a placenta praevia and what are the different classifications?
- 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
What is the presentation of a placenta praevia?
- painless PV bleeding
- malpresentation of fetus
- incidental
- maternal condition correlates with amount of PV bleeding
- soft, non-tender uterus
What is the investigation for a placenta praevia?
- US scan- to locate placental site
*MUST NOT perform vaginal examination with suspected placenta praevia*
What is the management for a placenta praevia?
- medical- oxytocin, ergometrine, carbaprost, tranexemic acid
- surgical- B Lynch suture, ligation of uterine iliac vessels, hysterectomy, C-section
- balloon tamponade
What is a placental abruption?
- haemorrhage resulting from premature separation of placenta before birth
- 0.6% of pregnancies
What are risk factors for placental abruption?
- pre-eclampsia/chronic hypertension
- multiple pregnancy
- polyhydramnios
- smoking, inc. age, parity
- previous abruption
- cocaine use
What is the presentation of a placental abruption and its different clinical types?
- pain
- vaginal bleeding (may be little)
- increased uterine activity
- revealed
- concealed
- mixed (revealed + concealed)
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”
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
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
What is the diagnosis for preterm labour?
Contractions with evidence of cervical change on vaginal examination
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
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
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
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
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
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)
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)
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)
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
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
What is prophylaxis for PET in subsequent pregnancy?
- low dose aspirin from 12 weeks till delivery
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
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
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
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
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
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
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
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
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
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
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
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
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
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
What are the investigations for suspected VTE?
- V/Q (ventilation perfusion) lung scan
- CTPA (computed tomography pulmonary angiogram)
