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Reproductive System > Complications of Pregnancy > Flashcards

Complications of Pregnancy Flashcards

1
Q

How is abortion and spontaneous miscarriage defined?

A

The termination or loss of pregnancy before 24 weeks of gestation

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2
Q

What is the incidence of spontaneous miscarriage?

A

~15%

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3
Q

What is a threatened miscarriage?

A

Bleeding from the gravid uterus before 24 weeks gestation when there is a viable fetus and no evidence of cervical dilatation

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4
Q

What is an inevitable miscarriage?

A

Dilation of the cervix, making abortion inevitable

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5
Q

What is an incomplete miscarriage?

A

Partial expulsion of the products of conception

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6
Q

What is a complete miscarriage?

A

Complete expulsion of the products of conception

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7
Q

What is a septic miscarriage?

A

Following incomplete abortion there is a risk of ascending infection into the uterus that can spread through the pelvis

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8
Q

What is a missed miscarriage?

A

A pregnancy in which the fetus has died but the uterus has made no attempt to expel the products of conception

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9
Q

What are the symptoms of a threatened miscarriage?

A

Vaginal bleeding +/- pain
Viable pregnancy
Closed cervix on speculum examination

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10
Q

What are the symptoms of an inevitable miscarriage?

A

Viable pregnancy

Open cervix with bleeding that may be heavy +/- clots

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11
Q

What are the symptoms of a missed miscarriage?

A

Also known as early fetal demise
May be asymptomatic
Could have bleeding or brown loss from vagina
On US scan a gestational sac will be seen but no clear fetus or a fetal pole with no fetal heart

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12
Q

What are the symptoms of an incomplete miscarriage?

A 
Open cervix 
Vaginal bleeding (may be heavy)
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13
Q

What are the symptoms of a complete miscarriage?

A

Have passed all products of conception

Cervix has closed and bleeding stopped

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14
Q

What are the symptoms of a septic miscarriage?

A

Incomplete miscarriage + symptoms of infection

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15
Q

What is the aetiology of spontaneous miscarriage?

A
  • Abnormal conceptus (chromosomal, genetic, structural)
  • Congenital uterine abnormality
  • Uterine fibroids
  • Cervical incompetence
  • Increasing maternal age
  • Maternal diabetes
  • Unknown cause
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16
Q

How is a threatened miscarriage managed?

A

Conservative management

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17
Q

How is an inevitable miscarriage managed?

A

May need evacuation if bleeding is heavy

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18
Q

How is a missed miscarriage managed?

A

Conservative
Medical (prostaglandins)
Surgical

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19
Q

How is a septic miscarriage managed?

A

Antibiotics

Evacuate uterus

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20
Q

What is an ectopic pregnancy?

A

A pregnancy that has implanted outside of the uterine cavity

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21
Q

Where do ectopic pregnancies usually implant?

A

95-97% in fallopian tubes- (ampulla > isthmus > interstitial)
Can also rarely occur in cervix, ovary or fimbria

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22
Q

What is the incidence of ectopic pregnancies?

A

1:90 pregnancies

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23
Q

What are the risk factors for an ectopic pregnancy?

A
  • Pelvic inflammatory disease
  • Previous STD
  • Previous tubal surgery
  • Previous ectopic
  • Assisted conception- IVF
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24
Q

How do ectopic pregnancies present?

A

Period of ammenorhoea (with positive urine pregnancy test)
+/- Vaginal bleeding
+/- Pain in abdomen
+/- GI or urinary symptoms

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25
Q

How can ectopic pregnancies be investigated?

A
  • US scan- no intrauterine gestational sac, may see adnexal mass or fluid in pouch of Douglas
  • Serum β-HCG levels- may need to track over 48hrs, if normal intrauterine pregnancy they will rise by at least 66%
  • Serum progesterone levels- with viable intrauterine pregnancy levels >25ng/ml
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26
Q

How is an ectopic pregnancy managed?

A

Medical with methotrexate
Surgical with a salpingectomy or salpingotomy
Conservative

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27
Q

What is antepartum haemorrhage?

A

Haemorrhage from the genital tract after the 24th week of pregnancy but before birth

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28
Q

What are the common causes of antepartum haemorrhage?

A
  • Placenta praevia
  • Placental abruption
  • APH of unknown origin
  • Local lesions of the genital tract
  • Vasa praevia (very rare)

Placenta praevia and placental abruption commonst two causes

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29
Q

What is placenta praevia?

A

When all or part of the placenta implants in the lower uterine segment

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30
Q

What are the risk factors for placenta praevia?

A
  • Multiparous women
  • Multiple pregnancies
  • Previous caesarean section
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31
Q

How is placenta praevia classified?

A
  • Grade I Placenta encroaching on the lower segment but not the internal cervical os
  • Grade II Placenta reaches the internal os
  • Grade III Placenta eccentrically covers the os
  • Grade IV Central placenta praevia
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32
Q

How does placenta praevia present?

A

Painless antepartum haemorrhage
Found during investigations due to malpresentation of the fetus
Incidental finding on ultrasound

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33
Q

What are the clinical features of placenta praevia?

A

Soft tender uterus +/- fetal malpresentation

Maternal condition corresponding to volume of blood loss

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34
Q

How is placenta praevia diagnosed?

A

Ultrasound scan to locate the placental site

Vaginal examination must not be done in cases of suspected placenta praevia

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35
Q

What is the management of placenta praevia?

A

Management varies with gestation and severity, but a caesarean section may be necessary, with care being taken to avoid postpartum haemorrhage

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36
Q

How is post-partum haemorrhage managed?

A

Medically with oxytocin, ergometrine, carbaprost and tranexemic acid
A balloon tamponade
Surgical options- B lynch suture, ligation of the uterine iliac vessels or a hysterectomy.

37
Q

What is placental abruption?

A

Haemorrhage resulting from premature separation of the placenta before the birth of the baby

38
Q

What is the pathological cause of placental abruption?

A

Retroplacental clot

39
Q

What are the risk factors of placental abruption?

A
  • Pre-eclampsia/ chronic hypertension
  • Multiple pregnancy
  • Polyhydramnios
  • Smoking, increasing age, parity
  • Previous abruption
  • Cocaine use
40
Q

What are the clinical types of placental abruption?

A
  • Concealed- haemorrhage occurs between placenta and uterine wall
  • Revealed- haemorrhage seen externally as has escaped through os
  • Mixed (concealed and revealed)
41
Q

How does placental abruption present?

A

Pain
Vaginal bleeding
Increased uterine activity on examination

42
Q

How is antepartum haemorrhage managed?

A

Varies from conservative management to an emergency caesarean section dependant on:

  • Amount of bleeding
  • General condition of mother and baby
  • Gestation
43
Q

What are the possible complications of placental abruption?

A
  • Maternal shock or collapse
  • Fetal death
  • Maternal DIC or renal failure
  • Postpartum haemorrhage
44
Q

What is preterm labour?

A

Onset of labour before 37 completed weeks of gestation. Can be spontaneous or induced

45
Q

How is preterm labour classified?

A
  • 32-36 weeks is deemed as mildly premature
  • 28-32 weeks is moderately premature
  • 24-28 weeks is extremely premature
46
Q

What is the incidence of preterm labour?

A

5-7% of single pregnancies

30-40% of multiple pregnancies

47
Q

What are the risk factors for preterm labour?

A
  • Muliple pregnancy
  • Polyhydramnios
  • APH
  • Pre-eclampsia
  • Infection eg UTI
  • Prelabour premature rupture of membranes
  • Majority idiopathic
48
Q

When is preterm labour diagnosed?

A

When there are contractions with evidence of cervical change on vaginal examination

49
Q

How is preterm labour managed?

A
  • Consider tocolysis to allow steroids/ transfer
  • Steroids unless contraindicated
  • Transfer to unit with NICU facilities
  • Aim for vaginal delivery
  • Discussion with parents regarding resuscitation and interventions, especially in neonates <24-26 weeks
50
Q

What neonatal morbidities can result from prematurity?

A
  • Respiratory distress syndrome
  • Intraventricular haemorrhage
  • Cerebral palsy
  • Nutrition
  • Temperature control
  • Jaundice
  • Infections
  • Visual impairment
  • Hearing loss
51
Q

How is hypertension defined in pregnancy?

A
  • Mild HT- Diastolic BP 90-99, Systolic BP 140-49
  • Moderate HT- Diastolic BP 100-109, Systolic BP 150-159
  • Severe HT- Diastolic BP ≥110, Systolic BP ≥ 160
52
Q

What is gestational hypertension?

A

Hypertension that has developed after 20 weeks of gestation

53
Q

What is pre-eclampsia?

A

Gestational hypertension with associated significant proteinuria

54
Q

How is significant proteinuria defined, with reference to pre-elampsia?

A
  • Automated reagent strip urine protein estimation > 1+
  • Spot urinary protein : creatinine ratio >30mg/mmol
  • 24 hours urine protein collection >300mg/day
55
Q

Which anti-hypertensives should be stopped in pregnancy?

A
  • ACE inhibitors (impairs growth)
  • Angiotensin receptor blockers
  • Diuretics
  • Lower dietary sodium
56
Q

What is the ideal BP for pregnant women with chronic hypertension and what drugs can help with this?

A 
Aim to keep BP <150/100
Drugs:
-Labetolol
-Nifedipine
-Methyldopa
57
Q

What extra monitoring should be done for mothers with chronic hypertension?

A

Monitored for superimposed pre-eclampsia and decreased fetal growth
Increased risk of pre-eclampsia

58
Q

How is pre-eclampsia defined?

A

Mild hypertension on two occasions more than four hours apart or one episode of moderate to sever hypertension PLUS proteinuria

59
Q

What are the risk factors for pre-eclampsia?

A
  • First pregnancy
  • Extremes of maternal age
  • Pre-eclampsia in a previous pregnancy
  • Pregnancy interval >10 years
  • BMI > 35
  • Family history of PET
  • Multiple pregnancy
  • Underlying medical disorders (chronic hypertension, pre-existing renal disease,pre-existing diabetes, autoimmune disorders like – eg. antiphospholipid antibodies, SLE)
60
Q

What are the causes of pre-eclampsia?

A

Immunological or due to genetic pre-disposition

61
Q

Which systems are affected by pre-eclampsia?

A
  • Renal
  • Liver
  • Vascular
  • Cerebral
  • Pulmonary
62
Q

What are the maternal complications of pre-eclampsia?

A
  • Eclampsia – seizures
  • Severe hypertension – cerebral haemorrhage, stroke
  • HELLP (hemolysis, elevated liver enzymes, low platelets)
  • DIC (disseminated intravascular coagulation)
  • Renal failure
  • Pulmonary oedema, cardiac failure
63
Q

What are the fetal complications of pre-eclampsia?

A

Impaired placental perfusion (can cause IUGR, fetal distress, prematurity, increase postnatal mortality)

64
Q

What are the signs and symptoms of severe pre-eclampsia?

A 
Symptoms:
-Headache
-Blurred vision
-Epigastric pain
-Pain below ribs
-Vomiting
-Sudden swelling of hands face legs 
-Convulsions
Signs:
-Severe Hypertension
-> 3+ of urine proteinuria
-Clonus / brisk reflexes
-Papillodema 
-Reducing urine output
65
Q

What biochemical and haematological changes occur in severe pre-eclampsia?

A
  • Raised liver enzymes (bilirubin if HELLP present)
  • Raise urea and creatinine
  • Raised urate
  • Low platelets
  • Low haemoglobin
  • Features of disseminated intravascular coagulation
66
Q

How is pre-eclampctic toxaemia managed?

A
  • Frequent BP checks, Urine protein
  • Check symptomatology (headaches, epigastric pain, visual disturbances)
  • Check for hyper-reflexia (clonus), tenderness over the liver
  • Blood investigations (FBC, LFT, renal function tests, coagulation if indicated)
  • Fetal investigations (scan for growth, cardiotocography (CTG))
67
Q

What are the symptoms of pre-eclampsia?

A

Headache
Epigastric pain
Visual disturbance

68
Q

What is the only cure for pre-eclampsia?

A

Delivery of the baby and placenta

69
Q

What are the aims of conservative management of pre-eclampsia and how is this achieved?

A

Fetal maturity
Involves:
- Close observation of clinical signs & investigations
-Anti-hypertensives (labetolol, methyldopa, nifedipine)
-Steroids for fetal lung maturity if gestation < 36wks

70
Q

When should induction of labour be considered in pre-eclampsia?

A

If fetal or maternal condition deteriorates

71
Q

When do most pre-eclamptic seizures occur?

A

44% postpartum
38% antepartum
11% intrapartum

72
Q

What are the treatment options for seizures of impending seizures in pre-eclampsia?

A
  • Magnesium sulphate bolus + IV infusion
  • Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
  • Avoid fluid overload
73
Q

How is prophylaxis given for pre-eclampsia in future pregnancies?

A

Low dose aspirin from 12 weeks until delivery

74
Q

What is gestational diabetes?

A

Carbohydrate intolerance that has its first onset during pregnancy

75
Q

How do the insulin requirements of a pre-existing diabetic change in pregnancy and what brings this about?

A

Insulin requirements increase due to the anti-insulin effects of the following:

  • Human placental lactogen
  • Progesterone
  • Human chorionic gonadotrophin
  • Cortisol
76
Q

What risks are associated with pre-existing diabetes in pregnancy?

A
  • Fetal congenital abnormalities
  • Miscarriage
  • Fetal macrosomia
  • Polyhydramnios
  • Operative delivery
  • Shoulder dystocia
  • Stillbirth
  • Increased perinatal mortality
  • Pre-eclampsia
  • Worsening of maternal nephropathy, retinopathy, hypoglycaemia
  • Infections
  • Neonatal complications (Impaired lung maturity, neonatal hypoglycemia, jaundice)
77
Q

What management can be given pre-conception to reduce risks associated with pre-existing diabetes?

A
  • Better glycemic control (blood sugars 4 – 7 mmol/l and hba1c < 48 mmol/mol)
  • Folic acid 5mg
  • Dietary advice
  • Retinal and renal assessment
78
Q

What management can be given during pregnancy to reduce risks associated with pre-existing diabetes?

A
  • Optimise glucose control
  • Can continue anti-diabetic agents but may need to swap to insulin for tighter glucose control
  • Watch for ketonuria or urine infections
  • Repeat renal assessments at 28 and 34 weeks
  • Monitor fetal growth
  • Observe for PET
  • Labour usually induced 38-40 weeks, earlier if fetal or maternal concerns
  • Consider elective caesarean section if significant fetal macrosomia
  • Maintain blood sugar in labour with insulin – dextrose infusion
  • Continuous CTG fetal monitoring in labour
  • Early feeding of baby to reduce neonatal hypoglycemia
79
Q

What are the ideal glucose levels in pregnancy?

A
  • < 5.3 mmol/l - Fasting
  • < 7.8 mmol/l - 1 hour postprandial
  • < 6.4 mmol/l - 2 hours postprandial
  • < 6 mmol/l – before bedtime
80
Q

What are the risk factors for gestational diabetes?

A
  • Increased BMI >30
  • Previous macrosomic baby > 4.5kg
  • Previous GDM
  • Family history of diabetes
  • Women from high risk groups for developing diabetes – eg. Asian origin
  • Polyhydramnios or big baby in current pregnancy
  • Recurrent glycosuria in current pregnancy
81
Q

How is gestational diabetes screened for?

A
  • If risk factor present, offer HbA1C estimation at booking, if >43 mmol/mol, 75gms OGTT to be done. If OGTT normal, repeat OGTT at 24 -28 weeks
  • Can also offer OGTT at around 16 weeks and repeat at 28 weeks if significant risk factors (eg. Previous GDM) present
82
Q

How is gestational diabetes managed?

A
  • Control blood sugars (diet, metformin, insulin)
  • Check OGTT 6-8 weeks PN
  • Yearly HbA1c checks as at a higher risk of developing overt diabetes
83
Q

What is Virchow’s triad of thromboembolism?

A

Stasis
Vessel wall injury
Hypercoagulability

84
Q

Why does risk of VTE increase in pregnancy?

A
  • Pregnancy is a hypercoagulable state to reduce bleeding post-delivery- this is achieved with an increase in fibrinogen, factor VIII, VW factor and platelets, a decrease in natural anticoagulants and an increase in fibrinolysis.
  • Increased stasis- progesterone causes vasodilation and so increases stasis, effects of enlarging uterus
  • May be vascular damage at delivery/caesarean section
85
Q

What are the risk factors for VTE in pregnancy?

A
  • Older mothers, increasing parity
  • Increased BMI, smokers
  • IV drug users
  • PET
  • Dehydration – hyperemesis
  • Decreased mobility
  • Infections
  • Operative delivery, prolonged labour
  • Haemorrhage, blood loss > 2 l
  • Previous VTE (not explained by other predisposing)
  • Sickle cell disease
86
Q

What prophylaxis can be given for VTE in pregnancy?

A
  • TED stockings
  • Advice increased mobility, hydration
  • Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk factor if significant risk), may need to continue 6 weeks postpartum
87
Q

What are the signs and symptoms of VTE?

A
  • Pain in calf
  • Unilateral calf swelling
  • Calf muscle tenderness
  • Dyspnoea
  • Chest pain
  • Cough
  • Tachycardia
  • Hypoxia
  • Pleural rub
88
Q

How should suspicion of VTE in pregnancy be investigated?

A
  • ECG
  • Blood gases
  • Doppler
  • V/Q scan
  • CTPA (Computed topography pulmonary angiogram)

Reproductive System (30 decks)

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