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
2
Q
What is the incidence of spontaneous miscarriage?
A
~15%
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
4
Q
What is an inevitable miscarriage?
A
Dilation of the cervix, making abortion inevitable
5
Q
What is an incomplete miscarriage?
A
Partial expulsion of the products of conception
6
Q
What is a complete miscarriage?
A
Complete expulsion of the products of conception
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
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
9
Q
What are the symptoms of a threatened miscarriage?
A
Vaginal bleeding +/- pain
Viable pregnancy
Closed cervix on speculum examination
10
Q
What are the symptoms of an inevitable miscarriage?
A
Viable pregnancy
Open cervix with bleeding that may be heavy +/- clots
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
12
Q
What are the symptoms of an incomplete miscarriage?
A
Open cervix Vaginal bleeding (may be heavy)
13
Q
What are the symptoms of a complete miscarriage?
A
Have passed all products of conception
Cervix has closed and bleeding stopped
14
Q
What are the symptoms of a septic miscarriage?
A
Incomplete miscarriage + symptoms of infection
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
16
Q
How is a threatened miscarriage managed?
A
Conservative management
17
Q
How is an inevitable miscarriage managed?
A
May need evacuation if bleeding is heavy
18
Q
How is a missed miscarriage managed?
A
Conservative
Medical (prostaglandins)
Surgical
19
Q
How is a septic miscarriage managed?
A
Antibiotics
Evacuate uterus
20
Q
What is an ectopic pregnancy?
A
A pregnancy that has implanted outside of the uterine cavity
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
22
Q
What is the incidence of ectopic pregnancies?
A
1:90 pregnancies
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
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
25
How can ectopic pregnancies be investigated?
- 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
26
How is an ectopic pregnancy managed?
Medical with methotrexate
Surgical with a salpingectomy or salpingotomy
Conservative
27
What is antepartum haemorrhage?
Haemorrhage from the genital tract after the 24th week of pregnancy but before birth
28
What are the common causes of antepartum haemorrhage?
- 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
29
What is placenta praevia?
When all or part of the placenta implants in the lower uterine segment
30
What are the risk factors for placenta praevia?
- Multiparous women
- Multiple pregnancies
- Previous caesarean section
31
How is placenta praevia classified?
- 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
32
How does placenta praevia present?
Painless antepartum haemorrhage
Found during investigations due to malpresentation of the fetus
Incidental finding on ultrasound
33
What are the clinical features of placenta praevia?
Soft tender uterus +/- fetal malpresentation
| Maternal condition corresponding to volume of blood loss
34
How is placenta praevia diagnosed?
Ultrasound scan to locate the placental site
| Vaginal examination must not be done in cases of suspected placenta praevia
35
What is the management of placenta praevia?
Management varies with gestation and severity, but a caesarean section may be necessary, with care being taken to avoid postpartum haemorrhage
36
How is post-partum haemorrhage managed?
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
What is placental abruption?
Haemorrhage resulting from premature separation of the placenta before the birth of the baby
38
What is the pathological cause of placental abruption?
Retroplacental clot
39
What are the risk factors of placental abruption?
- Pre-eclampsia/ chronic hypertension
- Multiple pregnancy
- Polyhydramnios
- Smoking, increasing age, parity
- Previous abruption
- Cocaine use
40
What are the clinical types of placental abruption?
- Concealed- haemorrhage occurs between placenta and uterine wall
- Revealed- haemorrhage seen externally as has escaped through os
- Mixed (concealed and revealed)
41
How does placental abruption present?
Pain
Vaginal bleeding
Increased uterine activity on examination
42
How is antepartum haemorrhage managed?
Varies from conservative management to an emergency caesarean section dependant on:
- Amount of bleeding
- General condition of mother and baby
- Gestation
43
What are the possible complications of placental abruption?
- Maternal shock or collapse
- Fetal death
- Maternal DIC or renal failure
- Postpartum haemorrhage
44
What is preterm labour?
Onset of labour before 37 completed weeks of gestation. Can be spontaneous or induced
45
How is preterm labour classified?
- 32-36 weeks is deemed as mildly premature
- 28-32 weeks is moderately premature
- 24-28 weeks is extremely premature
46
What is the incidence of preterm labour?
5-7% of single pregnancies
| 30-40% of multiple pregnancies
47
What are the risk factors for preterm labour?
- Muliple pregnancy
- Polyhydramnios
- APH
- Pre-eclampsia
- Infection eg UTI
- Prelabour premature rupture of membranes
- Majority idiopathic
48
When is preterm labour diagnosed?
When there are contractions with evidence of cervical change on vaginal examination
49
How is preterm labour managed?
- 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
What neonatal morbidities can result from prematurity?
- Respiratory distress syndrome
- Intraventricular haemorrhage
- Cerebral palsy
- Nutrition
- Temperature control
- Jaundice
- Infections
- Visual impairment
- Hearing loss
51
How is hypertension defined in pregnancy?
* 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
What is gestational hypertension?
Hypertension that has developed after 20 weeks of gestation
53
What is pre-eclampsia?
Gestational hypertension with associated significant proteinuria
54
How is significant proteinuria defined, with reference to pre-elampsia?
- Automated reagent strip urine protein estimation > 1+
- Spot urinary protein : creatinine ratio >30mg/mmol
- 24 hours urine protein collection >300mg/day
55
Which anti-hypertensives should be stopped in pregnancy?
- ACE inhibitors (impairs growth)
- Angiotensin receptor blockers
- Diuretics
- Lower dietary sodium
56
What is the ideal BP for pregnant women with chronic hypertension and what drugs can help with this?
```
Aim to keep BP <150/100
Drugs:
-Labetolol
-Nifedipine
-Methyldopa
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57
What extra monitoring should be done for mothers with chronic hypertension?
Monitored for superimposed pre-eclampsia and decreased fetal growth
Increased risk of pre-eclampsia
58
How is pre-eclampsia defined?
Mild hypertension on two occasions more than four hours apart or one episode of moderate to sever hypertension PLUS proteinuria
59
What are the risk factors for pre-eclampsia?
- 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
What are the causes of pre-eclampsia?
Immunological or due to genetic pre-disposition
61
Which systems are affected by pre-eclampsia?
- Renal
- Liver
- Vascular
- Cerebral
- Pulmonary
62
What are the maternal complications of pre-eclampsia?
- 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
What are the fetal complications of pre-eclampsia?
Impaired placental perfusion (can cause IUGR, fetal distress, prematurity, increase postnatal mortality)
64
What are the signs and symptoms of severe pre-eclampsia?
```
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
What biochemical and haematological changes occur in severe pre-eclampsia?
- Raised liver enzymes (bilirubin if HELLP present)
- Raise urea and creatinine
- Raised urate
- Low platelets
- Low haemoglobin
- Features of disseminated intravascular coagulation
66
How is pre-eclampctic toxaemia managed?
- 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
What are the symptoms of pre-eclampsia?
Headache
Epigastric pain
Visual disturbance
68
What is the only cure for pre-eclampsia?
Delivery of the baby and placenta
69
What are the aims of conservative management of pre-eclampsia and how is this achieved?
Fetal maturity
Involves:
- Close observation of clinical signs & investigations
-Anti-hypertensives (labetolol, methyldopa, nifedipine)
-Steroids for fetal lung maturity if gestation < 36wks
70
When should induction of labour be considered in pre-eclampsia?
If fetal or maternal condition deteriorates
71
When do most pre-eclamptic seizures occur?
44% postpartum
38% antepartum
11% intrapartum
72
What are the treatment options for seizures of impending seizures in pre-eclampsia?
- Magnesium sulphate bolus + IV infusion
- Control of blood pressure – IV labetolol, hydrallazine (if > 160/110)
- Avoid fluid overload
73
How is prophylaxis given for pre-eclampsia in future pregnancies?
Low dose aspirin from 12 weeks until delivery
74
What is gestational diabetes?
Carbohydrate intolerance that has its first onset during pregnancy
75
How do the insulin requirements of a pre-existing diabetic change in pregnancy and what brings this about?
Insulin requirements increase due to the anti-insulin effects of the following:
- Human placental lactogen
- Progesterone
- Human chorionic gonadotrophin
- Cortisol
76
What risks are associated with pre-existing diabetes in pregnancy?
- 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
What management can be given pre-conception to reduce risks associated with pre-existing diabetes?
- Better glycemic control (blood sugars 4 – 7 mmol/l and hba1c < 48 mmol/mol)
- Folic acid 5mg
- Dietary advice
- Retinal and renal assessment
78
What management can be given during pregnancy to reduce risks associated with pre-existing diabetes?
- 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
What are the ideal glucose levels in pregnancy?
- < 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
What are the risk factors for gestational diabetes?
- 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
How is gestational diabetes screened for?
- 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
How is gestational diabetes managed?
- 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
What is Virchow's triad of thromboembolism?
Stasis
Vessel wall injury
Hypercoagulability
84
Why does risk of VTE increase in pregnancy?
* 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
What are the risk factors for VTE in pregnancy?
* 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
What prophylaxis can be given for VTE in pregnancy?
* 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
What are the signs and symptoms of VTE?
* Pain in calf
* Unilateral calf swelling
* Calf muscle tenderness
* Dyspnoea
* Chest pain
* Cough
* Tachycardia
* Hypoxia
* Pleural rub
88
How should suspicion of VTE in pregnancy be investigated?
* ECG
* Blood gases
* Doppler
* V/Q scan
* CTPA (Computed topography pulmonary angiogram)
