Complications of Pregnancy Flashcards
What is a miscarriage
- Termination/loss of pregnancy before 24 weeks with no evidence of life
What are the categories of spontaneous miscarriage
- Threatened - refers to bleeding from gravid uterus before 24 wks when there is viable foetus with no evidence of cervical dilation
- Inevitable - as above but cervix begins to dilate
- Incomplete - only partial expulsion
- Complete - complete expulsion
- Septic - risk of infection following incomplete which can spread through pelvis
- Missed - foetus has died but uterus has made no attempt to expel
Characteristics of threatened miscarriage
- Vaginal bleeding +/- pain
- Viable pregnancy
- Closed cervix on speculum examination
- Not actually miscarrying
- Often settles and pregnancy continues
- Can lead to inevitable miscarriage
Characteristics of inevitable miscarriage
- Viable pregnancy
- Open cervix with bleeding that could be heavy (+/- clots)
Characteristics of missed miscarriage
- early foetal demise
- No symptoms, or could have bleeding/brown loss vaginally
- Gestational sac seen on scan
- No clear foetus (empty sac) or foetal pole with foetal heart beat
Characteristics of incomplete miscarriage
- Most of pregnancy expelled out, some products of pregnancy remaining in uterus
- Open cervix, vaginal bleeding (may be heavy)
Characteristics of complete miscarriage
- Passed all products of conception
- Cervix closed and bleeding has stopped
Characteristics of septic miscarriage
- Especially in cases of incomplete miscarriage and the leftover products have become infected
Cause of miscarriage
- Abnormal conceptus - chromosomal, genetic, structural
- Uterine abnormality - congenital (failure of Mullerian ducts), fibroids (submucous)
- Cervical incompetence - primary, secondary, trauma
- Maternal - age, diabetes
- Unknown
Management of miscarriage
- Threatened - conservative
- Inevitable- may need evacuation
- Missed
- Conservative
- Medical - prostaglandins to cause uterine contraction
- surgical - SMM
- Septic - antibiotics and evacuation
What is an ectopic pregnancy
- Pregnancy implanted outside the uterine cavity
What is the most common site of ectopic pregnancy
- In the tube
- Most common ampullary then isthmus
- Scarring of cervix can cause cervical placement
Incidence of ectopic pregnancy
- 1 in 90
Risk factors for ectopic pregnancy
- PID
- STD, e.g. chlamydia, gonorrhea
- Previous tubal surgery - damage to the tube
- Previous ectopic
- Assisted conception
Presentation of ectopic pregnancy
- Period of amenorrhoea (with +ve pregnancy test)
- +/- vaginal bleeding
- +/- abdominal pain
- +/- Gi or urinary symptoms (could be pressing on bladder/bowel)
Investigations for ectopic pregnancy
- Scan - no intrauterine gestational sac, may see adnexal mass, fluid in pouch of Douglas
- Serum B-hCG (high)
- Normal would be at least 66% increase
- Serum progesterone levels - normal would be >25ng/ml
Management of ectopic pregnancy
- Medical - methotrexate
- Shrinks tissue
- Must track HCG levels to check lowering
- Surgical - mostly laparoscopic
- Salpingectomy (most common) - removal of tube
- Salpingostomy - just tissue
- Conservative
What is antepartum haemorrhage (APH)
- Haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby
Is APH serious
- One of gravest obstetric emergencies
- associated with significant maternal and neonatal morbidity and mortality
Causes of APH
- Placenta praevia - placenta attached to lower segment of uterus
- Placental abruption - placenta has started to separate from uterine wall (before birth), associated with retroplacental clot
- Unkown
- Local lesions of the genital tract e.g. cervical erosions and polyps
- Vasa praevia (very rare) - blood loss is usually small and due to rupture of foetal vessels within foetal membranes
What is placenta praevia
- All or part of the placenta implants in the lower uterine segment
Incidence of placenta praevia
- 1/200
When in placenta praevia more common
- Multiparous
- Multiple pregnancy
- Previous C-section
Classification of placenta praevia
- Grade I - placenta encroaching on lower segment but not the internal cervical os
- Grade II - placenta reaches internal os
- Grade III - placenta eccentrically covers os
- Grade Iv - central placenta praevia
Presentation of placenta praevia
- Painless PV bleeding
- Malpresentation of the foetus
- Incidental
Clinical features of placental praevia
- Maternal condition correlates with amount of PV bleeding
- Soft, non-tender uterus +/- foetal malpresentation
- Pulse, BP, etc (correlates to amount of blood lost)
Diagnosis of placental praevia
- USS to locate placental site
- vaginal examination must not be done is suspected
management of PPH
- Depends on gestation, severity
- C section - watch for PPH
- Medical - oxytocin, ergometrine, carboprost, tranexamic acid
- Balloon tamponade
- Surgical - B lynch suture, ligation of uterine, iliac vessels, hysterectomy
What is placental abruption
- haemorrhage resulting from premature from premature separation of the placenta before birth of the baby
- A clot begins to form behind the placenta and sheers it off the uterine wall
What is the incidence of placental abruption
- 0.6%
- Depends on age, parity, social status
What factors are associated with placental abruption
- Pre-eclampsia/chronic hypertension
- Multiple pregnancy
- Polyhydramnios
- Smoking, increasing age, parity
- Previous abruption
- Cocaine use
Clinical types of placental abruption
- Revealed - blood escapes through cervical os
- Concealed - bleeding into uterus
- Occurs between placenta and uterine wall
- missed (concealed and revealed)
How can a concealed placental abruption be detected
- Uterine contents increases in volume and fundal height appears larger
Presentation of placental abruption
- Pain
- Vaginal bleeding
- Increased uterine activity
General management of placental abruption
- Varies form expectant treatment to C-section
What does the management of placental abruption depend on
- Amount of bleeding
- General condition of mother and baby
- Gestation
Complications of placental abruption
- Maternal shock, collapse (may be disproportionate to bleeding seen)
- Foetal death
- Maternal disseminated internal coagulation (DIC), renal failure
- Postpartum haemorrhage - ‘couvelaire uterus’
- Can get severe PPH as uterus struggles to contract
What is preterm labour
- Onset of labour before 37 weeks (257 days) gestation
What are the classifications of preterm labour
- 32-36 weeks - mildly preterm
- 28-32 weeks - ver preterm
- 24-28 weeks - extremely preterm
Incidence of preterm labour
- around 5-7% in singletons
- 30-40% multiple pregnancy
Predisposing factors to preterm labour
- Multiple pregnancy
- polyhydramnios
- APH
- Pre-eclampsia
- Infections - e.g. UTI
- Prelabour premature rupture of membranes
- Idiopathic - majority
Diagnosis of preterm labour
- Contractions with evidence of cervical change on VE
Management of preterm labour
- Consider possible cause - abruption, infection
- <24-26 weeks
- Generally regarded as very poor prognosis
- Decisions made in discussion with parents and neonatologists
- All cases considered viable
- Tocolysis to allow steroid/transfer
- Steroid (unless contraindicated) to help lung development
- Transfer to unit with NICU facilities
- Aim for vaginal delivery
Survival/prognosis of preterm labour
Gestation
Total Survival Rate
% of survivors with severe disabilities
<24
6
65 (34-96)
24
26
38 (23-45)
25
43
32 (24-38)
26
48
26 (20-32)
27
73
28
84
Common neonatal morbidities relating to prematurity
- Respirtory distress syndrome
- Intraventricular haemorrhage
- Cerebral palsy
- Nutrition
- Temperature control
- Jaundice
- Infections
- Visual imapairment
- Hearing loss
What is essential/chronic hypertension in pregnancy
- Hypertension either pre-pregnancy or at booking (<20 weeks)
Categories of essential/chronic hypertension in pregnancy
- Mild - d (90-90), s (140-149)
- Moderate - d (100-109), s (150-159)
- Severe d - >110, s >160
Who is essential/chronic hypertension in pregnancy commoner in
- Older mothers
What is the ideal pre-pregnancy care of essential/chronic hypertension in pregnancy
- Change anti-hypertensive drugs if indicated
- ACE inhibitors (birth defects, impaired growth)
- Angiotensinogen receptor blockers
- Diuretics
- Lower dietary sodium
Management of essential/chronic hypertension in pregnancy
- Aim to keep BP <150/100 (labetalol, nifedipine, methyldopa)
- Monitor for superimposed pre-eclampsia
- Monitor foetal growth
- May have higher incidence of placental abruption
What is gestational hypertension
- Pregnancy induced hypertension
- Develops after 20 weeks
Categories of gestational hypertension
- Mild - d (90-90), s (140-149)
- Moderate - d (100-109), s (150-159)
- Severe d - >110, s >160
What is pre-eclampsia
- New hypertension >20 weeks in association with significant proteinuria
- Multisystem, multi-organ disorder
- Renal, liver, vascular, cerebral, pulmonary
What is classified as significant proteinuria
- Automated reagent strip urine protein estimation >1+
- Spot urinary protein: creatinine ration >30mg/mmol
- 24 hours urine protein collection >300mg/day
Criteria for pre-eclampsia
- Mild hypertension on 2 occasions or moderate/severe hypertension
- proteinuria of more than 300mgms/24 hours (protein urine >+, protein:creatine ratio >30mgms/mmol
Pathophysiology of pre-eclampsia
- Immunological
- Genetic predisposition
- Secondary invasion of maternal spiral arterioles by trophoblasts impaired –> reduced placental effusion
- Imbalance between vasodilators/vasoconstrictors in pregnancy (prostacyclin/thromboxane)
Risk factors for pre-eclampsia
- First pregnancy
- Extremes of maternal age
- Pre-eclampsia in previous pregnancy
- Pregnancy interval >10 years
- BMI>35
- Family history
- Multiple pregnancy
- Underlying medical disorder
What medical disorders are a risk factor for preeclampsia
- Chronic hypertension
- Pre-existing renal disease
- Pre-existing diabetes
- Autoimmune disease e.g. antiphospholipid antibodies, SLE
Maternal complications of pre-eclampsia
- Eclampsia - seizures
- Severe hypertension - cerebral haemorrhage, stroke
- HELLP (haemolysis, elevated liver enzymes, low platelets)
- DIC (disseminated intravascular coagulation)
- Renal failure
- Pulmonary oedema
Foetal complications of pre-eclampsia
- impaired placental effusion –> IUGR, foetal distress, increased PN mortality
Symptoms/signs of severe pre-eclampsia
- Headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands, face or legs
- Severe hypertension; >3+ urine proteinuria
- Clonus/brisk reflexes; papilledema, epigastric tenderness
- Reducing urine output
- Convulsions (eclampsia)
Biochemical abnormalities in severe pre-eclampsia
- Raised liver enzymes, bilirubin if HELLP present
- Raised urea and creatinine, raised urate
Haematological abnormalities in severe pre-eclampsia
- Low platelets
- Low haemoglobin, signs of haemolysis
- Features of DIC
Investigations of pre-eclampsia
- Frequent BP checks and urine protein
- Check symptomatology - headaches, epigastric pain, visual disturbances
- Check hyperreflexia (clonus), tenderness over liver
- Bloods
- Foetal
Blood investigations in pre-eclampsia
- FBC (haemolysis, platelets)
- LFT
- Renal function tests - serum urea, creatinine urate
- Coagulation tests if indication
Foetal investigations in pre-eclampsia
- Scan for growth
- Cardiotocography (CTG)
Management of pre-eclampsia
- Only ‘cure’ is delivery of baby and placenta
- Conservative - aim for foetal maturity
- Close observation of clinical signs and investigations
- Anti-hypertensives (labetalol, methyldopa, nifedipine)
- Steroids for foetal lung maturity if gestation <36 weeks
- Induction of labour if condition deteriorates
- Risk may continue for 6 weeks after delivery so monitoring continued
Incidence of pre-eclampsia
- 5-8% women
- 0.5% have severe, 0.05% have eclamptic seizure
Occurrence of eclamptic seizures
- 38% antepartum
- 18% intrapartum
- 44% postpartum
Treatment of eclamptic seizures
- Magnesium sulphate bolus + IV infusion
- Control of BP - IV labetalol, hydralazine (if >160/110)
- Avoid fluid overload - aim for 80mls/hour
Prophylaxis of pre-eclampsia
- Low dose aspirin from 12 weeks
- Risk of hypertension later in life
What is gestational diabetes
- Carbohydrate intolerance with onset (first recognised) in pregnancy
- Abnormal glucose tolerance that revert to normal after
- More at risk of developing type 2 later in life
Why do insulin requirements of the mother increase during pregnancy
- Human placenta lactogen, progesterone, human chorionic gonadotrophin and cortisol from the placenta have anti-insulin action
What complications are associated with pre-existing diabetes after deliver
- More risk of neonatal hypoglycaemia
- Increased risk of respiratory distress
Foetal complications of diabetes in pregnancy
- Foetal congenital abnormalities e.g. cardiac abnormalities, sacral genesis (esp if blood sugars high peri-conception)
- MIscarriage
- Foetal macrosomia, polyhydramnios
- Operative delivery, shoulder dystocia
- Stillbirth, increased perinatal mortality
Maternal complications of diabetes in pregnancy
- Increased risk of pre-eclampsia
- Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
- Infections
Neonatal complications of diabetes in pregnancy
- Impaired lung maturity
- Neonatal hypoglycaemia
- Jaundice
Preconception management of diabetes during pregnancy
- Better glycaemic control, around 4-7 HbA1c <48
- Folic acid 5mg
- Dietary advice
- Retinal and renal assessment
Management of diabetes during pregnancy
- Optimise glucose control - insulin requirements increase
- <5.3 fasting, 7.8, 1 hour postprandial, <6.4, 2 hours, <6 bedtime
- Could continue oral but may need insulin to maintain control
- Risk of hypoglycaemia - glucagon injections
- Watch for ketonuria/infections
- Repeat retinal assessment 28 and 34 weeks
- Watch foetal growth
Other management of diabetes during pregnancy
- Observe for PET
- Labour usually induced 38-40 weeks
- C-section if macrosomia
- Maintain blood sugar in labour - dextrose infusion
- Continuous CTG foetal monitoring in labour
- Early feeding of baby to reduce hypoglycaemia
- Pre-pregnancy insulin regime post-delivery
Risk factors for gestational diabetes
- Increased BMo - >30
- Previous macrosomic babe >4.5kg
- Previous GDM
- Family history of diabetes
- High risk groups for diebets e.g. asian
- POlyhydramnios or big baby
- Recurrent glycosuria
Screening for gestational diabetes
- If risk factors present, offer HbA1c at booking
- if >43, 75gms OGTT to be done
- If normal, repeat at 24-28 weeks
- OGTT at 16 weeks and repeat at 28 weeks
Management of gestational diabetes
- Control of blood sugars
- diet
- Metformin/insuo=lin if remain high
- Post delivery - check OGTT at 6-8 weeks
- Yearly check of HbA1c as high risk of develping
How does pregnancy alter Virchow’s triad
- Hypercoaguble state - to protect post-delivery
- Increase in fibrinogen, factor VIII, VW factors, platelets
- Decrease in natural anticoagulants - antithrombin III
- Increase in fibrinolysis
- Increase in stasis - progesterone, effects of enlarging uterus
- May be vascular damage at delivery/C-section
Risk of venous thromboembolism in pregnancy
- Older mothers, increasing parity
- Increased BMI, smokers
- IV drug users
- PET
- Dehydration - hypermesis
- Decreased mobility
- Infections
- OPerative delivery, prolonged labour
- Haemorrhage, blood loss>2l
- Previous VTE, Thrombophilia
- Sickle cells disease
Prophylaxis of venous thromboembolism in pregnancy
- TED stockings
- Advise increased mobility, hydration
- Prophylactic anti-coagulation with 3 or more risk factors
Signs/symptoms of venous thromboembolism in pregnancy
- Pain in calf
- Increased girth of leg
- Calf muscle tenderness
- Breathlessness, pain on breathing, cough
- Tachycardia
- Hypoxic
- Pleural rub
Investigations of venous thromboembolism in pregnancy
- ECG
- Blood gases
- Doppler
- V/Q lung scan
- CT pulmonary angiogram
Treatment of venous thromboembolism in pregnancy
- Anticoagulation
