Complications of Pregnancy Flashcards
1
Q
What is a miscarriage
A
- Termination/loss of pregnancy before 24 weeks with no evidence of life
2
Q
What are the categories of spontaneous miscarriage
A
- 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
3
Q
Characteristics of threatened miscarriage
A
- Vaginal bleeding +/- pain
- Viable pregnancy
- Closed cervix on speculum examination
- Not actually miscarrying
- Often settles and pregnancy continues
- Can lead to inevitable miscarriage
4
Q
Characteristics of inevitable miscarriage
A
- Viable pregnancy
- Open cervix with bleeding that could be heavy (+/- clots)
5
Q
Characteristics of missed miscarriage
A
- 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
6
Q
Characteristics of incomplete miscarriage
A
- Most of pregnancy expelled out, some products of pregnancy remaining in uterus
- Open cervix, vaginal bleeding (may be heavy)
7
Q
Characteristics of complete miscarriage
A
- Passed all products of conception
- Cervix closed and bleeding has stopped
8
Q
Characteristics of septic miscarriage
A
- Especially in cases of incomplete miscarriage and the leftover products have become infected
9
Q
Cause of miscarriage
A
- Abnormal conceptus - chromosomal, genetic, structural
- Uterine abnormality - congenital (failure of Mullerian ducts), fibroids (submucous)
- Cervical incompetence - primary, secondary, trauma
- Maternal - age, diabetes
- Unknown
10
Q
Management of miscarriage
A
- Threatened - conservative
- Inevitable- may need evacuation
- Missed
- Conservative
- Medical - prostaglandins to cause uterine contraction
- surgical - SMM
- Septic - antibiotics and evacuation
11
Q
What is an ectopic pregnancy
A
- Pregnancy implanted outside the uterine cavity
12
Q
What is the most common site of ectopic pregnancy
A
- In the tube
- Most common ampullary then isthmus
- Scarring of cervix can cause cervical placement
13
Q
Incidence of ectopic pregnancy
A
- 1 in 90
14
Q
Risk factors for ectopic pregnancy
A
- PID
- STD, e.g. chlamydia, gonorrhea
- Previous tubal surgery - damage to the tube
- Previous ectopic
- Assisted conception
15
Q
Presentation of ectopic pregnancy
A
- Period of amenorrhoea (with +ve pregnancy test)
- +/- vaginal bleeding
- +/- abdominal pain
- +/- Gi or urinary symptoms (could be pressing on bladder/bowel)
16
Q
Investigations for ectopic pregnancy
A
- 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
17
Q
Management of ectopic pregnancy
A
- Medical - methotrexate
- Shrinks tissue
- Must track HCG levels to check lowering
- Surgical - mostly laparoscopic
- Salpingectomy (most common) - removal of tube
- Salpingostomy - just tissue
- Conservative
18
Q
What is antepartum haemorrhage (APH)
A
- Haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby
19
Q
Is APH serious
A
- One of gravest obstetric emergencies
- associated with significant maternal and neonatal morbidity and mortality
20
Q
Causes of APH
A
- 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
21
Q
What is placenta praevia
A
- All or part of the placenta implants in the lower uterine segment
22
Q
Incidence of placenta praevia
A
- 1/200
23
Q
When in placenta praevia more common
A
- Multiparous
- Multiple pregnancy
- Previous C-section
24
Q
Classification of placenta praevia
A
- 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
25
Presentation of placenta praevia
* Painless PV bleeding
* Malpresentation of the foetus
* Incidental
26
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)
27
Diagnosis of placental praevia
* USS to locate placental site
* vaginal examination must not be done is suspected
28
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
29
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
30
What is the incidence of placental abruption
* 0.6%
* Depends on age, parity, social status
31
What factors are associated with placental abruption
* Pre-eclampsia/chronic hypertension
* Multiple pregnancy
* Polyhydramnios
* Smoking, increasing age, parity
* Previous abruption
* Cocaine use
32
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)
33
How can a concealed placental abruption be detected
* Uterine contents increases in volume and fundal height appears larger
34
Presentation of placental abruption
* Pain
* Vaginal bleeding
* Increased uterine activity
35
General management of placental abruption
* Varies form expectant treatment to C-section
36
What does the management of placental abruption depend on
* Amount of bleeding
* General condition of mother and baby
* Gestation
37
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
38
What is preterm labour
* Onset of labour before 37 weeks (257 days) gestation
39
What are the classifications of preterm labour
* 32-36 weeks - mildly preterm
* 28-32 weeks - ver preterm
* 24-28 weeks - extremely preterm
40
Incidence of preterm labour
* around 5-7% in singletons
* 30-40% multiple pregnancy
41
Predisposing factors to preterm labour
* Multiple pregnancy
* polyhydramnios
* APH
* Pre-eclampsia
* Infections - e.g. UTI
* Prelabour premature rupture of membranes
* Idiopathic - majority
42
Diagnosis of preterm labour
* Contractions with evidence of cervical change on VE
43
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
44
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
45
Common neonatal morbidities relating to prematurity
* Respirtory distress syndrome
* Intraventricular haemorrhage
* Cerebral palsy
* Nutrition
* Temperature control
* Jaundice
* Infections
* Visual imapairment
* Hearing loss
46
What is essential/chronic hypertension in pregnancy
* Hypertension either pre-pregnancy or at booking (\<20 weeks)
47
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
48
Who is essential/chronic hypertension in pregnancy commoner in
* Older mothers
49
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
50
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
51
What is gestational hypertension
* Pregnancy induced hypertension
* Develops after 20 weeks
52
Categories of gestational hypertension
* Mild - d (90-90), s (140-149)
* Moderate - d (100-109), s (150-159)
* Severe d - \>110, s \>160
53
What is pre-eclampsia
* New hypertension \>20 weeks in association with significant proteinuria
* Multisystem, multi-organ disorder
* Renal, liver, vascular, cerebral, pulmonary
54
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
55
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
56
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)
57
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
58
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
59
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
60
Foetal complications of pre-eclampsia
* impaired placental effusion --\> IUGR, foetal distress, increased PN mortality
61
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)
62
Biochemical abnormalities in severe pre-eclampsia
* Raised liver enzymes, bilirubin if HELLP present
* Raised urea and creatinine, raised urate
63
Haematological abnormalities in severe pre-eclampsia
* Low platelets
* Low haemoglobin, signs of haemolysis
* Features of DIC
64
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
65
Blood investigations in pre-eclampsia
* FBC (haemolysis, platelets)
* LFT
* Renal function tests - serum urea, creatinine urate
* Coagulation tests if indication
66
Foetal investigations in pre-eclampsia
* Scan for growth
* Cardiotocography (CTG)
67
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
68
Incidence of pre-eclampsia
* 5-8% women
* 0.5% have severe, 0.05% have eclamptic seizure
69
Occurrence of eclamptic seizures
* 38% antepartum
* 18% intrapartum
* 44% postpartum
70
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
71
Prophylaxis of pre-eclampsia
* Low dose aspirin from 12 weeks
* Risk of hypertension later in life
72
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
73
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
74
What complications are associated with pre-existing diabetes after deliver
* More risk of neonatal hypoglycaemia
* Increased risk of respiratory distress
75
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
76
Maternal complications of diabetes in pregnancy
* Increased risk of pre-eclampsia
* Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
* Infections
77
Neonatal complications of diabetes in pregnancy
* Impaired lung maturity
* Neonatal hypoglycaemia
* Jaundice
78
Preconception management of diabetes during pregnancy
* Better glycaemic control, around 4-7 HbA1c \<48
* Folic acid 5mg
* Dietary advice
* Retinal and renal assessment
79
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
80
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
81
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
82
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
83
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
84
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
85
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
86
Prophylaxis of venous thromboembolism in pregnancy
* TED stockings
* Advise increased mobility, hydration
* Prophylactic anti-coagulation with 3 or more risk factors
87
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
88
Investigations of venous thromboembolism in pregnancy
* ECG
* Blood gases
* Doppler
* V/Q lung scan
* CT pulmonary angiogram
89
Treatment of venous thromboembolism in pregnancy
* Anticoagulation
