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Repro > Complications of Pregnancy > Flashcards

Complications of Pregnancy Flashcards

1
Q

What is a miscarriage

A
  • Termination/loss of pregnancy before 24 weeks with no evidence of life
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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
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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
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4
Q

Characteristics of inevitable miscarriage

A
  • Viable pregnancy
  • Open cervix with bleeding that could be heavy (+/- clots)
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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
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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)
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7
Q

Characteristics of complete miscarriage

A
  • Passed all products of conception
  • Cervix closed and bleeding has stopped
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8
Q

Characteristics of septic miscarriage

A
  • Especially in cases of incomplete miscarriage and the leftover products have become infected
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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
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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
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11
Q

What is an ectopic pregnancy

A
  • Pregnancy implanted outside the uterine cavity
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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
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13
Q

Incidence of ectopic pregnancy

A
  • 1 in 90
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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
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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)
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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
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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
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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
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19
Q

Is APH serious

A
  • One of gravest obstetric emergencies
  • associated with significant maternal and neonatal morbidity and mortality
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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
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21
Q

What is placenta praevia

A
  • All or part of the placenta implants in the lower uterine segment
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22
Q

Incidence of placenta praevia

A
  • 1/200
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23
Q

When in placenta praevia more common

A
  • Multiparous
  • Multiple pregnancy
  • Previous C-section
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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
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25
Q

Presentation of placenta praevia

A
  • Painless PV bleeding
  • Malpresentation of the foetus
  • Incidental
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26
Q

Clinical features of placental praevia

A
  • Maternal condition correlates with amount of PV bleeding
  • Soft, non-tender uterus +/- foetal malpresentation
  • Pulse, BP, etc (correlates to amount of blood lost)
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27
Q

Diagnosis of placental praevia

A
  • USS to locate placental site
  • vaginal examination must not be done is suspected
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28
Q

management of PPH

A
  • 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
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29
Q

What is placental abruption

A
  • 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
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30
Q

What is the incidence of placental abruption

A
  • 0.6%
    • Depends on age, parity, social status
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31
Q

What factors are associated with placental abruption

A
  • Pre-eclampsia/chronic hypertension
  • Multiple pregnancy
  • Polyhydramnios
  • Smoking, increasing age, parity
  • Previous abruption
  • Cocaine use
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32
Q

Clinical types of placental abruption

A
  • Revealed - blood escapes through cervical os
  • Concealed - bleeding into uterus
    • Occurs between placenta and uterine wall
  • missed (concealed and revealed)
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33
Q

How can a concealed placental abruption be detected

A
  • Uterine contents increases in volume and fundal height appears larger
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34
Q

Presentation of placental abruption

A
  • Pain
  • Vaginal bleeding
  • Increased uterine activity
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35
Q

General management of placental abruption

A
  • Varies form expectant treatment to C-section
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36
Q

What does the management of placental abruption depend on

A
  • Amount of bleeding
  • General condition of mother and baby
  • Gestation
37
Q

Complications of placental abruption

A
  • 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
Q

What is preterm labour

A
  • Onset of labour before 37 weeks (257 days) gestation
39
Q

What are the classifications of preterm labour

A
  • 32-36 weeks - mildly preterm
  • 28-32 weeks - ver preterm
  • 24-28 weeks - extremely preterm
40
Q

Incidence of preterm labour

A
  • around 5-7% in singletons
  • 30-40% multiple pregnancy
41
Q

Predisposing factors to preterm labour

A
  • Multiple pregnancy
  • polyhydramnios
  • APH
  • Pre-eclampsia
  • Infections - e.g. UTI
  • Prelabour premature rupture of membranes
  • Idiopathic - majority
42
Q

Diagnosis of preterm labour

A
  • Contractions with evidence of cervical change on VE
43
Q

Management of preterm labour

A
  • 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
Q

Survival/prognosis of preterm labour

A

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
Q

Common neonatal morbidities relating to prematurity

A
  • Respirtory distress syndrome
  • Intraventricular haemorrhage
  • Cerebral palsy
  • Nutrition
  • Temperature control
  • Jaundice
  • Infections
  • Visual imapairment
  • Hearing loss
46
Q

What is essential/chronic hypertension in pregnancy

A
  • Hypertension either pre-pregnancy or at booking (<20 weeks)
47
Q

Categories of essential/chronic hypertension in pregnancy

A
  • Mild - d (90-90), s (140-149)
  • Moderate - d (100-109), s (150-159)
  • Severe d - >110, s >160
48
Q

Who is essential/chronic hypertension in pregnancy commoner in

A
  • Older mothers
49
Q

What is the ideal pre-pregnancy care of essential/chronic hypertension in pregnancy

A
  • Change anti-hypertensive drugs if indicated
    • ACE inhibitors (birth defects, impaired growth)
    • Angiotensinogen receptor blockers
    • Diuretics
    • Lower dietary sodium
50
Q

Management of essential/chronic hypertension in pregnancy

A
  • 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
Q

What is gestational hypertension

A
  • Pregnancy induced hypertension
  • Develops after 20 weeks
52
Q

Categories of gestational hypertension

A
  • Mild - d (90-90), s (140-149)
  • Moderate - d (100-109), s (150-159)
  • Severe d - >110, s >160
53
Q

What is pre-eclampsia

A
  • New hypertension >20 weeks in association with significant proteinuria
  • Multisystem, multi-organ disorder
    • Renal, liver, vascular, cerebral, pulmonary
54
Q

What is classified as significant proteinuria

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

Criteria for pre-eclampsia

A
  • Mild hypertension on 2 occasions or moderate/severe hypertension
    • proteinuria of more than 300mgms/24 hours (protein urine >+, protein:creatine ratio >30mgms/mmol
56
Q

Pathophysiology of pre-eclampsia

A
  • Immunological
  • Genetic predisposition
  • Secondary invasion of maternal spiral arterioles by trophoblasts impaired –> reduced placental effusion
  • Imbalance between vasodilators/vasoconstrictors in pregnancy (prostacyclin/thromboxane)
57
Q

Risk factors for pre-eclampsia

A
  • 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
Q

What medical disorders are a risk factor for preeclampsia

A
  • Chronic hypertension
  • Pre-existing renal disease
  • Pre-existing diabetes
  • Autoimmune disease e.g. antiphospholipid antibodies, SLE
59
Q

Maternal complications of pre-eclampsia

A
  • Eclampsia - seizures
  • Severe hypertension - cerebral haemorrhage, stroke
  • HELLP (haemolysis, elevated liver enzymes, low platelets)
  • DIC (disseminated intravascular coagulation)
  • Renal failure
  • Pulmonary oedema
60
Q

Foetal complications of pre-eclampsia

A
  • impaired placental effusion –> IUGR, foetal distress, increased PN mortality
61
Q

Symptoms/signs of severe pre-eclampsia

A
  • 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
Q

Biochemical abnormalities in severe pre-eclampsia

A
  • Raised liver enzymes, bilirubin if HELLP present
  • Raised urea and creatinine, raised urate
63
Q

Haematological abnormalities in severe pre-eclampsia

A
  • Low platelets
  • Low haemoglobin, signs of haemolysis
  • Features of DIC
64
Q

Investigations of pre-eclampsia

A
  • Frequent BP checks and urine protein
  • Check symptomatology - headaches, epigastric pain, visual disturbances
  • Check hyperreflexia (clonus), tenderness over liver
  • Bloods
  • Foetal
65
Q

Blood investigations in pre-eclampsia

A
  • FBC (haemolysis, platelets)
  • LFT
  • Renal function tests - serum urea, creatinine urate
  • Coagulation tests if indication
66
Q

Foetal investigations in pre-eclampsia

A
  • Scan for growth
  • Cardiotocography (CTG)
67
Q

Management of pre-eclampsia

A
  • 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
Q

Incidence of pre-eclampsia

A
  • 5-8% women
  • 0.5% have severe, 0.05% have eclamptic seizure
69
Q

Occurrence of eclamptic seizures

A
  • 38% antepartum
  • 18% intrapartum
  • 44% postpartum
70
Q

Treatment of eclamptic seizures

A
  • Magnesium sulphate bolus + IV infusion
  • Control of BP - IV labetalol, hydralazine (if >160/110)
  • Avoid fluid overload - aim for 80mls/hour
71
Q

Prophylaxis of pre-eclampsia

A
  • Low dose aspirin from 12 weeks
  • Risk of hypertension later in life
72
Q

What is gestational diabetes

A
  • 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
Q

Why do insulin requirements of the mother increase during pregnancy

A
  • Human placenta lactogen, progesterone, human chorionic gonadotrophin and cortisol from the placenta have anti-insulin action
74
Q

What complications are associated with pre-existing diabetes after deliver

A
  • More risk of neonatal hypoglycaemia
  • Increased risk of respiratory distress
75
Q

Foetal complications of diabetes in pregnancy

A
  • 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
Q

Maternal complications of diabetes in pregnancy

A
  • Increased risk of pre-eclampsia
  • Worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
  • Infections
77
Q

Neonatal complications of diabetes in pregnancy

A
  • Impaired lung maturity
  • Neonatal hypoglycaemia
  • Jaundice
78
Q

Preconception management of diabetes during pregnancy

A
  • Better glycaemic control, around 4-7 HbA1c <48
  • Folic acid 5mg
  • Dietary advice
  • Retinal and renal assessment
79
Q

Management of diabetes during pregnancy

A
  • 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
Q

Other management of diabetes during pregnancy

A
  • 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
Q

Risk factors for gestational diabetes

A
  • 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
Q

Screening for gestational diabetes

A
  • 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
Q

Management of gestational diabetes

A
  • 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
Q

How does pregnancy alter Virchow’s triad

A
  • 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
Q

Risk of venous thromboembolism in pregnancy

A
  • 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
Q

Prophylaxis of venous thromboembolism in pregnancy

A
  • TED stockings
  • Advise increased mobility, hydration
  • Prophylactic anti-coagulation with 3 or more risk factors
87
Q

Signs/symptoms of venous thromboembolism in pregnancy

A
  • Pain in calf
  • Increased girth of leg
  • Calf muscle tenderness
  • Breathlessness, pain on breathing, cough
  • Tachycardia
  • Hypoxic
  • Pleural rub
88
Q

Investigations of venous thromboembolism in pregnancy

A
  • ECG
  • Blood gases
  • Doppler
  • V/Q lung scan
  • CT pulmonary angiogram
89
Q

Treatment of venous thromboembolism in pregnancy

A
  • Anticoagulation

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