Early and Late Complications in Pregnancy Flashcards
1
Q
What is the minimum Hb required in the 1st and 2nd trimester of pregnancy?
A
Minimum of 110 g/dl
2
Q
What is the minimum Hb requirement in the 3rd trimester of pregnancy?
A
Minimum of 105 g/dl
3
Q
What are the symptoms, investigations and treatments for anaemia in pregnancy?
A
-
Symptoms:
- Tired / exhausted
- Palpitations
- Breathlessness
-
Investigations:
- FBC
- Ferritin
- Folic acid
- Vit B12 levels
-
Treatment:
- Oral / injectable iron and/or
- Vit B12 and/or
- Folic acid
4
Q
What are the physiological changes in pregnancy of the urogenital tract?
A
- Bladder volume increases and detrusor tone decreases.
- 90% of pregnant women develop ureteric dilation as the result of a combination of progestogenic relaxation of ureteric smooth muscle and pressure from the expanding uterus.
- Relative sparing of the left ureter because of protection from the sigmoid colon and upper rectum.
- The net effect - increased urinary stasis, compromised ureteric valves and vesicoureteric reflux.
- Facilitates bacterial colonisation and ascending infection.
5
Q
Describe UTIs in pregnancy.
A
- Can be asymptomatic or symptomatic.
- Mid-stream sample (MSU) is sent for culture and sensitivity (C/S) at booking.
- In pregnancy overall incidence of UTI is approximately 8%.
- The incidence of asymptomatic bacteriuria in pregnant women is 2-5%.
- E. coli accounts for 80-90% of infections.
6
Q
What are the secondary concerns associated with asymptomatic bacteriuria?
What is the treatment?
A
- Preterm delivery and low birthweight
- Increased risks of pre-eclampsia
- Anaemia
- Chorioamnionitis
- Postpartum endometritis
- Fetal growth restriction
- Tratment - appropriate ABx for 7 days based on C/S.
7
Q
What are the symptoms and treatment for acute cystities?
How is it associated with pregnancy?
A
- Affects ~1% of all pregnant women.
-
Symptoms:
- Dysuria
- Frequency
- Urgency
- Suprapubic pain in the absence of systemic illness
-
Treatment:
- Hydration
- Antibiotics
8
Q
Describe pyelonephritis, its symptoms, investigation and treatment.
How common is it in pregnancy?
A
- Serious type of urinary infection in pregnancy.
- Occurs in 2% of pregnant women.
- 90% of antepartum cases occur in the last 2 trimesters.
- It represents infection of a renal papilla, which if untreated can spread to multiple papillae and occasionally to the renal cortex. Untreated - can completely destroy the kidney.
-
Symptoms:
- Sepsis (tachycardia, tachyapnoea, pyrexia)
- Loin pain
- Urinary symptoms
-
Investigations:
- MSU
- USS of the renal tract
- FBC
- Renal function tests
- Blood cultures
- CRP
-
Treatment:
-
ABx for 10-14 days.
- Trimethoprim, co-amoxiclav or gentamycin based on what it thought to be causing the infection.
- Based on the culture decide length of course of Abx.
-
ABx for 10-14 days.
9
Q
What are the risks associated with recurrent urinary infections in pregnancy?
What should be done for these patients?
A
- Urinary infection recurs in 4-5% of pregnancies.
- The risks of developing pyelonephritis and its potential consequences are the same as for the primary infection.
- Urinary tract anomalies must be excluded by USS.
- Long-term, low-dose antimicrobial cover or single postcoital doses have been advocated for the remainder of the pregnancy.
10
Q
Describe hyperemesis gravidarum.
A
- Extreme, persistent nausea and vomiting during pregnancy.
- It can lead to dehydration, weight loss and electrolyte imbalances.
- Look for ketones in the urunie = complete dehydration. Can be given anti-emetics as well as IV fluids.
- Morning sickness is mild nausea and vomiting that occurs in early pregnancy.
- Common during first 3 months.
- Cause is not known, but is believed to be caused by a rapidly rising blood level of a hormone called human chorionic gonadotrophin (HCG), released by the placenta.
11
Q
What are the risks for hyperemesis gravidarum?
A
- Twins
- Molar pregnancues
- Hx of hyperemesis in previous pregnancies or motion sickness
12
Q
What is the appropriate management of hyperemesis gravidarum?
A
- Hydration
- Antiemetics
- Multivitamin supplements
- In severe cases, steroids can be used
- It can cause weight loss of more than 5% body weight
13
Q
What are the causes of bleeding in early pregnancy?
A
- Implantation bleeding (physiological)
- when burrowing into the uterine muscle - if there is not much pain and bleeding for only 2-3 days.
- Miscarriage
- Ectopic pregnancy
- Cervical causes - ectropion / polyp, rarely cancer
- Molar pregnancy
14
Q
What is miscarriage?
Describe its symptoms and causes.
A
- Miscarriage is the loss of a pregnancy during the first 22 weeks.
-
Symptoms and signs:
- Vaginal bleeding
- Cramping and pain in the lower abdomen
-
Causes:
- Unknown
- Chromosomal (most common - it is a healthy thing to eliminate a pregnancy which would not have been viable).
- Placental problems
- Uterine anomalies
- Cervical incompetence
- Autoimmune conditions
- 1/8 pregnancies will end in miscarriage (15%)
15
Q
What is a threatened miscarriage?
A
The pregnancy remains viable in spite of bleeding and cramping
16
Q
What is a nonviable pregnancy?
A
Patient presents with pain but no bleeding. On the scan there is no fetal heart. This is a missed miscarriage.
17
Q
What is an incomplete miscarriage?
A
Products of conception partially expelled but still some tissue remaining.
The remaining contents must be removed.
18
Q
What is a complete miscarriage?
A
Products of conception are completely expelled - complete miscarriage.
19
Q
Define recurrent miscarriage.
A
3 or more consecutive miscarriages (1%) = recurrent miscarriage.
20
Q
Describe the diagnosis and management of miscarriage.
How can incidence be reduced?
A
- Miscarriages cannot be prevented but can be reduced by avoiding smoking, drinking annd drug use.
- Several chronic health conditions can increase the risk of having a miscarriage in the 2nd trimester, especially if they are not treated or well-controlled such as diabetes, hypertension, lupus etc.
- Diagnosis - transvaginal USS
- Medical management - Mifepristone and misoprostal
- Surgical management - evacuation of the uterus by suction evacuation or curettage
21
Q
Describe the management of a pregnant woman who is resus negative.
A
- If the blood group is resus negative, anti-D is administered.
- For pregnancies <12 weeks gestation, anti‐D Ig prophylaxis is indicated following ectopic pregnancy, molar pregnancy, therapeutic termination of pregnancy and in cases of heavy uterine bleeding associated with abdominal pain. The minimum dose should be 250 IU.
- Not necessary if there is only spotting.
- For potentially sensitising events between 12 and 20 weeks gestation, a minimum dose of 250 IU should be administered within 72 h of the event.
- For potentially sensitising events after 20 weeks gestation, a minimum anti‐D Ig dose of 500 IU should be administered within 72 h of the event.
22
Q
What is an ectopic pregnancy?
Describe the symptoms.
A
- An ectopic pregnancy is when a fertilised egg implants outside of the uterus, usually in one of the fallopian tubes.
- Risk of ectopic pregnancy in the UK is 1%.
-
Symptoms:
- Positive pregnancy test and other signs of pregnancy
- Lower abdominal pain, more on one side/localised
- Vaginal bleeding or a brown watery discharge
- Shoulder tip pain
- Discomfort while micturating or opening bowels
23
Q
Describe the investigation and management of ectopic pregnancy.
A
- Investigation - USS and blood test (β-HCG)
-
Management:
- Medical - methotrexate
- Surgical - salpingectomy
- If ectopic pregnancy is missed or not managed appropriately, it can be life threatening.
24
Q
Describe a hydatiform mole.
Include presentation, diagnosis, treatment and follow-up.
A
- Presents with bleeding in early pregnancy.
- Occasionally can be profuse accompanied with expulsion of grape like tissues.
- Pregnancy symptoms like nausea and vomiting can be occasionally profound.
-
Diagnosis: USS and high levels of β-HCG
- Confirmed by histology
-
Treatment: surgical evacuation
- Notify molar pregnancy register
- Biochemical follow up – till β-HCG is negative
- Avoid COCP as it delays the return of β-HCG
25
What are the differentials for abdominal pain associated with pregnancy?
* Heart burn - gastritis; treat as normal.
* Constipation
* Muscular - there are only 2 safe analgesics in pregnancy - **paracetamol** and **codeine**.
* Appendicities - investigation and intervention if necessary.
* Cholecystitis
* Renal colic - possible haematuria.
* IBS
* Ovarian cyst accidents
26
What is an antepartum haemorrhage?
What causes it?
* **Bleeding from the genital tract after the 22nd week of pregnancy.**
* Complicates 2-5% of all pregnancies.
* Associated with fetal and maternal morbidity and mortality.
* **Causes:**
* ****Placental abruption
* Placenta previa
* Vasa previa
* Cervicitis
* Trauma
* Vulvo-vaginal varicosities
* Genital tumours and infection
27
Describe how to manage an antepartum haemorrhage.
* Depends on the cause, severity and gestational weeks.
* Admit to hospital
* Cannula and take bloods (FBC, G&S, U&Es, coagulation profile)
* Resuscitation (IV fluids, blood transfusion)
* Examination
* Ultrasound
* Resus negative women need anti-D and a Keilhauer test.
28
Describe placenta praevia.
* Complicated 0.5% of pregnancies.
* **Placenta partly or completely inserted in the lower uterine segment.**
29
Describe placental abruption.
* Complicates 0.5 - 2% of pregnancies.
* It is **bleeding** following **premature separation** of normally situated **placenta**.
* Revealed or concealed.
* Majority of cases cause is unknown, the other causes are trauma, polyhydramnios, hypertension etc.
* **Diagnosis** – clinical presentation and examination, ultrasound.
* **Management** depends on severity, gestational age, maternal and fetal condition.
30
What is preterm labour?
What are the risk factors?
* **Onset of labour before 37 completed weeks of gestation.**
* **Risk factors:**
* ****Multiple pregnancies
* Hx of preterm labour
* Polyhydramnios
* Infection
* Diagnosis on clinical grounds, fetal fibronectin test and USS.
31
Describe the management of preterm labour.
* **Tocolysis** - to slow labour for administration of steroids and in-utero transfer if needed.
* **Steroids** - for fetal lung maturation.
* **Magnesium sulphate** - for neuro protection.
32
Describe Preterm Pre-labour Rupture of Membranes (PPROM).
What are the risk factors?
* Spontaneous rupture of membranes before 37 weeks of gestation in the absence of regular painful uterine contractions.
* Risk groups are:
* Polyhydramnios
* Previous Hx of PPROM
* Uterine anomalies
* Infections
33
Describe the **diagnosis** and **management** of Preterm Pre-labour Rupture of Membranes (PPROM).
* **Diagnosis**
* ****Examination
* Swabs
* USS
* **Management**
* ****Tocolysis
* ABx (to reduce risk of infection)
* Steroids
* Delivery
34
Describe Intra-Uterine Growth Retardation (IUGR).
State the diagnosis and management.
* IUGR is a failure of the fetus to achieve the expected weight for a given gestational age.
* Small for gestational age (SGA) refers to fetus estimated birth weight (EFW) on USS is below the 10th centile for the given population.
* SGA : Constitutionally small or growth restricted.
* IUGR : chromosomal, uteroplacental, environmental.
* **Diagnosis** : Regular SFH, use of customized growth charts, USS.
* **Management**: careful monitoring and appropriate intervention.
35
What is obstetric cholestasis?
* Obstetric cholestasis is a multifactorial condition of pregnancy characterised by pruritus (mainly on palms and soles) in the absence of a skin rash with abnormal liver function tests (LFTs), neither of which has an alternative cause and both of which resolve after birth.
* Affects 0.7% of pregnancies.
36
How is obstetric cholestasis diagnosed?
* Unexplained pruritus and abnormal liver function tests (LFTs) and/or
* raised bile acids occur in the pregnant woman and both resolve after delivery.
* Pruritus that involves the palms and soles of the feet is particularly suggestive.
* Postnatal resolution of symptoms and of biochemical abnormalities is required to secure the diagnosis. LFTS should be deferred 10 days following delivery.
37
What are the risk factors for pre-eclampsia and eclampsia?
* Diabetes
* Hypertension or kidney disease pre-pregnancy
* Lupus or antiphospholipid syndrome
* Personal or FHx of pre-eclampsia
* 1st pregnancy
* Maternal age \>40
* High BMI
* Multiple pregnancies
38
What are the complications of obstetric cholestasis?
How is it treated?
* **Complications:**
* ****Meconium passage
* Small risk of stillbirth
* Premature birth (iatrogenic)
* **Treatment:**
* ****Symptomatic management
39
Describe pre-eclampsia.
* Pre-eclampsia is a condition that typically occurs after 20 weeks of pregnancy (6%).
* It is a combination of raised blood pressure (hypertension) and protein in your urine (proteinuria).
40
What are the symptoms of pre-eclampsia and eclampsia?
* Asymptomatic
* Headaches
* Visual disturbance
* Pain in the right hypochondriac region
* Oedema
41
What investigations should be carried out in query pre-eclampsia?
* Bloods
* FBC
* U&E
* Uric acid
* Coagulation profile
* Fetal monitoring
* UACR
42
Describe the management of pre-ecpampsia.
What are the complications.
* **Management:**
* Regular BP monitoring and anti hypertensives
* Fetal growth monitoring
* Delivery
* **Complications:**
* Eclampsia - seizures - Magnesium sulphate
* Intracranial Haemorrhage
* Pulmonary edema****
* HELLP syndrome
* Placental abruption
* Stillbirth
* IUGR
