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Obstetrics & Gynaecology > Medical Disorders of Pregnancy > Flashcards

Medical Disorders of Pregnancy Flashcards

1
Q

What are the different classifications of PPH?

A

PPH = blood losss >500ml occurring <24h after delivery

Minor PPH = 500-1000ml blood loss
Major PPH = moderate: 1000-2000ml blood loss, severe: >2000ml blood loss

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2
Q

Causes of PPH

A

4 Ts

  • Tone: Uterine atony - uterus fails to contract properly (common in multiparity and prolonged labour)
  • Trauma: cervical tear, high vaginal tear, perineal tear
  • Tissue: retained placenta- which has not been delivered in 3rd stage - needs to be removed if not expelled within 60 mins of delivery
  • Thrombin: coagulopathy or patient taking anticoagulants
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3
Q

Clinical features of PPH…

A
  • External blood loss is visible in most cases
  • Enlarged, boggy uterus above the umbilicus suggests there is a uterine cause (normally feels solid and below umbilicus)
  • May present with hypovolaemic shock if no external blood loss seen - tachycardia, hypotension, dizziness
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4
Q

Management of PPH…

A

A-E approach:

  • Patient needs to be supine
  • Give high flow oxygen
  • Gain IV access - two wide bore cannulae
  • Bloods: FBC, U+E, G+S in minor PPH, X match in major
  • Fluid resuscitation- 500ml crystalloid in minor PPH, need blood transfusion ASAP in major PPH - MAJOR HAEMORRHAGE PROTOCOL
  • FFP and cryoprecipitate given to treat any coagulopathy

Medical:

  • Tranexamic acid can be given in short term
  • Bimanual uterine compression - induce uterine contractions
  • Slow IV Synctocinon (oxytocin) or IM/IV ergometrine or IM carboprost

Surgical - if medical management has not worked:

  • Intrauterine balloon tamponade
  • Uterine artery ligation
  • Hysterectomy - last resort
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5
Q

What are the most likely sites for ectopic pregnancy?

A
  • 97% = tubal, mainly in ampulla, also isthmus (more dangerous)
  • 3% in the ovaries, cervix or peritoneum
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6
Q

Risk factors for ectopic pregnancy…

A
  • Previous ectopic pregnancy
  • Lower maternal age
  • IVF procedure
  • PID
  • Smoking
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7
Q

Presentation of ectopic pregnancy…

A

Symptoms:

  • Severe lower abdominal pain - normally first symptom
  • 6-8 weeks of amenorrhoea
  • Followed by PV bleeding (dark brown in colour)
  • May have confirmed pregnancy
  • Breast tenderness
  • Dizziness, fainting - if large blood loss
  • Peritoneal blood loss may cause shoulder tip pain (due to irritation of diaphragm)

Signs:

  • Abdominal tenderness in peritoneal bleed
  • Bimanual examination - cervical excitation
  • Uterus is smaller than expected for gestation
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8
Q

Investigations in ectopic pregnancy …

A
  • Urinary hCG - confirm pregnancy
  • TV USS to identify if there is an intrauterine pregnancy
  • Serum hCG done if no IUP is seen - if serum hCG> 1000 and no IUP = ectopic is likely
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9
Q

Management of acute presentation of ectopic pregnancy…

A

25% of women will present acutely with symptoms of hypovolaemic shock
A-E approach is necessary :
- Gain IV access with two wide bore cannulae
- FBC, clotting, G&S or X-match 2 units
- Fluid resuscitation
- Give anti -D if rhesus -ve

*Inform surgical team to prepare for laparoscopy + salpingectomy +/- oophrectomy

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10
Q

Management of subacute presentation of ectopic pregnancy…

A

Expectant management (patients with serum hCG <200 IU/L and asymptomatic ): Serial serum B-hCG mesurements every 48 hours until <10 IU/L

Medical management (patients with serum hCG <1500 IU/L, ectopic mass <35mm) : Give 1 single IM methotrexate dose and regularly monitor B-hCG until <10 IU/L 
*women should not try to conceive for 3/12 after due to teratogenic effects of methotrexate

Surgical management (patients with serum hCG > 1500 IU/L, ectopic mass >35mm, foetal heartbeat present) : Salpingectomy/ salpingotomy

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11
Q

What is thought to be the cause of hyperemesis gravidarum?

A
  • B-hCG causes distension of the GI tract and cross-reacts with TSH leading to raised thyroid hormone levels which causes gastrointestinal thyrotoxicosis
  • High progesterone levels can decrease gut motility and relax the lower oesophageal sphincter
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12
Q

Clinical presentation of hyperemesis…

A
  • Severe, profuse vomiting throughout the day (>3 eps/ day)
  • Normally presents between week 8-12 and lasts till week 20
  • May show signs of dehydration - dizziness
  • Unable to keep any fluids/ food down
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13
Q

Diagnostic clinical triad for hyperemesis gravidarum…

A
  1. Dehydration
  2. Ketonuria
  3. Weight loss >5% of pre-pregnancy weight
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14
Q

Investigations for hyperemesis…

A
  • Full obs: BP, HR, O2 sats
  • Urinalysis - ketonuria
  • Bloods: FBC, U&Es, LFTs, TFTs (to see if there is cross-reaction with TSH)
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15
Q

Management of hyperemesis…

A

Mild:

  • First line = antihistamines (promethazine) or cyclizine
  • Second line = metoclopramide or ondansetron
  • PPI e.g. omeprazole to help with sx

Severe - need admission if:

  • Continued N+V and unable to keep fluids down despite oral antiemetic
  • Continued N+V with ketonuria and/or >5% of body weight loss
  • IV fluid resuscitation- 3L over 6 hours to correct electrolyte abnormalities
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16
Q

What is a molar pregnancy?

A

Abnormal growth of trophoblastic tissue after impaired fertilisation which leads to a pregnancy-like mass in-utero.

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17
Q

Risk factors for molar pregnancy…

A
  • Extremes of reproductive age
  • Previous molar pregnancy
  • Asian ethnicity
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18
Q

What are the different types of molar pregnancy?

A

Complete mole = entirely paternal as sperm fertilises an empty oocyte therefore no foetal tissue but proliferation of chorionic villi

Partial mole = two sperm fertilise one oocyte which leads to triploidy 69 XXX/XXY - foetus may be present but not viable

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19
Q

What happens if molar pregnancy becomes invasive…

A
  • Invasive mole if it invades locally within the uterus

- Choriocarcinoma if it becomes metastatic, normally spreading to the lung

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20
Q

Presentation of molar pregnancy…

A
  • Heavy vaginal bleeding
  • Hyperemesis (due to raised B-hCG)
  • Unusually large uterus for gestation
  • Pelvic pressure or pain
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21
Q

Diagnosis of molar pregnancy …

A
  • Very high B-hCG levels

- USS shows grape like clusters with no foetus

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22
Q

Management of molar pregnancy…

A
  • Growth removed by suction curettage, and then products sent for histology
  • Chemotherapy require for choriocarcinoma
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23
Q

What is the definition of miscarriage?

A

Death of a foetus before 24 weeks gestation

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24
Q

What are the different types of miscarriage…

A

Threatened miscarriage:

  • Painless PV bleeding
  • Uterus still growing as expected
  • Foetus is alive
  • Cervical os is closed

Inevitable miscarriage:

  • Heavy PV bleeding
  • Possible rupture of membranes
  • Cervical os is open

Incomplete miscarriage:

  • Parts of foetus have already been expelled
  • Some parts remain in-utero
  • Cervical os is open

Missed miscarriage:

  • Gestational sac containing dead foetus with no expulsion
  • May be some light vaginal bleeding
  • Cervical os is closed
  • Normally incidental finding

Complete miscarriage:

  • All products of conception have been expelled
  • Cervical os is closed
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25
Q

Presentation of miscarriage…

A
  • PV bleeding

- Lower abdominal pain

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26
Q

Diagnosis of miscarriage…

A
  • Urinary pregnancy test to confirm pregnancy
  • TV USS - show a viable /non-viable foetus or remaining products of conception
  • Serum B-hCG levels taken every 48 hrs: viable pregnancy will show >63% rise, non-viable pregnancy will show >50% decrease
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27
Q

Management of miscarriage…

A

Expectant management:

  • First line as long as no sign of infection/ haemodynamic instability
  • Wait 7-14 days to allow body to naturally expel products of conception
  • Can be distressing time

Medical management (if expectant did not work):

  • PV misoprostol to induce myometrial contractions to expel products
  • Bleeding should start within 24hrs
  • S/Es= N+V, diarrhoea

Surgical management:

  • Vacuum aspiration under LA as an outpatient
  • Suction catheter used in theatre under GA
  • Risk of adhesions in the uterus (Ashermann’s syndrome)
28
Q

What is the definition of recurrent miscarriage?

A

3 or more consecutive miscarriages which may warrant further investigation and treatment

29
Q

Causes of recurrent miscarriage, and their management…

A
  • Antiphospholipid syndrome (recurrent thrombosis in uteroplacental circulation) - Tx= aspirin and LMWH
  • Parental chromosomal abnormalities - refer to clinical geneticist
    Tx= IVF, donor oocyte/sperm
  • Uterine abnormality - USS to diagnose, then MRI
    Tx= surgical correction
  • Endocrine problems - thyroid disorders, PCOS, poorly controlled diabetes
    Tx= treat the cause
30
Q

What is the definition of antepartum haemorrhage?

A

Bleeding from genital tract after 24 weeks gestation up to 2nd stage of labour

31
Q

What are the three types of antepartum haemorrhage?

A 
Minor = <50m blood loss
Major = 50-1000ml blood loss
Massive = >1000ml blood loss +/- signs of shock
32
Q

Causes of antepartum haemorrhage…

A
  • Trauma (domestic violence)
  • Infection
  • Placenta praevia
  • Placental abruption
  • Uterine rupture
  • Vasa praevia
33
Q

General management of any cause of APH?

A
  • Admit for assessment - even with small amount of bleeding
  • Bloods : FBC, U&E, clotting, X-match if large bleed
  • Foetal monitoring + CTG to check for foetal distress
  • Urgent USS to check if placenta praevia
  • Vaginal exam when placenta praevia has been excluded
  • APH means preterm delivery is likely so give steroids prophylactically
34
Q

What is placenta praevia, and how is it classified?

A

Where the placenta is lies in lower segment of uterus.

Classified depending on proximity of placenta to the internal os:
I = placenta is low-lying but not at os
II = placenta reaches internal os but does not cover
III= placenta covers internal os, but moves during dilatation
IV= placenta completely obstructs internal os

35
Q

Risk factors for placenta praevia…

A
  • Multiparity
  • Previous placenta praevia
  • Previous C section (embryos more likely to implant on previous scar)
36
Q

Presentation of placenta praevia…

A
  • Intermittent bleeding which increases in frequency and intensity
  • May lead to signs of shock
  • NO pain
  • Transverse lie and breech presentation may be seen
37
Q

Management of placenta praevia…

A
  • Low-lying placenta seen at 16-20 week scan - need repeat scan at 34 weeks
  • Placenta praevia > 2cm from internal os - normal vaginal delivery can be tried
  • Placenta praevia <2cm from internal os - need elective C-section at 38 weeks
38
Q

What is placenta accreta?

A

Condition where the placenta is attached too deeply to the myometrium meaning it will not be expelled during 3rd stage of labour - may cause PPH.

39
Q

What is placental abruption?

A

Placenta separates away from the endometrium leading to bleeding which collects in the pocket between endometrium and placenta.

40
Q

What are the two types of bleeding possible from placental abruption?

A
  • Concealed bleed = blood accumulates in the space and may present with shock
  • Revealed bleed = blood tracks down through uterus and presents as APH
41
Q

Risk factors for placental abruption…

A
  • IUGR
  • Smoking
  • Hypertension
  • Pre-eclampsia
42
Q

How can placental abruption present?

A
  • Painful and dark bleeding (if any bleeding)
  • Uterus is very tender and hard upon examination
  • Patient may be in shock - hypotensive , tachycardic
43
Q

Management of placental abruption…

A
  • Foetal distress = emergency C-section required
  • No foetal distress and >34/30= induction of labour
  • No foetal distress and <34/40 = admit for monitoring and give steroids
  • prepare for PPH - have blood products ready
44
Q

What is vasa praevia?

A

Foetal vessels extend over the presenting part which means during delivery when the membranes rupture and presenting part descends, they will rupture and lead to severe foetal distress.
C-section cannot be done in time to save the foetus

45
Q

What is uterine rupture, and how does it present?

A

Rupture of the uterus normally occurs in labour but may happen in third trimester due to scarring from previous C-section.
Sx= tearing abdominal pain, PV bleeding, shoulder tip pain from intraperitoneal bleed, shock

46
Q

What are the different classifications of hypertension in pregnancy…

A

Pregnancy induced hypertension = BP >140/90 past 20 weeks gestation: pre-eclampsia or gestational hypertension

Pre-existing hypertension = BP> 140/90 before 20 weeks gestation: primary or secondary to another condition

47
Q

What are the main medications used for hypertension in pregnancy?

A
  • First line = Labetalol (B-blocker)
  • Second line = Nifedipine (calcium channel blocker)
  • Third line = Methyldopa
48
Q

What additions are made to antenatal care for someone with pre-existing hypertension?

A
  • Phaeochromacytoma excluded with two 24hr VMA
  • Check for existing disease with blood tests
  • Regular urinalysis for significant proteinuria
  • Additional growth scans at 28 and 32 weeks
49
Q

Management of pre-existing hypertension in pregnancy…

A
  • Medication review - stop ACEi and ARB, replace with Labetalol
  • Low dose aspirin if at risk of pre-eclampsia
  • Early delivery between 38-40 weeks
50
Q

What is gestational hypertension?

A

Pregnancy induced hypertension which develops after 20 weeks gestation, and will normally resolve about 1 month after birth.

51
Q

Classification of gestational hypertension and how it is managed…

A

Mild GH: 140/90 - 149/99

  • Weekly BP and proteinuria
  • Bloods weekly

Moderate GH: 150/100-159/109

  • Start Labetalol
  • 2x weekly BP and proteinuria
  • Bloods weekly

Severe GH: >160/110

  • Admit to hospital
  • Start Labetalol
  • Induction of labour
52
Q

What is the definition of pre-eclampsia?

A

BP > 140/90 and proteinuria > 0.3g/24hr after 20/40 gestation.

53
Q

Pathophysiology of pre-eclampsia…

A
  1. Poor placental perfusion - leads to oxidative stress which causes high resistance to flow in uterine arteries
  2. Oversecretion of proteins from oxidatively stressed placenta
  3. Endothelial damage leads to increased vasoconstriction (HTN) and vascular permeability (proteinuria)
54
Q

Risk factors for pre-eclampsia…

A
  • Nulliparity
  • Multiple pregnancy
  • Pre-existing hypertension
  • Age > 40
  • Family history
  • Pre-existing CVS/ renal disease
55
Q

Presentation of pre-eclampisa…

A

NORMALLY ASYMPTOMATIC

  • Severe headache
  • Seizures/ convulsion
  • Blurred vision
  • Vomiting
  • Epigastric pain
  • Peripheral oedema (hands, feet, face)
  • Clonus / hyperreflexia
56
Q

Investigations for pre-eclampsia…

A
  • Urine dipstick
  • BP measurement
  • Urine MC&S,
  • Bloods- FBC, U&E, LFTs
  • CTG and USS - foetal wellbeing
57
Q

Management of pre-eclampsia…

A

*All women with diagnosed pre-eclampsia should be admitted for monitoring - level of monitoring increases with severity of disease

Definitive treatment = delivery of the placenta!!

  • Mild pre-eclampsia = delivery by 37/40
  • Moderate -severe pre-eclampsia = delivery by 34-36 weeks

During delivery:

  • Usually vaginal delivery unless <34/40 (C-section)
  • Fluid restriction
  • Steroids for deliveries <34/40
  • Labetalol given throughout
  • Avoid prolonged 2nd stage

After delivery:

  • Continue fluid restriction
  • Maintain BP @140/90
  • Perform urine dip at 6 wks
58
Q

Complications from pre-eclampsia…

A

Maternal:

  • Eclampsia
  • Cerebrovascular haemorrhage
  • HELLP sydnrome (haemolysis, elevated liver enzymes, low platelets)
  • DIC

Foetal:

  • IUGR
  • Preterm
  • Placental abruption
59
Q

What is eclampsia, and how is it managed?

A

Eclampsia = generalised tonic -clonic seizures due to cerebral vasospasm

Tx:

  • Loading dose of magnesium sulphate 4g + infusion of 1g/hr for 24 hrs
  • IV labetalol to reduce BP
  • Deliver baby as soon as mother is stable - NOT before
60
Q

Risk factors for GDM…

A
  • Previous GDM
  • Previous macrosomia
  • Family history
  • S. Asian, A. Carribean
  • BMI>30
61
Q

Diagnosis of GDM…

A

Urinalysis shows 2+ glycosuria on one occasion or 1+ glycosuria on two occasions - refer for further investigation:

  • Fasting glucose > 5.6 mmol/L
  • OGTT - 2hr post > 7.8mmol/L
62
Q

Management of GDM…

A

General:

  • Target =glucose < 7.8mmol/L
    1. Diet and exercise
    2. Only metformin and insulin medications should be used others are stopped
  • Insulin started immediately if fasting glucose > 7mmol/L
  • Aspirin 75mg daily from 12/40 to reduce pre-eclampsia risk

Delivery:

  • Between 37-39 weeks
  • C-section if foetal weight >4kg
  • Sliding scale of insulin used to control glucose

Post-natal:

  • Breastfeeding early and regularly is strongly advised
  • Measure fasting glucose 6 weeks post-natal
  • HbA1c annually - high risk of T2DM
63
Q

What is the value used to define anaemia in pregnancy?

A

<110g/L in first and third trimester

<105g/L in second trimester

64
Q

Why does anaemiaoccur in pregnancy?

A

The rise in plasma volume is greater than the rise in red cell mass which leads to a dilutional effect on Hb, causing a net fall in Hb concentration

65
Q

Why may you see anaemia with low MCV in pregnancy?

A

Low MCV = microcytic anaemia - likely to be iron deficiency anaemia, as the physiological requirement for iron is 3x normal level therefore iron reserves have been used up.

66
Q

Management of anaemia in pregnancy…

A

Medical:

  • Iron +/- folic acid given when Hb<110g/L in 1st and 3rd trimester , and <105g/L in 2nd trimester
  • 100-200mg ferrous sulphate daily - 3 months, then 6 weeks post-partum

Sickle cell:
- More regular exchange transfusions required

Referral to haematology for severe anaemia (<70g/L)

67
Q

Prophylaxis gainst anaemia in pregnancy…

A
  • Iron supplements can be taken to reduce incidence of anaemia
  • Encourage greater dietary intake of:
    Iron =meat, eggs, green veg
    Folic acid = raw green veg, fish

Obstetrics & Gynaecology (10 decks)

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