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Year 4 - O&G > O&G - Complications in Pregnancy > Flashcards

O&G - Complications in Pregnancy Flashcards

1
Q

What is Cardiotocography?

A

Cardiotocography (CTG) records pressure changes in the uterus using internal or external pressure transducers - it is used for measuring fetal HR + uterine contractions

  • Cardiotocograph is commonly called electronic fetal monitor (EFM)
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2
Q

What is a normal fetal HR?

A

100-160 BPM

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3
Q

What can cause fetal bradycardia?

A
  1. Increased fetal vagal tone
  2. Maternal beta-blocker use
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4
Q

What can cause fetal tachycardia?

A
  • Maternal pyrexia
  • Chorioamnionitis - intra-amniotic infection (IAI) is inflammation of the fetal membranes (amnion and chorion) due to bacterial infection
    • Main risk factor = premature rupture of membranes
    • Associated with prolonged labour
  • Hypoxia
  • Prematurity
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5
Q

What is Premature rupture of membranes (PROM)?

A

PROM is a rupture of the membranes (amniotic sac) before labour

  • If PROM occurs < 37-weeks = it is called preterm premature rupture of membranes (PPROM)
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6
Q

What complications are associated with PPROM?

(preterm premature rupture of membranes)

A

Complications:

  • Fetal:
    • prematurity
    • infection
    • pulmonary hypoplasia (incomplete development of lungs)
  • Maternal:
    • chorioamnionitis
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7
Q

What causes Chorioamnionitis?

A

Often ascending bacterial infection from the vagina to the uterus

(thus PROM is a risk factor as it removes protective amniotic sac - HOWEVER it can occur without PROM)

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8
Q

How is Chorioamnionitis managed?

A
  1. IV Abx
  2. Prompt delivery (via C-section if needed)
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9
Q

What are uterine stimulants and relaxants?

A
  • Uterine stimulant = induce contractions
    • ​Often increase tone of uterine muscles
    • Used to facilitate labour (reducing PPH) + induce abortion
  • Uterine relaxant = inhibit contractions
    • ​Used to stop premature labour (time for fetal lungs to mature)
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10
Q

Give some examples of Uterine stimulants.

A
  • Oxytocin
  • Prostin
  • Ergometrine
  • Endothelin
  • Misoprostol
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11
Q

Name some examples of uterine relaxants.

A
  • Nifedipine
  • Nitric oxide
  • Terbutaline
  • Relaxin
  • Magnesium
  • Atosiban
  • Indomethacin
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12
Q

What is an Amniotomy?

also called artificial rupture of membranes (AROM)

A

Amniotomy or AROM is an intentional rupturing of the amniotic sac by an obstetrician or mifwife

  • Rupture is done via finger or specialised tool e.g. amnihook
  • Helps stimulate contractions
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13
Q

Study this image of different scenarios and how much blood loss they represent in Obstetric haemorrhage

A
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14
Q

What does antepartum mean?

A

Occuring not long BEFORE birth

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15
Q

What does Small for Gestational Age mean?

A

Small for gestational age (SGA) = A fetus born with a birth weight of < 10th centile

  • Ideally measured from customised growth chart as is more sensitive for detecting babies at higher risk of morbidity and mortality
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16
Q

What is fetal growth restriction (FGR)?

A

Fetal growth restriction (FGR) = failure of fetus to reach its pre-determined growth potential due to pathology

  • FGR –> increases perinatal mortality dramatically
  • FGR is likely when there is evidence of growth faltering e.g. poor growth velocity
  • Not all SGA babies are fetal growth restricted e.g. if predicted to have low growth potential (small baby), the baby can be SGA but not determined to be growth restricted
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17
Q

Name some Major risk factors for fetal growth restriction?

A
  • Mat age > 40
  • Smoker > 11 / day
  • Prev SGA or stillbirth
  • Parental Hx of SGA
  • Chronic HTN
  • Diabetes with vascular disease
  • Renal impairment
  • APS (antiphospholipid syndrome)
  • Heavy BPV (birth weight / placental volume ratio)
  • Low PAPP-A
  • Fetal echogenic bowel
  • Cocaine

If 1 or more major risk factors OR is unsuitable for monitoring of growth via SFH (e.g. fibroids or BMI > 35) –> serial scans from 28-weeks

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18
Q

Name some minor risk factors for fetal growth restriction.

A
  • Mat age > 35
  • IVF pregnancy
  • Nulliparity
  • BMI < 20 or > 25
  • Smoker 1-10 / day
  • Previous pre-eclampsia
  • Pregnancy interval < 6-months

If 3 or more minor risk factors –> Uterine artery Doppler at 20-week scan

  • If uterine artery is normal –> single scan in 3rd trimester (e.g. 36-weeks)
  • If uterine artery is abnormal –> serial scans from 28-weeks
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19
Q

What can cause fetal growth restriction?

A
  1. Impairment of gas exchange / nutrient delivery to fetus
    • Impaired maternal O2 carrying e.g. heart disease, smoking, haemaglobinopathies)
    • Impaired O2 delivery e.g. vascular disease, HTN, diabetes, autoimmune)
    • Placental dmg e.g. smoking, thrombophilia, pre-eclampsia)
  2. Instrinsic fetal problems
    • Chromosomal (e.g. T21 or T18) or congenital abnormalities
    • Intrauterine infections
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20
Q

What are some of the implications of fetal growth restriction or SGA in the short term and the long term?

A

SGA and FGR implications:

Short term:

  • Premature birth
  • Low Apgar score
  • Hypogyclaemia
  • Hypocalcaemia
  • Hypothermia
  • Polycythaemia
  • Hyperbilirubinaemia

Long term:

  • Learning difficulties
  • Short stature
  • Failure to thrive
  • Cerebral palsy
  • HTN
  • T2DM
  • Heart disease
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21
Q

When are women screened for risk factors of FGR and SGA?

A

Booking appointment

  • Risk factors present –> extra surveillance throughout pregnancy
  • No risk factors present –> screened via SFH throughout pregnancy at each antenatal visit
  • If SFH < 10th centile OR reduced growth velocity on chart / static growth –> refer for growth scan
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22
Q

How is FGR managed?

A
  1. Detailed USS looking for structural abnormalities –> if chromosomal abnormality suspected then offer amniocentesis
  2. Steroids if < 36-weeks –> fetal lung maturity
  3. Surveillance / monitoring
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23
Q

What measures can be taken to prevent FGR?

A
  1. Smoking cessation
  2. Aspirin for women at risk of pre-eclampsia
  3. Appropriate screening
24
Q

What scoring system can be used to assess the health of a newborn baby?

What are the elements of this system?

A

Apgar scoring system

each element is scored 0, 1 or 2, with a higher score being better

  • A - appearance
  • P - pulse
  • G - grimace (reflex irritability)
  • A - activity (muscle tone)
  • R - respiratory effort
25
Q

What opioid medications can be used for labour analgesia?

A

Pethidine (popular)

Diamorphine (increasing popularity)

26
Q

What can be inhaled as a labour analgesic?

A

Nitrous oxide

27
Q

What are some possible side-effects of nitrous oxide?

A
  • Drowsiness
  • Disorientation
  • Nausea
  • Brief TLOC
28
Q

What is given to manage fits due to pre-eclampsia?

A

Magnesium sulphate infusion

29
Q

What are the signs of Magnesium toxicity?

A
  1. Weakness
  2. Confusion
  3. Loss of tendon reflexes (hyporeflexia - due to neuromuscular blockade)
  4. Respiratory depression (RR down)
  5. Low BP
  6. Decrease PTH secretion –> Hypocalcaemia
  7. Arrhythmias
  8. Cardiac arrest
30
Q

What can be given to manage magnesium toxicity?

A
  1. Calcium gluconate - physiological antagonist (action of Ca2+ in neuromuscular + cardiac function opposes Mg2+)
  2. Furosemide IV –> promotes Mg2+ excretion
  3. Haemodialysis
31
Q

What is the max Apgar score?

What is the threshold for normal on Apgar?

A

Max Apgar = 10

Apgar 7 or above = normal

32
Q

In normal pregnancy, the uterine spiral arteries undergo remodelling to become which of the following?

  • High-capacitance, high resistance vessels
  • High-capacitance low resistance vessels
  • High-capacitance low resistance vessels
  • Low- Capacitance, high resistance vessels
  • Low-Capacitance, low resistance vessels
A

High-capacitance low resistance vessels

Failure to do so is a contributing factor to pre-eclampsia

33
Q

How is Post-partum haemorrhage (PPH) defined?

A

PPH = blood loss > 500 ml

from the genital tract within 24-hrs of birth

34
Q

What is primary PPH and what is secondary PPH?

A

Primary PPH:

  • within < 24-hrs of birth
  • ~ 5-7% of deliveries
  • Most common cause = Uterine atony (90%) - loss of uterine muscle tone
    • Normally, contraction of uterine muscles in labour compresses BVs –> reducing flow + increasing likelihood of coagulation (thus preventing haemorrhage) - this process normally continues in the weeks post-delivery
    • Other causes: genital trauma and clotting factors

Secondary PPH:

  • Occurs between 24-hrs and 12-weeks post delivery
  • Often due to retained placental tissue or endometritis (inflammation of inner lining of uterus)
35
Q

What are some risk factors for PPH?

A
  • Hx of PPH
  • prolonged labour
  • multiple pregnancy - same as below
  • High parity (> 5) - multiple pregnancies cause distension of uterus weaking tone and making atony more likely
  • pre-eclampsia
  • increased maternal age
  • polyhydramnios
  • emergency C-section
  • placenta praevia - when placenta partially/totally covers the cervix
  • placenta accreta - placenta grows too deeply into uterina wall
  • macrosomia
  • ritodrine (a beta-2 adrenergic receptor agonist used as uterine relaxant to suppress premature labour)
36
Q

How is PPH managed?

A
  • ABCDE assessment approach
  • Venapucture for:
    • Blood group
    • FBC
    • Coag screen + fibrinogen
  • Fundal massage if PPH due to uterine atony –> causes uterus to contract and clamp off BVs supplying uterus
  • No risk factors + vaginal delivery –> prophylactic IM syntocinon (oxytocin) 10 iu
    • Syntocinon = synthetic oxytocin used in 3rd stage of labour to induce uterine contraction –> reduces risk of PPH
  • C-section delivery –> syntocinon 5 iu via slow IV injection
  • Ergometrine:
    • alternative to oxytocin
    • alpha-adrenergic receptor agonist –> vasoconstriction of vascular SM –> reducing bloos loss
  • Carboprost
    • Synthetic prostaglandin –> induces myometrial contractions –> labour induction + expulsion of placenta
    • Myometrium = muscular middle-layer of uterine wall
    • Used in PPH due to uterine atony not controlled by other means
37
Q

What are Misoprostol and Mifepristone used for?

A

Both Mifepristone and Misoprostol are used in conjunction to terminate pregnancy

  • Mifepristone is used 1st then Misoprostol 24-48hrs after
  • Mifepristone = competitive progesterone receptor antagonist –> altering endometrium –> induces endometrial shedding i.e. bleeding
  • Misoprostol = prostaglandin anologue –> stims uterine contraction
38
Q

What is Antepartum Haemorrhage?

A

Antepartum Haemorrhage = bleeding from genital tract from 24-weeks pregnancy up till birth

39
Q

What are the 2 most important causes of antepartum haemorrhage (APH)?

Note: these are not the most common

A
  1. Placenta Praevia
  2. Placental abruption
40
Q

What is Placenta Praevia?

A

Placenta Praevia = when placenta is lying partially / completely in the lower uterine segment (i.e. potentially covering the cervix)

41
Q

What are the grades of Placenta Praevia and how is it measured?

A

Placenta praevia is measured as distance between the lower placental edge & internal os of the uterine cervix

Grades of Placenta praevia:

  • Grade I - (minor praevia) lower edge inside the lower uterine segment
  • Grade II - (marginal praevia) lower edge reaching internal os
  • Grade III - (partial praevia) placenta partially covers cervix
  • Grade IV - (complete praevia) placental completely covers the cervix
42
Q

How common in placenta praevia?

A

1 in 200 pregnancies at delivery

  • Note: ~5% of pregnancies will have ‘low-lying’ placenta when scanned at 16-20 weeks thus most of the time the placenta moves away from the cervix
43
Q

What are associated risk factors for placenta praevia?

A
  1. Multiparity
  2. Multiple pregnancy
  3. Previous C-section - embryos are more likely to implant on lower segment scar from previous C-section
44
Q

What is placenta accreta?

A

Placenta Accreta = attachment of placenta to myometrium (abnormal) due to defective decidua basalis

  • Risk of PPH as placenta does NOT seperate from uterus during labour
45
Q

What is placental abruption?

A

Placental abruption = seperation of a normally sited placenta from the uterine wall –> results in maternal haemorrhage into intervening space

  • Can cause PV bleeding or internal bleeding
46
Q

What are the clinical features of Placental Abruption?

A
  1. Vaginal bleeding
  2. Shock out of keeping with visible blood loss
  3. Abdo Pain - constant
  4. Uterus - tender + tense
  5. fetal heart - absent/distressed
  6. normal lie and presentation
  7. Complications - DADS:
    • Death
    • AKI
    • DIC
    • Shock
47
Q

Name causes of Antenatal haemorrhage using PPVVCC.

A
  • P - Placental abruption
  • P - Placenta praevia
  • V - Vasa praevia
  • V - Vaginal infection
  • C - Caner of the cervix
  • C - Cervicitis
48
Q

What is Vasa Praevia?

A

Vasa Praevia:

  • Is when unprotected fetal BVs traverse the fetal membranes near the internal OS
    • ​Can be due to velamentous insertion of the umbilical cord i.e. when umbilical cord fails to insert directly into placental body (centre)
    • Can be ude to BVs joining an accessory placental lobe to the main placenta
  • These BVs are at risk of rupture when the supporting membranes rupture, as they are unsupported by the umbilical cord or placental tissue
49
Q

What are the 4 T’s that cause Primary PPH?

A
  • Tone - uterine atony
  • Trauma - e.g. vaginal tear, C-section etc.
  • Tissue - e.g. retained placenta
  • Thrombin - coagulopathy (e.g. von Willebrand disease), eclampsia, clotting issue can lead to DIC
50
Q

Why can breast feeding ASAP be important in PPH?

A

Suckling action leads to oxytocin secretion from posterior pituitary

Oxytocin –> stims uterine contraction (could ↓ PV bleeding)

51
Q

What is involved in ‘Active’ management of 3rd stage of labour to reduce risk of PPH?

A
  1. Cut umbilical cord
  2. Controlled cord traction (pull donwards until placenta visible in vagina then pull upwards)
  3. Oxytocin IM
52
Q

Is placental abruption and obstetric emergency?

A

It CAN be!!

(depends on severity of haemorrhage)

  • If minor –> expectant management
  • If major –> emergency
    • Can cause fetal death in utero
    • Maternal coagulopathy
    • Ischaemia of area of myometrium
53
Q

What are some risk factors for Placental abruption?

A
  • Maternal age < 20-yrs or > 35-yrs
  • Hx of abruption
  • Multiparity
  • Multiple pregnancy
  • Smoking
  • Maternal thrombophilia (hypercoaguability)
  • HTN disorders e.g. pre-eclampsia, chronic HTN, diabetes
  • Abdominal trauma
  • Drug mis-use e.g. cocaine
54
Q

What is the RCOG cut-off distance in cm from the lower edge of the placenta to the internal cervical OS in placenta praevia - beneath which C-section is best?

A

2 cm

< 2cm –> C-section

55
Q

What are the features of Placenta Praevia?

A
  • Can have Painless PV bleeding - small bleeds can be followed by larger ones
  • Lie / presentation can be abnormal
  • No pain
  • Uterus not-tender
  • CTG normal
  • Shock in proportion to visible loss

Year 4 - O&G (12 decks)

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