Obstetrics - Signs and Symptoms Flashcards
Symptoms of pre-eclampsia
Symptoms • Severe headache – usually frontal • Sudden swelling of face, hands, feet • Liver tenderness • Severe pain just below the ribs • Visual disturbance (e.g. blurring or flashing lights in front of the eyes) • Epigastric pain and/or vomiting • SOB • Clonus • HELLP syndrome – haemolysis, Elevated LFTs, Low Platelets • Plt count <100x10^9 • Abnormal LFTs (ALT or AST > 70IU/L) • Papilloedema • Fetal distress - reduced FM • Small for gestational age infant
Signs of pre-eclampsia
Signs
• Look at definition of pre-eclampsia
• Pre-eclampsia: new onset hypertension (>140 mmHg SBP or >90 mmHg DBP) after 20 weeks of pregnancy + co-existence of 1 or more of the following new onset conditions
o Proteinuria (urine protein:creatinine ratio >30 g/mmol or albumin: creatinine ratio >8 mg/mmol or at least 1g/L [2+] protein on dipstick testing or >0.3g in 24 hours) or
o Other maternal organ dysfunction
Renal insufficiency (Cr > 90micromol/L, >1.02mg/100ml)
Liver involvement (raised transaminases – ALT or AST > 40IU/L) with or without RUQ or epigastric abdominal pain
Neurological complications (eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotomata)
Haematological complications (thrombocytopenia (plt < 150.000/microleter), DIC, or haemolysis)
Uteroplacental dysfunction e.g. IUGR, abnormal umbilical artery doppler waveform analysis, stillbirth
- SBP >140 mmHg or DBP >90 mmHg in the second half of pregnancy + >1+ proteinuria on reagent stick testing
- New HTN
• New/significant proteinuria
o (urine protein:creatinine ratio >30 g/mmol or albumin: creatinine ratio >8 mg/mmol or at least 1g/L [2+] protein on dipstick testing)
• Clinical signs of deterioration
o Reduction in plt count – falls below <100x10^9 (predicts severe disease + these women need urgent referral for further investigation)
o Renal insufficiency (Cr > 90micromol/L, >1.02mg/100ml)
o Liver involvement (raised transaminases – ALT or AST > 40IU/L) with or without RUQ or epigastric abdominal pain
o Neurological complications (eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, persistent visual scotomata)
o Haematological complications (thrombocytopenia (plt < 150.000/microleter), DIC, or haemolysis)
Amniotic fluid embolism symptoms + signs
• Entry of amniotic fluid into the maternal circulation
• Amniotic fluid embolises to the pulmonary circulation
• Patient responds with the rapid development of
o Sudden CV collapse
o Acute LVF w/ pulmonary oedema
o DIC
o Neurological impairment
• Classical scenario = older, multiparous woman in advanced labour who suddenly collapses
• Can occur during delivery with high likelihood of collapse + incipient DIC
• RCOG
o Collapse during labour or birth or within 30 minutes of birth in the form of acute hypotension, respiratory distress and acute hypoxia
o Seizures may occur
o Cardiac arrest may occur
• Different phases to disease progression
o Initially – pulmonary hypertension may develop secondary to vascular occlusion either by debris or vasoconstriction
o This often resolves and LV dysfunction or failure develops
o Coagulopathy develops if the mother survives long enough – massive PPH
o If AFE occurs prior to birth – profound fetal distress
Early nonspecific signs • Dyspnoea • Altered consciousness • Sudden anxiety • Restlessness • Fetal bradycardia
Main symptoms • Bleeding diathesis • Respiratory distress • Cyanosis • Hypotension • Seizures
Other possible symptoms • Tachypnoea • Peripheral cyanosis • Bronchospasm • Arrythmias • Uterine atony o Contributes to PPH
Signs of hypoglycaemia in babies + management
o Abnormal muscle tone o Level of consciousness o Fits o Apnoea o Rx – IV dextrose
Ectopic pregnancy symptoms + signs
• Commonly presents in an atypical way – consider the possibility in women of reproductive age
• Symptoms can resemble those of other more common conditions
o UTIs
o GI conditions
• Most common symptoms o Abdominal pain o Pelvic pain o Amenorrhoea or missed period (4-10 weeks) o Vaginal bleeding (+/- clots)
• Other symptoms o Dizziness, fainting, syncope If ruptured circulatory collapse o Breast tenderness o Shoulder tip pain (irritation of the diaphragm from blood etc – irritation of C3,C4,C5 – C3 is the dermatome of the shoulder) o Urinary symptoms o Passage of tissue o Rectal pain or pressure on defecation o GI symptoms e.g. D and or V o (diarrhoea, shoulder tip pain, back pain blood irritates surrounding viscera)
• Hx of previous ectopic pregnancy – after one ectopic pregnancy, the change of another is much increased
• If the ectopic has ruptured
o Profuse bleeding
o Features of hypovolaemic shock – feeling dizzy on standing
o Most bleeding will be into the pelvis – vaginal bleeding may be minimal + misleading
Signs
Common
• Pelvic/abdominal tenderness esp. in RIF or LIF – rebound tenderness +/- guarding
• Vaginal – cervical excitation (pain on manipulating the cervix), Adnexal tenderness +/- mass
Other signs • Rebound tenderness • Cervical tenderness • Pallor • Abdominal distension • Enlarged uterus • Tachycardia +/or hypotension • Shock or collapse
Symptoms and signs of placenta praevia
• Painless bleeding starting after the 24th week of gestation
o Main sign
o Spotting may occur earlier
o Sudden + profuse bleeding that does not last long + therefore is only rarely life-threatening
• Initial pain in approx. 10% of cases with coincidental placental abruption
• Small proportion of cases
o Less dramatic bleeding occurs or
o Does not start until SROM or onset of labour
• Potential signs of shock
Signs
• Incidental finding on routine anomaly USS
• High presenting part or abnormal lie
o May be impossible to push the high presenting part into the pelvic inlet
o In 15% of cases the fetus presents in an oblique or transverse lie
- No indication of fetal distress unless complications occur
- Maternal anaemia
• Highly suggestive of a low-lying placenta but may not be present
o High presenting part
o Abnormal lie
o Painless or bleeding provoked by sexual intercourse
Vasa praevia signs and symptoms
Signs + symptoms
• Typical picture – ROM - fresh PV bleeding + foetal bradycardia
o After the membranes rupture, the vessels alone can’t hold the weight of the baby - bleeding
• Foetal HR abnormalities – decelerations, bradycardia, sinusoidal trace, foetal demise
• O/E
o You can palpate the vessels in the membranes
o Amnioscope can directly visualise the vessels
Placental abruption symptoms + signs
- Vaginal bleeding
- Abdominal pain (usually continuous, RUQ or LUQ)
- Uterine contractions – sustained
- Shock
- Fetal distress
- Mother may be collapsed, fetus may be hypoxic or dead – depends on the degree of detachment + amount of blood loss
• Tense (hypertonic), tender, “woody” feel uterus
o Couvelaire uterus – extravasation of blood into myometrium and beneath peritoneum – very hard uterus
Symptoms + signs of UTI
Symptoms + signs of UTI • Frequency – urinate again <2h after you finished urinating? • Urgency – difficulty postponing urine? • Nocturia • Dysuria • Haematuria • Pelvic or lower back pain • Cloudy urine • Offensive urine • Dyspareunia • Signs of infection
Symptoms + signs of pyelonephritis
- Fever
- N+V
- Upper back pain, often on just one side
Grave’s disease during the first and second trimester
- 1st trimester Deterioration in the clinical features of Grave’s disease stimulation of thyroid by both hCG + thyrotropin receptor-stimulating antibodies
- 2nd trimester improvement in Grave’s disease due to the falling titre of thyroid-stimulating antibodies
Post partum thyroiditis signs and symptoms
• Three stages – thyrotoxicosis hypothyroidism euthyroid
• May present with TFTs showing an initial thyrotoxic pattern
o Swollen thyroid, not painful
o Rapid weight loss, heat intolerance or shakiness
Signs and symptoms of cardiac disease in pregnancy
can mimic the physiological changes of pregnancy (fatigue, SOB, oedema, systolic ejection murmurs)
Red flags for pregnant or recently delivered women presenting with chest pain
- Severe chest pain that radiates to the neck, jaw, back or is associated with other features such as
- Agitation
- Vomiting
- SOB
- Tachycardia
- Tachypnoea
- Orthopnoea
- Acidosis
- RF – smoking, obesity, hypertension
Puerperal cardiomyopathy + myositis/ Peripartum cardiomyopathy symptoms and signs - how do they differ from late pregnancy?
o Late Pregnancy or cardiomyopathy? – SOB, fatigue, ankle oedema
o Raised suspicion for cardiomyopathy – nocturnal dyspnoea, nocturnal cough, chest pain
o Regurgitant murmurs, pulmonary crackles, elevated JVP, hepatomegaly
Signs and symptoms of obstetric cholestasis in pregnancy
o Unexplained pruritus in pregnancy and
o Abnormal LFTs (ALT, AST) and/or
o Raised bile acids
o All of these occur in pregnancy and both resolve after delivery
• Usually presents in the late second trimester to the early third trimester
• Generalised intense pruritus
o Usually starts after the 30th week of pregnancy
o More common in palms and soles – pruritus that involves the palms and soles of the feet is particularly suggestive
o Typically worse at night
• Other symptoms of cholestasis
o Nausea, anorexia, fatigue, RUQ pain, dark urine, pale stool
• Insomnia secondary to pruritus
• Excoriation marks – Scratch marks on the skin from pruritus
• Lipid malabsorption
o Fatty stools due to absorption disorders
o Vitamin K deficiency prolonged prothrombin time + perinatal haemorrhages (e.g. bleeding into the fetal CNS)
• mild jaundice (only a few pregnant women develop jaundice)
Acute fatty liver of pregnancy signs and symptoms
• Most common in third trimester – begins at about 35w
• May appear immediately after delivery
• Prodroma phase – malaise, nausea, vomiting, abdominal pain, fevers, headache, pruritus, influenza-like symptoms
• Jaundice
o Follows the prodromal phase – appears soon after the onset of symptoms
o Can begin abruptly + become intense
• Fulminant liver failure may follow
o Within 1-2 weeks
o Increasing jaundice, hypoglycaemia, development of coagulopathy, ascites/pleural effusions, encephalopathy, acute kidney failure in up to 90% of affected women
• Majority of patients have associated HTN +/- proteinuria at initial presentation (50%)
Liver disease in pregnancy signs and symptoms
• The presenting clinical features of liver disease in pregnancy are often nonspecific and consist of jaundice, nausea, vomiting, and abdominal pain
HELLP syndrome symptoms + signs
• Presentation
o May present at any time in the last half of pregnancy
o Rapid onset
o 70% of cases present before delivery, peaking between 27-37 weeks of gestation
o 30% of women with HELLP syndrome present post-partum, usually within 48h of delivery
• Signs of liver damage
o Hepatomegaly
o Easy bruising/purpura
o Oedema, hypertension, proteinuria
o Tenderness over the liver
• Abnormalities in blood clotting
• Nonspecific symptoms – headache, visual symptoms, malaise, fatigue, RUQ or epigastric pain, N+V, flu-like symptoms
• Exacerbation of symptoms at night
• Relief of symptoms during the day
Anaemia in pregnancy signs and symptoms
• May be asymptomatic • Common symptoms o Fatigue o Dyspnoea/SOB o Dizziness o Pallor o Tachycardia/tachypnoea o Chest pain o Trouble concentrating • B12 specific o Glossitis o Depression o Psychosis/dementia o Paraesthesia o Peripheral neuropathy o Subacute combined degeneration of the spinal cord – loss of proprioception/vibration full paralysis
Oligohydramnios symptoms + signs
- May be discovered incidentally during routine screening or noted during antepartum surveillance for other conditions
- Commonly asymptomatic
- Hx of fluid leak PV, ROM
- Suspicion – discrepancies in sequential fundal height measurements, decreased fundal height or fetal parts that are easily palpated through the maternal abdomen
Polyhydramnios symptoms + signs
• Symptoms of underlying cause
• Large-for-dates uterus
o Increased fundal height
o Tense abdomen
o Acute polyhydramnios – when the uterus enlarges rapidly
Most common in twin pregnancies
Abnormal connecting blood vessels in the twin placenta result in unequal distribution of blood (twin-to-twin transfusion syndrome)
Recipient twin – twin receiving the larger amount of blood supply
Donor twin – twin receiving the smaller amount of blood supply
Recipient twin – produces a large amount of urine + is surrounded by excessive amniotic fluid
o Differential diagnosis for a large for dates uterus – ruled out by an USS
Multiple pregnancy
Fetal macrosomia
Placental abruption
• May cause rapidly expanding uterine size due to the development of intrauterine haematoma (can be concealed or revealed)
• Pain is the predominant symptoms
Chorioangioma
• Benign lesion of the placenta due to excess capillary formation in the absence of villus differentiation
• It may cause a large for dates uterus per se or be associated with polyhydramnios
• Fetal parts difficult to palpate
• Maternal breathlessness (amniotic fluid pressing on diaphragm)
• Early onset of labour or ROM
• Cord prolapse
• Abnormal fetal presentation
Syphilis symptoms and signs
- Anogenital ulcer – Small, painless sores or ulcers that typically appear on the vagina or around the anus – can also occur in the mouth
- Lymphadenopathy
- Diffuse rash – symmetrical, papular or maculopapular rash – secondary syphilis
- Constitutional symptoms – Lethargy, headache, joint pain, fever, lymphadenopathy (secondary syphilis)
- Blotchy red rash that often affects the palms of the hands or soles of the feet
- White patches in mouth
Congenital syphilis symptoms and signs
o Rhinitis (purulent or bloody discharge)
o Hepatosplenomegaly
o Rash, mucous membrane ulceration
o Early (first 2 years) – rash (incl. condylomata lata), vesiculobullous lesions, snuffes, haemorrhagic rhinitis, osteochondritis, periostitis, pseudoparalysis, mucous patches, perioral fissures, hepatosplenomegaly, generalised lymphadenopathy, glomerulonephritis, neurological or ocular involvement, haemolysis, thrombocytopenia
o Late – interstitial keratitis, Clutton’s joints (arthritis of the knees), Hutchinson’s incisors, mulberry molars, high palatal arch, rhagaedes, deafness, frontal bossing, short maxilla, protruberance of mandible, saddle nose deformity, sternoclavicular thickening, paroxysmal
Parvovirus symptoms + signs
- Fever
- Erythema infectiosum (fifth disease, slapped cheek syndrome)
- Generalised rash illness as seen in rubella
- Aplastic crises in patients with increased cell turnover
- Arthropathy
Clinical features may be indistinguishable from rubella
Viral infections that commonly present with a generalised rash illness in the UK
- Parvovirus B19
- Measles
- Rubella
- Varicella
- HHV-6, HHV-7
- Enterovirus
- (CMV + EBV rarely present as a rash but should be included as differential diagnoses)
Maculopapular rash/ Non-vesicular
- Measles
- Rubella
- Parvovirus B19
Vesicular rash
- Chicken pox
* Shingles
GBS mum sx
• Often asymptomatic until incidental finding
Early onset GBS sx
- Noisy breathing and grunting
- Increased RR, increased work of breathing
- Become very sleepy or unresponsive
- Constantly cry and seem distressed
- Unusually floppy
- Do not feed well
- Has had an abnormal temperature unexplained by environmental factors (<36, >38)
- Has a change in skin colour or have blotchy skin
- Tachycardia or bradycardia
Late onset GBS sx
• Similar to those associated with early-onset infection
GBS neonate infection red flags
- IAP for confirmed/suspected sepsis (not for GBS prophylaxis)
- Respiratory distress starting >4h PP
- Seizures
- Need for mechanical ventilation in a term baby
- Signs of shock
Chickenpox sigs and symptoms in mother + baby
• Incubation period = 7-21 days (most commonly 10-14 days)
• Mother
o Prodroma fever, malaise, myalgia
o Generalised rash (macular popular vesicular; different lesions at different stages)
• Baby
o Loss of red reflex = rubella, VZV
Rubella signs and symptoms in mother
o Prodromal phase of – lassitude, low-grade fever, mild conjunctivitis, coryzal symptoms
o Maculaopapular rash
Starts behind ears, spreads to head and neck then to rest of the body
o Posterior auricular lymphadenopathy
o Arthralgia, affecting mostly the wrist + joints of the hand
o Malaise in children, adults tend to feel more unwell
o Soft palate lesions (20% with Frochheimer spots)
Congenital rubella syndrome sx + signs
Congenital rubella syndrome
Transient
o IUGR
o Thrombocytopenic purpura (25% - blueberry skin), haemolytic anaemia, hepatosplenomegaly, jaundice
o Radiolucent bone disease (20%)
o Meningoencephalitis (25%) +/- neurological sequelae
Developmental
o Sensorineural deafness (80%, variable, unilateral or bilateral)
o General learning disability (55%)
o Insulin-dependent diabetes (20% - immune-related but often delayed to adolescence or adulthood)
o Late onset disease at 3-12 months – rash, diarrhoea, pneumonitis – high mortality
Permanent
o Congenital heart disease (patent ductus arteriosus or peripheral pulmonary artery stenosis)
o Eye defects – cataracts, congenital glaucoma, pigmentary retinopathy (50% “salt and pepper”), severe myopia, microphthalmia , chorioretinitis, blindness
o Microcephaly
CMV signs and sx in babies
Babies
• 10-15% of neonates with congenital CMV will by symptomatic at birth 65% have SNHL
• 90% will be asymptomatic or have subclinical manifestations of the disease 6-23% later develop some degree of SNHL
o Most children infected in utero appear healthy but may manifest late sequelae (sensorineural hearing loss, mental retardation, cerebral palsy)
• Congenital CMV at birth
o Peri-ventricular calcification
o Jaundice, splenomegaly, petechiae (blueberry muffin rash, thrombocytopenia), IUGR, microcephaly, retinitis
o Complications - Moderate to severe LD, Neurological abnormalities, Hearing loss
• CMV excretion – common in children with congenital infection, may represent a reservoir for infection of other children + day care workers
Listeria maternal infection during pregnancy
• Maternal infection during pregnancy
o early in pregnancy – miscarriage
o late in pregnancy – stillbirth or death of the infant within a few hours of birth
o can be asymptomatic or
o fever, myalgia, headache, sore throat, cough, D+V, vaginitis
o meconium staining
Infants with listeriosis sx
o poor feeding, lethargy, jaundice, vomiting, respiratory distress, skin rash, shock
o usually have pneumonia
o very high death rate
o infants presenting at age 5 days or older – often present with meningitis
Toxoplasmosis infection in pregnancy mother symptoms
Congenital infection in immunocompetent patients
• Mother
o Asymptomatic mother
o Some may have malaise and lymphadenopathy, rarely chorioretinitis, fever, arthralgia
o Some people get flu-like symptoms – high temperature, aching muscles, tiredness, feeling sick, sore throat, swollen glands
Toxoplasmosis infection in pregnancy fetus symptoms
• Fetus
o Fetal consequences are more severe if infection takes place within the first 10 weeks of conception
o May have no apparent symptoms at birth, with complications developing only later in life
o Neonatal features of infection – hydrocephalus, microcephaly, intracranial calcification, epilepsy, developmental delay, chorioretinitis, strabismus, severe sight impairment, thrombocytopenia, anaemia
o Classic triad of congenital infection/ the 4 C’s of toxoplasmosis – chorioretinitis, intracranial calcifications*, hydrocephalus, convulsions, hepatosplenomegaly/jaundice
o *intracranial calcifications scattered throughout the brain (unlike CMV, which is peri-ventricular)
Congenital
Neonatal
Congenital
• Rare but more likely in mothers who have disseminated herpes infection
• IU transmission is greatest during the first half of the pregnancy
• Most congenital herpes infections are due to HSV-2
• Can cause miscarriage, stillbirth, microcephaly, hydrocephalus, chorioretinitis, vesicular skin lesions
• High perinatal mortality (50%)
Neonatal
• Appear 2 days – 6 weeks after delivery
• Nonspecific signs + no mucocutaneous involvement
• Rarely a hx of maternal infection
Localised
Local CNS
Disseminated
Localised infection – skin, eyes or mouth (SEM) – 45%
• Blistering vesicular rash
• Vesicles at the presenting part or at sites of minor trauma e.g. scalp electrode
• Chorioretinitis
• Might progress to CNS or disseminated infection if not treated with IV acyclovir
Local CNS disease +/- SEM – 30%
• Often present late (generally between 10 days and 4 weeks of age)
• +/- skin, eye or mouth involvement
• Lethargy, feeding difficulty, seizures, irritability, bulging fontanelle, temperature instability
Disseminated infection involving multiple organs – 25% • Encephalitis (60-70%) • CNS (60-75%) • Hepatitis • Pneumonitis • Jaundice • Hepatosplenomegaly • DIC • No skin lesions
HDN haemolytic disease of the newborn, rhesus disease signs + symptoms AN
Antenatally
• Presence of anti-D antibodies in the mother (Coomb’s test)
• Hydrops fetalis
o Antenatally polyhydramnios
o Postnatally SC oedema, pericardial effusion, ascites, hepatosplenomegaly
o Thickened placenta
HDN haemolytic disease of the newborn, rhesus disease signs + symptoms in infants
Signs in infants
• Mild cases – may appear clinically normal
• Jaundice (yellow amniotic fluid, yellow vermix, yellow skin)
• Pallor
• Hepatosplenomegaly
• Hydrops fetalis
• Hypoglycaemia
Infants born after intrauterine transfusion prenatally
• High levels of cord bilirubin
Severe signs • Kernicterus (bilirubin encephalopathy) • Pallor • Hepatosplenomegaly • Oedema • Petechiae • Ascites
Multiple pregnancy signs and symptoms
• 1st trimester o Diagnosed in the first trimester by US Lambda sign = dichorionic diamniotic T sign = monochorionic diamniotic o Exaggerated pregnancy-related symptoms e.g. hyperemesis • 2nd trimester o Uterus might be palpable abdominally earlier than 12 weeks of gestation o Large for dates o Multiple parts on abdominal exam • In the second half of pregnancy, may present with o Large-for-dates uterine size o Higher than expected weight gain o >2 fetal poles on palpation o >2 FHR on auscultation • Abdominal exam o Increased SFH o Multiple parts o >1 FH
Prolonged pregnancy signs and symptoms
• Post-term neonate
o Lower amount of SC fat
o Reduced mass of soft tissue
o loose skin, flaky and dry
o fingernails + toenails may be longer than usual + stained yellow from meconium
• RFM
• Oligohydramnios – reduction in the size of the uterus
• Meconium stained amniotic fluid might be seen after SROM
Signs of shoulder dystocia
- Difficulty with delivery of face + chin
- Turtle-neck sign/ turtling neck – head appears but then retracts
- Failure of restitution of the head (when the shoulder turns) (difficulty or failure to accomplish external rotation of the head after it has passed the perineum)
- Failure of shoulder to descent (resistance to delivery of the anterior shoulder with the usual amount of traction applied to the fetal head)
