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
