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Year 4k: Obs and Gynae > Pathologies encountered in pregnancy > Flashcards

Pathologies encountered in pregnancy Flashcards

1
Q

What factorrs are important in a history of a presenting patient in established pregnancy?

A
  • Presenting Complaint
  • Past Obstetric history
  • PGHx – establish gestation: LMNP, cycle (K), previous ectopic/miscarriage
  • PMHx – anything significant
  • DHx – any teratogenic medication
  • Fhx – inheritable disease
  • SHx – consanguineous marriage, smoker, drugs
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2
Q

What factors are important in the examination of a presenting patient in established pregnancy?

A
  • General: collapse, pale, pain clinically shocked
  • Per abdomen: abdominal distension, scars
  • Per speculum: neck of womb opening? (internal os), bleeding
  • Bimanual examination: fibroids? Enlargement?
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3
Q

What factors are important in the investigations of a presenting patient in established pregnancy?

A
  • Urine pregnancy test
  • USS – TA vs TV
  • If need to exclude ectopic: serum beta-hcg
    • Discriminatory level >1500
    • Serial measurement – doubling time/rate of change (63% rise in 48 hours)
  • Group & Save – blood group + Rh status
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4
Q

What are risk factors for a Miscarriage?

A
  • Advanced maternal age
  • Previous miscarriage
  • Smoking
  • Alcohol and drug use (NSAIDs, Aspirin, Street Drugs)
  • Folate deficiency (can be iatrogenic if on methotrexate)
  • Consanguinity
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5
Q

What is Recurrent Spontaneous Miscarriage?

A
  • Defined as 3 or more consecutive spontaneous abortion with same partner (affects 1% of women)
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6
Q

What are causes of Recurrent Spontaneous Miscarriages?

A
  • Antiphospholipid syndrome
  • Endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome
  • Uterine abnormality: e.g. uterine septum
  • Parental chromosomal abnormalities: Robertsonian translocations
  • Smoking
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7
Q

What are investigations for Recurrent Spontenous Miscarriages?

A
  • Imaging: Ultrasound, 3D ultrasound, laparoscopy, hysteroscopy
  • Blood tests: measures hormones associated with pregnancy, anti-phospholipid antibody, lupus anticoagulant
  • Karyotyping
  • Thrombophilia screen
  • Screening for bacterial vaginosis
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8
Q

What is Threatened Miscarriage?

A
  • Bleeding and/or pain up to 24 weeks but typically 6-9 weeks (often less than menstrual bleeding).
  • Cervical os is closed
  • Complicates up to 25% of all pregnancies
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9
Q

What are symptoms of Missed (delayed) miscarriage?

A
  • Gestational sac which contains dead foetus before 20 weeks without symptoms of expulsion.
  • No cardiac pulsation on USS
  • Mother may have light vaginal bleeding/discharge and symptoms of pregnancy which disappear. Pain is usually not a feature
  • Cervical os is closed
  • When the gestational sac is > 25 mm and no embryonic/fetal part can be seen it is sometimes described as a ‘blighted ovum’ or ‘anembryonic pregnancy’
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10
Q

What is Inevitable miscarriage?

A
  • Heavy bleeding with clots and pain
  • Cervical (internal) os is open
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11
Q

What is Incomplete Miscarriage?

A

Not all products of conception have been expelled

  • Pain and vaginal bleeding
  • Cervical os is open
  • Can become septic miscarriage if any signs of infection present.
  • On USS, echogenic mass of blood clot and tissue within uterine cavity >20mm in AP diameter
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12
Q

How is a septic miscarriage treated?

A

Needs swift action with IV antibiotics and surgical removal of tissue

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13
Q

What is a complete miscarriage?

A
  • All products of conception have passed.
  • Complete sac may be identifiable which may look pale like colour of chicken
  • Cervix is closed.
  • Bleeding and pain are reducing.
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14
Q

What is the Expectant management?

A

Waiting for spontaneous miscarriage

  • 1st line: wait for 7-14 days for miscarriage to complete spontaneously. Needs 24-hour access to gynae services
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15
Q

What are advantages and disadvantages of Expectant management?

A

Advantages

  • Avoid risks of surgery/medication
  • Can be at home

Disadvantages

  • Pain and bleeding can be unpredictable
  • Worries of rebleeding at home
  • Takes longer
  • May be unsuccessful
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16
Q

What is the medical management of Miscarriages?

A

Using tablets to speed up miscarriage

  • Vaginal misoprostol: Prostaglandin analogue, binds to myometrial cells to cause strong myometrial contractions leading to the expulsion of tissue
    • Addition of oral mifepristone not recommended by NICE

Advice to contact doctor if the bleeding hasn’t started in 24 hours. Should be given antiemetics and pain relief

17
Q

What are advantages and disadvantages of Medical Management of Miscarriages?

A

Advantages of medical management

  • Avoid surgery
  • High patient satisfaction if successful
  • Can be done as an outpatient

Disadvantages of medical management

  • Pain and bleeding may be unpleasant
  • Side effect of drugs
  • Need for emergency SERPC <5%
18
Q

What is the surgical management of Miscarriages?

A
  • Vacuum aspiration (suction curettage): Done under local anaesthetic as outpatient or under GA as 5-minute procedure.
  • Surgical management in theatre: Done under general anaesthetic in theatre
19
Q

What are causes of bleeding throughout pregnancy?

A

1st Trimester

  • Spontaneous abortion
  • Ectopic pregnancy
  • Hydatidiform mole
  • Implantation bleeding

2nd Trimester

  • Spontaneous abortion
  • Hydatidiform mole
  • Placental abruption

3rd trimester

  • Bloody show
  • Placental abruption
  • Placenta praevia
  • Vasa praevia
20
Q

How is first trimester bleeding managed?

A
  • ≥ 6 weeks gestation: Refer to an early pregnancy assessment service
  • <6 weeks gestation: If NO pain or risk factors for ectopic pregnancy, then they can be managed expectantly. These women should be advised:
    • To return if bleeding continues or pain develops
    • Repeat a urine pregnancy test after 7–10 days and to return if it is positive. Negative pregnancy test means that the pregnancy has miscarried
21
Q

What are risks of VTE in pregnancy?

A
  • Leading cause of maternal death. Absolute risk is 1:1000. Pregnancy increases the relative risk by 4-6 folds
  • Pregnancy is risk factor for developing VTE and individual risk assessment for VTE should be completed at booking and subsequent hospital admissions.
22
Q

What are procoagulant pathophysiological changes in pregnancy?

A
  • Hypercoagulable state
  • Increase in fibrinogen and factors 8, 9 and 10
  • Concentration of endogenous anticoagulants decrease
  • Increased additional risk is present for at least 6 weeks postpartum
  • Venous stasis in lower limbs
  • Trauma of pelvic vein at the time of delivery
23
Q

When should LMWH be considered antenatally?

A
  • In a woman with previous VTE history as she is considered high risk
  • In a woman at intermediate risk of developing VTE due to hospitalisation, surgery, co-morbidities or thrombophilia
24
Q

What are risk factors for developing VTE?

A
  • Age >35
  • Body Mass index >30
  • Parity >3
  • Smoker
  • Gross varicose veins
  • Current pre-eclampsia
  • Immobility
  • Family history of unprovoked VTE
  • Low risk thrombophilia
  • Multiple pregnancy
  • IVF pregnancy
25
Q

How are VTE risk factors managed in pregnancy?

A
  • Four or more risk factors warrants immediate treatment with LMWH and continued until six weeks post-natal
  • If there are 3 risk factors, LMWH should be initiated from 28 weeks and continued until six weeks post-natal
26
Q

What is the anticoagulant of choice in pregnancy?

A
  • Low molecular weight heparin (LMWH) is the treatment of choice for VTE prophylaxis in pregnancy.
  • Direct Oral Anticoagulants (DOACs) and Warfarin should be avoided in pregnancy.
27
Q

How is a Deep Vein Thrombosis investigated in pregnancy?

A

Gold standard is Compression duplex ultrasound

  • Left sided DVT is more common in pregnancy. Clinical feature are unreliable.
  • Doppler ultrasound of leg veins undertaken if clinical suspicion of DVT.
  • If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 months as in other patients with provoked DVT
28
Q

How is a suspected pulmonary embolism (PE) investigated in pregnancy?

A
  • ECG and chest x-ray should be performed in all patients.
  • Bloods may show leucocytosis but D-dimer of limited use in pregnancy
  • ABG may show hypocapnia +/- hypoxaemia
  • In women who also have symptoms and signs of DVT, compression duplex ultrasound should be performed.
  • Decision to perform a V/Q (done if X-ray normal) or CTPA (done if x-ray abnormal) should be taken at a local level after discussion with the patient and radiologist
29
Q

What are risks of using V/Q scanning and CTPA in pregnancy?

A
  • CTPA slightly increases the lifetime risk of maternal breast cancer (increased by up to 13.6%, background risk of 1/200 for study population). Pregnancy makes breast tissue particularly sensitive to the effects of radiation
  • V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA (1/50,000 versus less than 1/1,000,000)
30
Q

How is a PE managed in pregnancy?

A
  • Commence LMWH, TEDS, leg care advice.
  • In high risk consider vena cava filters
31
Q

What is Gestational thrombocytopenia and Immune thrombocytopenia (ITP)?

A
  • Gestational thrombocytopenia: Relatively common condition of pregnancy that results from a combination of dilution, decreased production and increased destruction of platelets. The latter is thought to be due to the increased work of the maternal spleen leading to mild sequestration.
  • Immune thrombocytopenia (ITP): Autoimmune condition that is usually associated with acute purpuric episodes in children, but a chronic relapsing course may be seen more frequently in women.
32
Q

How are Gestational thrombocytopenia and immune thrombocytopenia (ITP) differentiated?

A
  • Gestational thrombocytopenia may be considered more likely if the platelet count continues to fall as pregnancy progresses, but this is not a reliable sign.
  • If the patient becomes dangerously thrombocytopenic, she will usually be treated with steroids and a diagnosis of ITP assumed.
33
Q

How is ITP tested in pregnancy?

A
  • Pregnant women found to have low platelets during a booking visit or those with a previous diagnosis of ITP may need to be tested for serum antiplatelet antibodies for confirmation
  • Gestational thrombocytopenia does not affect the neonate, but ITP can do if maternal antibodies cross the placenta.
  • Depending on the degree of thrombocytopenia in the newborn, platelet transfusions may be indicated. Serial platelet counts can also be performed to see whether there is an inherited thrombocytopenia.
34
Q

What is the Rhesus system and its implication on pregnancy?

A
  • The rhesus system is the most important antigen found on red blood cells. The D antigen is the most important antigen of the rhesus system. Around 15% of mothers are rhesus negative (Rh -ve)
  • If a Rh-ve mother delivers a Rh +ve child a leak of foetal red blood cells may occur. This causes anti-D IgG antibodies to form in mother. In later pregnancies these can cross placenta and cause haemolysis in fetus
  • This can also occur in the first pregnancy due to leaks
35
Q

How is haemolytic disease of the newborn prevented?

A
  • Test for D antibodies in all Rh -ve mothers at booking
  • Advise giving anti-D to non-sensitised Rh -ve mothers at 28 and 34 weeks
  • Anti-D is prophylaxis - once sensitization has occurred it is irreversible
  • If event is in 2nd/3rd trimester give large dose of anti-D and perform Kleihauer test - determines proportion of fetal RBCs present
36
Q

When should Anti-D immunoglobulin be given?

A

Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations:

  • Delivery of a Rh +ve infant, whether live or stillborn
  • Any termination of pregnancy
  • Miscarriage if gestation is > 12 weeks
  • Ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required)
  • External cephalic version
  • Antepartum haemorrhage
  • Amniocentesis, chorionic villus sampling, foetal blood sampling
  • Abdominal trauma
37
Q

What should happen to babies born to RH -ve mother?

A

All babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test

  • Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby
  • Kleihauer test: add acid to maternal blood, fetal cells are resistant
38
Q

What are symptoms of haemolytic disease of the newborn?

A
  • Oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
  • Jaundice
  • Anaemia
  • Hepatosplenomegaly
  • Heart failure
  • Kernicterus
39
Q

How is haemolytic disease of the newborn managed?

A
  • Transfusions
  • UV phototherapy

Year 4k: Obs and Gynae (19 decks)

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