Pathologies encountered in pregnancy Flashcards
What factorrs are important in a history of a presenting patient in established pregnancy?
- 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
What factors are important in the examination of a presenting patient in established pregnancy?
- General: collapse, pale, pain clinically shocked
- Per abdomen: abdominal distension, scars
- Per speculum: neck of womb opening? (internal os), bleeding
- Bimanual examination: fibroids? Enlargement?
What factors are important in the investigations of a presenting patient in established pregnancy?
- 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
What are risk factors for a Miscarriage?
- Advanced maternal age
- Previous miscarriage
- Smoking
- Alcohol and drug use (NSAIDs, Aspirin, Street Drugs)
- Folate deficiency (can be iatrogenic if on methotrexate)
- Consanguinity
What is Recurrent Spontaneous Miscarriage?
- Defined as 3 or more consecutive spontaneous abortion with same partner (affects 1% of women)
What are causes of Recurrent Spontaneous Miscarriages?
- 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
What are investigations for Recurrent Spontenous Miscarriages?
- 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
What is Threatened Miscarriage?
- 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
What are symptoms of Missed (delayed) miscarriage?
- 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’
What is Inevitable miscarriage?
- Heavy bleeding with clots and pain
- Cervical (internal) os is open
What is Incomplete Miscarriage?
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
How is a septic miscarriage treated?
Needs swift action with IV antibiotics and surgical removal of tissue
What is a complete miscarriage?
- 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.
What is the Expectant management?
Waiting for spontaneous miscarriage
- 1st line: wait for 7-14 days for miscarriage to complete spontaneously. Needs 24-hour access to gynae services
What are advantages and disadvantages of Expectant management?
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
What is the medical management of Miscarriages?
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
What are advantages and disadvantages of Medical Management of Miscarriages?
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%
What is the surgical management of Miscarriages?
- 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
What are causes of bleeding throughout pregnancy?
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
How is first trimester bleeding managed?
- ≥ 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
What are risks of VTE in pregnancy?
- 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.
What are procoagulant pathophysiological changes in pregnancy?
- 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
When should LMWH be considered antenatally?
- 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
What are risk factors for developing VTE?
- 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
How are VTE risk factors managed in pregnancy?
- 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
What is the anticoagulant of choice in pregnancy?
- 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.
How is a Deep Vein Thrombosis investigated in pregnancy?
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
How is a suspected pulmonary embolism (PE) investigated in pregnancy?
- 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
What are risks of using V/Q scanning and CTPA in pregnancy?
- 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)
How is a PE managed in pregnancy?
- Commence LMWH, TEDS, leg care advice.
- In high risk consider vena cava filters
What is Gestational thrombocytopenia and Immune thrombocytopenia (ITP)?
- 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.
How are Gestational thrombocytopenia and immune thrombocytopenia (ITP) differentiated?
- 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.
How is ITP tested in pregnancy?
- 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.
What is the Rhesus system and its implication on pregnancy?
- 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
How is haemolytic disease of the newborn prevented?
- 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
When should Anti-D immunoglobulin be given?
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
What should happen to babies born to RH -ve mother?
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
What are symptoms of haemolytic disease of the newborn?
- Oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls)
- Jaundice
- Anaemia
- Hepatosplenomegaly
- Heart failure
- Kernicterus
How is haemolytic disease of the newborn managed?
- Transfusions
- UV phototherapy
