Placental Problems in Pregnancy Flashcards
What are the stages of pregnancy?
Antepartum
Intrapartum (in labour)
Postpartum (delivery of fetus up to 6 weeks later)
How long is antepartum?
24 weeks
< 24 weeks = early pregnancy
> 24 weeks = late pregnancy
What is hyperemesis Gravidarum?
- poorly understood
- hCG effects
What are the symptoms of hyperemesis Gravidarum?
- severe nausea/vomiting
- electrolyte imbalance
- weight loss
- hospital admission
What usually happens when there is bleeding in pregnancy?
- 50% will settle
- 50% miscarry, ectopic, gestational trophoblastic disease
What is the definition of a spontaneous miscarriage?
Fetus dies/delivers dead < 24 weeks
What are the types of miscarriage?
- threatened
- inevitable
- incomplete
- complete
- septic
- missed
What is threatened miscarriage?
- light/painless bleeding from vagina
- fetus alive
- cervical os closed
- 25% go on to miscarry
What is an inevitable miscarriage?
- bleeding heavier than threatened
- fetus may be alive
- cervical os open
- miscarriage about to occur
What is an incomplete miscarriage?
- only some fetal parts passed
- cervical os open
- PV bleeding continues
What is a complete miscarriage?
- all fetal tissue passed
- bleeding diminished
- uterus no longer enlarged
- cervical os closed
What is a septic miscarriage?
- uterus contents infected = endometritis
- tender uterus
- fever may be absent
- may progress to pelvic infection
What is a missed miscarriage?
- fetus not developed and died in utero
- cervical os closed
What investigations do you do in a miscarriage?
- US scan (location/viability, restrained fetal tissue)
- serum bHCG (increases >66% in 48hrs if pregnancy viable)
- bloods (FBC and Rhesus)
How do you manage a miscarriage when it is expectant?
- wait for spontaneous resolution
- resuscitation if substantial blood loss
How do you medically manage a miscarriage?
- removal of fetal tissue
- use PG
How do you surgically manage a miscarriage?
Curettage
- scraping instrument/surgical aspiration
What is a recurrent miscarriage?
3 or more consecutive
in 1% of couples
What are the causes of miscarriage?
- autoimmune disease
- chromosomal defects
- hormonal factors
- anatomic factors
- infection
- others - obesity, smoking, maternal age, drug abuse
How do you investigate causes of recurrent miscarriage?
Autoimmune and thrombophilia screen
Karyotyping (parents and products of conception)
How do you manage recurrent miscarriages?
Depends on cause:
- anticoagulation therapy
- genetic counselling
- metformin
- cervical cerclage
What is an ectopic pregnancy?
Implantation of fertilised ovum outside endometrial cavity
- 70% of women have successful pregnancy if ectopic
What are the risk factors of EP?
STIs Emergency Contraception Assisted conception Pelvic surgery Failed sterilisation
What is the clinical presentation of EP?
- women of reproductive age with PV bleeding
- lower abdominal pain
- collapse
- amenorrhoea (4-10 weeks)
- tachycardia
- uterus smaller than expected gestation
- cervical os closed
How is EP investigated?
- uterine bHCG (confirms pregnancy)
- trans-vaginal USS (allows visualisation)
- quantitative spectrum (bHCG if uterus is empty)
- diagnostic laparoscopy
How is EP managed if there is acute presentation?
- patient haemodynamically unstable:
- urgent laparotomy
- salpingectomy (removal of fallopian tube)
How is EP managed if there is subacute presentation?
- surgical (laparoscopy and salpingectomy)
- medical
- conservative
What is molar pregnancy/gestational trophoblastic disease?
- trophoblastic tissue forms part of blastocyst proliferates more aggressively than normal
- hydatiform mole or partial hydatiform
What is a hydatiform mole?
No fetus
Only placenta forms
Cells diploid but all chromosomes derived from father
What is a partial hydatiform?
Some evidence of embryonic development can be found
What are the clinical features of molar pregnancy?
- PV bleeding
- Excess hCG production as secreted by syncytiotrophoblast
- passage of vesicles per vaginum
How does molar pregnancy present?
- large uterus
- early pre-eclampsia and hyperthyroidism
How is molar pregnancy investigated?
- ultrasound = snowstorm appearance
How is molar pregnancy managed?
- tissue histology analysis
- serial bHCG levels
- pregnancy/COCP avoided until bHCG normal
What are the causes of bleeding in early pregnancy?
- spontaneous miscarriage
- recurrent miscarriage
- ectopic pregnancy
- molar pregnancy
What are the causes of bleeding in late pregnancy?
- placental abruption
- placenta praevia
- hypertension in pregnancy
- multiple pregnancy
How does bleeding in late pregnancy present?
> 24 weeks gestation but before delivery
What is placental abruption?
Painful vaginal bleeding normally sites placenta due to placenta partially/completely separating from uterus before baby is born
What are the risk factors of placental abruption?
Trauma, smoking, malnutrition, previous abruption, idiopathic
What are the clinical features of placental abruption?
Intense constant abdominal pain
- with or without vaginal bleeding
- tense, tender uterus
- fetal parts not easily felt
- fetal heart weak/absent
What is placenta praevia?
- placenta inserted into lower segment of uterus after 24 weeks
- can block cervix
What is placenta praevia associated with?
Twin pregnancies
Multiparous women
Older mothers
Scarring of uterus
What is the difference between major and minor placenta praevia?
Major covers os minor does not
What are the clinical features of PP?
- painless vaginal bleeding
- all/part of placenta lies lower than fetal presenting part
- uterus soft and non-tender
What are the complications of PP?
- C section necessary as obstructed womb
- malpresentation of baby
- postpartum haemorrhage as lower part less able to constrict
How is PP examined?
Cannot do vaginal exam!
What is pre-eclampsia?
Hypertension in pregnancy
How does pre-eclampsia present?
- maternal hypertension
- renal impairment = proteinuria
- fluid retention = oedema
- weight gain
What causes pre-eclampsia?
abnormal maternal adaptation to trophoblasts and formation of placental blood vessels
How is pre-eclampsia managed?
- antihypertensives
- anticonvulsants
What is twin to twin transfusion?
Disproportionate blood supply
- affects monochorionic multiples
- laser treatment
- all complications more common
