Placental problems in pregnancy Flashcards
Describe the different stages of pregnancy.
Antepartum: Early (<24 wks) and Late (>24 wks)
Intrapartum: in labour - 1st and 2nd stages
Postpartum: delivery of foetus + 6 wks
What is hyperemesis gravidarum (HG)?
Severe, electrolyte imbalance, causing weight loss and requiring hospital admission
How is HG managed?
Dietary fluids
IV fluids (avoid dextrose)
Thiamine
Antiemetics
What is spontaneous miscarriage?
Foetus dies or delivers dead <24 weeks
majority of these occur <12 weeks, mother is usually older
What % of pregnancies miscarry? What is the biggest reason for this?
20-30%
60% of miscarriages are isolated, non-recurring chromosomal abnormalities
Name the different types of miscarriages.
- Threatened
- Inevitable
- Incomplete
- Complete
- Missed
- Septic
Describe the signs of threatened miscarriage, the state of the foetus and the state of the cervical os.
Signs: light and painless bleeding
Foetus: is still alive
Uterus size: expected from the dates
Cervical os: closed
Describe the signs of inevtiable miscarriage, the state of the foetus and the state of the cervical os.
Signs: heavy bleeding, pelvic pain
Foetus: may still be alive
Os: open
*Miscarriage is about to occur
Describe the signs of incomplete miscarriage, the state of the foetus and the state of the cervical os.
Signs: PV (vaginal) bleeding
Foetus: only some foetal parts have been passed
Os: open
Describe the signs of complete miscarriage, the state of the foetus and the state of the cervical os.
Signs: PV bleeding diminished/stopped
Foetus: all foetal tissues have been passed
Uterus: no longer enlarged
Os: closed
Describe the signs of missed miscarriage, the state of the foetus and the state of the cervical os.
Signs: abdo pain and bleeding minimal
Foetus: has not developed or died in utero - only recognised when bleeding occurs as US performed
Uterus: smaller than expected
Os: closed
Describe the signs of septic miscarriage.
Signs: contents of uterus infected causing endometriosis may have fever
tender uterus
pelvic infection - abdo pain and peritonism
What investigations are carried to out to determine whether a foetus has been/is about to be miscarried?
USS: detects location + viability; may show retained foetal tissue; if any doubt - repeat scan in 1 week
Serum bHCG: normally an increase >66% in 48 h with a VIABLE pregnancy
Bloods: FBC, Rhesus group
How should a (potential) miscarriage be managed?
Expectant: wait for spontaneous resolution
Resuscitation + syntocinon/ergometrine if blood loss is substantial
Pharma: removal of foetal tissue via prostaglandins -(misoprostol)
Surgical: curettage or surgical aspiration
What is considered to be a recurrent miscarriage?
3+ consecutive miscarriages
What are the causes of recurrent miscarriages?
Autoimmune disease = antiphospholipid syndrome
Chromosomal defects in couple
Anatomical factors = uterine septa, cervical incompetence
Infection = bacterial vaginosis
Obesity, age, smoking, drug abuse
What is an ectopic pregnancy? How common is it in the UK?
Embryo that implants outside the uterine cavity
1 in 60-100 pregnancies
What are the risk factors for an ectopic pregnancy?
STIs PID Emergency contraception Pelvic surgery IUCD in situ Failed sterilisation Previous ectopic Congenital abnormalities of tube
What is the typical clinical presentation of a woman with an ectopic pregnancy?
PV bleeding (scanty + dark) Lower abdo pain (initially colicky, but becoming constant) Collapse Amenorrhea for 4-10 weeks (if pt does not know they are pregnant)
What is usually found on examination of a woman with an ectopic pregnancy?
tachycardia abdo tenderness/rebound tenderness cervical tenderness adnexal tenderness uterus smaller than expected cervical os is closed
What investigation should be carried out if a woman is suspected of having an ectopic pregnancy?
Urine bHCG (confirm pregnancy) Transvaginal USS - allows visualisation of intrauterine pregnancy/adnexal mass/ free fluid in pouch of douglas Quantitative serum (bHCG) Diagnostic laparoscopy
What are the management methods for an ectopic pregnancy?
surgical = laparoscopy + salpingectomy/salpingotomy medical = single dose of methotrexate (IM - 50 mg/m2) + serial bHCG levels conservative = if small, unruptured ecptopic with reduced bHCG levels
What is gestational trophoblastic disease (GTD)?
when the trophoblastic tissue that forms part of the blastocyst proliferates more aggressively than normal
(results in molar pregnancy)
What is a hydatiform mole?
mother’s chromosomes are lost
only the paternal chromosomes will remain and duplicate (if monospermic fertilisation) or stay at 46 (if dispermic fertilisation)
Complete mole will just appear as chorionic villi and there will be no foetal tissue
What is a partial mole?
1 egg + 2 sperm = 69 chromosomes
Some foetal tissue is present
What are the clinical features of GTD?
PV bleeding
hyperemesis gravidarum
passage of vesicles per vaginum
What will clinical examination and US of a woman with GTD show?
Clinical examination: uterus often large, early pre-eclampsia; hyperthryoidism
USS: snowstorm appearance
How is a woman with GTD managed?
Evacuation of retained products of conception (ERPC) + send tissue for histology diagnosis
serial bHCG levels (persistent rising nHCG levels suggest malignancy)
What is antepartum haemorrhage and what are the causes?
Bleeding from the genital tract >24 weeks but before delivery of baby
Common causes: undetermined origin, placental abruption, placental praevia
Rare causes: incidental genital tract pathology –> uterine rupture, vasa praevia
What is placental abruption? What are the risk factors?
Painful vaginal bleeding from a normally sited placenta Risk factors: multiparity PIH polyhydramnios ECV trauma smoking malnutrition
What are the clinical features of placental abruption? What investigations should be carried out?
Clinical features: intense abdo pain, tense/tender uterus, foetal parts not easily felt
Investigations: FBC, urea, creatinine, coagulation screen, cross-match blood
USS to rule out placental praevia
CTG (cardiotocography)
What is placental praevia? What are the S+S? What are the different types? What are the risk factors?
= placenta is inserted into lower segment of uterus after 24 weeks S+S: - painless vaginal bleeding - soft non-tender uterus Types: - minor, not covering os - minor, covering os - major, not covering os - major, covering os Risk factors: - twin pregnancies - multiparous - older mothers - scarring of uterus
What are the signs of pre-eclampsia? Why does it occur? What are the risk factors?
Signs: HTN, proteinuria, fluid retention, weight gain
Due to abnormal adaptation to trophoblasts
Risk factors: primigravidity, genetic, multiparous, diabetes
How is hypertension managed?
Mainly: timely delivery of baby
Also: antihypertensives, anticonvulsants
4 hrly BP, daily urinalysis, FBCs, LFTs, CTG etc
What is the chance of having twins/triplets/quadruplets?
Twin: 1 in 80
Triplets: 1 in 6400
Quadruplets: 1 in 512000
What are the different types of twins (in terms of amniotic sac etc) and how do they arise?
Dichorionic/Diamniotic (cleavage of morula at days 1-3)
- either separate/fused placenta
Monochorionic/Diamniotic (cleavage of blastocyst at days 4-8)
Monochorionic/Monoamniotic (cleavage of implanted blastocyst at day 8-13)
Conjoined twins (cleavage of formed embryonic disc at days 13-15)
What complications can arise with twins?
Congenital anomalies
IUGR
Polyhydramnios
Malpresentation
Miscarriage
Preterm labour
Twin to twin transfusion
- vascular communication within placenta (monochorionic pregnancies)
- majority occur 16-24 weeks
- discrepant growth and either oligo/polyhydramnios
- can try to treat with later (70% survival rate)
