Placental problems in Pregnancy Flashcards
what does antepartum mean
occurring not long before childbirth.
what are the weak defining early and late antepartum
- Early<24 weeks
- Late>24 weeks
what does intrapartum mean
In labour- first and second stages
what does postpartum mean
From delivery of the fetus until 6 weeks later
what happens in the 3rd stage of labour
- placenta has been exepelled
what is hypermesis agravidarum
this is severe nausea and vomiting
how many women are affected by nausea and vomiting in pregnancy
affects 70-80% of women in early pregnancy
what can happen in severe hyeremesis gravidarium
Electrolyte imbalance
Weight loss
Hospital admission
what do people with hyperemesis gravidarium tend to have
- High amounts of beta HCG
- high placenta weight
what is thought to cause hyperemesis gravidarium
bHCG: Stimulating affects in upper GI tract
Reduced stomach motility and gastric emptying
How do you manage hyperemsis gravidarium
- correction of dehydration and electrolyte imbalance
- prophylaxis against complications
- provision of symptom release
admit if
- symptoms severe despite 24 hours of medication
- evidence of dehydration and ketosis
- coexisting conditions such as diabetes
what percentage does bleeding effect pregnancies
- complicates 25% of all pregnancies
- 50% will settle
- 50% will miscarry, ectopic, trophoblastic disease or have problems in late pregnancy
what is the definition of a spontaneous miscarriage
Fetus dies or delivers dead < 24 weeks
when do the majority of spontaneous miscarriages occur
Majority < 12 weeks
- more common in older women
why do spontaneous miscarriages tend to occur
20-30% of all pregnancies
60% due to chromosomal abnormalities
what does not cause miscarriage
Exercise, intercourse, emotional trauma
what are the 6 types of miscarriage
Threatened Inevitable Incomplete Complete Septic Missed
What is a threatened miscarriage
light/painless bleeding from vagina (PV).
Fetus is alive, cervical os is closed.
o 25% will go on to miscarry.
what is an inevitable miscarriage
bleeding heavier vs threatened.
Fetus may be alive at this point, cervical os is open.
o (!) Miscarriage about to occur.
what is an incomplete misccarige
only some of the fetal parts have passed.
Cervical os is open.
PV bleeding continues.
what is a complete miscarriage
All fetal tissues have been passed.
Bleeding has diminished stopped.
Uterus no longer enlarged, cervical os is closed.
What is a septic miscarriage
contents of uterus infected = endometritis or chorioamnionitis.
Tender uterus, fever may be absent.
May progress to pelvic infection.
What is an missed misccarige
Fetus has not developed and died in utero.
o Cervical os is closed.
what are the symptoms of a septic miscarriage
- Contents of uterus infected causing endometritis
- Vaginal loss offensive
- Tender uterus
- May be present with sings of pelvic infection
what are the investigations that you do in a miscarriage
Ultrasound scan
- Detects the location and viability – may show retained tissue, if any doubt repeat scan after 1 week (NICE)
Serum B HCG
- Increases in greater than 66% in 48 jrs in viable pregnancy
Other bloods
- FBC
- G+ S
- Rhesus status - give Anti D to rhesus negative women
How do you manage a miscarriage
Expectant
Wait for spontaneous resolution
o Resuscitation if blood loss is substantial
Medical Management
Removal of fetal tissue (using prostaglandins such as misoprostol).
Surgical Management
Curettage (scraping instrument)/surgical aspiration.= this can cause scarring of the womb which will cause fertility problems
= done under ultrasound guidance
what is recurrent miscarriage
3 or more consecutive miscarriages
Affects 1% of couples
What are the causes of a recurrent miscarriage
- problems in the uterine cavity e.g. large fibroids
Autoimmune disease (e.g. anti-phospholipid syndrome): 25%.
Chromosomal defects (4%).
Hormonal factors
Infection.
Others (obesity, smoking, maternal age, drug abuse.
How do you investigate a recurrent miscarriage
Autoimmune + thrombophilia screen
Karyotyping(of maternal and paternal causes)
Pelvic US scan
How do you manage a recurrent miscarriage
Depends on cause (anticoagulation theraphy, genetic counselling, metformin, cervical cerclage etc..).
what is cervical incompetence a cause of
- it is a cause of mid-trimester miscarriage
what is cervical incompetence
- this is when the cervix opens up too early and the foetus has passed
- scan now looks at people who are high risk or have had a pre-term and trimester
- can put a stitch in the cervix
what two stitches can you put in the cervix in cervical incompetence
- abdominal cerclage
- Vaginal cerclage
- Vaginal one can be snipped out and then there can be a vaginal birth whereas the abdominal one the baby has to be born by C section
What is an ectopic pregnancy
Implantation of the fertilised ovum outside the endometrial cavity.
What are the risk factors for an ectopic pregnancy
- Smoking
- Scarring in womb and previous structures
- Previous ectopic – 10-15% chance that you will have another
- STIs
- Emergency contraction
- IVF
- Pelvic surgery
- IUCD in situ
what are ectopics commonly found
Fallopian tube
- can be in the ampulla or isthmus or interstitial(junction between the tube and endometrial cavity
How do women present with ectopic pregnancies
- Women of reproductive age
- Positive pregnancy test/ Amenorrhoea 4-10 weeks
- PV bleeding
- Low abdo pain
- Collapse +/- shoulder tip pain
What would you find on examination of a ectopic pregnancy
Tachycardia, abdominal tenderness.
Uterus is smaller than expected gestation
Cervical os is closed.
How do you investigate an ectopic pregnancy
Uterine bHCG: confirms pregnancy
Trans-vaginal USS: allows visualisation.
Quantitative spectrum: bHCG if the uterus is empty.
Diagnostic Laparoscopy
How do you manage an ectopic pregnancy
Acute Presentation: if patient is haemodynamically unstable; urgent laparotomy and salpingectomy (removal
of the fallopian tube).
Subacute Presentation: various ways of treatment:
Surgical: laparoscopy and salpingectomy/salpingectomy.
Medical
Conservative
What is gestational trophoblastic disease
When the trophoblastic tissue that forms part of the blastocyst proliferates more aggressively than normal
who is gestational trophoblastic disease common in
More common at extremes of reproductive age
Twice as common in Asian women than Caucasian women
what are the types of gestational trophoblastic disease
complete molar pregnancy
partial molar pregnancy
What happens in a complete molar pregnancy
Hydatidiform mole: no fetus, only the placenta forms.
Cell are diploid but all chromosomes are derived from the father. ( no maternal chromosomes)
- sperm from the father fertilises an empty egg
5-10% will turn malignant
- excessive amounts of bHCG can be produced .
what do you manage the complete molar pregnancy
- surgery to remove the molar tissue
- 15% of molar tissue remains in the deeper tissue of the body and this can result in a gestational tumour
- need to have chemotherapy to get rid of it
what is a partial molar pregnancy
- some foetal tissue might be seen within the molar tissue
- ## two sperm fertilise the egg at the same time therefore there is one set of chromosomes from the mother and two from the father
How do you manage a partial molar pregnancy
- surgery to remove the molar tissue
- only 1% will have abnormal cells remaining in the deep tissue and have a persistent gestational tumour - this will need to have chemotherapy to get rid of it
What are the clinical features of a molar pregnancy
PV Bleeding
HG (excess HCG production)
o HCG secreted by syncytiotrophoblast.
Passage of vesicles per vaginum.
How would you investigate a molar pregnancy
Investigations
Ultrasound: snowstorm appearance.
What would you see on examination of a molar pregnancy
Examination
Large uterus
Early pre-eclampsia and hyperthyroidism may occur.
How else do you manage a molar pregnancy
ERCP + tissue for histology
Serial HCG: To detect persistent disease
Avoid pregnancy until HCG levels 0: otherwise increase need for chemotherapy
what is an antepartum haemorrhage
This is bleeding from the genital tract at >24 weeks gestation
what are the causes of an antepartum haemorrhage
Placenta abruption Placental praevia Incidental genital tract pathology Uterine rupture Vasa praevia
What is placental abruption
- painful vaginal bleed from a normally sited placenta due to placenta partially/completely from the uterus before the baby is born
- can be concealed, revealed or mixed
what are the risk factors for placenta abruption
- Prev abruption,
- ↑ BP, Trauma
- Smoking
- idiopathic
- Multiparity
- ECV
- Polyhydramnios
Why are the clinical features of placental abruption
- Intense constant abdo pain
- +/- PV bleeding
- Shock, Oliguria, DIC
- Tense ‘woody’ uterus
- Fetal heart rate weak or absent
what is the management of a placental abruption
- deliver the baby
- Stabilise mother first
- Admit and resuscitate
- Steroids in <39 weeks if time permits
- Anti D + Kleihauer
- Fetal distress: Urgent LSCS
- Dead baby: Coagulopathy likely, IOL when safe
- Conservative: If not fetal or maternal distress. Steroids and observe
what is a placenta praaevia
When the placenta is inserted into the lower segment of the uterus after 24 weeks
what are the two different types of a placenta praaevia and what is the difference between them
Major PP: covers the os
Minor PP: does not cover the os. (less than 2cm from the internal os)
what are the risk factors of a placenta praevai
Prior praevia
Multiparity
Multiple pregnancy
Advanced maternal age
Prev LSCS
Smoking
what are the clinical signs of a placenta praevia
- Painless vaginal bleeding: usually between 32-37 weeks
- Uterus soft and non tender
- Malpresentation is common
- Requires c section delivery
- May result in pre-term delivery
what do you not do in a placenta praaevia
no vagial examination
What is a placenta acreta
this is when the placenta Does not attach to the endometrium and goes further in for example to the myometrium
what is the management of the placenta acreta
Admit if bleeding
- IV Line, x match 4-6 units blood
- Anti D if rhesus negative
- If mother and baby stable, manage expectantly
- Consider antenatal steroids
- If maternal/fetal compromise/ >37 weeks: EMCS
- Consider Caesarean hysterectomy
What is pre-eclampsia
Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys
what is pre-eclampsia due to
• Due to abnormal maternal adaptation to trophoblasts and formation of placental blood vessels.
what is pre-eclamspia characterised by
- Maternal hypertension.
- Renal impairment; causing proteinuria.
- Fluid retention; oedema.
- Weight gain.
What are the risk factors for pre-eclampsia
- age
- previous
- diabetes
- obesity
- hypertension
- autoimmune diseases
- sickle cell disease
- high age gap between pregnancies e.g. not having a pregnancy for 10 years
placental abnormalities
- hypoxia
- ischemia repercussion injury
- damage to the placental vili
what are the signs and symptoms of pre eclampsia
- Headaches
- Seeing spots
- Stomach pain
- Feeling nausea and throwing up
How do you manage pre-eclampsia
Aim Bp<135/85
Monitor fetal growth
Anti-hypertensives + anti-convulsants
Timely delivery
what causes monozygotic twins versus what causes dizygotic twins
Monozygotic: chance event
Dizygotic: Racial predisposition, IVF, Parity >5, Older ages
when does twin to twin transfusion happen
Only in mono-chorionic pregnancies
16-24 weeks most common
Discrepant growth and liquor volume
how do you treat twin to twin transfusion
have laser treatment that is used to ablate anastomosing vessels
- has a 70% survival
