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reproductive system > pregnancy complications > Flashcards

pregnancy complications Flashcards

1
Q

what is miscarriage

A

spontaneous loss of pregnancy before 24 weeks gestation (15%)

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2
Q

list the types of miscarriage

A

threatened

inevitable

incomplete

complete

septic

missed

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3
Q

describe the types of miscarriage

A

threatened: viable pregnancy, vaginal bleeding +/- pain, closed cervix
inevitable: viable pregnancy, heavy bleeding +/- clots, open cervix
incomplete: most of pregnancy is expelled out, (heavy) bleeding, open cervix
complete: passed out all products of conception, bleeding stopped, closed cervix

septic:

missed: asymptomatic, brown discharge, no clear foetus (empty gestational sac) or foetal pole with no ♡

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4
Q

what is the aetiology of spontaneous miscarriage

A

maternal: uterine abnormality (fibroids), cervical weakness, increasing age, diabetes
conceptus: chromosomal, genetic or structural abnormality

unknown

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5
Q

what is the management of miscarriages?

A

expectant management:

medical management: misoprostol

surgical management:

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6
Q

what is an ectopic pregnancy?

A

pregnancy implanted outside the uterine cavity (~1%)

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7
Q

give examples of sites of miscarriage?

A
  • ampulla of fallopian tube (most common)
  • isthmus of fallopian tube
  • interstium of fallopian tube
  • ovary (rare)
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8
Q

what are the risk factors for ectopic pregnancy?

A
  • pelvic inflammatory disease
  • previous tubal surgery
  • previous ectopic surgery
  • assisted conception
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9
Q

how do ectopic pregnancies present?

A
  • vaginal bleeding
  • pain abdomen
  • GI or urinary symptoms
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10
Q

how are ectopic pregnancies investigated?

A

scan

  • no intrauterine gestational sac
  • may see adnexal mass
  • fluid in Pouch of Douglas

serum BHCG

  • track levels over 48 hour intervals
  • if normal early intrauterine pregnancy, HCG levels will increase by at least 66%
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11
Q

how are ectopic pregnancies managed?

A
  • conservative
  • medical: methotrexate
  • surgical: laproscopy - salpingectomy or salpingotomy
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12
Q

what is an antepartum haemorrhage?

A

haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby

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13
Q

what are the causes of antepartum haemorrhage?

A
  • placenta praevia
  • placental abruption
  • unknown origin
  • local lesions of the genital tract
  • vasa praevia (very rare)
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14
Q

what is placenta praevia

A

placenta implants in lower uterine segment

common in: multiparous women, multiple pregnancies, previous C section

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15
Q

what is the presentation of placenta praevia

A
  • painless bleeding
  • malpresentation of foetus
  • soft, non tender uterus

diagnosis: ultrasound scan (incidental)
management: c section, watch for PPH

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16
Q

what are the classifications of placenta praevia?

A

Grade I: Placenta encroaching on the lower segment but not the internal cervical os

Grade II: Placenta reaches the internal os

Grade III: Placenta eccentrically covers the os

Grade IV: Central placenta praevia

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17
Q

what is the management of PPH ?

A

medical

  • oxytocin
  • ergometrine
  • carboprost
  • tranexemic acid

surgica

  • balloon tamponade
  • b lynch cutre
  • ligation of the uterine and iliac vessels
  • hyserterectomy
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18
Q

what is placental abruption?

A

haemorrhage resulting from premature separation of the placenta before the birth of the baby

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19
Q

what are the risk factors for placental abruption?

A
  • pre-eclampsia/ chronic hypertension
  • polyhydramnios
  • smoking, increasing age, parity, cocaine use
  • previous abruption
  • multiple pregnancy
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20
Q

what is the presentation of placental abruption?

A
  • painful bleeding (may be minimal)
  • increased uterine activity

abruption can be:

  • revealed (can see blood)
  • concealed (bleeding inside so can’t see)
  • mixed
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21
Q

what is the management of APH depend on?

A

either:

  • expectant treatment
  • vaginal delivery
  • immediate Caesarean section

depends on:

  • amount of bleeding
  • general condition of mother and baby
  • gestation
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22
Q

what are possible complications of placental abruption?

A
  • maternal shock, collapse
  • foetal distress & death
  • maternal DIC, renal failure
  • postpartum haemorrhage ‘couvelaire uterus’
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23
Q

what is preterm labour?

A

onset of labour before 37 completed weeks of gestation (259 days)

  • 32-36 wks mildly preterm
  • 28-32 wks very preterm
  • 24-28 wks extremely preterm

spontaneous or induced

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24
Q

what are some predisposing factors for preterm labour?

A
  • multiple pregnancy
  • polyhydramnios
  • APH
  • pre-eclampsia
  • infection eg UTI
  • prelabour premature rupture of membranes
  • idiopathic
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25
Q

how is preterm labour diagnosed?

A
  • contractions with evidence of cervical change
  • test: foetal fibronectin

consider possible cause: abruption, infection

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26
Q

what is the management of preterm deliveries

A

< 24 - 26 weeks: poor prognosis

  • tocolysis: to allow steroids/ transfer
  • steroids (unless contraindicated)
  • transfer to unit with NICU facilities
  • aim for vaginal delivery
27
Q

What neonatal morbidity may result from prematurity?

A
  • respiratory distress syndrome
  • intraventricular haemorrhage
  • cerebral palsy
  • nutrition
  • temperature control
  • jaundice
  • infections
  • visual impairment
  • hearing loss
28
Q

examples of hypertensive disorders in pregnancy

A
  • chronic hypertension
  • gestational hypertension
  • pre-eclampsia
29
Q

what is considered significant proteinuria?

A

automated reagent strip urine protein: > 1+

spot urinary protein: creatinine Ratio > 30 mg/mmol

24 hours urine protein collection > 300mg/ day

30
Q

who is chronic hypertension commoner in?

A

older mothers

31
Q

How should chronic hypertension in pregnancy be managed?

A

keep BP < 150/100

monitor for superimposed pre-eclampsia and foetal growth

may have a higher incidence of placental abruption

32
Q

examples of safe antihypertensives to use in pregnancy.

A
  • labetolol
  • methyldopa
  • nifedipine
33
Q

describe pre-eclampsia

A
  • mild HT on two occasions more than 4 hours apart
  • moderate to severe HT

PLUS proteinuria of more than 300 mgms/ 24 hours

34
Q

describe pathophysiology of pre-eclampsia?

A

immunological

genetic

  • secondary invasion of maternal spiral arterioles by trophoblasts impaired -> reduced placental perfusion
  • imbalance between vasodilators and vasoconstrictors in pregnancy (prostacyclin/thromboxane)
35
Q

risk factors for PET?

A
  • first pregnancy
  • extremes of maternal age
  • previous PET
  • pregnancy interval >10 years
  • BMI >35
  • FMH
  • multiple pregnancy
  • underlying medical conditions (HT, renal disease, DM, autoimmune disorders)
36
Q

What are the possible complications of PET?

A

maternal

  • eclampsia (seizures)
  • severe HT (stroke)
  • HELLP (haemolysis, elevated liver enzymes, low platelets)
  • DIC
  • renal failure
  • pulmonary oedema and cardiac failure

foetal

  • IUGR
  • foetal distress
  • prematurity
37
Q

What are the signs and symptoms of severe PET?

A
  • headache
  • blurry vision
  • epigastric pain, pain below ribs
  • vomiting
  • swelling of hands face legs
  • severe hypertension; > 3+ of urine proteinuria
  • clonus/brisk reflexes; papillodema, epigastric tenderness
  • reducing urine output
  • convulsions (Eclampsia)
38
Q

What biochemical abnormalities can occur in severe PET?

A
  • raised liver enzymes, bilirubin if HELLP present

- raised urea an creatinine, raised urate

39
Q

What haematological abnormalities can occur in severe PET?

A
  • low platelets
  • low haemoglobin, signs of haemolysis
  • features of DIC
40
Q

What is the management for PET?

A

frequent checks: BP and urine protein

symptoms checks: headaches, epigastric pain, visual disturbances, hyperreflexia and tenderness over liver

bloods: FBC, LFTs, U+Es, coagulation

foetal investigations: scans and CTG

41
Q

What is the only cure for PET?

A

Delivery of the baby and placenta

42
Q

What is the conservative approach for PET?

A
  • observation
  • anti-hypertensives (labetolol, methyldopa, nifedipine)
  • steroids for fetal lung maturity if gestation < 36wks
43
Q

What is the epidemiology of PET and eclampsia?

A
  • 5-8% of pregnant women have PET
  • 0.5% women have severe PET & 0.05% have eclamptic seizures
  • 38% of seizures occur antepartum, 18% intrapartum, 44% postpartum
44
Q

How are eclamptic seizures and impending seizures treated?

A

magnesium sulphate bolus + IV infusion

blood pressure control
- IV labetolol, hydrallazine (if > 160/110)

avoid fluid overload
- aim for 80mls/hour fluid intake

45
Q

What is the prophylaxis for PET in further pregnancies?

A
  • low dose aspirin from 12 weeks to delivery

increased risk to develop hypertension in later life

46
Q

What is gestational diabetes?

A

carbohydrate intolerance with onset in pregnancy

abnormal glucose tolerance that reverts to normal after delivery

(however, more at risk of developing type II diabetes later in life)

47
Q

What effect does pre-existing diabetes have on pregnancy?

A
  • insulin requirements of the mother increase

- foetal hyper-insulinaemia occurs

48
Q

why do insulin requirements increase in pregnancy?

A
  • human placental lactogen
  • progesterone
  • human chorionic gonadotrophin
  • cortisol
    from placenta have anti-insulin action
49
Q

why does foetal hyper-insulinaemia occur?

A

maternal glucose crosses the placenta and induces increased insulin production in the foetus.

foetal hyperinsulinemia causes macrosomia

50
Q

what are neonates of diabetic mothers at increased risk of?

A
  • neonatal hypoglycaemia

- respiratory distress

51
Q

what does diabetes in pregnancy increase the risks of

A

maternal

  • pre-eclampsia
  • miscarriage
  • nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia
  • infections

foetal

  • congenital abnormalities (cardiac abnormalities, sacral agenesis)
  • macrosomia, polyhydramnios
  • shoulder dystocia, operative delivery
  • stillbirth, perinatal mortality

neonatal

  • impaired lung maturity
  • neonatal hypoglycaemia
  • jaundice
52
Q

what is the management for diabetes and pregnancy preconception?

A

preconception: glycemic control, folic acid 5mg, dietary advice, retinal and renal assessment
pregnancy: optimise glucose control - insulin requirements will increase, watch for ketonuria/infections, retinal assessment at 28 & 34 weeks

53
Q

What blood sugars are optimal during pregnancy?

A

<5.3mmol/l Fasting
<7.8mmol/l 1 hour postprandial
<6.4mmol/l 2 hours postprandial
<6mmol/l Before bedtime

54
Q

What is the management of diabetes regarding birth?

A

observe for PET

labour: 38-40 weeks or earlier
- consider C section if macrosomnia

blood sugar
- maintain with insulin and dextrose insulin solution

CTG monitoring

early feeding: to prevent hypoglycaemia

55
Q

what are the risk factors for gestation diabetes mellitus?

A
  • BMI >30
  • previous macrosomic baby > 4.5kg
  • previous GDM
  • FMH of diabetes
  • women from high risk groups for developing diabetes – eg. Asian origin
  • polyhydramnios or big baby in current pregnancy
  • recurrent glycosuria in current pregnancy
56
Q

what is GDM associated with?

A 
increase in:
maternal complications (eg PET) 
fetal complications (macrosomia)

but much less than with type I or II diabetes

57
Q

how is GDM managed?

A

control blood sugars: metformin and diet (insulin may be required)

post delivery: check OGTT 6-8 weeks

yearly check on Hb1AC/blood sugars as at higher risk of developing overt diabetes

58
Q

what are the components of Virchow’s triad?

A
  • stasis
  • hypercoaguability
  • vessel wall injury
59
Q

why is the risk of VTE increased in pregnancy?

A
  • pregnancy is a hypercoaguable state: protects mother against bleeding post delivery
  • increased stasis: progesterone, effects of enlarged uterus
  • may be vascular damage at delivery/ C section
60
Q

what are the risk factors for VTE in pregnancy?

A

high: age, BMI
health: dehydration, infections, decreased mobility, PET, haemorrhage
habits: IV drug users
history: VTE, FMH, thrombophilia, sickle cell disease

61
Q

what is the prophylaxis fro VTE in pregnancy?

A

TED stockings

advice increased mobility, hydration

prophylactic anti-coagulation with 3 or more risk factors

62
Q

what are the signs and symptoms of VTE?

A
  • pain in calf
  • increase girth of affected leg
  • calf muscle tenderness
  • breathlessness
  • pain on breathing
  • cough
  • tachycardia
  • hypoxic
  • pleural rub
63
Q

How is VTE investigated in pregnancy?

A
  • ECG
  • blood gases
  • doppler
  • V/Q lung scan
  • CT pulmonary angiogram
64
Q

How is VTE treated in pregnancy?

A

anticoagulation

reproductive system (31 decks)

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