pregnancy complications Flashcards
what is miscarriage
spontaneous loss of pregnancy before 24 weeks gestation (15%)
list the types of miscarriage
threatened
inevitable
incomplete
complete
septic
missed
describe the types of miscarriage
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 ♡
what is the aetiology of spontaneous miscarriage
maternal: uterine abnormality (fibroids), cervical weakness, increasing age, diabetes
conceptus: chromosomal, genetic or structural abnormality
unknown
what is the management of miscarriages?
expectant management:
medical management: misoprostol
surgical management:
what is an ectopic pregnancy?
pregnancy implanted outside the uterine cavity (~1%)
give examples of sites of miscarriage?
- ampulla of fallopian tube (most common)
- isthmus of fallopian tube
- interstium of fallopian tube
- ovary (rare)
what are the risk factors for ectopic pregnancy?
- pelvic inflammatory disease
- previous tubal surgery
- previous ectopic surgery
- assisted conception
how do ectopic pregnancies present?
- vaginal bleeding
- pain abdomen
- GI or urinary symptoms
how are ectopic pregnancies investigated?
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%
how are ectopic pregnancies managed?
- conservative
- medical: methotrexate
- surgical: laproscopy - salpingectomy or salpingotomy
what is an antepartum haemorrhage?
haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby
what are the causes of antepartum haemorrhage?
- placenta praevia
- placental abruption
- unknown origin
- local lesions of the genital tract
- vasa praevia (very rare)
what is placenta praevia
placenta implants in lower uterine segment
common in: multiparous women, multiple pregnancies, previous C section
what is the presentation of placenta praevia
- painless bleeding
- malpresentation of foetus
- soft, non tender uterus
diagnosis: ultrasound scan (incidental)
management: c section, watch for PPH
what are the classifications of placenta praevia?
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
what is the management of PPH ?
medical
- oxytocin
- ergometrine
- carboprost
- tranexemic acid
surgica
- balloon tamponade
- b lynch cutre
- ligation of the uterine and iliac vessels
- hyserterectomy
what is placental abruption?
haemorrhage resulting from premature separation of the placenta before the birth of the baby
what are the risk factors for placental abruption?
- pre-eclampsia/ chronic hypertension
- polyhydramnios
- smoking, increasing age, parity, cocaine use
- previous abruption
- multiple pregnancy
what is the presentation of placental abruption?
- painful bleeding (may be minimal)
- increased uterine activity
abruption can be:
- revealed (can see blood)
- concealed (bleeding inside so can’t see)
- mixed
what is the management of APH depend on?
either:
- expectant treatment
- vaginal delivery
- immediate Caesarean section
depends on:
- amount of bleeding
- general condition of mother and baby
- gestation
what are possible complications of placental abruption?
- maternal shock, collapse
- foetal distress & death
- maternal DIC, renal failure
- postpartum haemorrhage ‘couvelaire uterus’
what is preterm labour?
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
what are some predisposing factors for preterm labour?
- multiple pregnancy
- polyhydramnios
- APH
- pre-eclampsia
- infection eg UTI
- prelabour premature rupture of membranes
- idiopathic
how is preterm labour diagnosed?
- contractions with evidence of cervical change
- test: foetal fibronectin
consider possible cause: abruption, infection
what is the management of preterm deliveries
< 24 - 26 weeks: poor prognosis
- tocolysis: to allow steroids/ transfer
- steroids (unless contraindicated)
- transfer to unit with NICU facilities
- aim for vaginal delivery
What neonatal morbidity may result from prematurity?
- respiratory distress syndrome
- intraventricular haemorrhage
- cerebral palsy
- nutrition
- temperature control
- jaundice
- infections
- visual impairment
- hearing loss
examples of hypertensive disorders in pregnancy
- chronic hypertension
- gestational hypertension
- pre-eclampsia
what is considered significant proteinuria?
automated reagent strip urine protein: > 1+
spot urinary protein: creatinine Ratio > 30 mg/mmol
24 hours urine protein collection > 300mg/ day
who is chronic hypertension commoner in?
older mothers
How should chronic hypertension in pregnancy be managed?
keep BP < 150/100
monitor for superimposed pre-eclampsia and foetal growth
may have a higher incidence of placental abruption
examples of safe antihypertensives to use in pregnancy.
- labetolol
- methyldopa
- nifedipine
describe pre-eclampsia
- mild HT on two occasions more than 4 hours apart
- moderate to severe HT
PLUS proteinuria of more than 300 mgms/ 24 hours
describe pathophysiology of pre-eclampsia?
immunological
genetic
- secondary invasion of maternal spiral arterioles by trophoblasts impaired -> reduced placental perfusion
- imbalance between vasodilators and vasoconstrictors in pregnancy (prostacyclin/thromboxane)
risk factors for PET?
- 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)
What are the possible complications of PET?
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
What are the signs and symptoms of severe PET?
- 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)
What biochemical abnormalities can occur in severe PET?
- raised liver enzymes, bilirubin if HELLP present
- raised urea an creatinine, raised urate
What haematological abnormalities can occur in severe PET?
- low platelets
- low haemoglobin, signs of haemolysis
- features of DIC
What is the management for PET?
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
What is the only cure for PET?
Delivery of the baby and placenta
What is the conservative approach for PET?
- observation
- anti-hypertensives (labetolol, methyldopa, nifedipine)
- steroids for fetal lung maturity if gestation < 36wks
What is the epidemiology of PET and eclampsia?
- 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
How are eclamptic seizures and impending seizures treated?
magnesium sulphate bolus + IV infusion
blood pressure control
- IV labetolol, hydrallazine (if > 160/110)
avoid fluid overload
- aim for 80mls/hour fluid intake
What is the prophylaxis for PET in further pregnancies?
- low dose aspirin from 12 weeks to delivery
increased risk to develop hypertension in later life
What is gestational diabetes?
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)
What effect does pre-existing diabetes have on pregnancy?
- insulin requirements of the mother increase
- foetal hyper-insulinaemia occurs
why do insulin requirements increase in pregnancy?
- human placental lactogen
- progesterone
- human chorionic gonadotrophin
- cortisol
from placenta have anti-insulin action
why does foetal hyper-insulinaemia occur?
maternal glucose crosses the placenta and induces increased insulin production in the foetus.
foetal hyperinsulinemia causes macrosomia
what are neonates of diabetic mothers at increased risk of?
- neonatal hypoglycaemia
- respiratory distress
what does diabetes in pregnancy increase the risks of
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
what is the management for diabetes and pregnancy preconception?
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
What blood sugars are optimal during pregnancy?
<5.3mmol/l Fasting
<7.8mmol/l 1 hour postprandial
<6.4mmol/l 2 hours postprandial
<6mmol/l Before bedtime
What is the management of diabetes regarding birth?
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
what are the risk factors for gestation diabetes mellitus?
- 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
what is GDM associated with?
increase in: maternal complications (eg PET) fetal complications (macrosomia)
but much less than with type I or II diabetes
how is GDM managed?
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
what are the components of Virchow’s triad?
- stasis
- hypercoaguability
- vessel wall injury
why is the risk of VTE increased in pregnancy?
- 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
what are the risk factors for VTE in pregnancy?
high: age, BMI
health: dehydration, infections, decreased mobility, PET, haemorrhage
habits: IV drug users
history: VTE, FMH, thrombophilia, sickle cell disease
what is the prophylaxis fro VTE in pregnancy?
TED stockings
advice increased mobility, hydration
prophylactic anti-coagulation with 3 or more risk factors
what are the signs and symptoms of VTE?
- pain in calf
- increase girth of affected leg
- calf muscle tenderness
- breathlessness
- pain on breathing
- cough
- tachycardia
- hypoxic
- pleural rub
How is VTE investigated in pregnancy?
- ECG
- blood gases
- doppler
- V/Q lung scan
- CT pulmonary angiogram
How is VTE treated in pregnancy?
anticoagulation
