Pregnancy Complications Flashcards
Hyperemesis Gravidarum: definition and Mx
Intractable vomiting that can lead to: weight loss, electrolyte disturbance, ketosis
Ix/
Acute: Gas, BSL, electrolytes
Nutritional: CMP, B12, folate
DDx: urine dip
USS to exclude molar/ multiple
Mx/
- Frequent eating
- Pyridoxime (B12) 25mg TDS
- Doxylamine 25mg nocte, half mane.
- Metoclopramide (A)
- Ondansetron (B1)
- Prochlorperazine
–> Prednisolone 40-60mg/day (wean)
–> Mirtazepine 15mg daily
Statistically how common is 1st trimester bleeding? How many pregnancies end up fine?
25% experience it (1 in 4)
Immediately, 50% will reach term.
If a FHR then seen, 90% chance of reaching term.
What is the ‘discriminatory zone’
BHCG level that indicates a pregnancy should be able to be seen on USS.
>1500 = visible on TV (4-5/40)
>6500= visible on TA (6/40)
If below DZ, can only monitor progress with serial HCG
Ultrasound criteria for a (first tri) failed pregnancy:
Sac >25mm without fetal pole
Crown-rump length 7mm without FHR
At what gestation do the following appear on USS:
- Sac
- Fetal pole
- FHR
Sac= 4.5 - 5/40
Fetal pole and FHR= 6/40
DDx for first trimester bleed:
Obstetric
- Implantation
- Threatened miscarriage
- Ectopic
- Trophoblastic disease
Non-obstetric
- Fibroid
- Uterine AVM
- Cervical lesion
- PID
- Rupture of corpus luteum
Non-PV
- PR
- Haematuria
- Coagulopathy
Approach to 1st trimester bleed:
- Resusc, Hx, Exam
- If BHCG above discrim DZ (1000 TV, 6500 TA), do ultrasound
–> IUP = threatened misc.
–> Ectopic
–> Indeterminate = inevitable misc., or ectopic not seen. - If below DZ, serial BCHG
–> Doubling 48hrly = USS once above DZ to confirm N pregnancy.
–> Slow rise = Continue 48hrly BHCG.
–> Falling = Inev. misc. -
Consider Anti-D 250 IU if Rhesus neg
–> Insufficient evidence when miscarriage only THREATENED
Mx options for inevitable miscarriage:
EXPECTANT
- If started (incomplete), should take a few days
- If not yet started (missed)
—> 60% complete by 2 weeks, 90% complete by 6 weeks
- Confirm with urine preg test
- Risk of needing PRBC slightly higher
MEDICAL
- Only suitable up to approx. 9/40 (+not if infection)
- Mifepristone +- (death)
- Misoprostol 600-800mg PO (expulsion)
- Allow 2 weeks
- Confirm with urine preg test
SURGICAL
- Vacuum for missed
- D&C for incomplete
Treatment of septic miscarriage:
Clindamycin IV
plus
Gentamicin IV
Anti D:
- Indications
- Dose
- Adverse effects
Within 72 hours
INDICATIONS
FIRST TRI- 250 IU IM
- Miscarriage (insufficient evidence for threatened)
- Termination
- Trauma
- Villous sampling
SEC/THIRD TRI- 650 IU IM
- Routine: 28, 34 weeks
- ECV
- Amniocentesis
- Trauma
–> Dose as per *Kleihaur
- Delivery of Rh+ baby
ADVERSE
- Non-specific, mild
- Is blood product
Risk factors for ectopic pregnancy:
- Assisted fertility (+risk of heterotopic)
- Previous ectopic
- PID
- Tube disease
- Endometriosis
- IUD
Management options in ectopic pregnancy
EXPECTANT/ MEDICAL
- IM Methotrexate
- Carefully selected:
–> <3.5cm
–> No FHR
–> Unruptured
–> Crisp social/ follow up
SURGICAL
- ALL that are LIVE
- Salpingotomy/ectomy
(Long term fertility similar with med/surg options)
+- AntiD
At what gestation do ruptured ectopics tend to present?
6 weeks (ie. since LMP)
…if tubal (95%)
POCUS findings in ectopic:
- Adnexal mass
- May identify pregnancy: (sac/ fetal pole/ FHR)
- Pelvic (Pouch of Douglas) fluid if ruptured
Define:
- Chronic HTN
- Gestational HTN
- Pre-eclampsia
- Eclampsia:
HTN = >140/90 on 2 occasions
_________________
HTN documented prior to 20/40 = ‘chronic’
Onset of HTN after 20/40 + normalises within 3mo PP = ‘gestational’
Pre-eclampsia = gestational HTN (>20/40) + PROTEINURIA (or other end organ)
Eclampsia = gestational HTN (>20/40) + SEIZURE
HELLP syndrome:
- Complicates PrEc in 20%
- Can occur PP
Haemolysis (MAHA)
Elevated Liver enzymes AST > 70 (necrotic transaminitis)
Low platelets <100 (consumptive)
_______
SUSPECT IF >20/40 AND ABDO PAIN
Can get very sick with:
–> Liver bleeds (subcapsular, intrahepatic, liver rupture)
–> DIC
Mx as per Obstetric Hypertensive Emergency.
DDX for HELLP:
- Low plts/ transaminitis
- Hepatitis (infectious, paracetamol)
- TTP/ ITP
- HUS
- DIC
- Pre-eclampsia
- Cholestasis of pregnancy
- Sepsis
Define pre-eclampsia with values:
1- HTN >140/90 on 2 occasions, onset after 20/40
+
2- Proteinuria
–> 1+ dipstick
–> 0.3 protein/Cr ratio
–> 300mg in a 24/24 collect.
____________
ACTIVELY LOOK for proteinuria/ organ dysFx in ANYONE >20/40 with HTN or new symptoms
Define SEVERE pre-eclampsia with values:
Onset pre- 32/40
BP >160/ 110
2+ protein
IUGR
Any clinical, or lab, organ dysfunction
Risk Factors for pre-eclampsia:
PREGNANCY
- First pregnancy
- Multiple
- Molar
- Gestational HTN
MATERNAL
- Quite young (<20) or quite old (>40)
- Obesity
- HTN
- Vasculopathy
- PMHx/FHx PreE
Smoking is protective
“Young, fat mole with large belly**
Work-up for suspected PrE:
Hx/
- Risk factors
- Symptoms (incl. blurred vision, RUQ pain)
- Gestation
OE/
- BP (at least 2x must be HTN)
- Oedema
- Hyperreflexia
- Focal: retinopathy, RUQ pain, APO etc.
Ix/
- Urine dip and Pr/Cr ratio
–> 1+, >0.3 pr/cr, >300mg/hr 24/24
- UEC, LFT (AKI, transaminitis)
- FBC (plts)
- Haemolytic screen
Consider - Coags (N unless DIC)
- Group and hold
- CTG (>24/40)
- USS
Management of MILD PreEclampsia
ie. No organ dysfunction/ IUGR
>37/40: deliver
<24 weeks: advise termination
In between: expectant
- Admit for bedrest + close monitoring
–> 25% risk abruption/ HELLP/APO developing….
- Aim to at least get steroids in
Management of SEVERE Pre/Eclampsia:
REDUCE BP: (20,20,20)
Equal efficacy:
LABETALOL 10-20 IV Q10min or 1mg/min
or
HYDRALAZINE 10-20mg Q20min or 5mg/hr
or
NIFEDIPINE 20mg PO- if no IV access
- Target 140-160/100 over 2hrs. But as usual, don’t lower more than 20% in first hour.
MANAGE SEIZURE (prev/Tx):
- MgSO4 4g IV over 5mins. then 1-2g/hr until 24hrs post-seizure
- Reload with each seizure
- 2line: BZD, propofol.
DELIVERY:
- Immediate, regardless.
- Involve NPICU
Signs and treatment of MgSO4 toxicity:
Usually at level 2 and above:
Resp depression
HypoTN
Hyporeflexia
–> asystole
Calcium gluconate 10ml 10% over 10mins
