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Obstetrics & Gynae > Pregnancy Complications > Flashcards

Pregnancy Complications Flashcards

1
Q

Hyperemesis Gravidarum: definition and Mx

A

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

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2
Q

Statistically how common is 1st trimester bleeding? How many pregnancies end up fine?

A

25% experience it (1 in 4)

Immediately, 50% will reach term.

If a FHR then seen, 90% chance of reaching term.

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3
Q

What is the ‘discriminatory zone’

A

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

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4
Q

Ultrasound criteria for a (first tri) failed pregnancy:

A

Sac >25mm without fetal pole

Crown-rump length 7mm without FHR

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5
Q

At what gestation do the following appear on USS:
- Sac
- Fetal pole
- FHR

A

Sac= 4.5 - 5/40
Fetal pole and FHR= 6/40

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6
Q

DDx for first trimester bleed:

A

Obstetric
- Implantation
- Threatened miscarriage
- Ectopic
- Trophoblastic disease

Non-obstetric
- Fibroid
- Uterine AVM
- Cervical lesion
- PID
- Rupture of corpus luteum

Non-PV
- PR
- Haematuria
- Coagulopathy

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7
Q

Approach to 1st trimester bleed:

A
  • 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
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8
Q

Mx options for inevitable miscarriage:

A

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

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9
Q

Treatment of septic miscarriage:

A

Clindamycin IV
plus
Gentamicin IV

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10
Q

Anti D:
- Indications
- Dose
- Adverse effects

A

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

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11
Q

Risk factors for ectopic pregnancy:

A
  • Assisted fertility (+risk of heterotopic)
  • Previous ectopic
  • PID
  • Tube disease
  • Endometriosis
  • IUD
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12
Q

Management options in ectopic pregnancy

A

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

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13
Q

At what gestation do ruptured ectopics tend to present?

A

6 weeks (ie. since LMP)

…if tubal (95%)

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14
Q

POCUS findings in ectopic:

A
  • Adnexal mass
  • May identify pregnancy: (sac/ fetal pole/ FHR)
  • Pelvic (Pouch of Douglas) fluid if ruptured
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15
Q

Define:
- Chronic HTN
- Gestational HTN
- Pre-eclampsia
- Eclampsia:

A

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

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16
Q

HELLP syndrome:

A
  • 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.

17
Q

DDX for HELLP:
- Low plts/ transaminitis

A
  • Hepatitis (infectious, paracetamol)
  • TTP/ ITP
  • HUS
  • DIC
  • Pre-eclampsia
  • Cholestasis of pregnancy
  • Sepsis
18
Q

Define pre-eclampsia with values:

A

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

19
Q

Define SEVERE pre-eclampsia with values:

A

Onset pre- 32/40
BP >160/ 110
2+ protein
IUGR
Any clinical, or lab, organ dysfunction

20
Q

Risk Factors for pre-eclampsia:

A

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**

21
Q

Work-up for suspected PrE:

A

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
22
Q

Management of MILD PreEclampsia

A

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

23
Q

Management of SEVERE Pre/Eclampsia:

A

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

24
Q

Signs and treatment of MgSO4 toxicity:

A

Usually at level 2 and above:

Resp depression
HypoTN
Hyporeflexia
–> asystole

Calcium gluconate 10ml 10% over 10mins

25
Q

DDx bleeding in 2nd/3rd trimester:

A
  • **P/PROM
  • Abruption
  • Placenta praevia**
  • Vasa praevia (labour)
  • Marginal bleed
  • Accreta/increta/percreta
  • Bloody show
  • Infection: PID, chorioamnionitis
  • Non-obstetric
  • Non-PV

Do not PV or spec anyone with antepartum bleed (until praevia excluded with careful, sterile TV USS)

26
Q

Placenta Praevia:

A

Main risk factor previous c-section (uterine scar). Cocaine, smoking, older.

Most resolve in 3rd trimester.

  • PAINLESS
  • Small recurrent ‘warning’ bleeds +-
  • Maternal bleeding

MX:
- DO NOT PV OR SPEC
- Confirm with careful, sterile TV US

27
Q

Vasa Praevia

A

Fetal bleed from vessels that run through sac, distant to placenta.

Usually associated with ROM/labour

FETUS will be compromised, rather than mum.

28
Q

Placental Abruption:

A

Traumatic (incl minor, consider DV)
OR
Spontaneous (HTN, coag, cocaine, PreE…)

  • Pain, tenderness
  • Up to 4L can be concealed behind placenta, without PV loss
  • It is a maternal bleed+++

ULTRASOUND CAN MISS- keep high index suspicion
Normal CTG rules out abruption.

29
Q

Management of P/PROM:

A

PROM = before labour
PPROM = before 37/40
Prolonged = >24/24
________

If unclear, confirm
Careful, sterile spec away from cervix:
–> Liquor from cervix, meconium, fetal part
–> ‘Amniosure’
–> Cytology (‘ferning’)
–> Alkaline on nitraz blue paper.

Mx:
- Deliver in 24/24 if term
- Expectant otherwise
–> Bedrest
–> Antis
–> Steroids +/- (<34/40)

Obstetrics & Gynae (5 decks)

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