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4th year passmedicine by topic > Pregnancy Complications > Flashcards

Pregnancy Complications Flashcards

1
Q

Placenta accreta describes

A

the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage.

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2
Q

What can cause placenta accreta

A

previous caesarean section

placenta praevia

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3
Q

Placenta accreta - there are 3 different types:

A

accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade into the myometrium
percreta: chorionic villi invade through the perimetrium

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4
Q

Placenta praevia describes

A

a placenta lying wholly or partly in the lower uterine segment

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5
Q

Placenta praevia Epidemiology

A

5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from cervix

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6
Q

Placenta praevia Associated factors

A

multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section

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7
Q

Placenta praevia causes fetal tachycardia

A

false

fetal heart usually normal

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8
Q

Placenta praevia commonly cause coagulation problems

A

false

coagulation problems rare

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9
Q

Placenta praevia sx

A 
small bleeds before large
shock in proportion to visible loss
no pain
uterus NOT tender
lie and presentation may be abnormal
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10
Q

Investigations

placenta praevia

A

placenta praevia is often picked up on the routine 20 week abdominal ultrasound
the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

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11
Q

placenta praevia grading

A

I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV - placenta completely covers the internal os

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12
Q

If low-lying placenta at 16-20 week scan mx

A

rescan at 34 weeks
no need to limit activity or intercourse unless they bleed
if still present at 34 weeks and grade I/II then scan every 2 weeks
if high presenting part or abnormal lie at 37 weeks then Caesarean section should be performed

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13
Q

Placenta praevia with bleeding mx

A

admit
treat shock
cross match blood
final ultrasound at 36-37 weeks to determine method of delivery, Caesarean section for grades III/IV between 37-38 weeks. If grade I then vaginal delivery

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14
Q

Prognosis placenta praevia

A

death is now extremely rare

major cause of death in women with placenta praevia is now PPH

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15
Q

Placental abruption describes

A

separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

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16
Q

Placental abruption occurs in approximately 1/200 pregnancies

A

true

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17
Q

Placental abruption causes

A 
proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age
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18
Q

Placental abruption sx

A 
shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems
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19
Q

Placental abruption ms

Fetus alive and < 36 weeks

A

fetal distress: immediate caesarean

no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

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20
Q

Placental abruption mx

Fetus alive and > 36 weeks

A

fetal distress: immediate caesarean

no fetal distress: deliver vaginally

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21
Q

Placental abruption mx fetus dead

A

induce vaginal delivery

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22
Q

Placental abruption complications Maternal

A

shock
DIC
renal failure
PPH

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23
Q

Placental abruption complications fetal

A

IUGR
hypoxia
death

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24
Q

Placental abruption prognosis

A

associated with high perinatal mortality rate

responsible for 15% of perinatal deaths

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25
Q

Women who are at high risk of developing pre-eclampsia should take

A

aspirin 75mg od from 12 weeks until the birth of the baby.

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26
Q

Women who are at high risk of developing pre-eclampsia include?

A

hypertensive disease during previous pregnancies
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus

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27
Q

The classification of hypertension in pregnancy is complicated and varies. Remember, in normal pregnancy blood pressure :

A

blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks
after this time the blood pressure usually increases to pre-pregnancy levels by term

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28
Q

Hypertension in pregnancy in usually defined as:

A

systolic > 140 mmHg or diastolic > 90 mmHg

or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

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29
Q

Define Pre-existing hypertension

A

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation

No proteinuria, no oedema

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30
Q

Define Pregnancy-induced hypertension

PIH, also known as gestational hypertension

A

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks)

No proteinuria, no oedema

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31
Q

Define Pre-eclampsia

A

Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific

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32
Q

Epidemiology of
Pre-existing hypertension

gestational hypertension

Pre-eclampsia

A

Pre-existing hypertension: Occurs in 3-5% of pregnancies and is more common in older women

gestational hypertension: Occurs in around 5-7% of pregnancies

Pre-eclampsia: Occurs in around 5% of pregnancies

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33
Q

gestational hypertension often resolves folling birth

A

true

34
Q

gestational hypertension increased risk of future ?

A

pre-eclampsia or hypertension later in life

35
Q

Pre-eclampsia is important as it predisposes to the following problems

A

fetal: prematurity, intrauterine growth retardation
eclampsia
haemorrhage: placental abruption, intra-abdominal, intra-cerebral
cardiac failure
multi-organ failure

36
Q

High risk factors - pre eclampsia

A

hypertensive disease in a previous pregnancy
chronic kidney disease
autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome
type 1 or type 2 diabetes
chronic hypertension

37
Q

Moderate risk factors - pre eclampsia

A 
first pregnancy
age 40 years or older
pregnancy interval of more than 10 years
body mass index (BMI) of 35 kg/m² or more at first visit
family history of pre-eclampsia
multiple pregnancy
38
Q

Features of severe pre-eclampsia

A

hypertension: typically > 170/110 mmHg and proteinuria as above
proteinuria: dipstick ++/+++
headache
visual disturbance
papilloedema
RUQ/epigastric pain
hyperreflexia
platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

39
Q

mx pre-eclampsia?

A

a woman at moderate or high risk of pre-eclampsia should take aspirin 75mg daily from 12 weeks gestation until the birth
consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold
oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used
delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

40
Q

Eclampsia may be defined as

A

development of seizures in association pre-eclampsia. To recap, pre-eclampsia is defined as:
condition seen after 20 weeks gestation
pregnancy-induced hypertension
proteinuria

41
Q

Why is Magnesium sulphate used to treat eclampsia

A

used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop.

42
Q

Guidelines for magnesium sulphate in eclampsia?

A

should be given once a decision to deliver has been made

in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour

treatment should continue for 24 hours after last seizure or delivery

43
Q

What should be monitored when giving magnesium sulphate in eclampsia?

A

urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment

44
Q

Pre-eclampsia around ?% of seizures occur post-partum

A

around 40% of seizures occur post-partum)

45
Q

Major complication and mx of this when

magnesium sulphate in eclampsia?

A

respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

46
Q

important aspects of treating severe pre-eclampsia/eclampsia include

A

fluid restriction to avoid the potentially serious consequences of fluid overload

47
Q

HELLP is

A

acronym for Hemolysis, Elevated Liver enzymes, and a Low Platelet count. It is a serious condition that can develop in the late stages of pregnancy. Whilst there is significant overlap with severe pre-eclampsia in terms of the features some patients present with no prior history so many specialists consider it a separate entity in its own right

48
Q

?% of patients with severe preeclampsia will go on to develop HELLP.

A

10-20% of patients with severe preeclampsia will go on to develop HELLP.

49
Q

HELLP SX

A

nausea & vomiting
right upper quadrant pain
lethargy

50
Q

HELLP IX

A

bloods: Hemolysis, Elevated Liver enzymes, and a Low Platelet

51
Q

HELLP MX

A

delivery of the baby

52
Q

Antepartum haemorrhage is defined as

A

bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus

53
Q

vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - why?

A

women with placenta praevia may haemorrhage

54
Q

shock in proportion to visible loss - which placental issue?

A

Placenta praevia

55
Q

pain constant - which placental issue?

A

Placental abruption

56
Q

tender, tense uterus - Placenta praevia

A

false

Placental abruption

57
Q

Bleeding in pregnancy differential 1st trimester

A

Spontaneous abortion
Ectopic pregnancy
Hydatidiform mole

58
Q

Bleeding in pregnancy differential 2nd trimester

A

Spontaneous abortion
Hydatidiform mole
Placental abruption

59
Q

Bleeding in pregnancy differential 3rd trimester

A

Bloody show
Placental abruption
Placenta praevia
Vasa praevia

60
Q

Bleeding in pregnancy Alongside the pregnancy related causes, conditions such as sexually transmitted infections and cervical polyps should be excluded.

A

true

61
Q

Types of spontaneous abortion?

A

Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks

Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear

Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled.

Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain.

Complete miscarriage - little bleeding

62
Q

Typical picture of Ectopic pregnancy

A

Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present

63
Q

Typical picture of Hydatidiform mole

A

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

64
Q

Typical picture of Placental abruption

A

Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed

65
Q

Typical picture of Placental praevia

A

Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal

66
Q

Typical picture of Vasa praevia

A

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen

67
Q

Amniotic fluid embolism

Definition:

A

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below.

68
Q

Amniotic fluid embolism - Epidemiology:

A

Rare complication of pregnancy associated with a high mortality rate

69
Q

Amniotic fluid embolism aetiology

A

Many risk factors have been associated with amniotic fluid embolism but a clear cause has not been proven.

A consistent link has been demonstrated with maternal age and induction of labour.

It is widely accepted that maternal circulation must be exposed to fetal cells/ amniotic fluid in order for an amniotic fluid embolism to occur. However the precise underlying pathology of this process which leads to the embolism is not well understood, though suggestions have been made about an immune mediated process.

70
Q

Amniotic fluid embolism sx & signs

A

Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

71
Q

Amniotic fluid embolism occur when in pregnancy?

A

The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.

72
Q

Amniotic fluid embolism diagnosis?

A

Clinical diagnosis of exclusion, as there are not definitive diagnostic tests.

73
Q

Amniotic fluid embolism mx?

A

Critical care unit by a multidisciplinary team, management is predominantly supportive

74
Q

Gestational trophoblastic disorders

Describes

A

spectrum of disorders originating from the placental trophoblast:
complete hydatidiform mole
partial hydatidiform mole
choriocarcinoma

75
Q

Complete hydatidiform mole is?

A

Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

76
Q

Complete hydatidiform mole sx

A

bleeding in first or early second trimester
exaggerated symptoms of pregnancy e.g. hyperemesis
uterus large for dates

77
Q

Complete hydatidiform mole ix

A

very high serum levels of human chorionic gonadotropin (hCG)

hypertension and hyperthyroidism* may be seen

78
Q

Complete hydatidiform mole mx

A

urgent referral to specialist centre - evacuation of the uterus is performed
effective contraception is recommended to avoid pregnancy in the next 12 months

79
Q

Complete hydatidiform mole Around ?% go on to develop choriocarcinoma

A

Around 2-3% go on to develop choriocarcinoma

80
Q

In a partial mole what happens?

A

normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen

4th year passmedicine by topic (96 decks)

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