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Obstetrics and Gynaecology > Pregnancy Complications > Flashcards

Pregnancy Complications Flashcards

1
Q

What is placental abruption?

A

Separation of part or all of the decidua basalis from the uterine wall

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2
Q

What happens in placental abruption?

A

Rupture of maternal vessels within basal layer of endometrium. Blood accumulate and split placental attachment from basal layer. Detached portion of placenta unable to function –> fetal compromise

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3
Q

What are the types of placental abruption?

A

Revealed (80%)

Concealed (20%)

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4
Q

What is a revealed placental abruption?

A

Bleeding tracks down from site of placental separation

Drain through cervix resulting in vaginal bleeding

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5
Q

What is concealed placental abruption?

A

Bleeding collects between the uterus and the placenta. A retroplacental clot forms

Bleeding not visible but can cause systemic shock

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6
Q

How common is placental abruption and when does it normally happen?

A

1/200 pregnancies

Usually happen >20 week gestation

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7
Q

How is placental abruption diagnosed?

A

Clinical diagnosis based on:
Tense tender uterus with “woody” feel on examination
USS - clot may not be easily distinguishable
CTG abnormalities - foetal distress
Platelet count may be low
Coag screen - coagulopathy common

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8
Q

How does placental abruption present?

A

Painful vaginal bleeding
Pain between contractions (if in labour)
Uterus tense all the time
Shock out of proportion to blood loss - if concealed

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9
Q

What are the key risk factors for placental abruption?

A 
Previous Hx of abruption
Hypertension and smoking - diseased vessels
Abdominal trauma
Abnormal lie of baby
Polyhydramnios
Multiple pregnancy
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10
Q

How can placental abruption be managed?

A

Emergency C Section - if maternal or foetal compromise

Induction of labour - if haemorrhage at term without maternal or foetal compromise

Conservative - for partial or marginal abruptions without compromise

In all cases - give anti-D within 72hrs of onset if Rhesus D -ve

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11
Q

What is placenta praevia?

A

Placenta lie partially or wholly in lower uterine segment in front of the presenting part of the foetus

Usually happen >20 weeks gestation

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12
Q

How is placenta praevia graded?

A

1: low lying
2: reaches the internal os
3: covers the os when not dilated but on dilation it no longer covers the os
4: covers the os symmetrically

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13
Q

How common is placenta praevia?

A

5% low lying placenta at 16-20 week scan

Incidence at delivery only 0.5% - most rise away from cervix

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14
Q

What are the main risk factors for placenta praevia?

A

Previous hx
Previous caesarian - implant on scar
Multiple pregnancy
Advancing maternal age

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15
Q

How does placenta praevia present?

A

Picked up on routine 20 week scan
Painless vaginal bleeding - vary from spotting to haemorrhage
Lie and presentation may be abnormal

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16
Q

If a placenta praevia minor is picked up at a 20 week scan, what should happen?

A

Repeat scan at 36 weeks

Placenta likely to have moved superiorly in this time

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17
Q

If a placenta praevia major is picked up at a 20 week scan, what should happen?

A

Repeat scan at 32 weeks

Plan for delivery made at this time

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18
Q

What is the safest mode of delivery for confirmed placenta praevia?

A

C Section

Electively done at 37 weeks if placenta praevia major

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19
Q

What complications are associated with placenta praevia?

A

Pre-term delivery
Hypovolaemic shock
Placenta accreta
Fetal hypoxia and asphyxia

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20
Q

What must not be done if a patient has placenta praevia?

A

Vaginal exam

May start torrential bleeding

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21
Q

What is the difference in how placenta praevia and placental abruption present?

A

Placenta Praevia - painless, bright red blood, proportional blood loss to shock, no associated conditions

Placental abruption - painful, bleeding can be concealed, dark coloured, shock out of proportion to blood loss, associated with preeclampsia

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22
Q

What is the difference between placenta praevia and placental abruption on abdominal examination?

A

PP - Uterus size normal, soft and relaxed, fetus malpresentation common, Fetal heart sounds usually present

PA - Large for date tender, rigid uterus, fetal presentation unrelated, fetal heart sounds usually absent

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23
Q

What is the difference between placenta praevia and placental abruption on placentography and vaginal exam?

A

PP - Placenta in lower segment and palpable there in vaginal exam

PA - Placenta in upper segment and not palpable on vaginal exam

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24
Q

What is placenta accreta?

A

Attachment of the placenta to the myometrium due to defective decider basalis

Doesn’t separate in labour

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25
Q

What are the types of placenta accreta?

A

Accreta - Chorionic villi attach to myometrium rather than being restricted within decidua basalis

Increta - Chorionic villi invade into myometrium

Percreta - Chorionic villi invade all the way through to the perimetrium

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26
Q

What are the risk factors for placenta accreta?

A

Previous C Section

Placenta praevia

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27
Q

How can placenta accreta be diagnosed?

A

Imaging can raise suspicion

Definitive diagnosis through surgery

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28
Q

What are complications associated with placenta accreta?

A

Preterm delivery

Retained placenta and PPH

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29
Q

What should be done if you suspect placenta accreta?

A

Consultant obstetrician and anaesthetist at birth with blood

Uterus opened at site distant to placenta so baby can be delivered without disturbing it

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30
Q

What is done if placenta accreta is confirmed?

A

Hysterectomy

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31
Q

What does conservative management of placenta accreta involve?

A

Leave placenta in place
Uterine artery embolisation
Plan elective hysterectomy

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32
Q

What is rhesus isoimmunisation?

A

Production of antibodies in response to an isoantigen present on an erythrocyte

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33
Q

What happens in rhesus isoimmunisation and why is it dangerous?

A

Maternal antibodies formed in response to surface antigen on fetal RBC in sensitising event

Primary exposure - rarely any adverse effect
Secondary exposure - further pregnancies - maternal antibodies cross placenta and attack fetal RBC’s (if same surface antigen) –> haemolysis and fetal anaemia

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34
Q

Give an example of how you could get haemolytic disease of newborn

A

Mother Rhesus -ve, Father rhesus +ve
1st pregnancy - Rhesus +ve and sensitising event
2nd pregnancy - Rhesus +ve, maternal antibodies cross and attack fetal Rh+ve RBC’s
Haemolysis

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35
Q

What are some causes of sensitising events?

A 
Invasive obstetric testing - chorionic villi sampling, amniocentesis
Antepartum haemorrhage >12 weeks
Ectopic pregnancy
External cephalic version
Fall/trauma
Intrauterine death
Miscarriage >12 weeks
Termination of pregnancy
Delivery
36
Q

What investigations are done following a sensitising event?

A

Maternal blood group - find out ABO and Rhesus
Maternal antibody screen - detects antibodies against RBC surface antigens

Fetal maternal haemorrhage test - Kleihauers test

37
Q

What is kleihauers test? When is it used? What is it used for?

A

Assess how much fetal blood has entered maternal circulation

if sensitising event >20 week gestation

Used to determine how much AntiD immunoglobulin should be given

38
Q

How are women managed following a sensitising event?

A

Anti-D immunoglobulin administered - bind to maternal Rh+ cells - no immune response

39
Q

How is rhesus isoimmunisation screened in the UK?

What then happens if they are -ve?

A

All pregnant women have blood group and antibody test at booking visit (8-12 weeks) and again at 28 weeks

Any Rhesus -ve woman is offered anti D prophylaxis at 28 and 32 weeks

40
Q

When is a pregnancy considered prolonged?

A

> 42 weeks gestation

41
Q

What are the risk factors for prolonged pregnancy?

A

Nullparity
Maternal age >40
High BMI
Previous prolonged pregnancy

42
Q

How can prolonged pregnancy present?

A 
Macrosomia
Oligohydramnios
Reduced fetal movements
Meconium staining - on fingernails
Reduced vernix and dry skin
Reduced subcutaneous fat
43
Q

What complications are associated with prolonged pregnancy?

A

Still birth - exponential rise from 37 weeks on

Macrosomia complications - shoulder dystocia, perineal tears, obstructed labour

Placental insufficiency and degradation = distress

  • IUGR
  • meconium aspiration
  • hypoglycaemia
  • acidosis
44
Q

What can placental insufficiency lead to?

A 
Fetal acidaemia
Distress = meconium aspiration
IUGR features
Reduced O2 and nutrient transfer
Neonatal hypoglycaemia
45
Q

What are the maternal complications associated with prolonged pregnancy?

A

Perineal damage
Obstructed labour
Need for instrument or c section

46
Q

How are prolonged pregnancies managed?

A

Membrane sweep - 40 weeks if nullparous, 41 weeks if multiparous

Induction of labour - between 41 and 42+0 weeks

  • break water
  • intravaginal prostaglandins
  • oxytocin
47
Q

What should be done if women decline management for prolonged labour?

A

2x weekly CTG

Amniotic fluid measurements - identify fetal distress

48
Q

What is amniotic fluid made of?

A

Lung fluid
Fetal urine
Placental contributions

49
Q

What happens to amniotic fluid?

A

Fetus breathe and swallow fluid - get processed and fill bladder where it is voided

50
Q

How does the volume of amniotic fluid normally change? How much is left at term?

A

Increase steady until 33 weeks
Plateau 33-38 weeks
Decline until term to reach 500ml

51
Q

How is amniotic fluid measured?

A

Amniotic fluid index - measure maximum cord free vertical pocket in each of 4 quadrants of uterus and add together

Maximum pool depth - vertical measurement in any are

52
Q

How is oligohydramnios characterised?

A

Less than 500ml at 32-36 weeks

Amniotic fluid index <5th percentile

53
Q

What can cause oligohydramnios?

A 
Premature rupture of membranes
Placental insufficiency
Fetal renal problems - genesis, cystic
Obstructive uropathy
IUGR
Post-term gestation
Pre-eclampsia
54
Q

How would you assess a patient with oligohydramnios?

A 
Look for underlying cause:
Leakage - new urinary incontinence
Speculum examination - liquid in vagina
IUGR signs - UAD
Measure insulin like growth factor binding protein in vagina - suggest membrane rupture
55
Q

How is polyhydramnios characterised?

A

Amniotic fluid index >95th percentile

56
Q

What can cause Polyhydramnios?

A 
Idiopathic - 50-60%
Conditions that prevent fetal swallowing - oesophageal/duodenal atresia, CNS abnormalities, muscular dystrophy
Twin-twin transfusion syndrome
Maternal diabetes
Maternal ingestion of lithium
Macrosomia
TORCH infections
57
Q

What are the TORCH infections?

A

Perinatal infections

T - Toxoplasmosis
O - Other - syphilis, varicella, parvovirus
R - Rubella
C - Cytomegalovirus
H - Herpes
58
Q

How is Polyhydramnios managed?

A

Amnioreduction

Indomethacin - enhance water retention so reduced fetal urine output

For idiopathic, baby must be examined before first feed - nasogastric tube passed to ensure no tracheoesphageal fistula or oesophageal atresia

59
Q

What risks are associated with amnioreduction?

A

Infection

Placental abruption - sudden decrease in intrauterine pressure

60
Q

What risks are associated with indomethacin?

A

Premature closure of ductus arteriosus - not used beyond 32 weeks

61
Q

What symptoms do mothers with Polyhydramnios present with?

A 
Breathlessness
Swollen feet
Indigestion
Constipation
Baby bump very large/heavy
62
Q

What complications are associated with Polyhydramnios?

A

Pre-term labour - over distention of uterus
Malpresentation - fetus has more room to move
Cord prolapse
PPH - uterus has to contract down further

63
Q

What are the types of twin pregnancy?

A

2 ova fertilised:
2 chorion and 2 amnion
Can have own or fused placenta

1 ova fertilised:

  • Embryo split at 3 days - own placenta - 2 chorion, 2 amnion
  • Embryo split at 4-7 days - 1 placenta - 1 chorion, 2 amnion
  • Embryo split at 8-12 days - 1 placenta - 1 chorion and 1 amnion

Later - conjoint

64
Q

How do twin pregnancies normally present?

A

Pick up on scanning in 1st trimester
Hyperemesis
Exaggerated pregnancy symptoms
Uterus palpable earlier than 12 weeks

65
Q

How common are twin pregnancies in IVF?

A

24% of successful IVF

66
Q

How are multiple pregnancies monitored?

A

Scan at 11-13 weeks - gestational age, chronicity, screen for down’s

Other scans depend on type of twinning but monitor:

  • difference in fetal weight
  • IUGR
67
Q

What is twin-twin transfusion syndrome?

How is it managed?

A

Disproportionate blood supply between 2 twins leading to still birth and other complications

Laser treatment of the placental vascular anastomoses

68
Q

What fetal risks are associated with multiple pregnancy?

A

Greater risk if placenta shared

  • Miscarriage and still birth
  • Preterm birth
  • Down’s
  • Umbilical cord entanglement
  • IUGR
  • Developmental and behavioural problems
  • Feeding issues
69
Q

When should multiple pregnancies be offered delivery?

A

Triplets - 35 weeks
Monochorionic - 36 weeks
Dichorionic - 37 weeks

70
Q

What is the method of delivery for multiple pregnancy?

A 
Vaginal as long as twin 1 cephalic
C section if:
- twin 1 breech
- 1 amnion
- other complications
- triplets or more
71
Q

What are the risks of multiple pregnancy for the mother?

A 
Anaemia
Pre-eclampsia
Severe symptoms of pregnancy
Extra load on heart
Antepartum and Postpartum haemorrhage
72
Q

What is fetal distress?

A

Compromise to the fetus due to reduced oxygen or nutrition

73
Q

What are the signs of fetal distress?

A 
Reduced fetal movements
Abnormal non-stress test and/or contraction stress test
Abnormal amniotic fluid
Amnormal biophysical profile
Vaginal bleeding
Cramping
Maternal hypertension
Insufficient or excess maternal weight gain
74
Q

What can cause fetal distress?

A

Uteroplacental insufficiency

  • vascular disease
  • intrauterine sepsis
  • oligohydramnios
  • reduced fetal reserves
  • hypovolaemia
  • IUGR
75
Q

How is fetal distress managed?

A

Monitor - view for induction or C-Section

Balance risks of fetal distress and prematurity

76
Q

If fetal distress continues in labour, what should happen?

A

Expedite delivery

< 30mins

77
Q

What are the risks of smoking in pregnancy (including cannabis)?

A 
Miscarriage
Pre-term labour
Stillbirth
IUGR
SIDS
78
Q

What are the risks of alcohol in pregnancy?

A

Fetal alcohol syndrome:

  • Learning difficulties
  • Characteristic facies - smooth philtrum, thin vermilion, small palpebral fissures
  • IUGR and postnatal restricted growth
  • Microcephaly
79
Q

What are the risks of cocaine in pregnancy?

A

Maternal - HTN, pre-eclampsia, placental abruption

Fetus - prematurity, neonatal abstinence

80
Q

What is the main risk of heroin in pregnancy?

A

Neonatal abstinence syndrome

81
Q

What prescription drugs can’t be taken in pregnancy?

A

Antibiotics - tetracyclines, aminoglycosides, sulphonamides, trimethoprim, quinolones

ACE inhibitors, ARB's
Statins
Warfarin
Sulphonylureas
Retinoids
Cytotoxics
82
Q

How does foetal anaemia present?

A

HF
fluid retention (liver devoted to RBC production so albumin reduced)
death

After birth: jaundice (placenta clears bilirubin in utero and at birth the liver can’t)

83
Q

What can cause placental insufficiency?

A 
Smoking
HTN
Diabetes
Anaemia
Maternal hypovolaemia
84
Q

What are the results of placental insufficiency?

A 
Fetal distress
oligohydramnios
IUGR
Cerebral palsy due to reduced O2
Hypoglycaemia 
Placental vascular occlusion due to raised EPO
Infections due to low WCC
85
Q

How would you treat a UTI in pregnancy?

A

Can give nitrofurantoin in T1 and T2

Give cephalexin in T3

Obstetrics and Gynaecology (21 decks)

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