Pregnancy complications/ intra and postpartum care Flashcards
What is the normal pattern of blood pressure in pregnancy
The blood pressure should be less than 140/90 during pregnanct and then during the second trimester the blood pressure will normally fall and then rise again in the 3rd trimester
What are the ranges for hypertension and borderline hypertension
Greater than 140/90 is hypertensive and then 135-139/85-89 is borderline
What is the critea for proteinuria in pregnancy
- 0.3g in a 24hour sample
- 1+ on a dipstisk
What are possible non pathological causes of proteinuria 3
- UTI
- Renal disease
- Contamination from the vaginal fluid
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What is preeclampsia
This is where hypertension and proteinuria occur in the second half of pregnancy
What is the other name for preeclampsia
Gestational proteinuric hypertension
What is gestational hypertension
This is where hypertension appears in the second half of pregnancy without proteinuria
What is meant by chronic hypertension
This is where there is hypertension that is present in the first half of pregnancy or even before the pregnancy
What is eclampsia
This is a serious complication of pre eclampsia that is complicated by convulsions
What is the frequency of preeclampsia
5-6% of pregnancies
What are the complications of pre eclamsia that cause death in the patients
- Intracerebral hemorrhages
- Pulmonary edema
- Eclampsia
What is the blood pressure range where there is a significant risk of intracerebral hemorrhage
160/110mmHg
What are the complications to a fetus as a result of pre-eclampsia 3
- Preterm delivery as a result of deterioration of the mother’s condition
- Abruptio placentae
- Pre eclampsia results in decreased blood flow to the fetus causing growth restrictions
What are the symptoms of pre eclmpsia with severe features 5
- Severe headaches
- Visual disturbances
- Dyspnoea
- Altered mental status
- Upper abdominal pain
What are the signs that could indicate severe pre eclampsia features
- Liver tenderness
- Increased tendon reflexes
- Pulmonary odema
- Acites
What is the rough incidince of eclampsia in the WC
1/1000
What are some of the risk factors for pre eclampsia
- First pregnancy
- Chronic hypertension
- Over 34yo
- Multiple pregnancy
- Diabetics
What is the management of a patient that is at risk of pre-eclampsia
- 150mg of asprin
- 1g of Calsium
What level of hospital is able to manage a patient with pre eclampsia
A level 1 hospital with a c section facility
What is the medication that is used to manage the patient hypertension
Methyldopa 500mg 8hourly
What is the sequela of fetal well being in a patient with pre- eclampsia
- There will be placental insufficiency
- This will cause intrauterine growth restriction
- The growth restriction will cause fetal distress
- This will often lead to intrauterine death of the fetus
How can you monitor a fetus to check for fetal distress
At a level 2 or 3 hospital an umbilical artery doppler can be used to check the functioning of the umbilical cord and the placental function
When should a patient that has pre eclampsia deliver
At 34 weeks
What special investigation need to be done to definitively diagnose pre eclampsia
- MSU to check that there is no infections present
- Platelet count
- Serum creatinine to check renal function
- Ultrasound to check the gestational age of the fetus
- Umbilical artery doppler to assess placental function
What is the management of a patient with severe pre-eclampsia
- MgSO4
- Nepresol or Adalat to prevent intracranial hemorrhage
- IV fluids to prevent POdema
How is magnesium sulfate given to a patient
4g IV and then 5g in each butt
When is the Nepresol or Adalat given
This is given after the magnesuim sulfate if the blood pressure is still above 160/110
Which level of hospital should maintain a patient with severe symptoms of pre eclampsia
A level 2-3
What is the maintenance dose of magnesium sulfate
5 g every 4 hours in the butt
What do you check in order to make sure that you are not going to overdose Magnesium sulfate
The patellar reflex
What can be done if MgSO4 is OD
Then intubate the patient and give 10ml of calsium gluterate
What are the conditions under which the patient must deliver if they have pre eclampsia
- The patients condion does not stabilise
- The patient is very far from viability
- The duration of the pregnancy is 34 weeks or more
- Fetal distress is present
What level of hospital should a patient with gestational hypertension be managed
Level 1 hospital
What is the medication that is used to manage gestational hypertension
Alpha methyldopa
Should a patient with gestational hypertension deliver the baby
If the patients blood pressure is able to be managed well and there is no development of proteinuria then they can carry the baby to the full 40 weeks
Which chronic hypertension patients need to be cared for at a level 2 or 3 hospital
- Patients that have abnormal renal function
- If patients develop
How long should it take for the hypertension postpartum the settle in gestational hypertension
3 days
What is an antepartum haemorrhage
Any bleeding that occurs before 20 weeks
What would a bleed that occurs before 24weeks be considered as
Threatened miscarriage
What is the most common cause of a antepartum haemorrhage
Abruptio placentae
What is the general management of a patient in shock
- Put up 2 IV lines to manage fluid loss
- Insert a catheter to monitor the fluid output
- Cross match and give bloods if needed
What must be excluded before a digital vaginal exam is done
Placenta praevia
If bleeding comes from a closed cervical os what does that confirm
That it is an antepartum haemorrhage
What is a show in pregnancy
In pregnancy, a “show” refers to the passage of a mucus plug from the cervix, often tinged with blood.
What is the most likely cause if cervix is a few centimetres dilated with bulging membranes if there is some antepartum bleeding
This is most likely a show
Cause of blood-stained discharge in the vagina, with no bleeding through the cervical os
vaginitis
Cause of bleeding from the surface of the cervix caused by contact with the speculum
cervicitis or cervical intra-epithelial neoplasia CIN
What is meant by abruptio placentae
This is where a portion of the placenta has separated from the uterus before delivery of the baby
What are the risk factors for abruptio placentae
- Previous occurrence
- Pre-eclampsia
- Intrauterine growth restriction
- Cigarette smoking
- Poor socio-economic conditions
- Tauma
What are the 3 main signs that point to a diagnosis of abruptio placentae
- Severe abdominal pain
- Blood with dark red clots
- Absence of fetal movement after the bleeding
What would you do in the case of an abruptio placentae when there is still a fetal heart beat
The baby would need to be delivered as soon as possible
Why is it important to remember that pre-eclamsic patients often have abruptio placentae
This is because a patient that is in shock might still have a normal blood pressure because they were hypertensive before and so they should also be placed back on treatment for the hypertension after
What is a common complication that can occur in a patient with abruptio placentae after delivery
Postpartum hemorrhage
What can be done to prevent a post partum haemorrhage
The patient can be given Syntometrine 1 ampoule and if they are hypertensive they can be given 20 units of oxytocin
Which patients are at the highest risk for placenta praevia 4
- Patients that have had more than 5 pregnancies
- C sections
- Multiple pregnancy
- Threatened abortion
What in the history of an antepartum haemorrage would suggest placenta praevia
The bleeding is a bright red colour and there is still fetal movement after the bleeding has occured
What is done if the diagnosis of placentae privae is made
- If less than 38 weeks then the patient should be hospitalised to monitor for active bleed
- If older than 28 weeks then the patient needs to be given steroids to improve the lung function of the fetus incase of delivery
- Over 38 weeks the fetus must be delivered
What is the management for a patient that is actively bleeding
The baby should be delivered as soon as possible
Why do patients that have placentae praevia have increased risk of postpartum haemorrages
The bottom half of the uterus does not have as strong of an ability to contract as the upper segment
What is the most likely cause of an antepartum hemorrhage of unknown origin
A small abruptio placentae that is not life threatening
What is meant by Vasa Praevia
This is where the fetuses blood vessels lay across the internal cervical os opening thus when the labour occurs it causes life threatening hemorrhage from the fetus
Which level of hospitals should manage patients with antepartum hemorrhages
Level 1 hospitals with blood products and level 2 hospitals
g defects.
A patient with abruptio placentae and pre-eclampsia must be referred to a level
3 hospital as this patient is at high risk of pulmonary oedema and acute tubular necrosis
A patient with a grade 3 or 4 placenta praevia and a viable fetus of less than 34 weeks, who is going to be managed conservatively, should be managed in at least a level
2 hospital with a neonatal intensive care unit, or a level 3 hospital.
What is the most common cause of blood-stained discharge due to vaginitis in pregnancy
Trichomonal vaginitis, both the patient and her partner should receive a single dose of 2 g metronidazole, not in the first trimester
What should patients with contact bleeding be treated with
oral erythromycin 500 mg 6‑hourly for seven days
What is defined as preterm labour
This is regular uterine contractions before 37 weeks
What is defined as preterm membrane rupture
This is there is rupture of the membranes before 37 weeks