Pregnancy complications & mortality Flashcards
What are hypertensive disorders in pregnancy?
Gestational hypertension
Pre-eclampsia
What is gestational hypertension?
New hypertension develops after 20wks
What is pre-eclampsia?
New hypertension >20wks in association with significant proteinuria
What is mild hypertension?
Systolic 140-49
Diastolic 90-99
What is moderate hypertension?
Systolic 150-159
Diastolic 100-109
What is severe hypertension?
Systolic >160
Diastolic >110
What is significant proteinuria in pre-eclampsia?
Automated reagent strop urine protein estimation >1+
Spot urinary P:C ratio >30mg/mmol
24hr urine protein collection >300mg/day
What is the management of mothers with essential/chronic hypertension?
Pre-pregnancy care Keep BP <150/100 Monitor for superimposed pre-eclampsia Monitor fetal growth Higher incidence placental abruption
What is pre-pregnancy care for essential/chronic hypertension?
Change anti-hypertensive drugs if necessary ACE-i ARBs Anti diuretics Low dietary sodium
What is the definition of pre-eclampsia?
Mild HT on two occasions more than 4 hours apart
Moderate to severe HT
+ Proteinuria of more than 300mgms/24hrs
What are.the risk factors for developing pre-eclampsia?
First pregnancy Extremes of maternal age Pre-eclampsia in previous pregnancy Pregnancy interval >10yrs BMI >35 FHx Multiple pregnancy Underlying medical disorder
What are the complications of pre-eclampsia for the mother?
Seizures
Severe hypertension - cerebral haemorrhage, stroke
HELLP (hemolysis, elevated liver enzymes, low platelets)
DIC (disseminated intravascular coagulation)
Renal failure
Pulmonary oedema, cardiac failure
What are the complications of pre-eclampsia for the child?
Impaired placental perfusion:
- IUGR
- fetal distress
- prematurity
- increased PN mortality
What are symptoms/signs of severe pre-eclampsia?
Headache, blurred vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands/face/legs
Clonus/brisk reflexes
Reduced urine output
Convulsions
Severe hypertension; >3+ urine proteinuria
What are the investigations for pre-eclampsia?
Frequent BP checks, urine protein checks
Check symptomatology
Check for hyper-reflexia/tenderness of liver
Bloods: FBC, LFTs, renal function tests, coagulations tests
Fetal investigations: scans, CTG
What is the management for pre-eclampsia?
Only cure is delivery
Observation
Anti-hypertensives: labetolol, methyldopa
Steroids for fetal lung maturity if gestation <36wks
Consider induction of labour
What is the treatment for seizures/impending seizures in pre-eclampsia?
Magnesium sulphate bolus + IV infusion
Control BP
Avoid fluid overload
What is the prophylaxis for pre-eclampsia in future pregnancy?
Low dose aspirin from 12wks
What are the types of diabetes in pregnancy?
Pre-existing
Gestational
What are signs of gestational diabetes?
Carbohydrate intolerance with onset of pregnancy
Abnormal glucose tolerance that reverts to normal after delivery
What happens to insulin requirements of pre-existing diabetic women?
Increased insulin requirements
Why do insulin requirements increase in pregnancy?
Some hormones have anti-insulin action
What happens to fetus in women with pre-existing diabetes in pregnancy?
Fetal hyperinsulinemia occurs as maternal glucose crosses placenta and induces insulin production in fetus
What does fetal insulinaemia cause?
Macrosomia
What are the risks for baby in diabetic mum’s post-delivery?
More risk neonatal hypoglycaemia
Increased risk respiratory distress
What are there increased risks of in babies with diabetic mothers?
Fetal congenital anomalies Miscarriage Fetal macrosomia, polyhydramnios Operative delivery, shoulder dystocia Stillbirth, increased perinatal mortality Risk of pre-eclampsia Infections Neonatal: impaired lung maturity, neonatal hypoglycemia, jaundice
What is the management of diabetes pre-conception?
Better glycaemic control: 4-7mmol/l
Folic acid
Dietary advice
Retinal and renal assessment
What is the management of diabetes during pregnancy?
Optimise glucose control, insulin requirements will increase Oral anti-diabetic agents Risks of hypoglycemia Watch for ketonuria/infections Retinal assessments Fetal growth Observe for pre-eclampsia Consider labour induction/c-section CTG fetal monitoring Early feeding baby to reduce neonatal hypoglycemia
What are risk factors for gestational diabetes?
BMI >30 Previous macrosomic baby Previous GDM FHx diabetes Polydramnious Recurrent glycosuria in current pregnancy
What is screening for GDM?
If risk factors:
HbA1c estimation
OGTT repeated
What is management of GDM?
Control blood sugars: diet/metformin/insulin
Post delivery check OGTT
Yearly check HbA1c
What is Virchow’s triad for VTE?
Stasis
Vessel wall injury
Hypercoagulability
Why is pregnancy a risk of VTE?
Hypercoaguable state
Increased stasis
May be vascular damage at delivery/c-section
Why is pregnancy hypercoaguable state?
To protect mother against bleeding post-delivery
- increased fibrinogen, factor VIII, VW factor, platelets
- decreased natural anticoagulants
- increase in fibrinolysis
Who is at increased risk of VTE during pregnancy?
Older mothers, increasing parity Increased BMI Smokers IVDU Dehydration Decreased mobility Infections Operative delivery Prolonged labour Haemorrhage Previous VTE Sickle cell disease
What are VTE prophylaxis in pregnancy?
Stockings
Increased mobility/hydration
Prophylactic anti-coagulation if 3+ risk factors
What are signs/symptoms of VTE?
Pain in calf Increased size affected leg Calf muscle tenderness Breathlessness Pain on breathing Cough Tachycardia Hypoxic Pleural rub
What are the investigations for suspected VTE?
ECG
Blood gases
Doppler V/Q
CTPA
What is abortion or spontaneous miscarriage?
Termination/loss of pregnancy before 24wks gestation
What are the different types of spontaneous miscarriage?
Threatened Invisible Incomplete Complete Septic Missed
What are the signs/symptoms of threatened miscarriage?
Vaginal bleeding +/- pain
Viable pregnancy
Closed cervix on speculum examination
Body is showing signs that you might miscarry
What is an inevitable miscarriage?
Viable pregnancy
Open cervix with bleeding that could be heavy (+/- clots)
Most often the conception products are not expelled and intracervical contents are present at the time of examination.
What are the signs/symptoms of a missed miscarriage (early fetal demise)?
No symptoms, or could have bleeding/brown discharge PV
Gestational sac seen on scan
No clear fetus or fetal pole with no fetal heart seen in gestational sac
What are the signs/symptoms of incomplete miscarriage?
Most of pregnancy expelled out, some products of pregnancy remaining in uterus
Open cervix, vaginal bleeding (may be heavy)
What are the signs/symptoms of a complete miscarriage?
Passed all products of conception (POC), cervix closed and bleeding has stopped
What is a septic miscarriage?
Infection in uterus post-miscarrisge
Especially cases of incomplete miscarriage
What are some causes of spontaneous miscarriage?
Abnormal conceptus: chromosomal, genetic, structural
Uterine abnormality: congenital, fibroids
Cervical incompetence
Maternal: age, diabetes
Unknown
What is cervical incompetence/weakness?
Condition of pregnancy in which thecervixbegins to dilate (widen) and efface (thin) before the pregnancy has reached term
What is the management of threatened miscarriage?
Conservative
What is the management of inevitable miscarriage?
If bleeding heavy may need evacuation
What is the management of missed miscarriage?
Conservative
Medical - prostaglandins
Surgical - surgical management of miscarriage (SMM)
What is the management for septic miscarriage?
Antibiotics
Evacuate uterus
What is an ectopic pregnancy and where can it happen?
Pregnancy implanted outside uterine cavity Fallopian tube (tubal), ovary, interstitial, cervical
What are the different types of tubal ectopic pregnancy?
Ampullary - most common
Isthmus
Interstitial
What are the risk factors for ectopic pregnancy?
PID
Previous tubal surgery
Previous ectopic
Assisted conception
How does an ectopic pregnancy present?
Period of amenorrhea (with +ve pregnancy test)
+/- vaginal bleeding
+/- abdo pain
+/- GI or urinary symptoms
What are the investigations for an ectopic pregnancy?
Scan
Serum B-hCG levels
Serum progesterone levels - if viable IU pregnancy high
What is the management for ectopic pregnancy?
Methotrexate
Surgery: laparoscopic (salpingoectomy, salpingotomy)
Conservative
What is antepartum haemorrhage (APH)?
Haemorrhage from the genital tract after the 24th week of pregnancy but before delivery
What are causes of APH?
Placenta praevia Placental abruption APH of unknown origin Local lesions of genital tract Casa praevia
What is placenta praevia?
All or part of placenta impacts in the lower uterine segment
Who is placenta praevia most common in?
Multiparous women
Multiple pregnancy
Previous c-section
What are the grades of placenta praevia?
Grade I: placenta encroaching on lower segment but not the internal cervical os
Grade II: placenta reaches cervical os
Grade III: placenta eccentrically covers os
Grade IV: central placenta praevia
What is the presentation of placenta praevia?
*Painless PV bleeding
Malpresentation of fetus
Incidental
What are the clinical features of placenta praevia?
Maternal conditions correlates with amount of PV bleeding
Soft, non-tender uterus +/- fetal malpresentation
How do you make a diagnosis of placenta praevia?
USS
What must NOT be done in suspected placenta praevia?
Vaginal examination
What is the management for placenta praevia?
C-section and watch for PPH
Oxytocin, ergometrine, carbaprost, transexemic acid
Balloon tamponade
Surgical: B lynch suture, ligation of uterine/iliac vessels, hysterectomy
What is placental abruption?
Haemorrhage resulting from premature separation of placenta before birth
What are factors associated with placental abruption?
Pre-eclampsia/HTN Multiple pregnancy Polyhydramnious Smoking Age+ Parity Previous abruption Cocaine use
What are the different types of placental abruption?
Revealed
Concealed
Mixed
What is revealed placental abruption?
Bleeding tracks down from the site of placental separation and drains through the cervix. This results in vaginal bleeding.
What is concealed placental abruption?
The bleeding remains within the uterus, and typically forms a clot retroplacentally. This bleeding is not visible, but can besevere enough to cause systemic shock.
How does placental abruption present?
*Pain
Vaginal bleeding
Increased uterine activity
What does the management of placental abruption depend on?
Amount of bleeding
Condition of mother and baby
Gestation
What are the complications of placental abruption?
Maternal shock
Fetal death
Maternal DIC, renal failure
PPH
What is preterm labour?
Labour before 37 completed weeks gestation
- 32-36wks mildly preterm
- 28-32wks very preterm
- 24-28wks extremely preterm
What are predisposing factors for preterm labour?
Multiple pregnancy Polyhydramnious APH Pre-eclampsia Infection Prelabour premature rupture of membranes Majority idiopathic
How do you diagnosis preterm labour?
Contractions with evidence of cervical change on VE
What is the management of preterm labour?
Consider tocolysis
Steroids
Transfer to unit with NICU
Aim for vaginal delivery
What is classed as maternal mortality?
Death of woman whilst pregnant
Within 42 days of termination of pregnancy
Any cause related to or aggravated by pregnancy
What is maternal morbidity?
Severe health complications occurring in pregnancy and delivery, not resulting in death
What is maternal mortality ratio?
Number of maternal deaths during five time period per 100,000 live births during same time period
What is maternal mortality rate?
Number of maternal deaths in given time period per 100,000 women of reproductive age, or woman-years of risk exposure, in same time period
What is lifetime risk of maternal death?
Probability of maternal death during woman’s reproductive life
What is proportionate mortality ratio?
Maternal deaths as proportion of all female deaths of those of reproductive age
What does the maternal mortality ratio represent?
Risk associated with each pregnancy
What does the maternal mortality rate represent?
Not only obstetric risk but also frequency with which women are exposed to that risk
What are facility based methods for measuring maternal deaths?
Health info systems Registries Confidential enquiries Maternal death review Audits
What are population/community based methods for measuring maternal deaths?
Notification by law
Vital registration
Census
Surveys/surveillance
What are direct deaths?
Related to obstetric complications during pregnancy, labour or puerperium (6wks) or resulting from treatment
How long is puerperium?
6wks
What are indirect deaths?
Associated with disorder, effect of which is exacerbated by pregnancy
What are late deaths?
Occur >42 days after end of pregnancy but within 1yr
What are main causes of maternal death worldwide?
Haemorrhage Sepsis Hypertensive disorders Obstructed labour Unsafe abortion
What is the 3 delays model?
- Delay in decision to seek care
- Delay in reaching care
- Delay in receiving care
What ways can prevent maternal mortality?
Antenatal care
Skilled attendant at birth
Emergency obstetric care
What is early neonatal death?
Within 1wk
What is late neonatal death?
Within 1mo
What is infant mortality?
Within 1yr
What is stillbirth?
Birth of dead baby after 20/24/28 wks of gestation or weighing >500g
What are main causes of death in babies?
Congenital anomaly Cord Fetal Infection Maternal cause Placenta
What is essential newborn care?
Ensure breathing
Breastfeeding straight away
Keep baby warm
Wash hands before touch baby
What can health facilities provide to ensure improved perinatal mortality?
Emergency Obstetric Care
What policies can improve perinatal mortality?
IMNCH
Every Newborn Action Plan
