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Reproductive > Pregnancy complications & mortality > Flashcards

Pregnancy complications & mortality Flashcards

1
Q

What are hypertensive disorders in pregnancy?

A

Gestational hypertension

Pre-eclampsia

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2
Q

What is gestational hypertension?

A

New hypertension develops after 20wks

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3
Q

What is pre-eclampsia?

A

New hypertension >20wks in association with significant proteinuria

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4
Q

What is mild hypertension?

A

Systolic 140-49

Diastolic 90-99

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5
Q

What is moderate hypertension?

A

Systolic 150-159

Diastolic 100-109

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6
Q

What is severe hypertension?

A

Systolic >160

Diastolic >110

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7
Q

What is significant proteinuria in pre-eclampsia?

A

Automated reagent strop urine protein estimation >1+
Spot urinary P:C ratio >30mg/mmol
24hr urine protein collection >300mg/day

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8
Q

What is the management of mothers with essential/chronic hypertension?

A 
Pre-pregnancy care
Keep BP <150/100
Monitor for superimposed pre-eclampsia
Monitor fetal growth
Higher incidence placental abruption
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9
Q

What is pre-pregnancy care for essential/chronic hypertension?

A 
Change anti-hypertensive drugs if necessary
ACE-i
ARBs
Anti diuretics
Low dietary sodium
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10
Q

What is the definition of pre-eclampsia?

A

Mild HT on two occasions more than 4 hours apart
Moderate to severe HT
+ Proteinuria of more than 300mgms/24hrs

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11
Q

What are.the risk factors for developing pre-eclampsia?

A 
First pregnancy
Extremes of maternal age
Pre-eclampsia in previous pregnancy
Pregnancy interval >10yrs
BMI >35
FHx
Multiple pregnancy
Underlying medical disorder
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12
Q

What are the complications of pre-eclampsia for the mother?

A

Seizures
Severe hypertension - cerebral haemorrhage, stroke
HELLP (hemolysis, elevated liver enzymes, low platelets)
DIC (disseminated intravascular coagulation)
Renal failure
Pulmonary oedema, cardiac failure

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13
Q

What are the complications of pre-eclampsia for the child?

A

Impaired placental perfusion:

  • IUGR
  • fetal distress
  • prematurity
  • increased PN mortality
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14
Q

What are symptoms/signs of severe pre-eclampsia?

A

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

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15
Q

What are the investigations for pre-eclampsia?

A

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

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16
Q

What is the management for pre-eclampsia?

A

Only cure is delivery
Observation
Anti-hypertensives: labetolol, methyldopa
Steroids for fetal lung maturity if gestation <36wks
Consider induction of labour

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17
Q

What is the treatment for seizures/impending seizures in pre-eclampsia?

A

Magnesium sulphate bolus + IV infusion
Control BP
Avoid fluid overload

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18
Q

What is the prophylaxis for pre-eclampsia in future pregnancy?

A

Low dose aspirin from 12wks

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19
Q

What are the types of diabetes in pregnancy?

A

Pre-existing

Gestational

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20
Q

What are signs of gestational diabetes?

A

Carbohydrate intolerance with onset of pregnancy

Abnormal glucose tolerance that reverts to normal after delivery

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21
Q

What happens to insulin requirements of pre-existing diabetic women?

A

Increased insulin requirements

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22
Q

Why do insulin requirements increase in pregnancy?

A

Some hormones have anti-insulin action

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23
Q

What happens to fetus in women with pre-existing diabetes in pregnancy?

A

Fetal hyperinsulinemia occurs as maternal glucose crosses placenta and induces insulin production in fetus

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24
Q

What does fetal insulinaemia cause?

A

Macrosomia

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25
Q

What are the risks for baby in diabetic mum’s post-delivery?

A

More risk neonatal hypoglycaemia

Increased risk respiratory distress

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26
Q

What are there increased risks of in babies with diabetic mothers?

A 
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
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27
Q

What is the management of diabetes pre-conception?

A

Better glycaemic control: 4-7mmol/l
Folic acid
Dietary advice
Retinal and renal assessment

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28
Q

What is the management of diabetes during pregnancy?

A 
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
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29
Q

What are risk factors for gestational diabetes?

A 
BMI >30
Previous macrosomic baby
Previous GDM
FHx diabetes
Polydramnious
Recurrent glycosuria in current pregnancy
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30
Q

What is screening for GDM?

A

If risk factors:
HbA1c estimation
OGTT repeated

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31
Q

What is management of GDM?

A

Control blood sugars: diet/metformin/insulin
Post delivery check OGTT
Yearly check HbA1c

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32
Q

What is Virchow’s triad for VTE?

A

Stasis
Vessel wall injury
Hypercoagulability

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33
Q

Why is pregnancy a risk of VTE?

A

Hypercoaguable state
Increased stasis
May be vascular damage at delivery/c-section

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34
Q

Why is pregnancy hypercoaguable state?

A

To protect mother against bleeding post-delivery

  • increased fibrinogen, factor VIII, VW factor, platelets
  • decreased natural anticoagulants
  • increase in fibrinolysis
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35
Q

Who is at increased risk of VTE during pregnancy?

A 
Older mothers, increasing parity
Increased BMI
Smokers
IVDU
Dehydration
Decreased mobility
Infections
Operative delivery
Prolonged labour
Haemorrhage
Previous VTE
Sickle cell disease
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36
Q

What are VTE prophylaxis in pregnancy?

A

Stockings
Increased mobility/hydration
Prophylactic anti-coagulation if 3+ risk factors

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37
Q

What are signs/symptoms of VTE?

A 
Pain in calf
Increased size affected leg
Calf muscle tenderness
Breathlessness
Pain on breathing
Cough
Tachycardia
Hypoxic
Pleural rub
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38
Q

What are the investigations for suspected VTE?

A

ECG
Blood gases
Doppler V/Q
CTPA

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39
Q

What is abortion or spontaneous miscarriage?

A

Termination/loss of pregnancy before 24wks gestation

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40
Q

What are the different types of spontaneous miscarriage?

A 
Threatened
Invisible
Incomplete
Complete
Septic
Missed
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41
Q

What are the signs/symptoms of threatened miscarriage?

A

Vaginal bleeding +/- pain
Viable pregnancy
Closed cervix on speculum examination

Body is showing signs that you might miscarry

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42
Q

What is an inevitable miscarriage?

A

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.

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43
Q

What are the signs/symptoms of a missed miscarriage (early fetal demise)?

A

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

44
Q

What are the signs/symptoms of incomplete miscarriage?

A

Most of pregnancy expelled out, some products of pregnancy remaining in uterus
Open cervix, vaginal bleeding (may be heavy)

45
Q

What are the signs/symptoms of a complete miscarriage?

A

Passed all products of conception (POC), cervix closed and bleeding has stopped

46
Q

What is a septic miscarriage?

A

Infection in uterus post-miscarrisge

Especially cases of incomplete miscarriage

47
Q

What are some causes of spontaneous miscarriage?

A

Abnormal conceptus: chromosomal, genetic, structural
Uterine abnormality: congenital, fibroids
Cervical incompetence
Maternal: age, diabetes
Unknown

48
Q

What is cervical incompetence/weakness?

A

Condition of pregnancy in which thecervixbegins to dilate (widen) and efface (thin) before the pregnancy has reached term

49
Q

What is the management of threatened miscarriage?

A

Conservative

50
Q

What is the management of inevitable miscarriage?

A

If bleeding heavy may need evacuation

51
Q

What is the management of missed miscarriage?

A

Conservative
Medical - prostaglandins
Surgical - surgical management of miscarriage (SMM)

52
Q

What is the management for septic miscarriage?

A

Antibiotics

Evacuate uterus

53
Q

What is an ectopic pregnancy and where can it happen?

A 
Pregnancy implanted outside uterine cavity
Fallopian tube (tubal), ovary, interstitial, cervical
54
Q

What are the different types of tubal ectopic pregnancy?

A

Ampullary - most common
Isthmus
Interstitial

55
Q

What are the risk factors for ectopic pregnancy?

A

PID
Previous tubal surgery
Previous ectopic
Assisted conception

56
Q

How does an ectopic pregnancy present?

A

Period of amenorrhea (with +ve pregnancy test)
+/- vaginal bleeding
+/- abdo pain
+/- GI or urinary symptoms

57
Q

What are the investigations for an ectopic pregnancy?

A

Scan
Serum B-hCG levels
Serum progesterone levels - if viable IU pregnancy high

58
Q

What is the management for ectopic pregnancy?

A

Methotrexate
Surgery: laparoscopic (salpingoectomy, salpingotomy)
Conservative

59
Q

What is antepartum haemorrhage (APH)?

A

Haemorrhage from the genital tract after the 24th week of pregnancy but before delivery

60
Q

What are causes of APH?

A 
Placenta praevia
Placental abruption
APH of unknown origin
Local lesions of genital tract
Casa praevia
61
Q

What is placenta praevia?

A

All or part of placenta impacts in the lower uterine segment

62
Q

Who is placenta praevia most common in?

A

Multiparous women
Multiple pregnancy
Previous c-section

63
Q

What are the grades of placenta praevia?

A

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

64
Q

What is the presentation of placenta praevia?

A

*Painless PV bleeding
Malpresentation of fetus
Incidental

65
Q

What are the clinical features of placenta praevia?

A

Maternal conditions correlates with amount of PV bleeding

Soft, non-tender uterus +/- fetal malpresentation

66
Q

How do you make a diagnosis of placenta praevia?

A

USS

67
Q

What must NOT be done in suspected placenta praevia?

A

Vaginal examination

68
Q

What is the management for placenta praevia?

A

C-section and watch for PPH
Oxytocin, ergometrine, carbaprost, transexemic acid
Balloon tamponade
Surgical: B lynch suture, ligation of uterine/iliac vessels, hysterectomy

69
Q

What is placental abruption?

A

Haemorrhage resulting from premature separation of placenta before birth

70
Q

What are factors associated with placental abruption?

A 
Pre-eclampsia/HTN
Multiple pregnancy
Polyhydramnious
Smoking
Age+
Parity
Previous abruption
Cocaine use
71
Q

What are the different types of placental abruption?

A

Revealed
Concealed
Mixed

72
Q

What is revealed placental abruption?

A

Bleeding tracks down from the site of placental separation and drains through the cervix. This results in vaginal bleeding.

73
Q

What is concealed placental abruption?

A

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.

74
Q

How does placental abruption present?

A

*Pain
Vaginal bleeding
Increased uterine activity

75
Q

What does the management of placental abruption depend on?

A

Amount of bleeding
Condition of mother and baby
Gestation

76
Q

What are the complications of placental abruption?

A

Maternal shock
Fetal death
Maternal DIC, renal failure
PPH

77
Q

What is preterm labour?

A

Labour before 37 completed weeks gestation

  • 32-36wks mildly preterm
  • 28-32wks very preterm
  • 24-28wks extremely preterm
78
Q

What are predisposing factors for preterm labour?

A 
Multiple pregnancy
Polyhydramnious
APH
Pre-eclampsia
Infection
Prelabour premature rupture of membranes
Majority idiopathic
79
Q

How do you diagnosis preterm labour?

A

Contractions with evidence of cervical change on VE

80
Q

What is the management of preterm labour?

A

Consider tocolysis
Steroids
Transfer to unit with NICU
Aim for vaginal delivery

81
Q

What is classed as maternal mortality?

A

Death of woman whilst pregnant
Within 42 days of termination of pregnancy
Any cause related to or aggravated by pregnancy

82
Q

What is maternal morbidity?

A

Severe health complications occurring in pregnancy and delivery, not resulting in death

83
Q

What is maternal mortality ratio?

A

Number of maternal deaths during five time period per 100,000 live births during same time period

84
Q

What is maternal mortality rate?

A

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

85
Q

What is lifetime risk of maternal death?

A

Probability of maternal death during woman’s reproductive life

86
Q

What is proportionate mortality ratio?

A

Maternal deaths as proportion of all female deaths of those of reproductive age

87
Q

What does the maternal mortality ratio represent?

A

Risk associated with each pregnancy

88
Q

What does the maternal mortality rate represent?

A

Not only obstetric risk but also frequency with which women are exposed to that risk

89
Q

What are facility based methods for measuring maternal deaths?

A 
Health info systems
Registries
Confidential enquiries
Maternal death review
Audits
90
Q

What are population/community based methods for measuring maternal deaths?

A

Notification by law
Vital registration
Census
Surveys/surveillance

91
Q

What are direct deaths?

A

Related to obstetric complications during pregnancy, labour or puerperium (6wks) or resulting from treatment

92
Q

How long is puerperium?

A

6wks

93
Q

What are indirect deaths?

A

Associated with disorder, effect of which is exacerbated by pregnancy

94
Q

What are late deaths?

A

Occur >42 days after end of pregnancy but within 1yr

95
Q

What are main causes of maternal death worldwide?

A 
Haemorrhage
Sepsis
Hypertensive disorders
Obstructed labour
Unsafe abortion
96
Q

What is the 3 delays model?

A
  • Delay in decision to seek care
  • Delay in reaching care
  • Delay in receiving care
97
Q

What ways can prevent maternal mortality?

A

Antenatal care
Skilled attendant at birth
Emergency obstetric care

98
Q

What is early neonatal death?

A

Within 1wk

99
Q

What is late neonatal death?

A

Within 1mo

100
Q

What is infant mortality?

A

Within 1yr

101
Q

What is stillbirth?

A

Birth of dead baby after 20/24/28 wks of gestation or weighing >500g

102
Q

What are main causes of death in babies?

A 
Congenital anomaly
Cord
Fetal
Infection
Maternal cause
Placenta
103
Q

What is essential newborn care?

A

Ensure breathing
Breastfeeding straight away
Keep baby warm
Wash hands before touch baby

104
Q

What can health facilities provide to ensure improved perinatal mortality?

A

Emergency Obstetric Care

105
Q

What policies can improve perinatal mortality?

A

IMNCH

Every Newborn Action Plan

Reproductive (20 decks)

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