W04: Complications in Pregnancy; APH; PPROM Flashcards
Outline the basis of symptoms, main causes, dx, and mgmy of miscarriage
- spontaneous loss of pregnancy before reaching viability until 24w. 15% incidence
- multifactorial
- vaginal bleeding, pain
- asymptomatic possible in missed miscarriages (no clear fetus)
Threated
> conservative
Inevitable
> Evacuation if heavy bleeds
Missed
> conservative
> medical: prostaglandins (misoprostol)
> sx
Septic
> abx + evacuation
Outline the basis of symptoms, main causes, dx, and mgmy of pregnancy of unknown location
- nil pregnancy visualised either inside or outside the womb despite + preg test, abdo pain/ vag. bleeding
*? ectopic, miscarried, too early to dx
BUT PERSISTENT PUL (bHCG)
> conservative, waiting
> methotrexate injection = resorption of pregnancy
> sx. if emergency
Outline the basis of symptoms, main causes, dx, and mgmy of ectopic pregnancy
pregnancy implantation outside the uterine cavity
- commonly tubal implantation
- RF: pelvic inflamm. disease; prev tubal sx; prev. ectopic; assisted conception
- period of ammenorhoea
- vag. bleeding, abdo pain, GI/ urinary symptoms
- scan: nil sac, potentially adnexal mass, fluid in PoDouglas
- serum BHCG: 48hr interval (normal early preg increases levels 66%)
> methotrexate
sx: laparoscopy - salpingectomy (remove the tube); salpingotomy (remove embryo)
Outline the basis of symptoms, main causes, dx, and mgmy of molar pregnancy
gestational trophoblastic disease (GTD)
* inability to develop into normal preg.
* unstable chromosome
=> complete molar = 2 sperm empty egg etc.
=> partial molar = 3 sets
=> invasive molar preg (neoplastic)
- common to experience irregular or heavy vaginal bleeding in early pregnancy.
- USS
- abn high bHCG
- sent for biopsy (miscarriage or post-removal)
> sx removal
Identify Antepartum haemorrhage
24w+ haemorrhage but before delivery
- grave emergency, signficiant morbidity and mortality
- placenta praevia
- placental abruption: retroplacental clot
- APH of unknown origin
- local lesions in genital tract
- vasa praevia: small amt of loss from baby yet catastrophic
Initial mgmt of APH
a
Threated Vs Inevitable Miscarriage
Threatened = Bleeding from gravid , no evidence of cervical dilatation
Inevitable = Cervix has begun to dilate
Placenta praevia
1/200 pregos
implantation in lower uterine segment
risk:
multiparous women
multiple pregnancies
prev c-sect
Grade I to IV = describes placental approach/covering of os
or alternatively
low-lying vs full placenta previa
- painless PV bleeding
- malpresentation
- incidental
- USS; avoid vaginal examination
> c-sect
PPartum Haemorrhage Mgmt
> Oxytocin, ergmetrine, carboprost, tranexemic acid
Balloon tamponade
Sx: b lynch cutre, ligation of uterine and iliac vessels, hysterectomy
Placental abruption
Haemorrhage resulting from premature separation of the placenta before the birth of the baby
*retroplacental clot
* RF: pre-eclpsia, multiple preg., polyhydramnios, smoking, age, parity, prev. abruption, cocaine use
- revealed abruption = blood vis.
- concealed abruption = internal
- mixed abruption
- PAIN, PV BEEDING, INCREASED UTERINE ACTIVITY
! maternal shock, collapse, fetal distress and death, maternal DIC, renal failure, PPHaemorr.
Preterm Labour
Onset of labour before 37weeks
* spontaneous or induced
Preterm delivery:
* contractions with evidence of cervical change via VExam.
* Fetal fibronectin test: +ve thus increased risk
?consider abruption, infection
> consider tocolysis (DRUGS PREVENTING UTERINE CONTRACTIONS) to allow steroids/transfer
steroids
transfer
aim for vaginal delivery
Neonatal morbidity resulting from prematurity
- respiratory distress syndrome
- intraventircular haemorrhage
- cerebral palsy
- nutrition
- temperature control
- jaundice
- infections
- vis. impairment
- hearing loss
Recognise and describe initial management of hypertensive disorders in pregnancy
Pre-preg care
* CI anti-hypertensives: RAMIPRIL / ENALOPRIL
- ARBs (tans)
- antidiuretics
- lower dietary Na
- aim for BP <150/100 via LABETOLOL, NIFEDIPINE, METHYLDOPA
- monitoring
List the complications of hypertensive disorders
- higher risk of placantal abruption
- systemic organ disorder with pre-eclampsia
- seizures
- severe HT = cerebral haemorr., stroke
- HELLP: hemolysis, elevated liver enzymes, low platelets
- DIC
- renal failure
- pulm oedema
- fetal impaired placental perfusion
List the complications associated with diabetes in pregnancy
- higher risk of neonatal hypoglc. and increased risk of resp distress
- fetal congenital abn.
- miscarriage
- shoulder dystocia
- stillbirth
- maternal end organ dmg.
+ increased risk of pre-eclampsia
+ infections
Outline when to suspect thrombosis in pregnancy
VIRCHOWS TRIAD: statis, hypercoag., vessel wall injury
* pregnancy is a hypercoagualable state
- ⇧ fibrinogen, VIII, VW factor, platelets
* ⇧ stasis with progesterone on enlarging uterus
- Homan’s sign: dorsiflexion claudication
- V/Q scan
- CTPA
> TED stockings
⇧ mobility, hydration
prophylactic anti-coag with 3+ Risk factors; continued 6w postpartum
Chronic HT qualfiers in pregnancy
Mild HT
90/140 - 99/149
Moderate HT
100/150 - 150/159
Severe HT
110/160+
Chronic HT qualfiers in pregnancy
Mild HT
90/140 - 99/149
Moderate HT
100/150 - 150/159
Severe HT
110/160+
Define gestational HT
BP as bove but new HT (after 20w)
Define pre-eclampsia
New HT >20w in association with significant proteinuria
- mild HT on two occasions more than 4hrs apart; MODERATE to SEVERE
Significant proteinuria
spot urinary protein: creatinine ratio >30mg/mmol
24hr urine protein collection
>300mg/day
Pre-eclampsia pathophysiology
immunological aetiology
+ genetic predisposition
*2º invasion of maternal spiral arterioles by trophoblast
* dysregulated angiogenesis and thus maintenance of vasculature with vasodilators/vasoconstrictors imbalanced
- prostocyclin / thromboxane
Symptoms of pre-eclampsia
headache, blurring of vision, epigastric pain, vom.
sudden swelling of hands, face, legs
clonus/brisk reflexes: papillodema, epigastric tenderness
reduced urine output
convulsions
⇧ liver enzymes
+bilirubin if HELLP (hemolysis, elevated liver enzymes, low platelets)
⇧ urea, creatinine, urate
- low platelets, Hb
- features of DIC
Mgmt of DIC
- freq. BP checks, urine protein
- check: symptoms; clonus; liver tenderness
- FBC, LFT, renal function tests, coagulation tests
- CTG for foetus
> delivery of baby and placenta INDUCTION) OTHERWISE CONSERVATIVE
> labetolol, methyldopa, nifedipine
consider post-natal monitoring dt risk of complications
Mgmt of seizures (bg: pre-eclampsia)
> Mg sulphate bolus + IV infusion
+ IV labetolol, hydrallazine
avoid fluid overload
+ low dose aspirin from 12w til delivery = PROPHYLAXIS
Diabetes in Pregnancy
- DM 1, DM 2
- GESTATIONAL DM: carb intolerance with onset in preg., abn glc tolerance which reverts to normal after deliveryl; risk of DM2 later in life
- anti-insulin action of pregnancy hormones
- macrosomia and hyperinsulinemia in fetus
Mgmt of DM in pregnancy
better glycemic control
> folic acid
dietary advice
retinal and renal assessment
> oral anti-dm drugs e.g. metformin or swithc to insulin
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