W11L2 Tues pregnancy complication Flashcards

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1
Q

Pregnancy timeline

A

First trimester: First 12 weeks
* Embryonic period 3 – 8 weeks, Period of the fetus 9 weeks onward
* 4 – 13 weeks period of greatest risk to birth defects
Second trimester: 13 – 27 weeks

Third trimester: 28 weeks onward
* Pregnancy is considered at term after 37 weeks
* Post term anything above 40 weeks

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2
Q

What is Miscarriage ,it’s rate and possible cause

A

Spontaneous loss of a pregnancy before 20 gestational weeks
* Incidence: 20-30% of pregnancies
* Risk reduces with gestational age – highest in early pregnancy
* 50% due to chromosomal errors – not viable
* 50% potentially due to implantation errors – uterine environment

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3
Q

risk factor for miscarriage

A
  • Maternal age
  • Previous miscarriage
  • Chronic disease
  • Lifestyle factors; smoking, alcohol, drugs, BMI
  • Infections during early pregnancy; chicken pox, toxoplasmosis,listeriosis
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4
Q

Miscarriage – clinical presentation/diagnosis

A
  • clinical admission due to Vaginal bleeding and abdominal pains/cramping
  • Clinical investigations:
    – Serum hCG does not rise (or falls) when taken 48 hrs apart
    – On ultrasound, absence of fetal cardiac activity (diagnostic if no fetal heart and the gestational sac size is >25 mm, or crown- rump length >7mm)
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5
Q

Miscarriage – management

A

-observation (watch + wait),
-medical management (stimulate uterus to pass pregnancy tissue; induce myometrial contractility or inhibit progesterone to induce shedding of uterine lining; Mifepristone/Misoprostol);
- surgery (dilation + curettage D&C – suction to remove pregnancy tissue, if don’t want expectant management or bleeding/infection)

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6
Q

what is Ectopic pregnancy

A

Pregnancy implanting outside of the uterus
* 96% implant in the Fallopian tubes
* Possible other sites: cervical, interstitial, cesarean scar, ovary
* Pregnancy of unknown location

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7
Q

incidence of ectopic pregnancy and consequences

A
  • Incidence: 1-2% of pregnancies
  • Not viable pregnancies
  • Leading cause of maternal death in the first trimester – rupture
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8
Q

risk factor for ectopic pregnancy

A
  • Previous ectopic pregnancy
  • Pelvic inflammatory disease – other genital infections
  • Tubal surgery
  • IVF
  • Smoking
  • Age
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9
Q

Clinical presentaiton for ectopic

A
  • Positive pregnancy test
  • Abdominal pain
  • Bleeding
  • Can be asymptomatic
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10
Q

diagnosis of ectopic pregnancy

A
  • Confirm pregnancy – hCG
  • hCG discriminatory zone (not always reliable)
  • Assess pregnancy location
  • Ultrasound - if no gestational sac in the uterus then high clinical suspicion of an ectopic pregnancy
  • Determine site of the ectopic pregnancy
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11
Q

Ectopic pregnancy –expectant management

A
  • Watch and wait approach as it May resolve without intervention
  • Only offered if hCG is low (<500 IU/L) and declining and no signs or rupture
  • require Close monitoring
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12
Q

Ectopic pregnancy –medical management

A
  • Methotrexate – chemotherapeutic
  • Injected intramuscularly or in some intrasac
  • Only effective for smaller ectopic pregnancies (hCG < 3000 IU/L)
  • Must be stable and no signs of rupture
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13
Q

Ectopic pregnancy – surgery

A
  • Most common management
  • Shorter time to resolution
  • Salpingectomy – takes ectopic pregnancy and tube
  • Salpingostomy – pull out sac and leave the tube
  • Laparoscopic salpingectomy is the most common surgical treatment approach
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14
Q

Fetal anomalies, what is it, and incident

A
  • Structural changes to one or more part of the fetus
  • Incidence: 3% major anomalies, 4-5% minor anomalies
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15
Q

Possible cause of fetal abnormality

A
  • Can be structural or chromosol
  • Finding of a structural anomaly increases the probability of chromosomal abnormalities
  • Etiology is diverse; genetic (down syndrome), infectious (zika), nutritional (neural tube) or environmental (radiation, drugs)
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16
Q

common congenital anomalies

A
  • Heart defects – structural problem of the heart. Affects 1 per 100 babies born.
  • Neural tube defects – structural problems with the brain and spinal cord. 1-5 per 1000 babies born.
  • Down syndrome – additional chromosome 21 (trisomy 21). 1 per 600-700 babies born.
17
Q

Diagnosis of fetal anomalies

A
  • Structural fetal anomalies on ultrasound; 13 weeks and 20 week ultrasound
  • Offered further genetic testing
  • Amniocentesis - cytogenetic analysis (including FISH), prenatal microarray
  • Prenatal screening
  • Postnatal diagnostic testing - gene sequencing
18
Q

Fetal anomalies – management

A
  • Highly dependent on the anomaly
  • Some anomalies are not combatable with life
  • Many have no curative approach
  • Structural abnormalities
  • Fetal surgery –neural tube defects can be closed in-utero
  • Postnatal repair – heart defects
  • Termination
  • Management of the disorder postnatally
19
Q

What is genetic screening

A
  • Screening for chromosomal anomalies
  • Is NOT a diagnostic test
  • Occur prior or during pregnancy
20
Q

Pre-pregnancy screening

A
  • Genetic carrier screening
  • Most include cystic fibrosis, fragile X and spinal muscular atrophy
21
Q

pregnancy screening

A
  • Combined in first trimester screening (ultrasound, blood test and risk factors)
  • Non-invasive prenatal testing (NIPT) – analyses cell free fetal DNA circulating in mums blood. Provide a risk estimate for trisomy 21, 18 and 13, and sex chromosome aneuploidies
22
Q

Preterm birth: what is it and incident rate

A

Delivery <37 gestational weeks
* Incidence: 5- 10 %
* 60% Spontaneous preterm birth
* 40% Iatrogenic preterm birth
* Largest cause of neonatal mortality and morbidity

23
Q

Preterm birth - viability

A

Viability different in different clinical settings
* Poor lung maturity
* In Australia between 22 – 24 weeks
* In low resource settings – 28 weeks
-The longer it stay in the utero, the higher the rate of survival is

24
Q

Consequences of preterm birth

A

Immediate:
- Death
-Intracerebral bleeding
- respiratory
-distress syndrome
- bronchopulmonary dysplasia
-necrotising enterocolitis
Later in life: Cognitive delay, mental disability

25
Q

Preterm birth - management

A
  1. Give corticosteroids to prepare fetus ,Injected into mother. Shown to be beneficial in accelerating fetal lung maturation and has other benefits (decreases death by 50%, respiratory distress syndrome by 50% etc)
  2. Give agents to try to decrease the contractions
    Nifedipine (blocks calcium receptor)
    Atosiban (blocks oxytocin receptor, not licensed in Australia)
  3. Transfer the mother to a hospital where the paediatric team can care for the preterm fetus
    E.g. level 3 (tertiary hospital) if threatened preterm birth at <34 weeks
    gestation
26
Q

Preeclampsia

A

Onset of hypertension with end organ dysfunction (kidney, liver, brain) after 20 weeks gestation

27
Q

symptom of preeclampsia

A

systemic blood pressure >140mmHg or diastolic pressure <90mmHg AND proteinuria AND/OR symptoms of significant end-organ dysfunction
Ø End organ dysfunction: kidney, liver, haematological system, nervous system/brain (eclamptic fit + potentially stroke), foetal growth restriction

28
Q

management of preeclampsia

A

no cure – only delivery of placenta stops disease
Ø Expectant management: only if preterm; if >37 weeks will deliver with minimal risk to foetus, anti-hypertensive medication (reduce blood pressure), magnesium sulphate (prevent seizures)
Ø Delivery <37 weeks: maternal grounds of disease, foetal grounds of stress, large contributor to iatrogenic preterm birth

29
Q

Fetal growth restriction, what is it and incidence

A

The fetus does not grow to its genetic potential
* Incidence: 5-10% of all pregnancies.

30
Q

Cause of fetal growth restrcition

A
  • 80% of fetal growth restriction is due to abnormal placental implantation
  • Placenta in a state of chronic hypoxia
  • Does not supply fetus with sufficient oxygenation and nutrients
  • The remaining 20%, are associated with fetal:
    Structural abnormalities / Chromosomal or Genetics / Infections
31
Q

Fetal growth restriction – Management

A

Overall approach is to time delivery, balancing risks of prematurity and perceived risk of stillbirth to baby
* Deliver if growth restricted (<10 th centile) and the fetus has reached term (>37 weeks gestation)
* If preterm growth restriction, perform serial ultrasound tests of fetal wellbeing, and try to leave the fetus in utero for as long as possible before delivery

32
Q

How fetal well being is measure for growth restriction

A
  • Measuring blood flows in umbilical artery (more resistance to flow with a sicker, hypoxic baby)
  • Measure amniotic fluid around baby (decreased fluid with a sicker baby)
33
Q

what is stillbirth and incidences

A

Fetal death after 20 weeks
* 1 in 130 pregnancies or 6 babies everyday in Australia alone

34
Q

Cause for stillbirth

A
  • Placental disorders – including insufficiency
  • Fetal anomalies
  • Infection
  • Pregnancy disorders (preeclampsia, preterm birth)
  • Labour
  • Unexplained (30-60%)
  • Increasing risk as gestation progresses – greatest risk post term (after 40 weeks)
35
Q

Clinical Care through pregnancy

A

§ Preconception: genetic carrier screening, optimising health (BMI, smoking/drinking)
§ 1st visit: ultrasound (confirm baby in uterus) + blood tests
§ 10-13 weeks: ultrasound, prenatal screening (chromosomal abnormalities)
§ 20 weeks: foetal anomaly ultrasound (check organs)
§ 28 weeks: gestation diabetes test (common complications)
§ 32 weeks: foetal growth scan + monitor risk of stillbirth