W11L2 Tues pregnancy complication Flashcards
Pregnancy timeline
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
What is Miscarriage ,it’s rate and possible cause
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
risk factor for miscarriage
- Maternal age
- Previous miscarriage
- Chronic disease
- Lifestyle factors; smoking, alcohol, drugs, BMI
- Infections during early pregnancy; chicken pox, toxoplasmosis,listeriosis
Miscarriage – clinical presentation/diagnosis
- 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)
Miscarriage – management
-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)
what is Ectopic pregnancy
Pregnancy implanting outside of the uterus
* 96% implant in the Fallopian tubes
* Possible other sites: cervical, interstitial, cesarean scar, ovary
* Pregnancy of unknown location
incidence of ectopic pregnancy and consequences
- Incidence: 1-2% of pregnancies
- Not viable pregnancies
- Leading cause of maternal death in the first trimester – rupture
risk factor for ectopic pregnancy
- Previous ectopic pregnancy
- Pelvic inflammatory disease – other genital infections
- Tubal surgery
- IVF
- Smoking
- Age
Clinical presentaiton for ectopic
- Positive pregnancy test
- Abdominal pain
- Bleeding
- Can be asymptomatic
diagnosis of ectopic pregnancy
- 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
Ectopic pregnancy –expectant management
- 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
Ectopic pregnancy –medical management
- 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
Ectopic pregnancy – surgery
- 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
Fetal anomalies, what is it, and incident
- Structural changes to one or more part of the fetus
- Incidence: 3% major anomalies, 4-5% minor anomalies
Possible cause of fetal abnormality
- 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)
common congenital anomalies
- 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.
Diagnosis of fetal anomalies
- 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
Fetal anomalies – management
- 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
What is genetic screening
- Screening for chromosomal anomalies
- Is NOT a diagnostic test
- Occur prior or during pregnancy
Pre-pregnancy screening
- Genetic carrier screening
- Most include cystic fibrosis, fragile X and spinal muscular atrophy
pregnancy screening
- 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
Preterm birth: what is it and incident rate
Delivery <37 gestational weeks
* Incidence: 5- 10 %
* 60% Spontaneous preterm birth
* 40% Iatrogenic preterm birth
* Largest cause of neonatal mortality and morbidity
Preterm birth - viability
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
Consequences of preterm birth
Immediate:
- Death
-Intracerebral bleeding
- respiratory
-distress syndrome
- bronchopulmonary dysplasia
-necrotising enterocolitis
Later in life: Cognitive delay, mental disability
Preterm birth - management
- 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)
- Give agents to try to decrease the contractions
Nifedipine (blocks calcium receptor)
Atosiban (blocks oxytocin receptor, not licensed in Australia) - 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
Preeclampsia
Onset of hypertension with end organ dysfunction (kidney, liver, brain) after 20 weeks gestation
symptom of preeclampsia
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
management of preeclampsia
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
Fetal growth restriction, what is it and incidence
The fetus does not grow to its genetic potential
* Incidence: 5-10% of all pregnancies.
Cause of fetal growth restrcition
- 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
Fetal growth restriction – Management
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
How fetal well being is measure for growth restriction
- 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)
what is stillbirth and incidences
Fetal death after 20 weeks
* 1 in 130 pregnancies or 6 babies everyday in Australia alone
Cause for stillbirth
- 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)
Clinical Care through pregnancy
§ 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
