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Obstetrics > Complications in Pregnancy > Flashcards

Complications in Pregnancy Flashcards

1
Q

List 5 types of miscarriage

A 
Threatened
Inevitable
Complete
Incomplete
Missed
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2
Q

What would be seen on ultrasound in a threatened miscarriage? And what would be the clinical presentation (symptoms and speculum examination)?

A 
Ultrasound = Intrauterine pregnancy
Symptoms = PV bleed and pain
Speculum = Cervical os closed
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3
Q

What would be seen on ultrasound in an inevitable miscarriage? And what would be the clinical presentation (symptoms and speculum examination)?

A 
Ultrasound = Intrauterine pregnancy
Symptoms = PV bleed and pain
Speculum = Cervical os open
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4
Q

What would be seen on ultrasound in a complete miscarriage? And what would be the clinical presentation (symptoms and speculum examination)?

A 
Ultrasound = No intrauterine pregnancy, no retained products of conception
Symptoms = PV bleed and pain ended
Speculum = Cervical os closed
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5
Q

What would be seen on ultrasound in an incomplete miscarriage? And what would be the clinical presentation (symptoms and speculum examination)?

A 
Ultrasound = Retained products of conception
Symptoms = PV bleed and pain
Speculum = Cervical os open, products of conception within the cervical os
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6
Q

What would be seen on ultrasound in a missed miscarriage? And what would be the clinical presentation (symptoms)?

A 
Ultrasound = Fetal pole identified but no fetal heartbeat...or gestational sac present but no fetal sac identified
Symptoms = With or without pain or bleeding
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7
Q

What is antepartum haemorrhage?

A

Bleeding after 24 weeks gestation, but before labour

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8
Q

List 5 causes of antepartum haemorrhage

A 
Placenta praevia
Placental abruption
Uterine abruption
Vasa praevia
Other uterine / genital tract abnormalities
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9
Q

What is placenta previa and how is it classified?

A

When the placenta is situated in the lower uterine cavity. Classified based on the height of the placenta…May be complete (fully covering cervical os), partial, marginal, low-lying

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10
Q

From approximately how many weeks gestation does surfactant production begin?

A

About 30 weeks

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11
Q

Where are metal red blood cells produced during pregnancy?

A

Up to 8 weeks = yolk sac
8 - 20 weeks = Liver
After 20 weeks = Bone marrow

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12
Q

What is gestational trophoblastic disease?

A

Aggressive proliferation of the trophoblastic (placental) tissue. Includes hydatidiform moles and choriocarcinoma

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13
Q

What is a hydatidiform mole?

A

A fertilised embryo implants into the uterus but cells behave abnormally and undergo excessive proliferation, such that the embryo behaves as a benign tumour rather than a growing foetus.

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14
Q

What is a ‘complete’ hydatidiform mole?

A

Entirely paternal in origin, this involves fertilisation of a sperm with an empty oocyte i.e one without the maternal genome. The fertilised tissue then undergoes proliferation.

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15
Q

What is a ‘partial’ hydatidiform mole?

A

Involves fertilisation of a normal oocyte with 2 sperm.

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16
Q

What is the key serum marker of a hydatidiform mole?

A

Beta-HCG acts as a tumour marker and is incredibly accurate in the detection.

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17
Q

What is an ectopic pregnancy?

A

Implantation of the products of conception at a site other than the uterine cavity.

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18
Q

Where can an ectopic pregnancy implant? Where is most common for this to happen?

A 
Fallopian tubes (most common, accounting for 95% of ectopic pregnancies)
Ovaries
Cervix
Elsewhere in the abdomen
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19
Q

What is the medical management of ectopic pregnancy which may be suitable if the ectopic has not ruptured?

A

Methotrexate

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20
Q

What is the surgical management of an ectopic pregnancy?

A

Laparoscopic salpingectomy or salpingostomy

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21
Q

What is placental abruption?

A

Premature separation of the placenta from the uterine wall i.e. before birth

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22
Q

List some risk factors for placental abruption

A 
IUGR
Smoking
Cocaine use
Pre-eclampsia
Abdominal trauma
Multiparity
Over-distension e.g. in multiple pregnancy / polyhydramnios
Sudden decompression e.g. on rupture of membranes in multiple pregnancy / polyhydramnios
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23
Q

What is the classic presentation of placental abruption?

A

Painful PV bleeding
Uterine contractions
Woody uterus

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24
Q

True / False: In 20% of cases of placental abruption, there may be no visible bleeding

A

True

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25
Q

A ‘woody’ uterus is a sign of which pathology?

A

Placental abruption

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26
Q

What is placenta accreta?

A

Placenta becomes embedded in a previous Caesarean section scar such that it cannot separate.

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27
Q

How is placenta praevia diagnosed?

A

Ultrasound scan

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28
Q

How does placenta praevia present?

A

Painless, intermittent, bright red vaginal bleeding

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29
Q

What is the treatment for hyperemesis gravidarum?

A

Fluid replacement
Antiemetics
Thiamine

30
Q

What is the definition of gestational hypertension?

A

New onset (i.e. mother has not been hypertensive before) hypertension which develops after 20/40 gestation in the absence of proteinuria

31
Q

True / False: ACE Inhibitors should be continued in a pregnant woman with pre-existing hypertension

A

False - ACE Inhibitors are associated with abnormalities in the foetus and should be changed to an alternative therapy

32
Q

What is the definition of pre-eclampsia?

A

Hypertension (BP >140/90) detected on 2 separate readings at least 4 hours apart, in the presence of proteinuria (>300mg/24hrs or 1+ on urine dipstick)…developing after 20/40 gestation

33
Q

List some risk factors for developing pre-eclampsia

A 
Previous pre-eclampsia
Type I or II diabetes
Chronic or gestational hypertension
Chronic kidney disease
Primigravida
Obesity
Age > 40
Mother with pre-eclampsia in pregnancy
Multiple pregnancy
Interval between pregnancies of > 10 years
34
Q

List some presenting symptoms of pre-eclampsia

A 
Headache
Nausea / vomiting
Visual disturbances
Abdominal (epigastric and RUQ) tenderness
Hyperreflexia
Drowsiness
Oedema
35
Q

Which drug has been shown to reduce the risk of seizure in eclampsia?

A

Magnesium sulphate

36
Q

What is the antidote for magnesium sulphate e.g. if it causes respiratory depression?

A

Calcium gluconate

37
Q

What is the cutoff for glucose levels in pregnancy which may lead to a diagnosis of gestational diabetes?

A

Do an OGTT:

Fasting glucose should be 7.8mmol/L is defined as gestational diabetes

38
Q

How do levels of thyroid stimulating hormone vary throughout normal pregnancy?

A

TSH increases in first trimester

39
Q

What is the treatment for hyperthyroidism in pregnancy?

A

Propylthiouracil (PTU)…carbimazole is teratogenic

40
Q

List 3 hypertensive conditions affecting pregnancy

A

Pre-existing (chronic) hypertension
Gestational hypertension
Pre-eclampsia

41
Q

List some complications of chronic hypertension in pregnancy

A

Pre-eclampsia
IUGR
Placental abruption
Stillbirth

42
Q

What is ‘pre-existing’ or chronic hypertension in pregnancy?

A

High blood pressure which existed before the pregnancy or before 20/40 weeks gestation

43
Q

What is the definition of gestational hypertension?

A

Onset of high blood pressure after 20/40 gestation, in the absence of proteinuria

44
Q

What medication may be useful in gestational hypertension?

A

Labetolol (beta-blocker)
Nifedipine
Methyldopa

45
Q

What happens to BP after pregnancy in a woman with pre-eclampsia?

A

BP should resolve within 6/52 of delivery

46
Q

What is the management for women who are at high risk of pre-eclampsia?

A

Women who have 2 or more moderate risk factors or any significant risk factors for pre-eclampsia are given aspirin 75mg daily from 12/40 until the birth

47
Q

What are the ‘significant’ risk factors for pre-eclampsia?

A 
Previous pre-eclampsia
Chronic kidney disease
Autoimmune disorders: SLE or antiphospholipid syndrome
Diabetes (Type 1 or Type 2)
Chronic hypertension
48
Q

What is HELLP syndrome?

A 
A complication of pre-eclampsia:
Haemolysis
Elevated LFTs
Low platelets
Epigastric pain is often an indicator that there is liver involvement
49
Q

What is the treatment of pre-eclampsia?

A

Full physical assessment of the mother and baby (observations, examination, Dopplers etc.)
Aim for BP below 150/90 to reduce stroke risk
Steroids if before 34/40
Delivery is only true treatment
Give magnesium sulphate 24 hours before birth to reduce seizure risk
Anti-hypertensives until 6/52 post partum

50
Q

What is the management of eclampsia?

A

DRABCDE approach:

  • Call for help
  • Position woman on left lateral side
  • High flow oxygen
  • Monitor observations
  • Bloods for FBC, U+E, LFT, clotting
  • IV magnesium sulphate reduces risk of further seizures
  • BP control with IV labetolol or hydrazine
  • Delivery of the baby once stable
51
Q

What 3 key blood tests would you do in pre-eclampsia and why?

A

FBC - Low platelets, Hb may be low in HELLP
U+E - Raised urea and creatinine (?AKI)
LFTs - Haemolysis (raised bilirubin) and AST raised in HELLP

52
Q

How and when is gestational diabetes detected during pregnancy?

A

Women screened for their risk during booking history
High risk women given OGTT at 24-28 weeks
Women with previous gestational diabetes will be given OGTT at 16/40

53
Q

What risk factors prompt screening for gestational diabetes?

A 
1st degree relative with diabetes
Previous gestational diabetes
Obesity (BMI above 30)
High risk ethnic group (S. Asian, black African, M. Eastern)
Previous unexplained stillbirth
Previous macrosomia
PCOS
Polyhydramnios
54
Q

List some complications of diabetes in pregnancy

A 
Miscarriage (pre-existing DM only)
Congenital abnormalities (pre-existing DM only)
Shoulder dystocia
Macrosomia
Polyhydramnios
Stillbirth
Hypertension
Pre-eclampsia
Hypoglycaemia in the baby
55
Q

What are the principles of management for diabetes in pregnancy?

A
  • Pre-conception advice
  • Education and lifestyle advice
  • Optimise glycemic control (conservative, medical or insulin management)
  • Care of specialist diabetes team
  • High dose folic acid
  • Serial growth scans
  • Retinal screening to detect retinopathy
  • Induction at 38/40
56
Q

What is the treatment for obstetric cholestasis?

A

Vitamin K given from 36/40 to reduce risk of haemorrhage
Ursodeoxycholic acid
Anti-histamines
Induction at 38 weeks

57
Q

What is the definition of miscarriage?

A

Spontaneous ending of a pregnancy before a viable gestational age i.e. 24/40 gestation

58
Q

List some risk factors for miscarriage

A

Increasing maternal age
Smoking
Obesity
Alcohol
Cannabis use
Uterine abnormalities e.g. unicornate uterus
Maternal medical conditions e.g. SLE, antiphospholipid syndrome, diabetes
Congenital abnormalities
Infections e.g. listeria, toxoplasmosis, malaria, VZV

59
Q

What are the management options for miscarriage?

A

Expectant
Surgical i.e. evacuation of the products of conception
Medical i.e. misoprostol either orally or vaginally
Counselling and psychological support

60
Q

What steps should patients with antiphospholipid syndrome take to optimise their chance of a normal pregnancy?

A

LMWH and aspirin

61
Q

Give 2 diagnoses you may be suspicious of if a woman presents with hyperemesis gravidarum

A

Multiple pregnancy

Hydatidiform mole

62
Q

What is the characteristic appearance of a molar pregnancy on ultrasound scan?

A

‘Snowstorm appearance’ - there is no visible fetus but lots of surrounding tissue

63
Q

How might a woman with an ectopic pregnancy present?

A

Abdominal pain
PV bleeding after a missed period
Shoulder tip pain - classic feature of ruptured ectopic
Haemodynamic instability
Syncope
Adnexal tenderness and cervical excitation on examination

64
Q

What investigations would you do for suspected ectopic? What would they show?

A
  • Urine pregnancy test will be positive
  • Transvaginal ultrasound - Will NOT show intrauterine pregnancy, so when coupled with +ve pregnancy test, it is called ‘pregnancy of unknown location’ (may be intrauterine and just too small to visualise or may be outside uterine cavity i.e. ectopic)
  • Suboptimal rise in beta-HCG (serial measurements might be required if pregnancy has not been visualised on use)
  • Laparoscopy is diagnostic but not always required
65
Q

Describe the interpretation of beta-HCG result in a normal and ectopic pregnancy

A

Normal pregnancy: Beta-HCG will double, or rise by more than 66% every 48 hrs
Ectopic pregnancy: Beta-HCG will rise, but to a lesser extent than in normal pregnancy. Rise of less than 63% in 48 hours is indicative of ectopic or miscarriage

66
Q

What are the 3 possible diagnoses for ‘pregnancy of unknown location’?

A

Viable intrauterine pregnancy which is too early to visualise on the scan
Ectopic pregnancy
Miscarriage

67
Q

From what gestation might an external cephalic version be performed for a breech presentation?

A

From term (37 weeks onwards)

68
Q

Describe the process of an external cephalic version

A
  • Tocolytics given to relax uterine muscle
  • Fetal HR monitored pre- and post procedure
  • Under ultrasound guidance in hospital in case of complications
  • Two hands placed on abdomen, baby disengaged from pelvis and pushed upwards, rotated by forward somersault
69
Q

What investigations might you carry out in suspected pulmonary embolism?

A

ECG
CXR
Dopplers of leg if DVT suspected
CTPA (or V/Q scan)

70
Q

What might a chest x-ray show in pulmonary embolism?

A

Dilated pulmonary arteries with wedge shaped opacity

Obstetrics (5 decks)

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