Complicated Pregnancy 1

Question 1

This deck covers:

Answer 1

Misscarriage & Antepartum Haemorrhage

Question 2

Define a misscarriage/abortion?

Answer 2

Spontaneous termination <24wks gestation with no evidence of life

Question 3

Define a threatened miscarriage/abortion?

Answer 3

When a viable pregnancy (confirmed on US) presents with vaginal bleeding +/- pain
Must be <24 wks (otherwise its APH) and must be closed cervix.

Question 4

What if a patient presents <24wks with vaginal bleeding and the cervix is dilating?

Answer 4

At that point its termed an Inevitable Miscarriage

Question 5

Whats the difference between a complete or incomplete abortion?

Answer 5

In complete all the Products of conception have been expelled, the cervix closed and bleeding stopped.
In incomplete the POC are still partly inside, cervix open and bleeding ongoing

Question 6

How do we confirm if a woman has had a complete abortion?

Answer 6

We need to either see the POC and confirm them to be that.

Or have a previous scan that confirms there was a viable pregnancy before

Question 7

Define a septic miscarriage?

Answer 7

When infection ascends into the uterus and throughout the pelvis following a miscarriage.
Its most common if it was an incomplete abortion

Question 8

Define a missed abortion?

Answer 8

When the foetus has died but the uterus hasn’t attempted to expel the POC.

It can appear on US like a gestational sac lacking a foetus or a foetal pole without a developed heart

Question 9

List all the major causes of a miscarriage you can think of?

Answer 9

• Abnormal conceptus (problems with the foetus, mainly chromosomal)
• Uterine abnormality (problems with the uterus)
• Cervical Incompetence (problems with cervix)
• Maternal conditions (problems with the mother)

Question 10

What uterine abnormalities could cause a misscarriage?

Answer 10

A congenital abnormality

Fibroids

Question 11

What causes cervical incompetence?

Answer 11

Trauma including past surgical procedures

Question 12

What maternal problems could cause a misscarriage?

Answer 12

Low progesterone
SLE
Thyroid disease
Acute infections e.g. appendicitis

Question 13

How would we manage a threatened abortion?

Answer 13

Conservative Management, best to try to get the foetus past 24wks so we can deliver and it will survive

Question 14

How would we manage an inevitable abortion?

Answer 14

At this point there’s no point trying to save the foetus.

If the bleeding is heavy they may need evacuation of the uterus

Question 15

How would we manage a missed misscarriage?

Answer 15

Several options:

• Conservative in the hope the uterus will self-evacuate
• Push the uterus with prostaglandins (MIsoprostol)
• Surgical Management of Misscarriage (SMM)

Question 16

How do we manage a septic misscarriage?

Answer 16

Abx

Evacuate the uterus of remaining POC

Question 17

Define an Antepartum Haemorrhage?

Answer 17

Bleeding from genital tract >24wks but before delivery
Contrast to a miscarriage which is used for bleeds <24wks

This is because 24wks is when the foetus is considered viable

Question 18

List the major causes of an APH?

Answer 18

Placenta Praevia
Placental Abruption
Local lesion of genital tract
Idiopathic
Vasa Praevia (Very rare)

Question 19

In what women is Placenta Praevia a risk?

Answer 19

Multiparous
Multiple pregnancy
Previous C-section

Question 20

What are the types of placenta praevia?

Answer 20

GRaded 1-4:

1) Placenta doesn’t touch internal cervical orifice (Os)
2) Placenta reaches Os
3) Placenta covers Os
4) Central Placenta Praevia (directly over Os)

Question 21

How does a case of placenta praevia present?

Answer 21

Painless PV bleeding >24wks
With a soft non-tender uterus and often malpresentation.

Often they present because we spot malpresentation on exam, send for an US and discover placenta praevia as the source of the bad alignment

Question 22

How do we confirm a case of placenta praevia?

Answer 22

US!

Don’t do vaginal exam till you’ve ruled it out with US as it could trigger a bigger bleed

Question 23

How do we handle a Placenta Praevia?

Answer 23

If possible be conservative e.g. blood transfusions etc to get the baby to term then deliver by C-section.
Either way you can’t deliver vaginally.

Question 24

Define placental Abruption?

Answer 24

The placenta seperates from the wall early, usually with a retroplacental clot forming

Question 25

What are the types of placental abruption?

Answer 25

Revealed - blood can escape through Os
Concealed - Blood trapped between placenta/uterine wall
Mixed

Question 26

How does a Placental Abruption present?

Answer 26

Severe abdo pain and APH
May increase uterine tone & have contractions
Foetus will be longitunidal

Question 27

How extra can a Concealed placental abruption present?

Answer 27

Blood can’t escape through os so builds up –> Uterine volume increases –> Fundal height excessive

Couvelaire Uterus (bruising in myometrium)

Question 28

What are the risk factors for a placenta abruption?

Answer 28

Hypertensive disorders (chronic hyp or pre-eclampsia)
Multiple pregnancy
Polyhydramnios
Smoking, Age & Parity
H/o
Cocaine

Question 29

Placenta Abruption can be very dangerous, especially if the bleed is concealed. What complications can it trigger? (Think big bleed and clot)

Answer 29

• Maternal shock & collapse
• Foetal Death
• Maternal DIC & renal failure
• PPH
• Coevelaire Uterus

Question 30

List some local genital tract lesions that could be the source of APH?

Answer 30

• Cervical polyps
• Cervical Cancer
• Vaginal Thrush

Question 31

So how do manage an APH over?

Answer 31

IT varies based on severity, maternal/foetal condition and gestation but includes:

• Expectant treatment
• Conservative e.g. blood transfusions
• Attempt a vaginal delivery
• Emergency C-sections