Complications in Pregnancy

Question 1

What is a spontaneous miscarriage?

Answer 1

Loss of pregnancy before 24 weeks gestation

Question 2

What is the incidence of spontaneous miscarriage?

Answer 2

15%

Question 3

What are the different classifications for spontaneous miscarriage?

Answer 3

threatened
inevitable
incomplete
complete
septic
missed

Question 4

how does a threatened miscarriage present?

Answer 4

vaginal bleeding +/- pain
viable pregnancy
closed cervix on speculum examination

Question 5

how does an inevitable miscarriage present?

Answer 5

viable pregnancy

open cervix with bleeding that could be heavy (+/- clots)

Question 6

how does a missed miscarriage present?

Answer 6

no symptoms, or could have bleeding/brown loss vaginally
gestational sac seen on scan
no clear foetus (empty gestational sac) or a foetal pole with no foetal heart seen in the gestational sac

Question 7

how does an incomplete miscarriage present?

Answer 7

most of pregnancy expelled out, some products of pregnancy remaining in uterus
open cervix, vaginal bleeding (may be heavy)

Question 8

how does a complete miscarriage present?

Answer 8

passed all products of conception
cervix closed and bleeding has stopped (should ideally have confirmed the POC or should have had a scan previously that confirmed an intrauterine pregnancy)

Question 9

What are some of the causes of spontaneous miscarriage?

Answer 9

abnormal conceptus
- chromosomal, genetic, structural
uterine abnormality
- congenital, fibroids
cervical incompetence
- primary, secondary
maternal
- increasing age, diabetes
unknown

Question 10

how is a threatened miscarriage managed?

Answer 10

conservatively

Question 11

how is an inevitable miscarriage managed?

Answer 11

if bleeding heavily, may need evacuation

Question 12

how is a missed miscarriage managed?

Answer 12

conservatively
medical - prostaglandins (misoprostol)
surgical - SMM (surgical management of miscarriage)

Question 13

how is a septic miscarriage managed?

Answer 13

antibiotics and evacuate uterus

Question 14

what is the incidence of ectopic pregnancy?

Answer 14

1 in 90 pregnancies

Question 15

what are the risk factors for ectopic pregnancy?

Answer 15

pelvic inflammatory disease
previous tubal surgery
previous ectopic
assisted conception

Question 16

how does an ectopic pregnancy present?

Answer 16

period of amenorrhoea (with +ve urine pregnancy test)
+/- vaginal bleeding
+/- abdominal pain
+/- GI or urinary symptoms

Question 17

how should an ectopic pregnancy be investigated?

Answer 17

scan - no intrauterine gestational sac, may see adnexal mass, fluid in pouch of douglas
serum bhcg levels - may need to serially track levels over 48 hour intervals, if a normal early intrauterine pregnancy hcg levels will increase by at least 66% ish
serum progesterone levels - with viable IU pregnancy high levels >25ng/ml

Question 18

how is an ectopic pregnancy managed?

Answer 18

medical - methotrexate
surgical - mostly laparoscopic - salpingectomy, salpingotomy for few indications
conservatively

Question 19

what is antepartum haemorrhage?

Answer 19

haemorrhage from the genital tract after the 24th week of pregnancy but before delivery of the baby

Question 20

what are the cutoffs for mild hypertension?

Answer 20

diastolic bp 90-99

systolic bp 140-149

Question 21

what are the cutoffs for moderate hypertension?

Answer 21

diastolic bp 100-109

systolic bp 150-159

Question 22

what are the cutoffs for severe hypertension?

Answer 22

diastolic bp >110

systolic >160

Question 23

what is the difference between chronic hypertension and gestational hypertension?

Answer 23

chronic hypertension - hypertension either pre-pregnancy or at booking (<20 weeks gestation)
gestational hypertension - new hypertension, develops after 20 weeks

Question 24

how is pre-eclampsia diagnosed?

Answer 24

new hypertension >20 weeks in association with significant proteinuria

Question 25

how do you diagnose proteinuria?

Answer 25

automated reagent strip urine protein estimation > 1+ spot urinary protein:creatinine ratio > 30mg/mmol 24 hours urine protein collection > 300mg/day

Question 26

how should chronic hypertension be managed?

Answer 26

change anti-hypertensive drugs if indicated e.g. - ACE inhibitors - angiotensin receptor blockers - diuretics aim to keep bp <150/100 (labetolol, nifedipine, methyldopa) monitor for superimposed pre-eclampsia monitor foetal growth

Question 27

what are the risk factors for developing pre-eclampsia?

Answer 27

``` first pregnancy extremes of maternal age pre-eclampsia in previous pregnancy pregnancy interval >10 years bmi >35 family history of pre-eclampsia multiple pregnancy underlying medical disorders - chronic hypertension - pre-existing renal disease - pre-existing diabetes - autoimmune disorders ```

Question 28

what are the possible maternal complications of pre-eclampsia?

Answer 28

seizures severe hypertension - cerebral haemorrhage, stroke HELLP (haemolysis, elevated liver enzymes, low platelets) DIC (disseminated intravascular coagulation) renal failure pulmonary oedema cardiac failure

Question 29

what are the possible foetal complications of pre-eclampsia?

Answer 29

intrauterine growth restriction foetal distress prematurity increased mortality

Question 30

what is the pathophysiology of pre-eclampsia?

Answer 30

secondary invasion of maternal spiral arterioles by trophoblasts - impaired --> reduced placental perfusion imbalance between vasodilators and vasoconstrictors in pregnancy

Question 31

what are the symptoms/signs of severe pre-eclampsia?

Answer 31

- headache, blurring of vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands, face, legs - severe hypertension, >3+ of urine proteinuria - clonus/brisk reflexes, papilloedema, epigastric tenderness - reducing urine output - convulsions (eclampsia)

Question 32

what are the biochemical abnormalities found in pre-eclampsia?

Answer 32

raised liver enzymes, bilirubin if HELLP present raised urea and creatinine raised urate

Question 33

what are the haematological abnormalities found in pre-eclampsia?

Answer 33

low platelets low haemoglobin, signs of haemolysis features of DIC

Question 34

how should pre-eclampsia be managed?

Answer 34

- frequent bp checks, urine protein - check symptomatology - headaches, epigastric pain, visual disturbances - check for hyper reflexia (clonus), tenderness over the liver - blood investigations - fbc (for haemolysis, platelets), lfts, renal function tests (serum urea, creatinine, urate), coagulation tests if indicated - foetal investigations - scan for growth, CTG

Question 35

how should an eclamptic seizure/impending seizure be treated?

Answer 35

- magnesium sulphate bolus + IV infusion - control of blood pressure - iv labetolol, hydralazine (if >160/110) - avoid fluid overload - aim for 80ml/hour fluid intake

Question 36

when do the majority of eclamptic seizures occur?

Answer 36

postnatally

Question 37

how does macrosomia occur in diabetes?

Answer 37

maternal glucose crosses the placenta and induces increased insulin production in the foetus, the foetal hyperinsulinaemia causes macrosomia

Question 38

what are the risk factors for gestational diabetes?

Answer 38

increased bmi >30 previous macrosomic baby >4.5kg previous gdm family history of diabetes women from high risk groups for developing diabetes e.g. asian orgin polyhydramnios or big baby in current pregnancy recurrent glycosuria in current pregnancy

Question 39

what is virchow's triad?

Answer 39

three factors that contribute to thrombosis: - stasis - vessel wall injury - hypercoagulability