Pregnancy Complications

Question 1

Placenta accreta describes

Answer 1

the attachment of the placenta to the myometrium, due to a defective decidua basalis. As the placenta does not properly separate during labour there is a risk of post-partum haemorrhage.

Question 2

What can cause placenta accreta

Answer 2

previous caesarean section

placenta praevia

Question 3

Placenta accreta - there are 3 different types:

Answer 3

accreta: chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
increta: chorionic villi invade into the myometrium
percreta: chorionic villi invade through the perimetrium

Question 4

Placenta praevia describes

Answer 4

a placenta lying wholly or partly in the lower uterine segment

Question 5

Placenta praevia Epidemiology

Answer 5

5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from cervix

Question 6

Placenta praevia Associated factors

Answer 6

multiparity
multiple pregnancy
embryos are more likely to implant on a lower segment scar from previous caesarean section

Question 7

Placenta praevia causes fetal tachycardia

Answer 7

false

fetal heart usually normal

Question 8

Placenta praevia commonly cause coagulation problems

Answer 8

false

coagulation problems rare

Question 9

Placenta praevia sx

Answer 9

small bleeds before large
shock in proportion to visible loss
no pain
uterus NOT tender
lie and presentation may be abnormal

Question 10

Investigations

placenta praevia

Answer 10

placenta praevia is often picked up on the routine 20 week abdominal ultrasound
the RCOG recommend the use of transvaginal ultrasound as it improves the accuracy of placental localisation and is considered safe

Question 11

placenta praevia grading

Answer 11

I - placenta reaches lower segment but not the internal os
II - placenta reaches internal os but doesn’t cover it
III - placenta covers the internal os before dilation but not when dilated
IV - placenta completely covers the internal os

Question 12

If low-lying placenta at 16-20 week scan mx

Answer 12

rescan at 34 weeks
no need to limit activity or intercourse unless they bleed
if still present at 34 weeks and grade I/II then scan every 2 weeks
if high presenting part or abnormal lie at 37 weeks then Caesarean section should be performed

Question 13

Placenta praevia with bleeding mx

Answer 13

admit
treat shock
cross match blood
final ultrasound at 36-37 weeks to determine method of delivery, Caesarean section for grades III/IV between 37-38 weeks. If grade I then vaginal delivery

Question 14

Prognosis placenta praevia

Answer 14

death is now extremely rare

major cause of death in women with placenta praevia is now PPH

Question 15

Placental abruption describes

Answer 15

separation of a normally sited placenta from the uterine wall, resulting in maternal haemorrhage into the intervening space

Question 16

Placental abruption occurs in approximately 1/200 pregnancies

Answer 16

true

Question 17

Placental abruption causes

Answer 17

proteinuric hypertension
cocaine use
multiparity
maternal trauma
increasing maternal age

Question 18

Placental abruption sx

Answer 18

shock out of keeping with visible loss
pain constant
tender, tense uterus
normal lie and presentation
fetal heart: absent/distressed
coagulation problems

Question 19

Placental abruption ms

Fetus alive and < 36 weeks

Answer 19

fetal distress: immediate caesarean

no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Question 20

Placental abruption mx

Fetus alive and > 36 weeks

Answer 20

fetal distress: immediate caesarean

no fetal distress: deliver vaginally

Question 21

Placental abruption mx fetus dead

Answer 21

induce vaginal delivery

Question 22

Placental abruption complications Maternal

Answer 22

shock
DIC
renal failure
PPH

Question 23

Placental abruption complications fetal

Answer 23

IUGR
hypoxia
death

Question 24

Placental abruption prognosis

Answer 24

associated with high perinatal mortality rate

responsible for 15% of perinatal deaths

Question 25

Women who are at high risk of developing pre-eclampsia should take

Answer 25

aspirin 75mg od from 12 weeks until the birth of the baby.

Question 26

Women who are at high risk of developing pre-eclampsia include?

Answer 26

hypertensive disease during previous pregnancies chronic kidney disease autoimmune disorders such as SLE or antiphospholipid syndrome type 1 or 2 diabetes mellitus

Question 27

The classification of hypertension in pregnancy is complicated and varies. Remember, in normal pregnancy blood pressure :

Answer 27

blood pressure usually falls in the first trimester (particularly the diastolic), and continues to fall until 20-24 weeks after this time the blood pressure usually increases to pre-pregnancy levels by term

Question 28

Hypertension in pregnancy in usually defined as:

Answer 28

systolic > 140 mmHg or diastolic > 90 mmHg | or an increase above booking readings of > 30 mmHg systolic or > 15 mmHg diastolic

Question 29

Define Pre-existing hypertension

Answer 29

A history of hypertension before pregnancy or an elevated blood pressure > 140/90 mmHg before 20 weeks gestation No proteinuria, no oedema

Question 30

Define Pregnancy-induced hypertension | PIH, also known as gestational hypertension

Answer 30

Hypertension (as defined above) occurring in the second half of pregnancy (i.e. after 20 weeks) No proteinuria, no oedema

Question 31

Define Pre-eclampsia

Answer 31

Pre-eclampsia is a condition seen after 20 weeks gestation characterised by pregnancy-induced hypertension in association with proteinuria (> 0.3g / 24 hours). Oedema used to be third element of the classic triad but is now often not included in the definition as it is not specific

Question 32

Epidemiology of Pre-existing hypertension gestational hypertension Pre-eclampsia

Answer 32

Pre-existing hypertension: Occurs in 3-5% of pregnancies and is more common in older women gestational hypertension: Occurs in around 5-7% of pregnancies Pre-eclampsia: Occurs in around 5% of pregnancies

Question 33

gestational hypertension often resolves folling birth

Answer 33

true

Question 34

gestational hypertension increased risk of future ?

Answer 34

pre-eclampsia or hypertension later in life

Question 35

Pre-eclampsia is important as it predisposes to the following problems

Answer 35

fetal: prematurity, intrauterine growth retardation eclampsia haemorrhage: placental abruption, intra-abdominal, intra-cerebral cardiac failure multi-organ failure

Question 36

High risk factors - pre eclampsia

Answer 36

hypertensive disease in a previous pregnancy chronic kidney disease autoimmune disease, such as systemic lupus erythematosus or antiphospholipid syndrome type 1 or type 2 diabetes chronic hypertension

Question 37

Moderate risk factors - pre eclampsia

Answer 37

``` first pregnancy age 40 years or older pregnancy interval of more than 10 years body mass index (BMI) of 35 kg/m² or more at first visit family history of pre-eclampsia multiple pregnancy ```

Question 38

Features of severe pre-eclampsia

Answer 38

hypertension: typically > 170/110 mmHg and proteinuria as above proteinuria: dipstick ++/+++ headache visual disturbance papilloedema RUQ/epigastric pain hyperreflexia platelet count < 100 * 106/l, abnormal liver enzymes or HELLP syndrome

Question 39

mx pre-eclampsia?

Answer 39

a woman at moderate or high risk of pre-eclampsia should take aspirin 75mg daily from 12 weeks gestation until the birth consensus guidelines recommend treating blood pressure > 160/110 mmHg although many clinicians have a lower threshold oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine (e.g. if asthmatic) and hydralazine may also be used delivery of the baby is the most important and definitive management step. The timing depends on the individual clinical scenario

Question 40

Eclampsia may be defined as

Answer 40

development of seizures in association pre-eclampsia. To recap, pre-eclampsia is defined as: condition seen after 20 weeks gestation pregnancy-induced hypertension proteinuria

Question 41

Why is Magnesium sulphate used to treat eclampsia

Answer 41

used to both prevent seizures in patients with severe pre-eclampsia and treat seizures once they develop.

Question 42

Guidelines for magnesium sulphate in eclampsia?

Answer 42

should be given once a decision to deliver has been made in eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g / hour treatment should continue for 24 hours after last seizure or delivery

Question 43

What should be monitored when giving magnesium sulphate in eclampsia?

Answer 43

urine output, reflexes, respiratory rate and oxygen saturations should be monitored during treatment

Question 44

Pre-eclampsia around ?% of seizures occur post-partum

Answer 44

around 40% of seizures occur post-partum)

Question 45

Major complication and mx of this when | magnesium sulphate in eclampsia?

Answer 45

respiratory depression can occur: calcium gluconate is the first-line treatment for magnesium sulphate induced respiratory depression

Question 46

important aspects of treating severe pre-eclampsia/eclampsia include

Answer 46

fluid restriction to avoid the potentially serious consequences of fluid overload

Question 47

HELLP is

Answer 47

acronym for Hemolysis, Elevated Liver enzymes, and a Low Platelet count. It is a serious condition that can develop in the late stages of pregnancy. Whilst there is significant overlap with severe pre-eclampsia in terms of the features some patients present with no prior history so many specialists consider it a separate entity in its own right

Question 48

?% of patients with severe preeclampsia will go on to develop HELLP.

Answer 48

10-20% of patients with severe preeclampsia will go on to develop HELLP.

Question 49

HELLP SX

Answer 49

nausea & vomiting right upper quadrant pain lethargy

Question 50

HELLP IX

Answer 50

bloods: Hemolysis, Elevated Liver enzymes, and a Low Platelet

Question 51

HELLP MX

Answer 51

delivery of the baby

Question 52

Antepartum haemorrhage is defined as

Answer 52

bleeding from the genital tract after 24 weeks pregnancy, prior to delivery of the fetus

Question 53

vaginal examination should not be performed in primary care for suspected antepartum haemorrhage - why?

Answer 53

women with placenta praevia may haemorrhage

Question 54

shock in proportion to visible loss - which placental issue?

Answer 54

Placenta praevia

Question 55

pain constant - which placental issue?

Answer 55

Placental abruption

Question 56

tender, tense uterus - Placenta praevia

Answer 56

false | Placental abruption

Question 57

Bleeding in pregnancy differential 1st trimester

Answer 57

Spontaneous abortion Ectopic pregnancy Hydatidiform mole

Question 58

Bleeding in pregnancy differential 2nd trimester

Answer 58

Spontaneous abortion Hydatidiform mole Placental abruption

Question 59

Bleeding in pregnancy differential 3rd trimester

Answer 59

Bloody show Placental abruption Placenta praevia Vasa praevia

Question 60

Bleeding in pregnancy Alongside the pregnancy related causes, conditions such as sexually transmitted infections and cervical polyps should be excluded.

Answer 60

true

Question 61

Types of spontaneous abortion?

Answer 61

Threatened miscarriage - painless vaginal bleeding typically around 6-9 weeks Missed (delayed) miscarriage - light vaginal bleeding and symptoms of pregnancy disappear Inevitable miscarriage - complete or incomplete depending or whether all fetal and placental tissue has been expelled. Incomplete miscarriage - heavy bleeding and crampy, lower abdo pain. Complete miscarriage - little bleeding

Question 62

Typical picture of Ectopic pregnancy

Answer 62

Typically history of 6-8 weeks amenorrhoea with lower abdominal pain (usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and cervical excitation may be present

Question 63

Typical picture of Hydatidiform mole

Answer 63

Typically bleeding in first or early second trimester associated with exaggerated symptoms of pregnancy e.g. hyperemesis. The uterus may be large for dates and serum hCG is very high

Question 64

Typical picture of Placental abruption

Answer 64

Constant lower abdominal pain and, woman may be more shocked than is expected by visible blood loss. Tender, tense uterus* with normal lie and presentation. Fetal heart may be distressed

Question 65

Typical picture of Placental praevia

Answer 65

Vaginal bleeding, no pain. Non-tender uterus* but lie and presentation may be abnormal

Question 66

Typical picture of Vasa praevia

Answer 66

Rupture of membranes followed immediately by vaginal bleeding. Fetal bradycardia is classically seen

Question 67

Amniotic fluid embolism | Definition:

Answer 67

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below.

Question 68

Amniotic fluid embolism - Epidemiology:

Answer 68

Rare complication of pregnancy associated with a high mortality rate

Question 69

Amniotic fluid embolism aetiology

Answer 69

Many risk factors have been associated with amniotic fluid embolism but a clear cause has not been proven. A consistent link has been demonstrated with maternal age and induction of labour. It is widely accepted that maternal circulation must be exposed to fetal cells/ amniotic fluid in order for an amniotic fluid embolism to occur. However the precise underlying pathology of this process which leads to the embolism is not well understood, though suggestions have been made about an immune mediated process.

Question 70

Amniotic fluid embolism sx & signs

Answer 70

Symptoms include: chills, shivering, sweating, anxiety and coughing. Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

Question 71

Amniotic fluid embolism occur when in pregnancy?

Answer 71

The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.

Question 72

Amniotic fluid embolism diagnosis?

Answer 72

Clinical diagnosis of exclusion, as there are not definitive diagnostic tests.

Question 73

Amniotic fluid embolism mx?

Answer 73

Critical care unit by a multidisciplinary team, management is predominantly supportive

Question 74

Gestational trophoblastic disorders | Describes

Answer 74

spectrum of disorders originating from the placental trophoblast: complete hydatidiform mole partial hydatidiform mole choriocarcinoma

Question 75

Complete hydatidiform mole is?

Answer 75

Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin

Question 76

Complete hydatidiform mole sx

Answer 76

bleeding in first or early second trimester exaggerated symptoms of pregnancy e.g. hyperemesis uterus large for dates

Question 77

Complete hydatidiform mole ix

Answer 77

very high serum levels of human chorionic gonadotropin (hCG) | hypertension and hyperthyroidism* may be seen

Question 78

Complete hydatidiform mole mx

Answer 78

urgent referral to specialist centre - evacuation of the uterus is performed effective contraception is recommended to avoid pregnancy in the next 12 months

Question 79

Complete hydatidiform mole Around ?% go on to develop choriocarcinoma

Answer 79

Around 2-3% go on to develop choriocarcinoma

Question 80

In a partial mole what happens?

Answer 80

normal haploid egg may be fertilized by two sperms, or by one sperm with duplication of the paternal chromosomes. Therefore the DNA is both maternal and paternal in origin. Usually triploid - e.g. 69 XXX or 69 XXY. Fetal parts may be seen