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Obstetrics and Gynaecology > Pregnancy Complications > Flashcards

Pregnancy Complications Flashcards

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1
Q

What is placental abruption?

A

Separation of part or all of the decidua basalis from the uterine wall

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2
Q

What happens in placental abruption?

A

Rupture of maternal vessels within basal layer of endometrium. Blood accumulate and split placental attachment from basal layer. Detached portion of placenta unable to function –> fetal compromise

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3
Q

What are the types of placental abruption?

A

Revealed (80%)

Concealed (20%)

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4
Q

What is a revealed placental abruption?

A

Bleeding tracks down from site of placental separation

Drain through cervix resulting in vaginal bleeding

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5
Q

What is concealed placental abruption?

A

Bleeding collects between the uterus and the placenta. A retroplacental clot forms

Bleeding not visible but can cause systemic shock

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6
Q

How common is placental abruption and when does it normally happen?

A

1/200 pregnancies

Usually happen >20 week gestation

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7
Q

How is placental abruption diagnosed?

A

Clinical diagnosis based on:
Tense tender uterus with “woody” feel on examination
USS - clot may not be easily distinguishable
CTG abnormalities - foetal distress
Platelet count may be low
Coag screen - coagulopathy common

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8
Q

How does placental abruption present?

A

Painful vaginal bleeding
Pain between contractions (if in labour)
Uterus tense all the time
Shock out of proportion to blood loss - if concealed

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9
Q

What are the key risk factors for placental abruption?

A 
Previous Hx of abruption
Hypertension and smoking - diseased vessels
Abdominal trauma
Abnormal lie of baby
Polyhydramnios
Multiple pregnancy
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10
Q

How can placental abruption be managed?

A

Emergency C Section - if maternal or foetal compromise

Induction of labour - if haemorrhage at term without maternal or foetal compromise

Conservative - for partial or marginal abruptions without compromise

In all cases - give anti-D within 72hrs of onset if Rhesus D -ve

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11
Q

What is placenta praevia?

A

Placenta lie partially or wholly in lower uterine segment in front of the presenting part of the foetus

Usually happen >20 weeks gestation

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12
Q

How is placenta praevia graded?

A

1: low lying
2: reaches the internal os
3: covers the os when not dilated but on dilation it no longer covers the os
4: covers the os symmetrically

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13
Q

How common is placenta praevia?

A

5% low lying placenta at 16-20 week scan

Incidence at delivery only 0.5% - most rise away from cervix

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14
Q

What are the main risk factors for placenta praevia?

A

Previous hx
Previous caesarian - implant on scar
Multiple pregnancy
Advancing maternal age

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15
Q

How does placenta praevia present?

A

Picked up on routine 20 week scan
Painless vaginal bleeding - vary from spotting to haemorrhage
Lie and presentation may be abnormal

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16
Q

If a placenta praevia minor is picked up at a 20 week scan, what should happen?

A

Repeat scan at 36 weeks

Placenta likely to have moved superiorly in this time

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17
Q

If a placenta praevia major is picked up at a 20 week scan, what should happen?

A

Repeat scan at 32 weeks

Plan for delivery made at this time

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18
Q

What is the safest mode of delivery for confirmed placenta praevia?

A

C Section

Electively done at 37 weeks if placenta praevia major

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19
Q

What complications are associated with placenta praevia?

A

Pre-term delivery
Hypovolaemic shock
Placenta accreta
Fetal hypoxia and asphyxia

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20
Q

What must not be done if a patient has placenta praevia?

A

Vaginal exam

May start torrential bleeding

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21
Q

What is the difference in how placenta praevia and placental abruption present?

A

Placenta Praevia - painless, bright red blood, proportional blood loss to shock, no associated conditions

Placental abruption - painful, bleeding can be concealed, dark coloured, shock out of proportion to blood loss, associated with preeclampsia

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22
Q

What is the difference between placenta praevia and placental abruption on abdominal examination?

A

PP - Uterus size normal, soft and relaxed, fetus malpresentation common, Fetal heart sounds usually present

PA - Large for date tender, rigid uterus, fetal presentation unrelated, fetal heart sounds usually absent

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23
Q

What is the difference between placenta praevia and placental abruption on placentography and vaginal exam?

A

PP - Placenta in lower segment and palpable there in vaginal exam

PA - Placenta in upper segment and not palpable on vaginal exam

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24
Q

What is placenta accreta?

A

Attachment of the placenta to the myometrium due to defective decider basalis

Doesn’t separate in labour

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25
What are the types of placenta accreta?
Accreta - Chorionic villi attach to myometrium rather than being restricted within decidua basalis Increta - Chorionic villi invade into myometrium Percreta - Chorionic villi invade all the way through to the perimetrium
26
What are the risk factors for placenta accreta?
Previous C Section | Placenta praevia
27
How can placenta accreta be diagnosed?
Imaging can raise suspicion Definitive diagnosis through surgery
28
What are complications associated with placenta accreta?
Preterm delivery | Retained placenta and PPH
29
What should be done if you suspect placenta accreta?
Consultant obstetrician and anaesthetist at birth with blood Uterus opened at site distant to placenta so baby can be delivered without disturbing it
30
What is done if placenta accreta is confirmed?
Hysterectomy
31
What does conservative management of placenta accreta involve?
Leave placenta in place Uterine artery embolisation Plan elective hysterectomy
32
What is rhesus isoimmunisation?
Production of antibodies in response to an isoantigen present on an erythrocyte
33
What happens in rhesus isoimmunisation and why is it dangerous?
Maternal antibodies formed in response to surface antigen on fetal RBC in sensitising event Primary exposure - rarely any adverse effect Secondary exposure - further pregnancies - maternal antibodies cross placenta and attack fetal RBC's (if same surface antigen) --> haemolysis and fetal anaemia
34
Give an example of how you could get haemolytic disease of newborn
Mother Rhesus -ve, Father rhesus +ve 1st pregnancy - Rhesus +ve and sensitising event 2nd pregnancy - Rhesus +ve, maternal antibodies cross and attack fetal Rh+ve RBC's Haemolysis
35
What are some causes of sensitising events?
``` Invasive obstetric testing - chorionic villi sampling, amniocentesis Antepartum haemorrhage >12 weeks Ectopic pregnancy External cephalic version Fall/trauma Intrauterine death Miscarriage >12 weeks Termination of pregnancy Delivery ```
36
What investigations are done following a sensitising event?
Maternal blood group - find out ABO and Rhesus Maternal antibody screen - detects antibodies against RBC surface antigens Fetal maternal haemorrhage test - Kleihauers test
37
What is kleihauers test? When is it used? What is it used for?
Assess how much fetal blood has entered maternal circulation if sensitising event >20 week gestation Used to determine how much AntiD immunoglobulin should be given
38
How are women managed following a sensitising event?
Anti-D immunoglobulin administered - bind to maternal Rh+ cells - no immune response
39
How is rhesus isoimmunisation screened in the UK? What then happens if they are -ve?
All pregnant women have blood group and antibody test at booking visit (8-12 weeks) and again at 28 weeks Any Rhesus -ve woman is offered anti D prophylaxis at 28 and 32 weeks
40
When is a pregnancy considered prolonged?
>42 weeks gestation
41
What are the risk factors for prolonged pregnancy?
Nullparity Maternal age >40 High BMI Previous prolonged pregnancy
42
How can prolonged pregnancy present?
``` Macrosomia Oligohydramnios Reduced fetal movements Meconium staining - on fingernails Reduced vernix and dry skin Reduced subcutaneous fat ```
43
What complications are associated with prolonged pregnancy?
Still birth - exponential rise from 37 weeks on Macrosomia complications - shoulder dystocia, perineal tears, obstructed labour Placental insufficiency and degradation = distress - IUGR - meconium aspiration - hypoglycaemia - acidosis
44
What can placental insufficiency lead to?
``` Fetal acidaemia Distress = meconium aspiration IUGR features Reduced O2 and nutrient transfer Neonatal hypoglycaemia ```
45
What are the maternal complications associated with prolonged pregnancy?
Perineal damage Obstructed labour Need for instrument or c section
46
How are prolonged pregnancies managed?
Membrane sweep - 40 weeks if nullparous, 41 weeks if multiparous Induction of labour - between 41 and 42+0 weeks - break water - intravaginal prostaglandins - oxytocin
47
What should be done if women decline management for prolonged labour?
2x weekly CTG | Amniotic fluid measurements - identify fetal distress
48
What is amniotic fluid made of?
Lung fluid Fetal urine Placental contributions
49
What happens to amniotic fluid?
Fetus breathe and swallow fluid - get processed and fill bladder where it is voided
50
How does the volume of amniotic fluid normally change? How much is left at term?
Increase steady until 33 weeks Plateau 33-38 weeks Decline until term to reach 500ml
51
How is amniotic fluid measured?
Amniotic fluid index - measure maximum cord free vertical pocket in each of 4 quadrants of uterus and add together Maximum pool depth - vertical measurement in any are
52
How is oligohydramnios characterised?
Less than 500ml at 32-36 weeks | Amniotic fluid index <5th percentile
53
What can cause oligohydramnios?
``` Premature rupture of membranes Placental insufficiency Fetal renal problems - genesis, cystic Obstructive uropathy IUGR Post-term gestation Pre-eclampsia ```
54
How would you assess a patient with oligohydramnios?
``` Look for underlying cause: Leakage - new urinary incontinence Speculum examination - liquid in vagina IUGR signs - UAD Measure insulin like growth factor binding protein in vagina - suggest membrane rupture ```
55
How is polyhydramnios characterised?
Amniotic fluid index >95th percentile
56
What can cause Polyhydramnios?
``` Idiopathic - 50-60% Conditions that prevent fetal swallowing - oesophageal/duodenal atresia, CNS abnormalities, muscular dystrophy Twin-twin transfusion syndrome Maternal diabetes Maternal ingestion of lithium Macrosomia TORCH infections ```
57
What are the TORCH infections?
Perinatal infections ``` T - Toxoplasmosis O - Other - syphilis, varicella, parvovirus R - Rubella C - Cytomegalovirus H - Herpes ```
58
How is Polyhydramnios managed?
Amnioreduction Indomethacin - enhance water retention so reduced fetal urine output For idiopathic, baby must be examined before first feed - nasogastric tube passed to ensure no tracheoesphageal fistula or oesophageal atresia
59
What risks are associated with amnioreduction?
Infection | Placental abruption - sudden decrease in intrauterine pressure
60
What risks are associated with indomethacin?
Premature closure of ductus arteriosus - not used beyond 32 weeks
61
What symptoms do mothers with Polyhydramnios present with?
``` Breathlessness Swollen feet Indigestion Constipation Baby bump very large/heavy ```
62
What complications are associated with Polyhydramnios?
Pre-term labour - over distention of uterus Malpresentation - fetus has more room to move Cord prolapse PPH - uterus has to contract down further
63
What are the types of twin pregnancy?
2 ova fertilised: 2 chorion and 2 amnion Can have own or fused placenta 1 ova fertilised: - Embryo split at 3 days - own placenta - 2 chorion, 2 amnion - Embryo split at 4-7 days - 1 placenta - 1 chorion, 2 amnion - Embryo split at 8-12 days - 1 placenta - 1 chorion and 1 amnion Later - conjoint
64
How do twin pregnancies normally present?
Pick up on scanning in 1st trimester Hyperemesis Exaggerated pregnancy symptoms Uterus palpable earlier than 12 weeks
65
How common are twin pregnancies in IVF?
24% of successful IVF
66
How are multiple pregnancies monitored?
Scan at 11-13 weeks - gestational age, chronicity, screen for down's Other scans depend on type of twinning but monitor: - difference in fetal weight - IUGR
67
What is twin-twin transfusion syndrome? How is it managed?
Disproportionate blood supply between 2 twins leading to still birth and other complications Laser treatment of the placental vascular anastomoses
68
What fetal risks are associated with multiple pregnancy?
Greater risk if placenta shared - Miscarriage and still birth - Preterm birth - Down's - Umbilical cord entanglement - IUGR - Developmental and behavioural problems - Feeding issues
69
When should multiple pregnancies be offered delivery?
Triplets - 35 weeks Monochorionic - 36 weeks Dichorionic - 37 weeks
70
What is the method of delivery for multiple pregnancy?
``` Vaginal as long as twin 1 cephalic C section if: - twin 1 breech - 1 amnion - other complications - triplets or more ```
71
What are the risks of multiple pregnancy for the mother?
``` Anaemia Pre-eclampsia Severe symptoms of pregnancy Extra load on heart Antepartum and Postpartum haemorrhage ```
72
What is fetal distress?
Compromise to the fetus due to reduced oxygen or nutrition
73
What are the signs of fetal distress?
``` Reduced fetal movements Abnormal non-stress test and/or contraction stress test Abnormal amniotic fluid Amnormal biophysical profile Vaginal bleeding Cramping Maternal hypertension Insufficient or excess maternal weight gain ```
74
What can cause fetal distress?
Uteroplacental insufficiency - vascular disease - intrauterine sepsis - oligohydramnios - reduced fetal reserves - hypovolaemia - IUGR
75
How is fetal distress managed?
Monitor - view for induction or C-Section | Balance risks of fetal distress and prematurity
76
If fetal distress continues in labour, what should happen?
Expedite delivery < 30mins
77
What are the risks of smoking in pregnancy (including cannabis)?
``` Miscarriage Pre-term labour Stillbirth IUGR SIDS ```
78
What are the risks of alcohol in pregnancy?
Fetal alcohol syndrome: - Learning difficulties - Characteristic facies - smooth philtrum, thin vermilion, small palpebral fissures - IUGR and postnatal restricted growth - Microcephaly
79
What are the risks of cocaine in pregnancy?
Maternal - HTN, pre-eclampsia, placental abruption | Fetus - prematurity, neonatal abstinence
80
What is the main risk of heroin in pregnancy?
Neonatal abstinence syndrome
81
What prescription drugs can't be taken in pregnancy?
Antibiotics - tetracyclines, aminoglycosides, sulphonamides, trimethoprim, quinolones ``` ACE inhibitors, ARB's Statins Warfarin Sulphonylureas Retinoids Cytotoxics ```
82
How does foetal anaemia present?
HF fluid retention (liver devoted to RBC production so albumin reduced) death After birth: jaundice (placenta clears bilirubin in utero and at birth the liver can't)
83
What can cause placental insufficiency?
``` Smoking HTN Diabetes Anaemia Maternal hypovolaemia ```
84
What are the results of placental insufficiency?
``` Fetal distress oligohydramnios IUGR Cerebral palsy due to reduced O2 Hypoglycaemia Placental vascular occlusion due to raised EPO Infections due to low WCC ```
85
How would you treat a UTI in pregnancy?
Can give nitrofurantoin in T1 and T2 | Give cephalexin in T3

Obstetrics and Gynaecology (21 decks)

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