Pregnancy Complications

Question 1

What is the definition of a spontaneous abortion?

Answer 1

Spontaneous loss of pregnancy before 24 weeks

Question 2

What is the difference between a threatened and inevitable abortion?

Answer 2

A threatened miscarriage refers to bleeding from the gravid uterus before 24 weeks gestation when there is a viable foetus and no evidence of cervical dilatation.
Abortion becomes inevitable if the cervix has already begun to dilate

Question 3

What is a missed miscarriage?

Answer 3

This is a missed miscarriage, also called a silent miscarriage. It’s called a missed miscarriage because you won’t realise that anything has gone wrong. You may not have had any of the usual signs of miscarriage, such as pain or bleeding. It may be that an embryo didn’t develop at all and the pregnancy sac is empty.

Question 4

What are some causes of spontaneous abortion?

Answer 4

Hormone Imbalances
Trauma to cervix, previous surgery
Chromosomal, genetic or structural abnormalities of foetus
Congenital uterine issues
Fibroids
Cervical Incompetence
Increasing maternal age
Maternal diabetes

Question 5

What are some risk factors for an ectopic pregnancy?

Answer 5

Pelvic inflammatory disease
Previous tubal surgery
Previous ectopic
Assisted conception

Question 6

What are the symptoms of an ectopic pregnancy?

Answer 6

Period of amenorrhoea (with +ve urine pregnancy test)
+/_ Vaginal bleeding
+/_ Pain abdomen
+/_ GI or urinary symptoms

Question 7

What investigations should be done for an ectopic pregnancy?

Answer 7

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 8

What is an antepartum haemorrhage?

Answer 8

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

Question 9

What are the causes of APH?

Answer 9

Placenta praevia
Placental abruption
APH of unknown origin
Local lesions of the genital tract
Vasa praevia (very rare)- Usually the blood loss is small and is due to rupture of a foetal vessel within the foetal membranes

Question 10

When is placenta praevia more common?

Answer 10

Multiparous women
Multiple pregnancies
Previous caesarean section

Question 11

What are the grades of placenta praevia?

Answer 11

Grade I Placenta encroaching on the lower segment but not the internal cervical os
Grade II Placenta reaches the internal os
Grade III Placenta eccentrically covers the os
Grade IV Central placenta praevia

Question 12

What is the presentation of placenta praevia?

Answer 12

Painless PV bleeding
Malpresentation of the foetus
Incidental
Soft, non tender uterus +/- fetal malpresentation

Question 13

What are the managements of PPH?

Answer 13

Medical management – oxytocin, ergometrine, carbaprost, tranexemic acid
Balloon tamponade
Surgical – B Lynch cutre, ligation of uterine, iliac vessels, hysterectomy

Question 14

What is a placental abruption?

Answer 14

Haemorrhage resulting from premature separation of the placenta before the birth of the baby (due to a retroplacental clot)

Question 15

What are factors associated with placental abruption?

Answer 15

Pre-eclampsia/ chronic hypertension
Multiple pregnancy
Polyhydramnios
Smoking, increasing age, parity
Previous abruption
Cocaine use

Question 16

What are the three types of placental abruption?

Answer 16

Revealed
Concealed
Mixed (concealed and revealed)

Question 17

What is the presentation of placental abruption?

Answer 17

Pain
Vaginal bleeding (may be minimal bleeding)
Increased uterine activity

Question 18

What is the definition of preterm labour?

Answer 18

Onset of labour before 37 completed weeks gestation (259 days)

32-36 wks mildly preterm
28-32 wks very preterm
24-28 wks extremely preterm

Question 19

What are predisposing factors for preterm labour?

Answer 19

Multiple pregnancy
Polyhydramnios
APH
Pre-eclampsia
Infection eg UTI
Prelabour premature rupture of membranes
Majority no cause (idiopathic

Question 20

What does tocolysis allow in preterm labour?

Answer 20

Allows time to give steroids to help with foetus’ breathing. Allows time for transfer

Question 21

What are the parameters for hypertension in pregnancy?

Answer 21

Mild HT– Diastolic BP 90-99, Systolic BP 140-49
Moderate HT- Diastolic BP 100-109, Systolic BP 150-159
Severe HT- Diastolic BP ≥110, Systolic BP ≥ 160

Question 22

What are the definitions of gestational hypertension and pre-eclampsia in terms of onset?

Answer 22

Gestational hypertension BP in set classed raised parameters but new hypertension (develops after 20 weeks)
Pre-eclampsia- New hypertension > 20 weeks in association with significant proteinuria

Question 23

What are the parameters for proteinuria in pre eclampsia?

Answer 23

Automated reagent strip urine protein estimation > 1+
Spot Urinary Protein: Creatinine Ratio > 30 mg/mmol
24 hours urine protein collection > 300mg/ day

Question 24

What hypertensive drugs are safe and widely used in pregnancy?

Answer 24

Labetalol
Nifedipine
Methyldopa

Question 25

What is the definition of pre eclampsia?

Answer 25

A hypertensive syndrome that occurs in pregnant women after 20 weeks' gestation, consisting of new-onset, persistent hypertension (defined as a BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic, based on at least 2 measurements taken at least 4 hours apart) with one or more of the following: 1) proteinuria (defined as urinary excretion of ≥0.3 g/24 hours of protein); 2) evidence of systemic involvement, such as renal insufficiency (elevated creatinine), liver involvement (elevated transaminases and/or right upper quadrant pain), neurological complications, haematological complications; 3) fetal growth restriction

Question 26

What are the risk factors of pre eclampsia?

Answer 26

``` Primiparity Pre-eclampsia in previous pregnancy Family history of pre-eclampsia BMI >30 Maternal age >35 years Multiple (twin) pregnancy Sub-fertility Gestational hypertension Pre-gestational diabetes Polycystic ovary syndrome (PCOS) Autoimmune disease Renal disease Chronic hypertension BP ≥80 mmHg diastolic at booking Interval of 10 years or more since previous pregnancy High-altitude residence ```

Question 27

What are the symptoms and signs of pre eclampsia?

Answer 27

``` 20 weeks' gestation BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic and previously normotensive Headache Upper abdominal pain Reduced fetal movement Foetal growth restriction Oedema Visual disturbances Seizures Breathlessness- pulmonary oedema Oliguria Hyper-reflexia and/or clonus Cerebral haemorrhage, stroke HELLP (hemolysis, elevated liver enzymes, low platelets) DIC (disseminated intravascular coagulation) Renal failure Cardiac Failure IUGR Prematurity Increased foetal mortality ```

Question 28

What investigations should be done in pre eclampsia?

Answer 28

``` LFTs FBC Renal function tests Frequent BP checks Urine Dipstick Coagulation tests CTG US for baby growth ```

Question 29

What is the management of pre eclampsia?

Answer 29

Delivery of baby is the best treatment but depends on gestation Anti-hypertensives Steroids for fetal lung maturity if gestation <36 weeks Magnesium sulphate bolus + IV infusion for seizures Avoid fluid overload – aim for 80mls/hour fluid intake Low dose Aspirin from 12 weeks till delivery for prophylaxis

Question 30

How is the diagnosis of gestational hypertension made?

Answer 30

To establish the diagnosis, 2 blood pressure (BP) measurements should be taken at least 6 hours, and no more than 7 days, apart

Question 31

What are the risk factors for gestational hypertension?

Answer 31

``` Nulligravidity Black or Hispanic ethnicity Multiple pregnancies Obesity Mother being small for gestational age Type 1 diabetes mellitus Migraine ```

Question 32

Why does gestational diabetes occur?

Answer 32

Human placental lactogen, progesterone, human chorionic gonadotrophin and cortisol from the placenta have anti-insulin action so the insulin requirements of the mother increase Maternal glucose crosses the placenta and induces increased insulin production in the fetus. The fetal hyperinsulinemia causes macrosomia

Question 33

What are the effects of gestational diabetes on the foetus?

Answer 33

Hypoglycemia at birth Resp distress at birth Fetal congenital abnormalities e.g – cardiac abnormalities, sacral agenesis especially if blood sugars high peri-conception Miscarriage Fetal macrosomia, polyhydramnios Operative delivery, shoulder dystocia Stillbirth, increased perinatal mortality

Question 34

What are the risk factors for gestational diabetes?

Answer 34

``` Advanced maternal age (>40 years) Elevated BMI Polycystic ovarian syndrome (PCOS) Non-white ancestry FHx of diabetes mellitus Low-fibre and high-glycaemic index diet Weight gain as young adult Previous gestational diabetes Physical inactivity ```

Question 35

How is Virchow's triad affected during pregnancy?

Answer 35

Pregnancy is a hypercoagulable state (to protect mother against bleeding post delivery) -increase in fibrinogen, factor VIII, VW factor, platelets -decrease in natural anticoagulants – antithrombin III -increase in fibrinolysis (Hypercoagulability) Increased stasis – progesterone, effects of enlarging uterus (stasis) May be vascular damage at delivery/ caesearean section (vessel damage)

Question 36

What are the risk factors for VTE in pregnancy?

Answer 36

``` Older mothers, increasing parity Increased BMI Smokers IV drug users PET Dehydration – hyperemesis Decreased mobility Infections Operative delivery, prolonged labour Haemorrhage, blood loss > 2 l Previous VTE (not explained by other predisposing eg. fractures, injury), those with thrombophilia (protein C, protein S, Anti thrombin III deficiencies, etc), strong family history of VTE Sickle cell disease ```

Question 37

What is the prevention for VTE during pregnancy?

Answer 37

TED stockings Advice increased mobility, hydration Prophylactic anti-coagulation with 3 or more risk factors (may be indicated even with one risk factor if significant risk), may need to continue 6 weeks postpartum