Pregnancy complications/ intra and postpartum care Flashcards
(173 cards)
1
Q
What is the normal pattern of blood pressure in pregnancy
A
The blood pressure should be less than 140/90 during pregnanct and then during the second trimester the blood pressure will normally fall and then rise again in the 3rd trimester
2
Q
What are the ranges for hypertension and borderline hypertension
A
Greater than 140/90 is hypertensive and then 135-139/85-89 is borderline
3
Q
What is the critea for proteinuria in pregnancy
A
- 0.3g in a 24hour sample
- 1+ on a dipstisk
4
Q
What are possible non pathological causes of proteinuria 3
A
- UTI
- Renal disease
- Contamination from the vaginal fluid
§§
5
Q
What is preeclampsia
A
This is where hypertension and proteinuria occur in the second half of pregnancy
6
Q
What is the other name for preeclampsia
A
Gestational proteinuric hypertension
7
Q
What is gestational hypertension
A
This is where hypertension appears in the second half of pregnancy without proteinuria
8
Q
What is meant by chronic hypertension
A
This is where there is hypertension that is present in the first half of pregnancy or even before the pregnancy
9
Q
What is eclampsia
A
This is a serious complication of pre eclampsia that is complicated by convulsions
10
Q
What is the frequency of preeclampsia
A
5-6% of pregnancies
11
Q
What are the complications of pre eclamsia that cause death in the patients
A
- Intracerebral hemorrhages
- Pulmonary edema
- Eclampsia
12
Q
What is the blood pressure range where there is a significant risk of intracerebral hemorrhage
A
160/110mmHg
13
Q
What are the complications to a fetus as a result of pre-eclampsia 3
A
- Preterm delivery as a result of deterioration of the mother’s condition
- Abruptio placentae
- Pre eclampsia results in decreased blood flow to the fetus causing growth restrictions
14
Q
What are the symptoms of pre eclmpsia with severe features 5
A
- Severe headaches
- Visual disturbances
- Dyspnoea
- Altered mental status
- Upper abdominal pain
15
Q
What are the signs that could indicate severe pre eclampsia features
A
- Liver tenderness
- Increased tendon reflexes
- Pulmonary odema
- Acites
16
Q
What is the rough incidince of eclampsia in the WC
A
1/1000
17
Q
What are some of the risk factors for pre eclampsia
A
- First pregnancy
- Chronic hypertension
- Over 34yo
- Multiple pregnancy
- Diabetics
18
Q
What is the management of a patient that is at risk of pre-eclampsia
A
- 150mg of asprin
- 1g of Calsium
19
Q
What level of hospital is able to manage a patient with pre eclampsia
A
A level 1 hospital with a c section facility
20
Q
What is the medication that is used to manage the patient hypertension
A
Methyldopa 500mg 8hourly
21
Q
What is the sequela of fetal well being in a patient with pre- eclampsia
A
- There will be placental insufficiency
- This will cause intrauterine growth restriction
- The growth restriction will cause fetal distress
- This will often lead to intrauterine death of the fetus
22
Q
How can you monitor a fetus to check for fetal distress
A
At a level 2 or 3 hospital an umbilical artery doppler can be used to check the functioning of the umbilical cord and the placental function
23
Q
When should a patient that has pre eclampsia deliver
A
At 34 weeks
24
Q
What special investigation need to be done to definitively diagnose pre eclampsia
A
- MSU to check that there is no infections present
- Platelet count
- Serum creatinine to check renal function
- Ultrasound to check the gestational age of the fetus
- Umbilical artery doppler to assess placental function
25
What is the management of a patient with severe pre-eclampsia
1. MgSO4
2. Nepresol or Adalat to prevent intracranial hemorrhage
3. IV fluids to prevent POdema
26
How is magnesium sulfate given to a patient
4g IV and then 5g in each butt
27
When is the Nepresol or Adalat given
This is given after the magnesuim sulfate if the blood pressure is still above 160/110
28
Which level of hospital should maintain a patient with severe symptoms of pre eclampsia
A level 2-3
29
What is the maintenance dose of magnesium sulfate
5 g every 4 hours in the butt
30
What do you check in order to make sure that you are not going to overdose Magnesium sulfate
The patellar reflex
31
What can be done if MgSO4 is OD
Then intubate the patient and give 10ml of calsium gluterate
32
What are the conditions under which the patient must deliver if they have pre eclampsia
1. The patients condion does not stabilise
2. The patient is very far from viability
3. The duration of the pregnancy is 34 weeks or more
4. Fetal distress is present
33
What level of hospital should a patient with gestational hypertension be managed
Level 1 hospital
34
What is the medication that is used to manage gestational hypertension
Alpha methyldopa
35
Should a patient with gestational hypertension deliver the baby
If the patients blood pressure is able to be managed well and there is no development of proteinuria then they can carry the baby to the full 40 weeks
36
Which chronic hypertension patients need to be cared for at a level 2 or 3 hospital
1. Patients that have abnormal renal function
2. If patients develop
37
How long should it take for the hypertension postpartum the settle in gestational hypertension
3 days
38
What is an antepartum haemorrhage
Any bleeding that occurs before 20 weeks
39
What would a bleed that occurs before 24weeks be considered as
Threatened miscarriage
40
What is the most common cause of a antepartum haemorrhage
Abruptio placentae
41
What is the general management of a patient in shock
1. Put up 2 IV lines to manage fluid loss
2. Insert a catheter to monitor the fluid output
3. Cross match and give bloods if needed
42
What must be excluded before a digital vaginal exam is done
Placenta praevia
43
If bleeding comes from a closed cervical os what does that confirm
That it is an antepartum haemorrhage
44
What is a show in pregnancy
In pregnancy, a "show" refers to the passage of a mucus plug from the cervix, often tinged with blood.
45
What is the most likely cause if cervix is a few centimetres dilated with bulging membranes if there is some antepartum bleeding
This is most likely a show
46
Cause of blood-stained discharge in the vagina, with no bleeding through the cervical os
vaginitis
47
Cause of bleeding from the surface of the cervix caused by contact with the speculum
cervicitis or cervical intra-epithelial neoplasia CIN
48
What is meant by abruptio placentae
This is where a portion of the placenta has separated from the uterus before delivery of the baby
49
What are the risk factors for abruptio placentae
1. Previous occurrence
2. Pre-eclampsia
3. Intrauterine growth restriction
4. Cigarette smoking
5. Poor socio-economic conditions
6. Tauma
50
What are the 3 main signs that point to a diagnosis of abruptio placentae
1. Severe abdominal pain
2. Blood with dark red clots
4. Absence of fetal movement after the bleeding
51
What would you do in the case of an abruptio placentae when there is still a fetal heart beat
The baby would need to be delivered as soon as possible
52
Why is it important to remember that pre-eclamsic patients often have abruptio placentae
This is because a patient that is in shock might still have a normal blood pressure because they were hypertensive before and so they should also be placed back on treatment for the hypertension after
53
What is a common complication that can occur in a patient with abruptio placentae after delivery
Postpartum hemorrhage
54
What can be done to prevent a post partum haemorrhage
The patient can be given Syntometrine 1 ampoule and if they are hypertensive they can be given 20 units of oxytocin
55
Which patients are at the highest risk for placenta praevia 4
1. Patients that have had more than 5 pregnancies
2. C sections
3. Multiple pregnancy
4. Threatened abortion
56
What in the history of an antepartum haemorrage would suggest placenta praevia
The bleeding is a bright red colour and there is still fetal movement after the bleeding has occured
57
What is done if the diagnosis of placentae privae is made
1. If less than 38 weeks then the patient should be hospitalised to monitor for active bleed
2. If older than 28 weeks then the patient needs to be given steroids to improve the lung function of the fetus incase of delivery
3. Over 38 weeks the fetus must be delivered
58
What is the management for a patient that is actively bleeding
The baby should be delivered as soon as possible
59
Why do patients that have placentae praevia have increased risk of postpartum haemorrages
The bottom half of the uterus does not have as strong of an ability to contract as the upper segment
60
60
What is the most likely cause of an antepartum hemorrhage of unknown origin
A small abruptio placentae that is not life threatening
61
What is meant by Vasa Praevia
This is where the fetuses blood vessels lay across the internal cervical os opening thus when the labour occurs it causes life threatening hemorrhage from the fetus
62
Which level of hospitals should manage patients with antepartum hemorrhages
Level 1 hospitals with blood products and level 2 hospitals
63
g defects.
A patient with abruptio placentae and pre-eclampsia must be referred to a level
3 hospital as this patient is at high risk of pulmonary oedema and acute tubular necrosis
64
A patient with a grade 3 or 4 placenta praevia and a viable fetus of less than 34 weeks, who is going to be managed conservatively, should be managed in at least a level
2 hospital with a neonatal intensive care unit, or a level 3 hospital.
65
What is the most common cause of blood-stained discharge due to vaginitis in pregnancy
Trichomonal vaginitis, both the patient and her partner should receive a single dose of 2 g metronidazole, not in the first trimester
66
What should patients with contact bleeding be treated with
oral erythromycin 500 mg 6‑hourly for seven days
67
What is defined as preterm labour
This is regular uterine contractions before 37 weeks
68
What is defined as preterm membrane rupture
This is there is rupture of the membranes before 37 weeks
69
What is prelabour rupture of the membranes
This is the rupture of membranes at least 1 hour before a term pregnancy
70
What is classified as a preterm labour if the date is not known
1. If the birth weight less than 2500g
2. The syphysis- fundus height is less than 35 cm
71
What is the main complication from premature membrane rupture
Infection of the placenta and the membranes
72
What is the most common cause of preterm membrane rupture and labour
Infection
73
What is the pathogenesis of infection of the membranes and placenta
1. Bacteria from the cervix and vagina spread through the endocervical canal
2. This infects the placenta and the membranes and later the liquor
3. Chorioamnionitis may cause the release of prostaglandins which in turn stimulate uterine contractions and cause the onset of labour.Chorioamnionitis may also weaken the membranes and lead to their rupture
74
What are Braxton Hicks contractions
These "practice" contractions help the uterus prepare for labor, but they do not cause cervical dilation or lead directly to labor.
75
What is the difference between braxton hicks contractions and contraction that are prelabour
1. Braxton hicks are irregular
2. They are uncomfortable but they are not painful
3. They do not increase in duration or frequency
4. They dont cause cervical dialation
76
What is the regular cycle of contraction in preterm
There is at least 1 contraction per 10 mins and the contractions are painful
77
What is ferning and what does it indicate
Ferning is a pattern that is observed when there is dying of liquor on a slide and so it indicates that there is liquor present
78
What are the contraindications to the suspension of a preterm labour 9
1. Fetal distress
2. If the fetus is over 34 weeks or under 24weeks
3. Chorioamnionitis
4. Intrauterine death
5. Congenetal abnormalities that are incompatible with life
6. Pre eclampsia
7. Antepartum haemorrhage with unknown cause
8. Cervical dilatation of more than 6 cm.
9. Severe intra-uterine growth restriction
79
What are the medications given to suppress pregnancy
1. Nifedipine (Adalat)
2. Salbutamol and beta 2 stimulants
4. Prostaglandin antagonists
80
What is the function of each of the drugs given in the suppression of preterm labour
1. Nifedipine (Adalat): Nifedipine inhibits calcium from entering smooth muscle cells, including the uterine muscles, which relaxes the uterus and decreases contractions.
2. Salbutamol stimulates beta2 receptors, which leads to relaxation of smooth muscle, including the uterus.
3. Prostaglandin Antagonists: These drugs inhibit the enzyme cyclooxygenase (COX), reducing prostaglandin production, which is a key mediator in uterine contractions.
81
What are the dangers of using steroid to promote fetal lung maturity
1. They increase the risk of infection
2. Cause fluid retention
82
What can be done to make the delivery of a preterm infant more successful
1. Epidural anesthesia can be given to the mother
2. Membranes should not be ruptured as it is better at cervical dilation
3. Vertex delivery is prefered
83
What are the treatments given to a patient that is in septic shock as a result of chorioamnionitis
Ampicillin, Metronidazole and gentamicin
84
What is meant by chorioamnionitis
An infection of the membranes and the placenta
85
What are the 4 main risk factors that predispose you to chorioamnionitis?
1. Rupture of the membranes
2. Coutis in the second half of pregnancy
3. Exposure of the membranes via dilatation
4. Digital vaginal exam
86
What is the pathogenesis of chorioamnionitis
1. Bacteria from the vagina make their way up the endocervix
2. The infection causes the release of prostaglandins leading to labor and the rupture of membranes
87
What are the 4 diagnostic signs of chorioamnionitis
1. Fetal tachy
2. Maternal pyrexia
3. Uterine tenderness
4. Offensive drainage of liquor
88
What are the antibiotics that are used to treat the infection
Amoxicillin or metronidazole
89
What are the 2 major sequelae of chorioamnionitis
1. Premature labor and membrane rupture
2. Septicemia
90
What is defined as premature membrane rupture
Rupture of the membranes before 37 weeks without associated uterine contractions
91
What is the timing of the normal prelabour rupture
Roughly 1 hour before
92
What is the most common cause of premature membrane rupture
Chorioamnionitis
93
What are the maternal cause of premature membrane rupture 3
1. Uterine abnormalities
2. Cervical incompetance
3. Pyexia
94
What are the 2 placental causes of premature membrane rupture
1. Abruptio placentae
2. Placentae priva
95
What are the fetal causes of premature membrane rupture 3
1. Polyamhydrosis
2. Multipregnancy
3. Congenital abnormalities and congenital infections
96
What are the levels of referal in a patient with premature membrane rupture
1. 34-36 weeks: Level 1
2. 28-33 weeks: Level 2/3
97
What are the 2 diagnostic tests that can be done to confirm that it is liquor that is draining
1. Fern test
2. Vaginal pHW
98
What are the conditions under which we would induce labor in a preterm rupture of the membranes
1. HIV with immunocompromise
2. Older than 34 and less than 26
3. Intrauterine death
4. Chorioamnionitis
5. Pregnancy complications
6. Anteparem hemorrhage of unknown origin
99
What is the major complication for a preterm infant when membrane rupture has occurred and what can be done
Hyaline lung disease
Give corticosteroids to mature the lungs
100
Define preterm labor
This is regular uterine contractions before 37 weeks, with cervical dilation and membrane rupture
101
What is the definition of preterm labor if the gestational age of the baby is unknown
An SF of less than 35 cm and a weight of less than 2500g
102
What are the levels of hospital needed for preterm labour
34-36 weeks: Level 1
28- 34 weeks: Level 2/3
103
What is the difference between Braxton hicks contractions and normal labor contractions
Braxton hicks are:
Not painful
Irregular
Do not increase in frequency
No cervical dilation occurs
104
When would you delivery a preterm infant
If it is older than 28weeks and younger than 24 weeks
105
What medications are given to stop uterine contractions 3
1. Adalat 30mg
2. Subutamol
3. Prostaglandin antagonists
106
What are the indications for stopping a preterm labor
If the fetus is over 24 weeks and there are no contraindications
107
What are the 3 most common causes of UTIs in pregnancy
1. Cystitis
2. Asymptomatic bacteriuria
3. Acute pyelonephritis
108
What are the 2 factors that put women who are pregnant at higher risk
1. Pregnancy decreases the immunity
2. Hormones dilate the cervix
109
What is meant by cystitis
This is inflammation of the bladder
110
What are the 3 main diagnostic symptoms of cystitis
1. Pain on urination
2. Tender bladder
3. Frequent urination and noctouria
111
What is the treatment of cystitis
4 cotrimoxazole tablets and 3g of amoxicillin
112
What is the main complication of an asymptomatic bacteriuria
In about 1/3 cases it can lead to a acute pyelonephritis
113
What is the treatment for an asymptomatic bacteriuria
4 cotrimoxazole tablets and 3 g of amoxicillin
114
What is an acute pyelonephritis
This is a severe bacteria infection of the kidney
115
What is the treatment for an acute pyelonephritis
Cefuroxime 750 mg and pethidine for the pain
116
When should a mother receive a blood transfusion
1. If her HB is less than 8 and she has signs of shock or if her HB is less than 6 with no other signs
117
Which mothers should take iron supplements
All patient should take one 200mg ferous sulfate iron tablet
118
What are the common side effects of iron supplements and what can be done to reduce them
Nausea and vomiting due to irritation of the bowel:
1. Take the iron after a meal
2. Take Ferrous gluconate instead
119
What can be done in each stage of pregnancy in a patient that has heart valve damage
1. Pulmonary odema must be monitored keeping the head up to prevent severe symptoms
2. Episiotomy can be done to reduce symptoms
3. Oxytocins should not be given as it can increase the BP
120
Define gestational diabetes
This is diabetes that develops for the first time during pregnancy and spontaneously recovers after
121
How can you diagnose gestational diabetes
A random glucose should be done if 8 or above then a fasting glucose it is below 8 then normal and if it is between 6-8 then a glucose profile must be done
122
When should a mother undergo glucose testing
28weeks
123
What are the 5 possible complications of gestational diabetes
1. Pregnancy infections like candidosis
2. 1st term congenital abnormalities
3. Large fetus
4. Postpartum hemorrhage
5. Hypoglycemia in the infant
124
What are the 3 stages of labour
First stage: This starts at the beginning of regular uterine contractions and ends with the cervix being fully dilated
Second stage: Starts when the cervix is fully dilated and ends with the birth of the baby
Third stage: Delivery of the placenta
125
What are the 2 substages of the first stage
Latent phase: 0-4cm
Active phase: 4-10cm
126
What are the 6 factors that are recorded on a partogram
1. General condition
2. Temp
3. HR
4. BP
5. Urine
6. Maternal exhaustion
127
What are the possible causes of severe continuous pain in the first stage of labor
1. Abruptio placentae
2. Ruptured uterus
3. Acute pyelonephritis and choirioamnionitis
128
What causes severe maternal dehydration and exhaustion
Cephalodpelvic disproportion
129
What would cause the mother to look pale during birth
1. Chronic anemia
2. Blood loss
130
What is the sequelae of a maternal fever
Fetal tachycardia
131
What is the normal maternal blood pressure
100/60 mmHg to 140/90mmHg
132
What is a common cause of hypotension
Supine hypotension caused by the fetus placing increased pressure on the inferior vena cava
133
What are the major complications of hypotension
Renal damage as a result of shock
134
What causes the decreased volume of urine
1. Dehydration
2. Shock
3. Severe pre-eclampsia
135
What causes very high ketone levels in the urine
Maternal exhaustion
136
How does compression of the head lead to fetal distress
1. Compression of the head
2. Compression of the skull resulting in increased vagal tone
3. Decreased HR
4. Decreased organ perfusion and so acidosis
137
What are the 4 possible causes of decreased O2 supply to a fetus
1. Uterine contractions
2. Placental insufficiency in conditions like preeclampsia
3. Abruptio placenta
4. Cord prolapse or compression
138
How often should the HR be monitored
In the latent phase every 2 hours and in the active phase every 30 minutes
139
What causes an early deceleration
A decrease during contraction
140
What causes late decelerations
Decreases in the heart rate during and after a contraction
141
What is a variable deceleration
This is where there is no relationship between the contraction and the decrease in heart rate
142
What is the baseline heart rate of an infant
110 - 160
143
Which conditions cause early decelerations
Compression of the head
144
Which conditions cause late decelerations
[This is where the HR only returns after about 30s after the contraction] This is caused by fetal hypoxia in conditions like placental insufficiently, abruptio placenta and IUGR
145
Which conditions cause variable decelerations
Compression of the cord
146
What are the factors that cause cause fetal tachycardia
1. Maternal pyrexia
2. Maternal exhaustion
3. Subutomal use
4. Fetal hemorrhage
5. Chroioamniosis
147
How do you resus a fetus in utero
1. Place the patient on their side
2. Start IV ringers and subutamal
148
What are the 3 recordings that should be made about the liquor
ICM
I: Intact membrane
C: Clear draining
M: Melconium stained
149
What is meant by engagement
This is when the largest transverse diameter of the head passes through the cervix
150
What are the drawbacks to dorsal birthing position
Postural hypotension
151
What are the indications for an episiotomy
1. Fetal distress
2. Maternal exhaustion
3. Maternal heart disease
4. Increased risk of 3rd degree tear
5. Prolonged second stage
152
What are the factors that increase the risk of a prolonged second stage of pregnancy and what is considered a long second stage
1. Large fetus
2. DM
3. Increased BMI
4. Hx of large infants
5. Slow progression of the first stage
More than 30 mins for a multi and more than 45 mins for a prima
153
What is the medication that is given to a prolonged second stage of pregnancy and what causes it
IV salbutamol causes the uterus to relax
154
What is the active and the passive management of the 3rd stage of labor and at what level of hospital are each performed
Active management: This is where 10 units of oxytocin are given and there is traction placed on the placenta (Done at a level 2-3 hospital)
Passive management: Allow for the placenta to separate naturally, and then once the placenta is developed then oxytocin is given (Done at a level 1 and MOU)
155
What is the sign that there is separation of the placenta
The fundus of the uterus will rise into the abdomen and the umbilical cord will suddenly lengthen
156
What are the benefits 2 of letting the maternal side of the placenta bleed out and why should it not be done
1. It decreases the volume of the placenta
2. If the mother is Rh - it decreases the exposure for sensitization to occur
Contraindication: If there are twins it might cause the other twin to bleed out
157
What could be the cause of a heavy oedematous placenta
Syphilis
158
What causes a heavy pale placenta
Rhesus hemolytic disease
159
What could be the cause of a small placenta
IUGR
160
What is done of the placenta is not delivered within 30mins
Give 20 Units of oxytocin in 1l of saline over. 4 hours
161
What is considered a postpartum haemorrage
Bleeding of more than 500ml in the 24 hours post partum
162
What is the immediate treatment for a postpartum hemorrhage?
1. Rub the uterus
2. 20 units of oxytocin
3. Check for tears
4 Empty the bladder
163
What are the 2 main causes of PPH
1. Atonic uterus: This is where the uterus if full of blood, and retained products of the bladder are full preventing uterine contraction
2. Tears
164
What is the management of a PPH
1. 20 units of oxytocin/ syntometrine
2. Ballon tamponade or manual compression can be done
165
What is the puerperium state
This is the stage between the 3rd stage of pregnancy and 6 weeks
166
What is the main worry in the first hour after birth
PPH
167
What is a secondary PPH
abnormal or excessive vaginal bleeding occurring after the first 24 hours postpartum and up to 12 weeks postpartum
168
What are the possible causes of a secondary PPH
1. RPOC
2. Infection
3. Placental atone
4. Uterine rupture
169
What are the 4 categories of risk in pregnancy patient
1. Low risk: These can deliver in a district (1) or MOU
2. Intermediate risk: Developed a risk at one stage of pregnancy
3. High risk: At significant risk in more than one stage of pregnancy [Should deliver at a level 2 or 3 hospital]
4. Special care patients: Should deliver at a level 3
170
What is the hierarchy in hospitals
1. MOU
2. District
3. Level 2 or 3 Regional hospital
4. Level 3 hospital
171
What is the maternal mortality ratio
The is the number of women that die during pregnancy, labor, or perineum
172
What are the 5 most important primary causes of death in mothers
1. HIV
2. Haemorrahe
3. Hypertensive disorders
4. Infections
5. Medical issues before pregnancy
