Pregnancy complications & mortality Flashcards
(105 cards)
1
Q
What are hypertensive disorders in pregnancy?
A
Gestational hypertension
Pre-eclampsia
2
Q
What is gestational hypertension?
A
New hypertension develops after 20wks
3
Q
What is pre-eclampsia?
A
New hypertension >20wks in association with significant proteinuria
4
Q
What is mild hypertension?
A
Systolic 140-49
Diastolic 90-99
5
Q
What is moderate hypertension?
A
Systolic 150-159
Diastolic 100-109
6
Q
What is severe hypertension?
A
Systolic >160
Diastolic >110
7
Q
What is significant proteinuria in pre-eclampsia?
A
Automated reagent strop urine protein estimation >1+
Spot urinary P:C ratio >30mg/mmol
24hr urine protein collection >300mg/day
8
Q
What is the management of mothers with essential/chronic hypertension?
A
Pre-pregnancy care Keep BP <150/100 Monitor for superimposed pre-eclampsia Monitor fetal growth Higher incidence placental abruption
9
Q
What is pre-pregnancy care for essential/chronic hypertension?
A
Change anti-hypertensive drugs if necessary ACE-i ARBs Anti diuretics Low dietary sodium
10
Q
What is the definition of pre-eclampsia?
A
Mild HT on two occasions more than 4 hours apart
Moderate to severe HT
+ Proteinuria of more than 300mgms/24hrs
11
Q
What are.the risk factors for developing pre-eclampsia?
A
First pregnancy Extremes of maternal age Pre-eclampsia in previous pregnancy Pregnancy interval >10yrs BMI >35 FHx Multiple pregnancy Underlying medical disorder
12
Q
What are the complications of pre-eclampsia for the mother?
A
Seizures
Severe hypertension - cerebral haemorrhage, stroke
HELLP (hemolysis, elevated liver enzymes, low platelets)
DIC (disseminated intravascular coagulation)
Renal failure
Pulmonary oedema, cardiac failure
13
Q
What are the complications of pre-eclampsia for the child?
A
Impaired placental perfusion:
- IUGR
- fetal distress
- prematurity
- increased PN mortality
14
Q
What are symptoms/signs of severe pre-eclampsia?
A
Headache, blurred vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands/face/legs
Clonus/brisk reflexes
Reduced urine output
Convulsions
Severe hypertension; >3+ urine proteinuria
15
Q
What are the investigations for pre-eclampsia?
A
Frequent BP checks, urine protein checks
Check symptomatology
Check for hyper-reflexia/tenderness of liver
Bloods: FBC, LFTs, renal function tests, coagulations tests
Fetal investigations: scans, CTG
16
Q
What is the management for pre-eclampsia?
A
Only cure is delivery
Observation
Anti-hypertensives: labetolol, methyldopa
Steroids for fetal lung maturity if gestation <36wks
Consider induction of labour
17
Q
What is the treatment for seizures/impending seizures in pre-eclampsia?
A
Magnesium sulphate bolus + IV infusion
Control BP
Avoid fluid overload
18
Q
What is the prophylaxis for pre-eclampsia in future pregnancy?
A
Low dose aspirin from 12wks
19
Q
What are the types of diabetes in pregnancy?
A
Pre-existing
Gestational
20
Q
What are signs of gestational diabetes?
A
Carbohydrate intolerance with onset of pregnancy
Abnormal glucose tolerance that reverts to normal after delivery
21
Q
What happens to insulin requirements of pre-existing diabetic women?
A
Increased insulin requirements
22
Q
Why do insulin requirements increase in pregnancy?
A
Some hormones have anti-insulin action
23
Q
What happens to fetus in women with pre-existing diabetes in pregnancy?
A
Fetal hyperinsulinemia occurs as maternal glucose crosses placenta and induces insulin production in fetus
24
Q
What does fetal insulinaemia cause?
A
Macrosomia
25
What are the risks for baby in diabetic mum's post-delivery?
More risk neonatal hypoglycaemia
| Increased risk respiratory distress
26
What are there increased risks of in babies with diabetic mothers?
```
Fetal congenital anomalies
Miscarriage
Fetal macrosomia, polyhydramnios
Operative delivery, shoulder dystocia
Stillbirth, increased perinatal mortality
Risk of pre-eclampsia
Infections
Neonatal: impaired lung maturity, neonatal hypoglycemia, jaundice
```
27
What is the management of diabetes pre-conception?
Better glycaemic control: 4-7mmol/l
Folic acid
Dietary advice
Retinal and renal assessment
28
What is the management of diabetes during pregnancy?
```
Optimise glucose control, insulin requirements
will increase
Oral anti-diabetic agents
Risks of hypoglycemia
Watch for ketonuria/infections
Retinal assessments
Fetal growth
Observe for pre-eclampsia
Consider labour induction/c-section
CTG fetal monitoring
Early feeding baby to reduce neonatal hypoglycemia
```
29
What are risk factors for gestational diabetes?
```
BMI >30
Previous macrosomic baby
Previous GDM
FHx diabetes
Polydramnious
Recurrent glycosuria in current pregnancy
```
30
What is screening for GDM?
If risk factors:
HbA1c estimation
OGTT repeated
31
What is management of GDM?
Control blood sugars: diet/metformin/insulin
Post delivery check OGTT
Yearly check HbA1c
32
What is Virchow's triad for VTE?
Stasis
Vessel wall injury
Hypercoagulability
33
Why is pregnancy a risk of VTE?
Hypercoaguable state
Increased stasis
May be vascular damage at delivery/c-section
34
Why is pregnancy hypercoaguable state?
To protect mother against bleeding post-delivery
- increased fibrinogen, factor VIII, VW factor, platelets
- decreased natural anticoagulants
- increase in fibrinolysis
35
Who is at increased risk of VTE during pregnancy?
```
Older mothers, increasing parity
Increased BMI
Smokers
IVDU
Dehydration
Decreased mobility
Infections
Operative delivery
Prolonged labour
Haemorrhage
Previous VTE
Sickle cell disease
```
36
What are VTE prophylaxis in pregnancy?
Stockings
Increased mobility/hydration
Prophylactic anti-coagulation if 3+ risk factors
37
What are signs/symptoms of VTE?
```
Pain in calf
Increased size affected leg
Calf muscle tenderness
Breathlessness
Pain on breathing
Cough
Tachycardia
Hypoxic
Pleural rub
```
38
What are the investigations for suspected VTE?
ECG
Blood gases
Doppler V/Q
CTPA
39
What is abortion or spontaneous miscarriage?
Termination/loss of pregnancy before 24wks gestation
40
What are the different types of spontaneous miscarriage?
```
Threatened
Invisible
Incomplete
Complete
Septic
Missed
```
41
What are the signs/symptoms of threatened miscarriage?
Vaginal bleeding +/- pain
Viable pregnancy
Closed cervix on speculum examination
Body is showing signs that you might miscarry
42
What is an inevitable miscarriage?
Viable pregnancy
Open cervix with bleeding that could be heavy (+/- clots)
Most often the conception products are not expelled and intracervical contents are present at the time of examination.
43
What are the signs/symptoms of a missed miscarriage (early fetal demise)?
No symptoms, or could have bleeding/brown discharge PV
Gestational sac seen on scan
No clear fetus or fetal pole with no fetal heart seen in gestational sac
44
What are the signs/symptoms of incomplete miscarriage?
Most of pregnancy expelled out, some products of pregnancy remaining in uterus
Open cervix, vaginal bleeding (may be heavy)
45
What are the signs/symptoms of a complete miscarriage?
Passed all products of conception (POC), cervix closed and bleeding has stopped
46
What is a septic miscarriage?
Infection in uterus post-miscarrisge
| Especially cases of incomplete miscarriage
47
What are some causes of spontaneous miscarriage?
Abnormal conceptus: chromosomal, genetic, structural
Uterine abnormality: congenital, fibroids
Cervical incompetence
Maternal: age, diabetes
Unknown
48
What is cervical incompetence/weakness?
Condition of pregnancy in which the cervix begins to dilate (widen) and efface (thin) before the pregnancy has reached term
49
What is the management of threatened miscarriage?
Conservative
50
What is the management of inevitable miscarriage?
If bleeding heavy may need evacuation
51
What is the management of missed miscarriage?
Conservative
Medical - prostaglandins
Surgical - surgical management of miscarriage (SMM)
52
What is the management for septic miscarriage?
Antibiotics
| Evacuate uterus
53
What is an ectopic pregnancy and where can it happen?
```
Pregnancy implanted outside uterine cavity
Fallopian tube (tubal), ovary, interstitial, cervical
```
54
What are the different types of tubal ectopic pregnancy?
Ampullary - most common
Isthmus
Interstitial
55
What are the risk factors for ectopic pregnancy?
PID
Previous tubal surgery
Previous ectopic
Assisted conception
56
How does an ectopic pregnancy present?
Period of amenorrhea (with +ve pregnancy test)
+/- vaginal bleeding
+/- abdo pain
+/- GI or urinary symptoms
57
What are the investigations for an ectopic pregnancy?
Scan
Serum B-hCG levels
Serum progesterone levels - if viable IU pregnancy high
58
What is the management for ectopic pregnancy?
Methotrexate
Surgery: laparoscopic (salpingoectomy, salpingotomy)
Conservative
59
What is antepartum haemorrhage (APH)?
Haemorrhage from the genital tract after the 24th week of pregnancy but before delivery
60
What are causes of APH?
```
Placenta praevia
Placental abruption
APH of unknown origin
Local lesions of genital tract
Casa praevia
```
61
What is placenta praevia?
All or part of placenta impacts in the lower uterine segment
62
Who is placenta praevia most common in?
Multiparous women
Multiple pregnancy
Previous c-section
63
What are the grades of placenta praevia?
Grade I: placenta encroaching on lower segment but not the internal cervical os
Grade II: placenta reaches cervical os
Grade III: placenta eccentrically covers os
Grade IV: central placenta praevia
64
What is the presentation of placenta praevia?
*Painless PV bleeding
Malpresentation of fetus
Incidental
65
What are the clinical features of placenta praevia?
Maternal conditions correlates with amount of PV bleeding
| Soft, non-tender uterus +/- fetal malpresentation
66
How do you make a diagnosis of placenta praevia?
USS
67
What must NOT be done in suspected placenta praevia?
Vaginal examination
68
What is the management for placenta praevia?
C-section and watch for PPH
Oxytocin, ergometrine, carbaprost, transexemic acid
Balloon tamponade
Surgical: B lynch suture, ligation of uterine/iliac vessels, hysterectomy
69
What is placental abruption?
Haemorrhage resulting from premature separation of placenta before birth
70
What are factors associated with placental abruption?
```
Pre-eclampsia/HTN
Multiple pregnancy
Polyhydramnious
Smoking
Age+
Parity
Previous abruption
Cocaine use
```
71
What are the different types of placental abruption?
Revealed
Concealed
Mixed
72
What is revealed placental abruption?
Bleeding tracks down from the site of placental separation and drains through the cervix. This results in vaginal bleeding.
73
What is concealed placental abruption?
The bleeding remains within the uterus, and typically forms a clot retroplacentally. This bleeding is not visible, but can be severe enough to cause systemic shock.
74
How does placental abruption present?
*Pain
Vaginal bleeding
Increased uterine activity
75
What does the management of placental abruption depend on?
Amount of bleeding
Condition of mother and baby
Gestation
76
What are the complications of placental abruption?
Maternal shock
Fetal death
Maternal DIC, renal failure
PPH
77
What is preterm labour?
Labour before 37 completed weeks gestation
- 32-36wks mildly preterm
- 28-32wks very preterm
- 24-28wks extremely preterm
78
What are predisposing factors for preterm labour?
```
Multiple pregnancy
Polyhydramnious
APH
Pre-eclampsia
Infection
Prelabour premature rupture of membranes
Majority idiopathic
```
79
How do you diagnosis preterm labour?
Contractions with evidence of cervical change on VE
80
What is the management of preterm labour?
Consider tocolysis
Steroids
Transfer to unit with NICU
Aim for vaginal delivery
81
What is classed as maternal mortality?
Death of woman whilst pregnant
Within 42 days of termination of pregnancy
Any cause related to or aggravated by pregnancy
82
What is maternal morbidity?
Severe health complications occurring in pregnancy and delivery, not resulting in death
83
What is maternal mortality ratio?
Number of maternal deaths during five time period per 100,000 live births during same time period
84
What is maternal mortality rate?
Number of maternal deaths in given time period per 100,000 women of reproductive age, or woman-years of risk exposure, in same time period
85
What is lifetime risk of maternal death?
Probability of maternal death during woman's reproductive life
86
What is proportionate mortality ratio?
Maternal deaths as proportion of all female deaths of those of reproductive age
87
What does the maternal mortality ratio represent?
Risk associated with each pregnancy
88
What does the maternal mortality rate represent?
Not only obstetric risk but also frequency with which women are exposed to that risk
89
What are facility based methods for measuring maternal deaths?
```
Health info systems
Registries
Confidential enquiries
Maternal death review
Audits
```
90
What are population/community based methods for measuring maternal deaths?
Notification by law
Vital registration
Census
Surveys/surveillance
91
What are direct deaths?
Related to obstetric complications during pregnancy, labour or puerperium (6wks) or resulting from treatment
92
How long is puerperium?
6wks
93
What are indirect deaths?
Associated with disorder, effect of which is exacerbated by pregnancy
94
What are late deaths?
Occur >42 days after end of pregnancy but within 1yr
95
What are main causes of maternal death worldwide?
```
Haemorrhage
Sepsis
Hypertensive disorders
Obstructed labour
Unsafe abortion
```
96
What is the 3 delays model?
- Delay in decision to seek care
- Delay in reaching care
- Delay in receiving care
97
What ways can prevent maternal mortality?
Antenatal care
Skilled attendant at birth
Emergency obstetric care
98
What is early neonatal death?
Within 1wk
99
What is late neonatal death?
Within 1mo
100
What is infant mortality?
Within 1yr
101
What is stillbirth?
Birth of dead baby after 20/24/28 wks of gestation or weighing >500g
102
What are main causes of death in babies?
```
Congenital anomaly
Cord
Fetal
Infection
Maternal cause
Placenta
```
103
What is essential newborn care?
Ensure breathing
Breastfeeding straight away
Keep baby warm
Wash hands before touch baby
104
What can health facilities provide to ensure improved perinatal mortality?
Emergency Obstetric Care
105
What policies can improve perinatal mortality?
IMNCH
| Every Newborn Action Plan
