6.1 C Vi-Xii O&g Complications Of Pregnancy Em

Front 1

First trimester bleeding - which is incorrect
1. Occurs in 50% of clinically diagnosed pregnancies before 12/40
2. Indicates failed pregnancy in 50% of cases
3. Differentials include failed pregnancy, ectopic, molar, physiological and incidental bleeding
4. Embryonic death = embryo greater than 6mm, no cardiac activity, fetal death = greater than8/40 no cardiac activity

Back 1

1. Occurs in only 25% of pregnancies

Front 2

Define missed abortion, incomplete and complete miscarriage

Back 2

Missed abortion - remains in uterus
Incomplete - some products of conception remain
Complete - empty uterus

Front 3

Regarding 1st TM bleeding T/F
1 heavy bleeding and clots are more common with ectopic pregnancy cf miscarriage
2 risk factors for ectopic pregnancy include increased age, smoking,and progesterone only contraception
3 IUD increase the likelihood of ectopic pregnancy
4 bimanual exam is sensitive for small unruptured ectopic pregnancies

Back 3

1F - more common with miscarriage
2 t
3 t
4 f

Front 4

Regarding betaHCG answer the following
1 when is it first detectable
2 what is its rate of increase every 48hours
3 when does it usually begin to fall
4 what is the half life?
5 can it be used to confirm ongoing pregnancy or RPOC?

Back 4

1 9 days
2 1.66x
3 at 12 weeks (plateaus earlier than this)
4 48 hours - therefore after failed pregnancy weeks to normalise
5 not as a single level, serial measurements may be more helpful

NB urinary tests are less sensitive than blood detecting down to 25-60IU

Front 5

Regarding ultrasound, when can the following be seen?
1. Embryonic cardiac activity on transvaginal us
2. Developing pregnancy transabdominal us

Back 5

1 5.5 weeks, crown rump length 5mm, BetaHCG approx 1500. At about the same time the yolk sac may be seen in gestational sac. Note the gestational sac itself may be seen earlier at 31 days but DDx is endometrial cyst or pseudo sac
2. 6 weeks, betaHCG approx 6500

Front 6

Incidence heterotropic pregnancy in normal and assisted reproductive tech pregnancies (= ectopic and intrauterine coexisting)

Back 6

Normal approx 1:4000, ART 1:100- 1:500

Front 7

Regarding Rh isoimmunisation, which is incorrect
1. 0.1 ml fetal blood may cause isoimmunisation
2 dose of RhD immunoglobulin is 250IU for early pregnancy bleeding, singleton
3 should be given within 48 hours
4 the standard dose given will prevent immunisation from up to 2.5mL of fetal blood
5 multiple pregnancies or gestation greater than 13 weeks require 625IU

Back 7

3. Incorrect - ASAP, but within 72 hours is acceptable

5. Correct. Kleihauer test may also be used in later pregnancy to quantify degree of fetomaternal haemorrhage

Front 8

Define antepartum haemorrhage. List causes

Back 8

Bleeding after 20 weeks gestation

Incidental (commonest cause after first TM) e.g. non obstetric causes
physiological cervical erosion or ectropion (spontaneous or traumatic eg post coital)
cervical polyps
cervical malignancy
cervical or vaginal infections
haemorrhoids, vulval varices (e.g NOT vaginal source)

Obstetric causes
Vasa praevia
Placenta praevia
Abruption

Front 9

Regarding antepartum haemorrhage T/F
1 placenta praevia is usually associated with painless bleeding of fetal source; small 'warning' bleeds may occur
2 placental abruption is usually associated with constant uterine or lower back pain, and the bleeding is of maternal source
3 placental abruption may be concealed and may present as shock; large bleeds cause fetal compromise and death
4 cocaine use, inherited disorders of coagulation and hypertension may predispose to vasa praevia
5 vasa praevia produces bleeding from the maternal vessels running through the amniotic membrane across the cervical os
6 bleeding that requires a pad after 20 weeks of pregnancy should be assessed as an APH
7 painless bleeding is reassuring as it suggests an incidental cause
8 spotting/mild bleeding, increased pelvic pressure and mucous fluid loss between 14-22 weeks is suspicious for placenta praevia

Back 9

1 F - maternal source
2 T
3 T
4 F - they predispose to PLACENTA praevia
5 F - from the FETAL vessels
6 T - less than this may be physiological, or a show
7 F - may be either incidental cause or placental praevia - latter is not reassuring
8 F - this is classically cervical incompetence

Front 10

Regarding 2nd trimester bleeding which is incorrect
1. Speculum exam should be deferred until ultrasound is performed
2 digital examination should be performed (after ultrasound) if labour is suspected
3 ultrasound is sensitive for placental abruption
4 transvaginal ultrasound can identify cervical incompetence

Back 10

1 correct - to exclude placenta praevia; digital or speculum exam may precipitate torrential haemorrhage
2 correct to assess for dilatation
3 INCORRECT - only 50% will be seen
4 correct - as cervical shortening, or beaking of the amniotic sac into internal os

Front 11

Regarding management of APH which is incorrect
1. Placenta praevia if small may be managed by close observation
2 placental abruption even if small mandates early delivery
3 massive antepartum haemorrhage requires urgent delivery and is usually associated with fetal demise and due to antepartum haemorrhage
4 if fetus is between 23 - 34 weeks and delivery can be delayed 24 hours betamethasone or dexamethasone should be given

Back 11

2 INCORRECT may also be managed conservatively but delivery is usually advised around 37 weeks
4 correct - decreases risk of respiratory distress syndrome, necrotising enterocolitis, intraventricular haemorrhage

Front 12

Define preeclampsia, severe preeclampsia and eclampsia

Back 12

Preeclampsia = HT (DBP >90 twice consecutively or 110 once) and proteinuria (1+ on dipstick = 300mg/d). Oedema is NOT a defining feature

Severe = at least one of DBP > 110, SBP > 160, >5gm/day proteinuria, target organ dysfunction (eg HELLP syndrome), IUGR

Eclampsia - seizure OR COMA complicating pre-eclampsia

Other definitions - chronic hypertension is that which predates the pregnancy, gestational hypertension is that without proteinuria/end organ dysfunction

Front 13

Regarding hypertensive disorders of pregnancy which is incorrect
1 pathogenesis is incompletely understood but includes abnormal placental vascularisation and increased maternal and uteroplacental vasomotor tone
2 seizures are a manifestation of elevated uric acid
3 maternal and uteroplacental circulations at both at risk of hypoperfusion
4 risk factors for preeclampsia include no prenatal care, increased BMI, renal disease and DM
5 fetal risk factors include large placenta, multiple gestation, molar pregnancy, fetal hydrops

Back 13

2 incorrect - seizures are secondary to cerebral ischaemia, with pathological changes similar to hypertensive encephalopathy

4 others are gestational HT, PHx/FHx preeclampsia, prime parity, hypercoagulable states, collagen vascular disease

Front 14

Explain the use and dosing of Magnesium sulphate in pregnancy induced hypertension

Back 14

For the PREVENTION (!!) and treatment of seizures.

PREVENTION - Symptomatic women with signs imminent seizure such as headache and blurred vision - NNT to prevent seizure is 16.
TREATMENT - it is more efficacious at preventing further seizures compared to phenytoin and aborting seizures compared to diazepam

Dose 6gm (=24mmol) IV over 15 mins and then 2gm/hr infusion. If seizures recur 2gm over 5 minutes

Toxicity can be assessed by loss of tendon reflexes/respiratory depression

Front 15

List the manifestations of preeclampsia

Back 15

Hypertension
Neuro - headache, blurred vision, hyperreflexia, altered level of consciousness, seizures, coma, intracranial haemorrhage
Resp - acute noncardiogenic APO
Hepatic syndrome - a spectrum from mildly altered LFTs to subcapsular bleeding, liver capsular rupture and HELLP syndrome
Renal dysfunction - proteinuria, impaired GFR
Elevated serum uric acid

Front 16

Regarding pre-eclampsia/eclampsia which is CORRECT
1 risk period includes up to 10 days postpartum
2 serum uric acid elevation occurs before clinical manifestations
3 hypertension is always present
4 up to 30% of eclamptic patients less than 32 weeks gestation will not have hypertension or proteinuria

Back 16

1. incorrect - 4/52!!
2 CORRECT
3 incorrect - not there in 16% preeclamptic patients
4 incorrect - not there in 0% of these patients

Front 17

What are the objectives of management of preeclampsia?

Back 17

Treat hypertension to prevent cx (esp intracranial haemorrhage)
Prevent maternal hypoxaemia and hypertension
Prevent/Rx seizures

Front 18

Regarding treatment of preeclampsia/eclampsia which is INCORRECT
1 the sole contraindication for hydralazine is hypotension
2 adverse effects of hydralazine include headache, epigastric pain and vomiting
3 immediate delivery is essential for eclampsia, and for preeclampsia complicated by HELLP syndrome
4 hydralazine is the first line treatment for hypertension 2.5-5mg boluses every 15-20mins

Back 18

1 false - the contraindication is coronary artery disease

Front 19

What are the complications/prognoses for preeclampsia/eclampsia?

Back 19

Maternal
- morbidity and mortality cf a normal pregnancy increase 400x
- major cause mortality - intracranial haemorrhage
- major causes morbidity - cardioresp arrest, noncardiogenic pulmonary oedema, aspiration pneumonia, DIC, placental abruption
- recurrence (25% of subsequent pregnancies if onset <32 weeks, 5-8% if later onset)
- lifelong increased risk hypertension and risk death from stroke

Fetal
- increased mortality due to prematurity at delivery and placental abruption