Obs/Gynae - Complications During Pregnancy

  1. Vaginal bleeding during pregnancy is normal or abnormal?
  2. Vaginal haemorrhage may be two things during pregnancy:
    Revealed – evident blood loss • E.g. miscarriage and placenta previa

    Concealed – occurs within the abdomen / uterus • E.g. ruptured ectopic pregnancy and placental abruption
  3. What are the causes of Haemorrhaging in early pregnancy (≤24 weeks)?

    Ectopic pregnancy/Ruptured Ectopic pregnancy
  4. What are the causes of Haemorrhaging in late pregnancy (>24 weeks)?
    Placenta praevia

    Placental abruption
  5. Define miscarriage:
    Loss of pregnancy before 23 completed weeks gestation.  

    Commonly seen at 6 – 14 weeks gestation; can occur after 14 weeks
  6. What percentage of confirmed pregnancies result in miscarriage?
    15% of confirmed pregnancies result in miscarriage
  7. What causes miscarriages?
    Fetal cause – chromosomal, genetic or structural abnormalities of the fetus

    Maternal cause – maternal age, structural abnormalities of the genital tract, infections, maternal diseases and environmental factors
  8. What is the Pathophysiology of miscarriage?
    Products of conception are partly passed through the cervix, become trapped leading to blood loss

    – Mother may present with level of shock out of proportion to the amount of blood loss
  9. How is a miscarriage resolved?
    Situation resolves with removal / expulsion of the products – complete miscarriage or surgical removal
  10. What is an Incomplete miscarriage
    Incomplete miscarriage – remnants of placenta remain within the uterus causing excessive bleeding and can be fatal; commonly complication of septic miscarriage
  11. Miscarriage – Signs & Symptoms?
    Bleeding - Light or heavy, often with clots and/or jelly-like tissue

    Pain - Central, crampy, suprapubic, or backache Can be as intense as labour pains

    Signs of pregnancy subsiding (E.g. nausea; breast tenderness)

    Hypotension and bradycardia
  12. What is the RED FLAG amount of blood loss in pregnancy?
  13. How do you manage a potential miscarriage?
    A B C D issues – rapid transport


    Assess blood volume lost

    Early call for Paramedic

    History of fetal movement

    Pain relief

    Transport to hospital (ED) – pre alert
  14. Define ectopic pregnancy:
    The egg implants somewhere other than the uterine wall

    Presents at around 6-8 weeks gestation

    Usually only one missed period

    Estimated rate of ectopic pregnancies is 11:1000
  15. Ectopic pregnancy risk factors?
    Previous ectopic pregnancy

    Previous surgery on the uterine tube

    An intra-uterine contraceptive device fitted

    Sterilisation or reversal of sterilisation


    Previous infections
  16. Ectopic pregnancy signs and symptoms?
    Acute localised, lower abdominal pain

    Vaginal bleeding or spotting – may present as brownish vaginal discharge


    Signs of blood loss within the abdomen with tachycardia and skin coolness

    Nausea, vomiting and unusual bowel symptoms

    Unexplained dizziness and fainting
  17. Management of Ectopic pregnancy?
    A B C D issues – rapid transport


    Assess blood volume lost

    Early call for Paramedic

    Pain relief: Paracetamol; Entonox

    Transport to hospital (ED) – pre alert
  18. Antepartum Vaginal bleeding (APH) in late pregnancy (after 24 weeks) is confined to what?
    Vaginal bleeding in late pregnancy (after 24 weeks) is confined to placental separation
  19. What are the two types of antepartum haemorrhage (APH) in late pregnancy?
    Placenta Praevia • Placental Abruption
  20. Antepartum Haemorrhage (APH) affects how many pregnancies?
  21. What is Placenta Praevia?
    The placenta is partially / wholly implanted in the lower uterine segment

    Segment grows and stretches ++ after 12th week of pregnancy

    Later weeks may cause placenta to separate and severe bleeding can occur
  22. How does Placenta Praevia present?
    Usually presents at 24-32 weeks with small episodes of painless bleeding
  23. What are the four types of placenta previa?
    Complete - placenta central over cervix. High risk of bleeding.  WIll need c-section. 

    Partial - Placenta over internal cervical os (mouth). Risk of severe haemorrhage – will require caesarean section

    Marginal - Placenta is located lower segment of uterus. Vaginal delivery possible with moderate risk of bleeding

    Low-lying - Placenta mainly located upper segment of uterus. Vaginal delivery possible with mild risk of bleeding
  24. Risk Factors for Placenta Praevia?
    Previous history of placenta praevia

    Previous caesarean section or other uterine surgery

    Advanced maternal age

    Multiparity / increasing parity


    Cocaine use during pregnancy

    Previous spontaneous or induced abortion

    Deficient endometrium due to past history of e.g. endometritis, manual removal of placenta, curettage

    Assisted conception
  25. What is Placental Abruption?
    Premature separation of a normally situated placenta occurring after the 22nd week of pregnancy

    Bleeding occurs between the placenta and wall of the uterus, where the placenta has detached from the uterine wall
  26. How common is is Placental Abruption?
    Estimated occurrence is 6:1000 births
  27. Risk factors for Placental Abruption?
    Previous abruption carries the highest risk

    Pregnancy Induced Hypertension / Pre-eclampsia

    Trauma – RTC, domestic violence, Iatrogenic e.g. external cephalic version

    Multiple pregnancy e.g. twice as common with a twin pregnancy


    Threatened miscarriage earlier in current pregnancy

    Smoking and substance abuse e.g. cocaine, amphetamine use

    Previous caesarean section

    Intrauterine infections

  28. Signs and Symptoms for Placental Abruption?
    Continuous severed / sudden abdominal or back pain

    Placental abruption commonly have concealed bleeding but may also have revealed bleeding

    There is a risk of underestimating the amount of blood loss

    50ml of revealed blood loss in pregnancy is considered significant

    Tender abdomen – rigid or ‘woody’, no signs of relaxation
  29. How should you manage any Later Antepartal Haemorrhaging (APH)?
    A B C D issues – rapid transport


    Assess blood volume lost

    Early call for Paramedic

    Take soaked pads to the hospital

    History of fetal movement

    Pain relief

    Transport to nearest Obstetric Unit – pre alert

    Think woman positioning
  30. What is Uterine Rupture?
    Can be:

    • Complete – tear in the wall of the uterus (with or without explusion of fetus)

    • Incomplete – tearing of uterine wall but not perimetrium

    Rare and tends to occur during labour
  31. Causes of Uterine Rupture?
    Previous caesarean section, most common cause

    High parity

    Obstructed labour e.g. shoulder dystocia, pressure or excess thinning of uterus

    Previous uterine trauma from assisted birth e.g. forceps

    Trauma – e.g. blast injury or accident i.e. seatbelt injury in RTC
  32. Signs and Symptoms of complete Uterine Rupture?
    Maternal tachycardia and signs of shock

    Sudden collapse of mother

    Severe abdominal pain

    Vaginal bleeding

    Uterine contractions may stop

    Fetus may be palpable in abdomen

    Scar pain and tenderness
  33. Signs and Symptoms of incomplete Uterine Rupture?
    May have minimal pain or blood loss

    Labour may progress normally

    Disproportionate signs of haemorrhagic shock in the third stage of labour – may manifest as postpartum haemorrhage
  34. Where should you take any cases of APH pre 20 weeks?
    Time critical transfer to ED.
  35. Where should you take any cases of APH post 20 weeks?
    Nearest obstetrics unit
  36. What is Pregnancy Induced Hypertension (PIH)?
    A generic term for a significant rise in blood pressure after 20 weeks gestation, in the absence of proteinuria or other features of pre-eclampsia.
  37. What is pre-ecalampsia?
    PIH (pregancy induced hypertension) associated with proteinuria with or without oedema

    Is relatively common condition but can be fatal for mother and baby - commonly occurs 24-28 weeks gestation

    Primarily a placental disorder – poor placental perfusion
  38. How is severe pre-eclampsia classified?
    Severe - >160 / 110mmHg
  39. What is the incidence of severe pre-eclampsia?
    Incidence of severe pre eclampsia is approximately 5:1000
  40. Risk factors for pre-eclampsia?
    10 years or more since last pregnancy

    Primiparity or first pregnancy with new partner

    Previous severe pre-eclampsia

    Essential hypertension

    Diabetes (type I or II)


    Twins or higher multiples

    Renal disease

    Advanced or Young maternal age (over 40 or less than 16 years)

    Pre existing cardiovascular disease
  41. Signs and symptoms for severe pre-eclampsia?

    BP > 160/110 with proteinuria and any one or more of the following:

    • • Headache (severe and frontal)
    • • Visual disturbances
    • • Epigastric pain
    • • Side sided upper quadrant abdominal pain • Muscle twitching or tremor
    • • Nausea
    • • Confusion
    • • Rapidly progressive oedema
  42. How should you manage suspected pre-eclampsia?
    – Is it Mild / Moderate or Severe?

    – Assess <c> A B C D E F • Are there any TIME CRITICAL features?

    • If YES, pre-alert to Nearest Obstetric Unit • If NO, continue with thorough assessment

    – Observations – BP, Blood Glucose, SP02 [maintain 94-98%], positioning

    • – Consider early call for Paramedic assistance
    • • Management of seizure
    • • Caution – ambulance lights and sirens
  43. What is eclampsia?
    The new onset of convulsions during pregnancy or postpartum, generally in a woman with pre-eclampsia
  44. How does eclampsia present?
    Presents as generalized tonic / clonic convulsion – identical to epilepsy

    1/3 of cases present for first time post delivery (within 48 hours)

    BP may only be mildly elevated at presentation
  45. How should you manage suspected eclampsia?
    – Rapid assessment <c> A B C D E F

    • Patient past medical history

    • Consider non self limiting or recurrent convulsions – Epileptic convulsion VS Eclampsic convulsion?

    • Early call for Paramedic / APP assist but do not delay – Can administer Diazepam / IV Magnesium

    – Observations – BP, Blood Glucose, SP02 [maintain 02 at 94-98%]

    – Positioning – full lateral (i.e. recovery position) or if interventions required, supine with manual uterine displacement (MUD)

    – Pre-alert to Nearest Obstetric Unit
  46. What is HELLP Syndrome?
    • A complication of pre-eclampsia / Eclampsia – Haemolysis
    • – Elevated Liver Enzymes
    • – Low Platelet count

    • Typically manifests between 32-34 weeks gestation, can present postpartum
  47. What is an amniotic fluid embolism?
    Entry of amniotic fluid into the maternal circulation via the placental bed
  48. Risk factors for amniotic fluid embolism?
    Risk Factors

    • – Termination of pregnancy
    • – Amniocentesis
    • – Placental abruption
    • – Trauma
    • – C section
    • – Prior to and up to 30 mins post delivery
  49. Signs and symptoms for amniotic fluid embolism?
    Signs & Symptoms

    • – Often rapid collapse in advanced labour
    • – Dyspnoea
    • – Cyanosis
    • – Acute hypotension
    • – Cardiac arrest
    • – May have feeling of impending doom, agitation, restlessness
  50. What is a Pulmonary Embolism? (PE)
    Pulmonary embolism [PE] is an obstruction of the pulmonary vessels reducing perfusion

    Can be small, major or massive
  51. Risk factors for maternal PE?
    Risk Factors

    • – Age (esp >35)
    • – Obesity
    • – Previous History of PE
    • – Gross varicose veins
    • – Major concurrent illness e.g cancer
    • – Prolonged immobility
    • – Long haul travel
    • – Lower segment C-section
    • – Prolonged labour (>12 hrs)
    • – Surgical procedures during pregnancy
  52. Signs and symptoms for maternal PE?
    Signs & Symptoms

    • – Dyspnoea
    • – Tachycardia
    • – Pleuritic / substernal chest pain
    • – Apprehension
    • – Cough
    • – Haemoptysis
    • – Syncope / sudden collapse
    • – Signs of DVT – check legs
  53. What is maternal sepsis?
    Can be – Directly related – i.e. pregnancy or genital tract related – Indirectly related e.g. influenza, pneumonia, E-coli, Group A & B strep
  54. Risk factors for maternal sepsis?
    High risk factors:-

    – Impaired immune system due to illness / drugs

    – Gestational diabetes, diabetes or other comorbidities

    – Undergone invasive procedures e.g. C-section, forceps delivery, removal of retained product of conception

    – Prolonged rupture of membranes

    – Been in close contact with people with Group A strep

    – Have continued vaginal bleeding or offensive vaginal discharge
  55. Signs and Symptoms:-

    • • History of infection
    • • SBP < 90 mmHg
    • • Tachypneoa
    • • Body temperature < 36°C or > 38°C
    • • Cardiovascular compromise – tachycardia; prolonged capillary refill (> 2 seconds)
    • • Altered mental state
    • • Diarrhoea or vomiting
    • • Mottled skin or Rash – generalised / purpuric (non-blanching)
    • • Abdominal / pelvic pain
    • • Offensive vaginal discharge or wound
    • • Productive cough
    • • Not passed urine in last 12-18 hours
Card Set
Obs/Gynae - Complications During Pregnancy
Obstetrics and gynaecology - Complications during pregnancy flash card set