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Year 4 - Reproductive Health > 2.01 - Antenatal Care > Flashcards

2.01 - Antenatal Care Flashcards

1
Q

Define the following terms:

a) Last menstrual period (LMP)

b) Gestational age (GA)

c) Estimated date of delivery (EDD)

d) Gravida (G)

e) Primigravida

f) Multigravida

g) Para (P)

h) Nulliparous

i) Primiparous

j) multiparous

A

a) the date of the first day of the most recent period.

b) the duration of the pregnancy starting from the date of the LMP.

c) the estimate date of delivery (40 weeks gestation).

d) the total number of pregnancies a woman has had.

e) patient is pregnant for the first time

f) patient is pregnancy for at least the second time

g) the number of times the patient has given birth after 24 weeks gestation, regardless of whether the foetus was alive or stillborn.

h) patient that has never given birth after 24 weeks gestation.

i) refers to a patient that has given birth after 24 weeks gestation once before.

f) refers to a patient that has given birth after 24 weeks gestation two or more times.

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2
Q

How can the estimated date of delivery be calculated?

A

(LMP + 7 days + 1 year) - 3 months

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3
Q

Gestational age is described in weeks and days:

a) 5+0

b) 13+6

A

a) 5 weeks

b) 13 weeks and 6 days

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4
Q

Give the gestational ages for

a) first trimester

b) second trimester

c) third trimester

A

a) up to 12 weeks gestation

b) 13 weeks to 26 weeks gestation

c) 27 weeks to birth

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5
Q

What is covered in routine antenatal appointments?

A
  • discuss plans for remainder of pregnancy and delivery
  • symphysis-fundal height measurement from 24 weeks onwards
  • foetal presentation assessment from 36 weeks onwards
  • urine dipstick and protein for pre-eclampsia
  • blood pressure for pre-eclampsia
  • urine for microscopy and culture for asymptomatic bacteriuria
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6
Q

What vaccines are offered to all pregnant women?

A
  • Whooping cough (G16)
  • influenza in autumn or winter

NOTE live vaccines should be avoided in pregnancy.

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7
Q

What lifestyle advice can be given to pregnant women?

A
  • take folic acid 400mcg throughout the first trimester (reduces neural tube defects)
  • take vitamin D supplement
  • avoid vitamin A supplements (teratogenic)
  • alcohol and smoking cessation
  • avoid unpasteurised dairy
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8
Q

Give some complications of alcohol consumption in prengnacy.

A
  • miscarriage
  • small for dates
  • preterm delivery
  • fetal alcohol syndrome
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9
Q

Features of fetal alcohol syndrome.

A
  • microcephaly
  • thin upper lip
  • learning disability
  • behavioural difficulties
  • cerebral palsy
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10
Q

Complications of smoking during pregnancy.

A
  • fetal growth restriction (FGR)
  • miscarriage
  • stillbirth
  • preterm labour and delivery
  • pre-eclampsia
  • sudden infant death syndrome
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11
Q

What advice can be given to pregnant women regarding flying?

A

RCOG advises flying is generally okay in uncomplicated pregnancies up to:

  • 37 weeks in single pregnancy
  • 32 weeks in twin pregnancy

After 28 weeks gestation, most airlines need a note from a midwife, GP or obstetrician.

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12
Q

What is the booking clinic?

A

The initial appointment to discuss pregnancy and arrange plans, ideally occurring before G10.

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13
Q

In booking clinic, what pregnancy-related topics are covered?

A
  • what to expect at different stages of pregnancy
  • lifestyle advice
  • supplements
  • plans for birth
  • screening tests
  • antenatal classes
  • breastfeeding classes
  • discuss mental health
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14
Q

What bloods are taken in booking clinic?

A
  • blood group, antibodies and rhesus D status
  • full blood count for anaemia
  • screening for thalassaemia and sickle cell disease

Patients are also offered screening for infectious diseases (HIV, HepB and syphilis).

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15
Q

How is Down Syndrome screened for in pregnancy?

A

Combined test is used first line and the most accurate screening test.

Performed between G11 and G14, involving combining results from ultrasound and maternal blood tests.

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16
Q

Outline the ultrasound and maternal blood test findings that would be suggestive of Down Syndrome.

A

Ultrasound - nuchal thickness >6mm.

Bloods:
- raised bHCG
- low PAPPA

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17
Q

How is Down’s Syndrome tested for in pregnancy?

A

If screening test provides a risk score greater than 1 in 150, the woman is offered amniocentesis or chorionic villus sampling.

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18
Q

What is the role of

a) chorionic villus sampling

b) amniocentesis

in antenatal Down Syndrome testing?

A

a) ultrasound guided biopsy of placental tissue for karyotyping.

b) ultrasound-guided aspiration of amniotic fluid for karyotyping.

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19
Q

What are some complications of untreated hypothyroidism in pregnancy?

A
  • miscarriage
  • anaemia
  • small for gestational age
  • pre-eclampsia
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20
Q

How is hypothyroidism in pregnancy treated?

A

Prescribe levothyroxine - titrate dose to TSH level (low-normal TSH level).

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21
Q

Which antihypertensives are contraindicated in pregnancy?

A
  • ACEi
  • ARBs
  • Thiazide like diuretics
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22
Q

What medications can be used to treat hypertension in pregnancy?

A
  • labetalol
  • CCBs (e.g. nifedipine)
  • alpha-blockers (e.g. doxazosin)
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23
Q

What are the maternal effects of epilepsy in pregnancy?

A

Worsen seizure control due to additional stress, lack of sleep, hormonal changes and altered medication regimes.

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24
Q

What anti-epileptics are contraindicated by pregnancy?

A
  • sodium valporate
  • phenytoin
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25
Q

What anti-epileptics are preferred in pregnancy?

A
  • levetiracetam
  • lamotrigine
  • carbamazepine
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26
Q

How should rheumatoid arthritis be treated during pregnancy?

A

Hydroxychloroquine is considered safe and is the first-line choice.

Suflasalazine is second line, and corticosteroids can be used in acute flares.

AVOID METHOTREXATE!

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27
Q

Give some medications that are commonly avoided in pregnancy.

A
  • NSAIDs
  • beta-blockers (other than labetalol)
  • ACEi / ARBs
  • opiates
  • warfarin
  • sodium valporate
  • lithium
  • SSRIs
  • isotretinoin
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28
Q

Why are NSAIDs avoided during pregnancy?

A

Block prostaglandins, therefore:
- premature closure of ductus arteriosus
- delay labour

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29
Q

Why are beta-blockers avoided during pregnancy?

A
  • fetal growth restriction
  • hypoglycaemia in neonate
  • bradycardia in neonate
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30
Q

Why are ACEi / ARBs avoided during pregnancy?

A
  • oligohydramnios
  • miscarriage or fetal death
  • hypocalvaria (incomplete formation of skull bones)
  • renal failure in neonate
  • hypotension in neonate
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31
Q

Why are opiates avoided during pregnancy?

A

Causes neonatal abstinence syndrome (NAS), essentially after birth:
- irritability
- tachypnoea
- high temperature
- poor feeding

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32
Q

Why is warfarin avoided during pregnancy?

A
  • fetal death
  • congenital malformations
  • bleeding during pregnancy, PPH, fetal haemorrhage
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33
Q

Why is sodium valporate avoided during pregnancy?

A
  • congenital cardiac abnormalities
  • Ebstein’s anomaly

AVOID IN PREGNANCY AND BREASTFEEDING.

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34
Q

What is Ebstein’s anomaly?

A

Caused by lithium in pregnancy.

Tricuspid valve is set lower on the right side of the heart, causing a bigger right atrium and smaller right ventricle.

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35
Q

Why are SSRIs avoided during pregnancy?

A
  • congenital heart defects
  • congenital malformations
  • persistent pulmonary hypertension
  • withdrawal symptoms after birth
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36
Q

Why is isotretinoin avoided during pregnancy?

A
  • miscarriage
  • congenital defects
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37
Q

What is congenital rubella syndrome?

A

Caused by maternal infection with the rubella virus during the first 20 weeks of pregnancy.

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38
Q

How can congenital rubella syndrome be prevented?

A

MMR vaccine BEFORE pregnancy.

NOTE cannot give once pregnant as it’s a live vaccination.

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39
Q

What are the features of congenital rubella syndrome?

A
  • congenital deafness
  • congenital cateracts
  • congenital heart disease
  • learning disability
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40
Q

What is the effect of chickenpox in pregnancy?

A
  • fetal varicella syndrome
  • neonatal varicella infection
  • more severe infection in the mother
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41
Q

Exposure to chickenpox in pregnancy

a) previously had chickenpox

b) unsure about immunity

c) no immunity

A

a) safe

b) test VZV IgG levels - if positive, safe

c) treat with IV varicella immunoglobulins within 10 days of exposure

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42
Q

Features of congenital varicella syndrome.

A
  • fetal growth restriction
  • microcephaly
  • limb hypoplasia
  • cataracts
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43
Q

Why are pregnant women advised to avoid unpasteurised dairy products and processed meats?

A

Avoid listeria infection:
- miscarriage
- fetal death
- severe neonatal infection

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44
Q

Outline the pathophysiology of haemolytic disease of the newborn.

A
  1. Mother RhD-ve and baby RhD+ve
  2. In first pregnancy, mother sensitised to RhD+ve and produces antibodies to RhD-antigen
  3. In second pregnancy, mother re-exposed to RhD+ve baby causes haemolysis of fetal blood (immune response).
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45
Q

How can haemolytic disease of the newborn be prevented?

A

Prevent sensitisation by giving IM anti-D injections to RhD-ve women at G28 and birth.

Anti-D attaches itself to RhD antigens on fetal red blood cells in maternal circulation, causing them to be destroyed and preventing sensitisation.

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46
Q

Give some sensitisation events for rhesus incompatability.

A
  • antepartum haemorrhage
  • amniocentesis procedure
  • abdominal trauma

Give anti-D within 72 hours of a sensitisation event.

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47
Q

What is Kleihauer test?

A

Checks how much fetal blood has passed into maternal circulation during a sensitisation event, to calculate the dose of anti-D prophylaxis required.

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48
Q

Which measurements are taken on ultrasound to assess fetal size?

A
  • estimated foetal weight
  • foetal abdominal circumference
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49
Q

Define small for gestational age (SGA).

A

Fetus that measures below the 10th centile for their gestational age, compared to customised growth charts based upon maternal:

  • ethnic group
  • weight
  • height
  • parity
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50
Q

Causes of SGA.

A
  1. Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart.
  2. Fetal growth restriction:
    - idiopathic
    - pre-eclampsia
    - maternal smoking / alcohol
    - infection
    - malnutrition
    - genetic abnormalities
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51
Q

What are the signs of fetal growth restriction?

A
  • SGA
  • oligohydramnios
  • abnormal Doppler
  • reduced fetal movements
  • abnormal CTGs
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52
Q

Complications of SGA.

A
  • fetal death or stillbirth
  • birth asphyxia
  • neonatal hypothermia
  • neonatal hypoglycaemia
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53
Q

Risk factors for SGA.

A
  • previous SGA baby
  • obesity
  • smoking
  • diabetes
  • pre-eclampsia
  • increased age
  • multiple pregnancy
  • low PAPPA
  • antepartum haemorrhage
  • antiphospholipid syndrome
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54
Q

How is gestational age monitored in low-risk women?

A

Symphysis-fundal height measurements at every antenatal appointment from24 weeks onwards.

Compared to growth chart, and if symphysis fundal height is less than the 10th centile, women are booked for serial growth scans with umbilical artery doppler.

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55
Q

Women at risk or with SGA are monitored closely with serial ultrasound scans measuring:

A
  • estimated fetal weight and abdominal circumference
  • umbilical artery pulsatility index to measure blood flow through the umbilical artery
  • amniotic fluid volume
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56
Q

How is SGA managed?

A
  • identify SGA
  • treat modifiable risk factors (e.g. smoking / alcohol cessation)
  • serial growth scan
  • early delivery where growth is static, or other concerns
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57
Q

What investigations are used to explore SGA?

A
  • blood pressure and urine dipstick for pre-eclampsia
  • uterine artery doppler
  • detailed fetal anatomy scan
  • karyotyping for chromosomal abnormalities
  • testing for infections
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58
Q

Define large for gestational age (macrosomia).

A
  • birth weight >4.5kg
  • estimated fetal weight above 90th centile
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59
Q

Causes of macrosomia.

A
  • constitutional
  • maternal diabetes
  • GESTATIONAL DIABETES
  • previous macrosomia
  • maternal obesity
  • overdue
  • male baby
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60
Q

Risks of macrosomia to mother.

A
  • SHOULDER DISTOCIA
  • perineal tears
  • instrumental delivery
  • PPH
  • uterine rupture
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61
Q

Risks of macrosomia to baby.

A
  • birth injury (e.g. Erb’s palsy, clavicular fracture)
  • neonatal hypogylcaemia
  • obesity
  • T2DM
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62
Q

How can macrosomia be investigated?

A
  • ultrasound to exclude polyhydramnios and estimate fetal weight
  • oral glucose tolerance test to exclude gestational diabetes
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63
Q

How can the risk of shoulder distocia in macrosomia be reduced?

A
  • delivery on consultant led unit
  • delivered by experienced midwife or obstetrician
  • access to obstetrician and theatre if required
  • early decision for caesarian section if required
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64
Q

When is multiple pregnancy usually diagnosed?

A

On booking ultrasound scan (<G10).

Ultrasound is used to determine the:
- gestational age
- number of placentas and amniotic sacs
- risk of Down’s syndrome

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65
Q

What are the risks of multiple pregnancy to the mother?

A
  • anaemia
  • polyhydramnios
    -hypertension
  • malpresentation
  • spontaneous preterm birth
  • PPH
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66
Q

What are the risks of multiple pregnancy to the foetus?

A
  • miscarriage
  • stillbirth
  • fetal growth restriction
  • prematurity
  • twin-twin transfusion syndrome
  • twin anaemia polycythaemia sequence
  • congenital abnormalities
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67
Q

What is twin-twin transfusion syndrome?

A

When multiple fetuses share a placenta, and there is a connection between the blood supplies:

1) One fetus receives the majority of blood from the placent (recipient), causing fluid overload, heart failure and polyhydramnios.

2) One fetus is starved of blood (donor), causing growth restriction, anaemia and oligohydramnios.

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68
Q

What is twin anaemia polcythaemia sequence?

A

Similar to twin-twin transfusion syndrome, except:

1) Twin 1 becomes anaemic

2) Twin 2 develops polycythaemia

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69
Q

In order to monitor for anaemia in women with multiple pregnancies, when should FBC be taken?

A
  • booking clinic
  • G20
  • 28
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70
Q

Additional ultrasound scans are required in multiple pregnancy to monitor for fetal growth restriction, unequal growth and twin-twin transfusion syndrome:

a) monochorionic twins

b) dichorionic twins

A

a) 2 weeks scans from 16 weeks

b) 4 weekly scans from 20 weeks

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71
Q

Planned birth in normal pregnancy is offered between:

a) monochorionic monoamniotic twins

b) monochorionic diamniotic twins

c) dichorionic diamniotic twins

d) triplets

A

a) G32 - G33+6

b) G36 - G36+6

c) G37 - G37+6

d) before G35+6

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72
Q

What is the delivery preference for:

a) monoamniotic twins

b) diamniotic twins

A

a) elective caesarean section between G32 - G33+6

b) vaginal delivery in cephalic presentation (otherwise caesarian)

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73
Q

What are the risks of UTI in pregnancy?

A
  • preterm delivery
  • low birth weight
  • pre-eclampsia
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74
Q

What is asymptomatic bacteriuria?

A

Bacteria present in the urine, without symptoms of infection.

Pregnant women are tested for asymptomatic bacteriuria throughout pregnancy, by sending a MSU for MC&S.

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75
Q

How is UTI in pregnancy managed?

A

7 days of abx:
- nitrofurantoin (avoid in third trimester)
- amoxicillin
- cefalexin

DO NOT GIVE TRIMETHOPRIM AS FOLATE ANTAGONIST = NEURAL TUBE DEFECTS.

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76
Q

When are women screened for anaemia in pregnancy?

A
  • booking clinic
  • G28
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77
Q

How are women who are anaemic and pregnant managed?

A

Microcytic anaemia (?iron deficiency) give iron replacement.

Macrocytic anaemia (?folate/B12 deficiency) give folate/B12 supplements.

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78
Q

Risk factors for VTE in pregnancy.

A
  • smoking
  • parity ≥ 3
  • age > 35 years
  • reduced mobility
  • multiple pregnancy
  • pre-eclampsia
  • immobility
  • IVF pregnancy
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79
Q

RCOG advise starting VTE prophylaxis in pregnancy when?

A
  • G28 if 3 risk factors
  • first trimester if ≥4 risk factors

Additional scenarios include:
- hospital admission
- surgical procedures
- previous VTE

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80
Q

VTE prophylaxis in pregnancy.

A

Prescribe LWMH throughout pregnancy:
- dalteparin
- enoxaparin

Can also prescribe intermittent pneumatic compression and anti-embolic compression stockings.

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81
Q

Presentation of DVT.

A

Unilateral:
- calf or leg swelling
- dilated superficial veins
- tenderness to calf
- oedema
- colour changes

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82
Q

Presentation of PE.

A
  • SOB
  • haemoptysis
  • pleuritic chest pain
  • hypoxia
  • tachycardia
  • low grade fever
  • tachypnoea
  • hypotension
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83
Q

How is DVT diagnosed?

A

Doppler ultrasound

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84
Q

How should women with suspected PE be investigated?

A
  • CXR
  • ECG
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85
Q

How is PE definitively diagnosed?

A
  • CTPA
  • VQ scan
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86
Q

Treatment options for PE with haemodynamic instability in pregnancy.

A
  • unfractionated heparin
  • thrombolysis
  • surgical embolectomy

Life-threatening condition and maternal wellbeing often prioritised.

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87
Q

What is pre-eclampsia?

A

Pregnancy-induced hypertension associated with end-organ damage, notably proteinuria.

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88
Q

What is the triad of pre-eclampsia?

A
  • hypertension
  • proteinuria
  • oedema
89
Q

Pathophysiology of pre-eclampsia.

A

When the blastocyst implants on the endometrium, the syncytiotrophoblast forms chorionic villi that contain fetal blood vessels.

Trophoblast invasion of the endometrium sends signals to spiral arteries, reducing vascular resistance and making them more fragile. At around G20, the spiral arteries are so fragile they break down, leaving pools of blood called lacunae.

If lacunae formation is inadequate, vascular resistance is greater through the spiral arteries as blood flow increases, causing poor perfusion of the placenta.

This induces oxidative stress in the placenta, releasing inflammatory chemicals systemically. This causes systemic inflammation and impaired endothelial function in the blood vessels.

90
Q

High-risk factors for pre-eclampsia.

A
  • pre-existing hypertension
  • previous hypertension in pregnancy
  • autoimmune conditions
  • diabetes
  • CKD
91
Q

Moderate-risk factors for pre-eclampsia.

A
  • age >40 years
  • BMI >35
  • multiple pregnancy
  • first pregnancy
  • FHx of pre-eclampsia
92
Q

How is pre-eclampsia prophylactically managed?

A

Women are offered aspirin from G12 until birth if they have ONE HIGH-RISK factor or MORE THAN ONE MODERATE-RISK factor.

93
Q

Symptoms of pre-eclampsia.

A
  • headache
  • visual disturbance
  • n+v
  • epigastric pain (liver swelling)
  • oedema
  • reduced urine output
  • brisk reflexes
94
Q

NICE (2019) advise a diagnosis of pre-eclampsia can be made with a:

A

SBP >140mmHg
or
DBP >90mmHg

PLUS ONE OF:
- proteinuria (>1+ dipstick)
- organ dysfunction (e.g. raised creatinine, ALT, seizures, haemolytic anaemia)
- placental dysfunction (e.g. fetal growth restriction, abnormal Doppler studies)

95
Q

What blood test can be taken to exclude pre-eclampsia?

A

Placental Growth Factor (PlGF) testing between G20-G35 in women suspected of having pre-eclampsia.

PlGF if a protein released by the placenta that stimulates the development of new blood vessels - a low PlGF is supportive of pre-eclampsia.

96
Q

All pregnant women are routinely monitored at every antenatal appointment for evidence of pre-eclampsia how?

A
  • blood pressure
  • symptoms
  • urine dipstick for proteinuria
97
Q

Outline the management of gestational hypertension WITHOUT proteinuria.

A
  • BP target <135/85mmHg
  • admission if BP >160/110mmHg
  • weekly urine dipstick
  • weekly blood test monitoring (FBC, LFTs, RFTs)
  • serial growth scans to monitor fetal growth
  • PlGF testing G20-G35
98
Q

Outline the management of pre-eclampsia.

A

Treat as gestational hypertension plus:
- BP every 48hrs
- ultrasound monitoring of fetus, amniotic fluid and Doppler’s twice weekly

NOTE urine dipstick testing is not routinely necessary, as the diagnosis is already made.

99
Q

Which scoring systems are used to determine whether to admit a woman with pre-eclampsia?

A
  • fullPIERS
  • PREP-S
100
Q

How is gestational hypertension treated?

a) first line

b) second-line

c) third line

d) severe pre-eclampsia

e) eclampsia

A

a) labetolol

b) nifedipine

c) methyldopa

d) IV hydralazine*

e) IV magnesium sulphate**

*plus fluid restriction to avoid fluid overload.

**also routinely given during labour and in the 24 hours afterwards to prevent seizures.

101
Q

If blood-pressure cannot be controlled or eclampsia occurs, how is pre-eclampsia managed?

A

Planned early birth

Corticosteroids given to woman to help mature fetal lungs.

102
Q

HELLP syndrome.

A

A combination of features that occurs as a complication of pre-eclampsia and eclampsia.

Haemolysis
Elevated Liver enzyme
Low platelets

103
Q

What is gestational diabetes?

A

Diabetes triggered by pregnancy due to reduced insulin sensitivity, resolving after birth.

104
Q

Complications of gestational diabetes.

A
  • large for date fetus
  • macrosomia

Birthing implications include shoulder dystocia.

105
Q

Risk factors for gestational diabetes.

A
  • previous gestational diabetes
  • previous macrosomic baby
  • BMI >30
  • ethnic origin
  • FHx of diabetes
106
Q

How is gestational diabetes screened for?

A

Oral glucose tolerance test (OGTT) if risk factors or features suggestive of gestational diabetes.

Blood sugar level measured in the morning after a fast, then 2 hours after drinking a glucose drink.

Normal results:
- fasting <5.6mmol/L
- at 2 hrs < 7.8mmol/L

Cut-off for gestational diabetes is 5-6-7-8.

107
Q

Features suggestive of gestational diabetes.

A
  • large for date fetus
  • polyhydramnios
  • glucose on urine dipstick
108
Q

NICE (2015) management of gestational diabetes:

a) fasting glucose <7.0mmol/L

b) fasting glucose >7.0mmol/L

c) fasting glucose >6.0mmol/L PLUS macrosomia

A

a) diet and exercise trial, followed by metformin, then insulin.

b) insulin +/- metformin

c) insulin +/- metformin

109
Q

How is gestational diabetes generally managed?

A
  • four weekly ultrasound scans to monitor fetal growth and amniotic fluid volume
  • daily monitoring of blood glucose
  • dietician input
110
Q

What screening is often performed in antenatal clinics for women with pre-existing diabetes?

A

Retinopathy screening to be performed after booking clinic and at G28.

111
Q

How is pre-existing diabetes managed during pregnancy?

A

5mg folic acid from preconception to G12.

T2DM - metformin and insulin (stop other oral diabetic medications).

T1DM - insulin / sliding-scale insulin regime during labour.

112
Q

Babies of mothers with diabetes are at risk of:

A
  • neonatal hypoglycaemia
  • polycythaemia
  • jaundice
  • congenital heart disease
  • cardiomyopathy
113
Q

How is neonatal hypoglycaemia managed?

A
  • regular blood glucose checks (>2mmol/L)
  • frequent feeds

If CBG <2mmol/L:
- IV dextrose
- NG feeding

114
Q

What is obstetric cholestasis?

A

The reduced outflow of bile salts from the liver, caused by increased oestrogen and progesterone.

115
Q

Presentation of obstetric cholestasis.

A
  • itching (palms of hands and soles of feet)
  • fatigue
  • dark urine
  • pale, greasy stools
  • jaundice

Typically presents later in pregnancy (T3). THERE IS NO ASSOCIATED RASH.

116
Q

Differential diagnoses for pruritis / deranged LFTs:

A
  • gallstone
  • acute fatty liver
  • autoimmune hepatitis
  • viral hepatitis
117
Q

How should women with pruritis be investigated?

A
  • LFTs (ALT, AST and GGT raised*)
  • raised bile acids

*placenta produces ALP, so a rise in ALP without other abnormal LFT results in pregnancy is normal.

118
Q

How is obstetric cholestasis managed?

A
  • ursodeoxycholic acid
  • emollients to soothe the skin
  • antihistamines to help sleeping
119
Q

Outline the rationale of Vitamin-K prescription for women with obstetric cholestasis.

A

Bile acids are important in the absorption of fat-soluble vitamins in the intestines. A lack of bile acids can lead to vitamin K deficiency.

Water-soluble vitamin K can be given if prothrombin time is deranged.

120
Q

What are some complications of obstetric cholestasis?

A
  • stillbirth
  • PPH (vitamin K)
121
Q

What is acute fatty liver of pregnancy?

A

Rapid accumulation of fat in hepatocytes, causing acute hepatitis.

There is a high risk of liver failure and mortality for the mother and fetus.

122
Q

Pathophysiology of acute fatty liver of pregnancy.

A

LCHAD deficiency of the fetus means the fetus and placenta cannot break down fatty acids.

The fatty acids enter the maternal circulation, and accumulate in the liver. This leads to inflammation and liver failure.

123
Q

Presentation of acute fatty liver of pregnancy.

A
  • ascites
  • anorexia
  • abdominal pain
  • jaundice
  • n+v
  • general malaise and fatigue
124
Q

Blood results supportive of acute fatty liver in pregnancy.

A
  • elevated LFTs*
  • low platelets*
  • raised bilirubin
  • raised WCC
  • raised PT and INR

*raised LFTs and low platelets should make you think of HELLP syndrome rather than acute fatty liver of pregnancy; HELLP syndrome is more common, but keep acute fatty liver in pregnancy in mind as a differential.

125
Q

Management of acute fatty liver in pregnancy.

A

Obstetric emergency, requiring prompt admission and delivery of the baby.

Management involves treatment of acute liver failure if it occurs, including consideration of liver transplant.

126
Q

A patient presents who is 31 weeks pregnant (T3). They complain of an itchy rash and, upon examination, you see the following (see image).

What is the diagnosis and what are the key features?

A

Polymorphic eruption of pregnancy. Characterised by:
- urticarial papules
- wheals
- plaques

127
Q

How is polymorphic eruption of pregnancy managed?

A
  • topical emollients
  • topical steroids
  • oral antihistamines
  • oral steroids (severe cases)

Condition will get better towards the end of pregnancy and after delivery.

128
Q

A patient who is 18 weeks pregnant (T2) presents to the GP with red, itchy skin affecting the insides of the elbows, back of knees and neck. You see the following on examination (see image).

What is the diagnosis and what are the key features?

A

E-type atopic eruption of pregnancy. Characterised by:
- eczematous, inflamed, red and itchy skin
- affects flexor surfaces

Occurs in women that have never suffered with eczema, as well as those with pre-existing eczema.

129
Q

A patient who is 14 weeks pregnant (T2) presents to the GP with itchy spots affected in the abdomen, back and limbs. You see the following on examination (see image).

What is the diagnosis and what are the key features?

A

P-type atopic eruption of pregnancy. Characterised by:
- itchy papules
- affect the abdomen, back and limbs

130
Q

How is atopic eruption of pregnancy managed?

A
  • topic emollients
  • topical steroids
  • phototherapy with UV light (severe)
  • oral steroids (severe)

Condition usually gets better after delivery.

131
Q

A patient who is 25 weeks pregnant (T2) presents to antental clinic with darkened patches of skin on her face. On examination, you see the following (see image).

What is the diagnosis and what are the characteristic features?

A

Melasma:
- hyperpigmentation patches on face
- symmetrical
- flat
- affecting sun-exposed areas

132
Q

Pathophysiology of melasma.

A

Caused by increased female sex hormones associated with pregnancy.

Can also occur with COCP and combined HRT.

133
Q

How is melasma treated?

A
  • avoid sun exposure / use suncream
  • makeup (camouflage)
  • skin lightening cream (specialist initiation)
134
Q

A woman who is 29 weeks pregnant presents to A&E because she is worried about a lump that appeared on her finger. She says it has grown significantly over the last 3 days. On examination, you see the following (see image).

What is the diagnosis and what are the key features?

A

Pyogenic granuloma - a rapidly growing tumour of capillaries.

  • discrete lump
  • red or dark appearance
  • rapidly growing
  • occur on fingers, upper check, back, neck or head
  • bleeding profusely if injured
135
Q

How is pyogenic granuloma treated?

A

Usually resolve without treatment after delivery if occurring in pregnancy.

If no associated pregnancy (ie. hormonal contraceptives, minor trauma, infection) treatment is with surgical removal with histology to confirm the diagnosis.

136
Q

A woman who is 29 weeks pregnant (T3) presents to GP with an itchy rash around her belly button. It has been present for a few weeks, but she has come to see you today as it has blistered. On examination, you see the following (see image).

What is the diagnosis and what are the key features?

A

Pemphigoid gestationis - a rare autoimmune condition where antibodies damage the connection between the epidermis and dermis.

  • occurs in T2 or T3
  • itchy red papular rash
  • blistering rash
  • around umbilicus, spreading
137
Q

How is pemphigoid gestationis managed?

A

Rash usually resolves without treatment after delivery; the blisters heal without scarring.

Treatment is with:
- topical emollients
- topical steroids
- oral steroids (severe)
- immunosuppressants (steroids inadequate)
- abx if infection

138
Q

Complications of pemphigoid gestationis.

A
  • fetal growth restriction
  • preterm delivery
  • blistering rash after delivery (maternal antibodies pass to baby)
139
Q

What are some causes of spotting / minor bleeding in pregnancy?

A
  • cervical ectropion
  • infection
  • vaginal abrasions from intercourse / procedures
140
Q

What are some causes of antepartum haemorrhage?

A
  • placenta praevia
  • placental abruption
  • vasa praevia
141
Q

According to RCOG (2018), what is:

a) low-lying placenta

b) placenta praevia

A

a) placenta is within 20mm of the internal cervical os.

b) placenta is over the internal cervical os.

142
Q

Risks associated with placenta praevia.

A
  • antepartum haemorrhage
  • emergency caesarean section
  • emergency hysterectomy
  • maternal anaemia / transfusions
  • preterm birth
  • stillbirth
143
Q

Risk factors for placenta praevia.

A
  • previous caesarean section
  • previous placenta praevia
  • older maternal age
  • maternal smoking
  • structural uterine abnormalities (e.g. fibroids)
  • assisted reproduction (e.g. IVF)
144
Q

How is placenta praevia diagnosed?

A

Usually an asymptomatic finding on the 20-week anomaly scan, used to assess position of the placenta.

It may present with painless vaginal bleeding (antepartum haemorrhage), usually occurring around 36 weeks.

145
Q

After low-lying placenta / placenta praevia is diagnosed at the 20-week anomaly scan, RCOG recommend repeat transvaginal ultrasound scan at:

A
  • 32 weeks gestation
  • 36 weeks gestation (if present on 32-week scan, to guide decisions about delivery)
146
Q

How is placenta praevia generally managed?

A

Corticosteroids given between G34 and G35+6 to mature fetal lungs.

Planned delivery between G36 and G37 via elective caesarean section, reducing the risk of spontaneous labour and bleeding.

147
Q

What are the indications for emergency caesarean in placenta praevia?

A
  • preterm labour
  • antepartum haemorrhage
148
Q

How is antepartum haemorrhage managed?

A
  • emergency caesarean section
  • blood transfusions
  • intrauterine balloon tamponade
  • uterine artery occlusion
  • emergency hysterectomy
149
Q

What is vasa praevia?

A

Fetal vessels are within the fetal membranes and travel across the internal cervical os.

150
Q

The fetal vessels consist of

A
  • two umbilical arteries
  • one umbilical vein
151
Q

How are the fetal vessels usually protected?

A

Fetal vessels usually run through the umbilical cord, or the placenta.

The umbilical cord contains Wharton’s jelly, which is a layer of soft connective tissue that surrounds the blood vessels in the umbilical cord.

152
Q

Pathophysiology of vasa praevia.

A

Fetal vessels are exposed outside the protection of the umbilical cord or the placenta, travelling:
- through chorioamniotic membrane
- across internal cervical os

153
Q

Risk factors for vasa praevia.

A
  • low-lying placenta
  • IVF pregnancy
  • multiple pregnancy
154
Q

Presentation of vasa praevia.

A

Ultrasound during pregnancy allows for planned caesarean section. However, ultrasound is not reliable and cannot always be diagnosed antenatally.

May present with antepartum haemorrhage, with bleeding in T2 or T3.

Detected by vaginal examination during labour, when pulsating fetal vessels are seen in the membranes through a dilated cervix.

It may be detected during labour when fetal distress and dark-red bleeding occur following rupture of membranes. This carries a high risk of fetal mortality.

155
Q

Management of vasa praevia (RCOG, 2018).

A
  • corticosteroids from G32 (mature fetal lungs)
  • elective caesarean section (G34-36)

When antepartum haemorrhage occurs, emergency caesarean section is required to deliver the fetus before death occurs.

156
Q

What is placental abruption?

A

Occurs when the placenta separates from the wall of the uterus during pregnancy, causing significant bleeding.

157
Q

Risk factors for placental abruption.

A
  • pre-eclampsia
  • trauma (domestic violence)
  • fetal growth restriction
  • smoking
  • cocaine use
158
Q

Presentation of placental abruption.

A
  • sudden onset severe abdominal pain that is continuous
  • vaginal bleeding (antepartum haemorrhage)
  • shock (hypotension / tachycardia)
  • abnormalities on CTG
  • woody abdomen on palpation
159
Q

RCOG (2011) defines the severity of antepartum haemorrhage:

a) spotting

b) minor haemorrhage

c) major haemorrhage

d) massive haemorrhage

A

a) spots of blood noticed on underwear

b) <50ml blood loss

c) 50-1000ml blood loss

d) >1000ml blood loss, or signs of shock

160
Q

What is concealed placental abruption?

A

The cervical os remains closed, meaning bleeding remains within the uterine cavity.

The severity of bleeding can be significantly underestimated.

161
Q

Initial management of major / massive antepartum haemorrhage.

A
  • urgent involvement of senior obstetrician, midwife and anaesthetist
  • 2x grey cannula
  • bloods (FBC, UE, LFT, coagulation studies)
  • crossmatch 4 units of blood
  • fluid and blood resuscitation as required
  • CTG monitoring of the fetus
  • anti-D prophylaxis if RhD-ve
  • emergency caesarean if unstable or fetal distress
162
Q

What is placenta accreta?

A

Placenta implants deeper, through and past the endometrium. This makes it difficult to separate after delivery of the baby.

163
Q

Layers of the uterine wall.

A

1) Endometrium - inner layer containing connective tissue, epithelial cells and blood vessels.

2) Myometrium - middle layer containing smooth muscle.

3) Perimetrium - outer serous membrane.

164
Q

Pathophysiology of placenta accreta.

A

Defects in the endometrium allow for the placenta to embed past the endometrium:
- caesarean section
- curettage procedure

The deep implantation makes it difficult for the placenta to separate during delivery, leading to extensive bleeding.

165
Q

What is

a) superficial placenta accreta

b) placenta increta

c) placenta perceta

A

a) placenta plants in the surface of the myometrium, but not beyond.

b) placenta attaches deeply into the myometrium

c) placenta invades past the myometrium and perimetrium, reaching other organs such as the bladder

166
Q

Risk factors for placenta accreta.

A
  • previous placenta accreta
  • previous endometrial curettage procedures
  • previous caesarean section
  • increased maternal age
  • low-lying placenta or placenta praevia
167
Q

Presentation of placenta accreta.

A

Usually asymptomatic and diagnosed on antenatal ultrasound scans.

It may be diagnosed at birth, when it becomes difficult to deliver the placenta. It is a cause of significant postpartum haemorrhage.

168
Q

Management of placenta accreta.

A

Ideally antenatally diagnosed via ultrasound with MRI to assess depth of invasion.

MDT approach as additional management required at birth:
- complex uterine surgery
- blood transfusions
- intensive care for mother
- neonatal intensive care

169
Q

Options during caesarean for placenta accreta.

A
  • hysterectomy with the placenta remaining in the uterus
  • uterus preserving surgery, with resection of part of the myometrium along with the placenta
  • expectant management, leaving the placenta in place to be reabsorbed over time*

*risk of bleeding and infection

170
Q

RCOG (2018) recommendation if placenta accreta is seen when opening the abdomen for elective caesarean section?

A

Close the abdomen and delay delivery whilst specialist services are put in place.

171
Q

RCOG (2018) recommendation if placenta accreta is discovered after delivery of a baby.

A

Hysterectomy is recommended.

172
Q

What is breech presentation?

A

Refers to when the presenting part of the fetus is the legs and bottom, occurring in <5% of pregnancies by G37.

173
Q

Types of breech:

a) complete breech

b) incomplete breech

c) frank breech

d) footling breech

A

a) legs are fully flexed at the hips and knees

b) one leg flexed at the hip and extended at the knee

c) both legs flexed at the hip and extended at the knee

d) foot is presenting through the cervix with the leg extended

174
Q

Management of babies that are breech before 36 weeks gestation.

A

Often turn spontaneously, so no intervention is advised.

175
Q

Management of babies that are breech after 36 weeks.

A

External cephalic version (ECV) - administration of tocolysis with subcutaneous terbutaline.

This reduces the contractility of the myometrium, making it easier for the baby to turn.

RhD-ve women require anti-D prophylaxis when ECV is performed, with a Kleihauer test to quantify dose of anti-D required.

176
Q

Management of breech presentation after 36 weeks if ECV is unsuccessful.

A
  • vaginal delivery (safer for mother)
  • caesarean section (safer for baby)

ECV is 50% successful

177
Q

Define stillbirth.

A

The birth of a dead fetus after 24 weeks gestation, a result of intrauterine fetal death (IUFD).

178
Q

Causes of stillbirth.

A
  • unexplained (~50%)
  • pre-eclampsia
  • placental abruption
  • vasa praevia
  • cord prolapse
  • obstetric cholestasis
  • diabetes
  • thyroid disease
  • infection
179
Q

Factors that increase the risk of stillbirth:

A
  • fetal growth restriction
  • smoking
  • alcohol
  • increased maternal age
  • maternal obesity
  • twins
  • sleeping on the back
180
Q

Prevention of stillbirth.

A

Risk assessment for having a baby that is small for gestational age or with fetal growth restriction.

Those at risk have fetal growth monitored closely with serial growth scans.

Modifiable risk factors for stillbirth are treated (e.g. smoking and alcohol cessation, sleeping on side).

181
Q

Key symptoms to always ask during a pregnancy consultation.

A
  • reduced fetal movements
  • abdominal pain
  • vaginal bleeding
182
Q

Diagnosis of intrauterine fetal death.

A

Ultrasound scan to visualise the fetal heartbeat to confirm if the fetus is alive.

183
Q

Management of IUFD.

A
  • anti-D prophylaxis if RhD-ve
  • vaginal birth (induction of labour or expectant delivery)
184
Q

How is labour induced following IUFD?

A

Combination of oral mifepristone and misoprostol.

185
Q

How can lactation be suppressed after stillbirth?

A

Dopamine agonists (e.g. cabergoline).

186
Q

How can the cause of stillbirth be determined?

A

Testing with parental consent:
- genetic testing of fetus and placenta
- postmortem examination
- testing for maternal and fetal infection
- maternal testing for diabetes, thyroid disease and thrombophilia

Identifying the cause can help reduce the risk in future pregnancies.

187
Q

What support is available following stillbirth?

A

Counselling offered to women, partners and family members.

Individuals supported with individual choices:
- seeing the baby
- naming the baby
- keeping photographs
- funeral arrangements

188
Q

What are the reversible causes of cardiac arrest?

A

4Hs:
- hypoxia
- hypovolaemia
- hypothermia
- hyperkalaemia / hypoglycaemia

4Ts:
- thrombosis
- tension pneumothorax
- toxins
- tamponade

189
Q

What are the major causes of cardiac arrest in pregnancy?

A
  • obstetric haemorrhage
  • pulmonary embolism
  • sepsis leading to metabolic acidosis and septic shock
190
Q

What are the causes of obstetric haemorrhage?

A
  • ectopic pregnancy
  • placental abruption
  • placenta praevia
  • placenta accreta
  • uterine rupture
191
Q

What is aortocaval compression?

A

After 20 weeks gestation, the uterus can compress the inferior vena cava and aorta when a pregnant woman lies on her back.

The compression of the vena cava reduces venous return, reducing cardiac output and leading to hypotension. In severe cases, this could lead to loss of cardiac output and cardiac arrest.

192
Q

How is aortocaval compression prevented?

A

Place the woman in the left lateral position.

The vena cava is slightly to the right side of the body, so this relieves compression on the inferior vena cava and should improve venous return and cardiac output.

193
Q

Give some factors that can complicate resuscitation in pregnancy.

A
  • aortocaval compression
  • increased oxygen requirements
  • difficulty with intubation
  • increased risk of aspiration
  • obstetric haemorrhage
194
Q

How is cardiac arrest in pregnancy generally managed?

A

Same principles of adult life support, plus:
- 15 degree tilt to left side for CPR
- early intubation to protect the airway
- early supplementary oxygen
- aggressive fluid resuscitation
- delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

195
Q

Immediate caesarean section is performed in cardiac arrest in pregnancy when?

A

No response after 4 minutes to CPR in a woman more than 20 weeks gestation.

The aim is to deliver the baby and placenta within 5 minutes of CPR commencing. The operation is performed at the site of the arrest.

196
Q

What is the reason for immediate caesarean section in cardiac arrest in pregnancy?

A

Improve survival of mother:
- improve venous return to heart
- improve cardiac output
- reduce oxygen consumption

Delivery increases the chance of the baby surviving, but this is secondary to the survival of the mother.

197
Q

What is congenital cyclomegalovirus infection and what are the features?

A

CMV infection in the mother during pregnancy causes congenital infection:
- fetal growth restriction
- microcephaly
- hearing loss
- vision loss
- learning disability
- seizures

Most cases of CMV in pregnancy do not cause congenital CMV. Spread is via infection saliva or urine of asymptomatic children.

198
Q

What infection does Parvovirus B19 normally cause?

A

Fifth disease

199
Q

Presentation of Parvovirus B19 infection.

A

1) Non-specific viral symptoms

2) Rash appears across cheeks on days 2-5

3) Reticular rash remains between days 5-10

The illness is self-limiting and the rash and symptoms usually fade over 1-2 weeks.

200
Q

When is exposure to parvovirus B19 considered significant?

A

15 minutes in the same room with someone that has the virus.

Note people are infectious for 10 days before the rash appears - they are NOT infectious once the rash has appeared.

201
Q

Complications of parvovirus B19 infection in pregnancy.

A
  • miscarriage
  • fetal death
  • severe fetal anaemia
  • hydrops fetalis
  • maternal pre-eclampsia-like syndrome
202
Q

How does hydrops fetalis occur as a result of parvovirus B19 infection?

A

Parvovirus infection of erythroid progenitor cells in the fetal bone marrow and liver causes severe fetal anaemia. This leads to fetal heart failure.

203
Q

What is maternal pre-eclampsia-like syndrome?

A

A rare complication of parvovirus B19 infection in pregnancy.

Triad:
- hydrops fetalis
- placental oedema
- oedema in mother

It also causes hypertension and proteinuria.

204
Q

Women suspected of parvovirus infection in pregnancy need tests for:

A
  • IgM (acute infection in past 4 weeks)
  • IgG (long-term immunity after previous infection)
  • Rubella antibodies (differential diagnosis)
205
Q

How is parvovirus B19 infection in pregnancy treated?

A

Referral to fetal medicine to monitor for complications and malformations; supportive treatment.

206
Q

How is Zika virus spread?

A
  • Aedes mosquitos as vector
  • sexual contact with infected individual
207
Q

Presentation of Zika virus.

A
  • asymptomatic
  • minimal symptoms
  • mild flu-like illness
208
Q

Features of congenital Zika syndrome:

A
  • microcephaly
  • fetal growth restriction
  • ventriculomegaly
  • cerebellar atrophy
209
Q

How are pregnant women tests for Zika virus?

A
  • viral PCR
  • antibodies to Zika virus
210
Q

How are pregnant women with Zika virus managed?

A

Referred to fetal medicine for close monitoring of pregnancy.

There is no treatment for the virus

211
Q

How can HIV be spread from mother to baby?

A
  • through placenta while pregnant
  • during birth
  • through breast milk
212
Q

What extra antenatal care is offered to HIV positive pregnant ladies?

A

Offered specialist care and regular health checks:
- obstetrician led care
- doctor who specialises in HIV
- specialist midwife
- paediatrician

Extra ultrasound scans for monitoring throughout pregnancy, plus testing of viral load and CD4 count for monitoring.

213
Q

How can the chances of vertical transmission of HIV be reduced?

A
  • treatment with ART
  • avoid breastfeeding
  • caesarean section
214
Q

Is anti-retroviral treatment safe in pregnancy?

A

ART does not appear to be harmful for babies; not taking the medication is much more likely to be harmful for the baby.

Early labour is more likely if taking ART in pregnancy.

Regular LFTs to check liver function, and FBCs to exclude anaemia.

215
Q

How is delivery recommended for pregnant women with HIV?

A

Normal vaginal delivery possible if taking ART and:
- viral load <50
- CD4 >350

Caesarean section will be recommended at 38 weeks if viral load is high, or hepatitis C virus is detected.

216
Q

What treatment is given to babies after birth if mother is HIV positive?

A

Baby given ART within 4 hours, continued for at least 4 weeks.

Baby tested for HIV:
- 2 days old
- discharge from hospital
- 6 weeks old
- 12 weeks old
- 18 months old

217
Q

What are the features of congenital syphilis?

A
  • poor growth
  • premature birth
  • stillbirth
  • jaundice
  • hearing difficulty
  • vision problems
  • skeletal deformities
  • learning disability
218
Q

How is syphilis passed between mother and baby?

A
  • placenta
  • contact with syphilitic sore at birth

Not transmitted during breastfeeding.

219
Q

What is the effect of pregnancy upon covid-19 infection?

A

Women more likely to get seriously ill if more than 28 weeks pregnancy (T3). Baby also at high risk of harm.

Year 4 - Reproductive Health (12 decks)

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