Antenatal Flashcards
What are the complications of oligohydramnios?
Fetal pulmonary hypoplasia
Clubbed feet
Facial deformity
Congenital hip dysplasia
Combination of above features - Potter syndrome
What are dizygous twins?
fraternal, 2 diff zygotes, 2 diff sperm/eggs
What are monogynous twins?
identical, division of single, already developing embryo. Random, IVF ↑risk.
What are triplets?
trizygotic, can be dizygotic (2 zygote, 1 split)
What is twin to twin transfusion?
only in monochorionic.
Vascular anastomoses of placenta, blood flow from 1 twin to another.
Donor: amniotic fluid depleted, anaemia, IUGR, oligohydramnios dehydration.
Recipient: volume overloaded, polycythaemia, cardiac failure, polyhydramnios
Complications of multiple pregnancy?
Hyperemesis gravid arum due to ^ bHCG Miscarriage Pre-eclampsia Anaemia PPH, antenatal haem DM Preterm PRM Pregnancy HTN Prematurity (twins 37wks, triplets 33) Polyhydramnios/ oligohydramnios Congen malformation IUGR Fetal death Cord prolapse Twin interlocking Malpresentation
Management of multiple pregnancies?
Consultant led care
Prophylaxis with aspirin if risk of pre-eclampsia
Nuchal translucency unreliable.
If monochorionic send to specialist
Induction of lower segment C-section 37-38 wks, vaginal delivery possible if 1st twin cephalic.
C section if there is delayed delivery of 2nd twin, malpresentation, triplets.
Causes of early pregnancy bleeding?
PV bleed in 1st 20 wks.
cervical polyp, ectopic, trauma, UTIs, implantation bleed, STIs, molar pregnancy, miscarriage, ectropion, vaginal varicose.
What is a miscarriage?
A miscarriage is the loss of a pregnancy during the first 23 weeks
Features of:
Abdo, central pelvic pain, cramp like, lower back pain.
PV spotting, passing clots, post coital bleed
Usually haemodynamically stable, mass of fetus normally small.
Risk factors for miscarriage?
prior miscarriage
multiparity ↑maternal age
smoking
substance abuse
chromosomal abnormalities
structural uterine anomalies (eg cervical insuff, fibroids)
maternal infections (BV, toxoplasmosis, coxsackie virus, measles, mumps)
maternal comorbidities (thrombophilia, hypothyroidism, DM, SLE, obesity)
trauma
iatrogenic procedures.
Complications of a miscarriage?
Infection eg septic abortion: retained products of conception.
DIC, missed abortion, retained products, coagulopathy
Investigations for miscarriage?
Pregnancy test
Abdo + pelvic exam
Blood products for histopathology
Transvaginal USS
FBC, antibodies (RH)
Serum progesterone: ↓indicate non-viable pregnancy
<6wks repeat urine test after 7-10 days if neg miscarried.
Management of miscarriage?
Expectant - waiting for spontaneous, first-line and involves waiting for 7-14 days, if unsuccessful then medical or surgical
Medical: vaginal misoprostol > prostaglandin analogue, bind to myometrial cells, cause contraction, contact Dr if bleeding hasn’t started in 24hrs, given with antiemetics and pain relief
Surgery: vacuum aspiration (suction curettage LA) or in theatre (GA).
Managed medically/ surgically if: ↑risk of haem (late 1st trim or mum has coagulopathies or unable to have transfusion), prev adverse/traumatic experience of pregnancy, infection
What is threatened miscarriage?
> embryo/ fetus jeopardised by bleeding > painless vaginal bleeding before 24 weeks (typically 6-9 wks) > may have abdo pain > bleeding often less than menstruation > cervical os CLOSED > complicates up to 25% of pregnancies
Intact membranes, viable intrauterine pregnancy detected
Give paracetamol, counselling, anti-D
What is missed miscarriage?
> gestational sac which contains a dead foetus before 20 wks w/o Sx of expulsion
mother may have light vaginal bleeding/discharge and Sx of pregnancy may disappear
pain not usually a feature
cervical os is closed
gestational sac > 25mm and no embryonic/fetal part seen - blighted ovum or an embryonic pregnancy
Tx - await 7-14 days, some women may not want Tx straight away
- remove gestational sac and other products
What is an inevitable miscarriage?
> heavy bleeding with clots and pain
> cervical os is open
What is an incomplete miscarriage?
> not all products of conception have been expelled
pain and vaginal bleeding
cervical os is open
What is a recurrent miscarriage?
Consecutively 3 times
Causes > chromosomal abnormalities not viable with life, PCOS, thrombophilia, largely unexplained, APS, DM/ thyroid disorders, uterine abnormality eg uterine septum, smoking
What is complete miscarriage?
> Spont. passage of all products of conception
Heavy bleed initially, gotten better since
Cervix open or closed depending on stage
Empty uterus
Sometimes need resus for heavy bleed
What is an ectopic pregnancy?
Implantation of a fertilized ovum outside the uterus results in an ectopic pregnancy
97% tubal (most in ampulla, most dangerous if in isthmus), ovary, cervix, peritoneum, c-section scar.
Heterotopic: concurrent ectopic pregnancy + IU pregnancy
Features of an ectopic pregnancy?
typical history is a female with a history of 6-8 weeks amenorrhoea who presents with lower abdominal pain and later develops vaginal bleeding
lower abdominal pain - due to tubal spasm, typically first Sx, pain constant and may be unilateral
vaginal bleeding - less than normal period, may be dark brown
history of recent amenorrhoea - typically 6-8 weeks from LMP, if longer can suggest another cause (e.g., inevitable abortion)
peritoneal bleeding > shoulder tip pain and pain of defection/urination
dizziness, fainting, syncope
Sx of pregnancy - e.g. breast tenderness
Examination findings of ectopic pregnancy?
abdominal tenderness
cervical excitation (also known as cervical motion tenderness)
adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy. A pelvic examination to check for cervical excitation is however recommended
In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
RF’s for ectopic pregnancy?
infertility
recurrent PID
surgery
chlamydia (damage cilia lining fallopian tube)
gonorrhoea (clubbed fimbriae, blocked/tortuous tube)
anti- retroviral therapy + HIV.
Prev abdo surgery (appendicitis, uterine, adhesions)
smoking
IUD
prev ectopic
POP
IVF
ligation
endometriosis
Investigations for ectopic pregnancy?
Cervical excitation: pulls on peritoneum if tender means blood on it (ectopic) or inflamed (endometriosis/PID)
Pos pregnancy test
Serial bHCG, 48hrs, normally double every 2 days or ↑ >63%, if not think ectopic
Transvaginal USS: empty uterus, bHCG >1500 should see something on USS, repeat in 7 days if low risk
FAST: if haem unstable, detects peritoneal bleeding
Management of ectopic pregnancy?
Expectant: <35mm, unruptured, asymptomatic no FHB, bHCG <1000. Closely monitor over 48hrs bHCG ↑ or if Sx intervene, compatible with another IU pregnancy
Medical: <35mm, unruptured, no sig pain, no FHB, hCG <1500 - methotrexate but pt. needs to attend follow up, not if another IU preg.
Surgery: >35mm, ruptured pain, visible FHB, bHCG >5000. Compatible if another IU preg. Salpingotomy, mostly salpingectomy
What is a complete hydatidiform mole?
Benign tumour of trophoblastic material. Occurs when an empty egg is fertilized by a single sperm that then duplicates its own DNA, hence the all 46 chromosomes are of paternal origin
What is partial hydatidiform mole?
1 egg fertilised by 2 sperm 69XXY, 69XYY, 69XXX. Some fetal cells evident eg amnion, RBCs, not usually invasive.
What is a molar pregnancy?
Abnormal prolif of trophoblastic tissue. Paternal gene over expression. Vesicular placental villi swelling. Can develop from cells that remain in uterus after miscarriage, full term or ectopic
80% noncancerous. Rest can persist + invade surrounding tissues, develop into choriocarcinomas
Features of a molar pregnancy?
Missed menses, enlarging uterus + feeling of pelvic pressure
Uterus larger than preg age
Exaggerated Sx of preg eg hyperemesis
HTN
Vaginal bleed: as mole deteriorates, small tissues like grapes passed. Dark prune juice coloured discharge (accumulated oxidised blood)
Mets: hyperthyroid, ↑HR, HTN warm skin, tremor heat intol, insomnia, diarrhoea, tremor.
Complications of a molar pregnancy?
Infection of uterus sepsis, shock.
Pre-eclampsia: ↑ hCG, theca lutein cysts
Potential for malig + mets
Investigations for a molar pregnancy?
bHCG: urine or blood (very high), monitor to asses malig transformation.
TFTs
USS complete: no embryo, fetus or gestational sac, absent FHB. Absence of amniotic fluid, numerous anechoic spaces: bunch of grapes, swiss cheese, snow storm
USS incomplete: fetus amniotic fluid, chorionic villi echogenicity, usually no theca lutein cysts.
Biopsy: dilation + curettage passed tissue. Products of conception, if smeared don’t break, clot will Hydropic swelling of chorionic villi, cluster of grapes. Trophoblastic prolif. Complete: p57 pos. Partial: p57 neg.
CXR: commonly spread to lung
Management of a molar pregnancy?
Evacuation of the uterus > Removal with dilation + curettage, scraping of contents
Hysterectomy rarely required
Methotrexate/ dactinomycin indicated by bHCG don’t ↓, histological features of malig GTD, mets on XR.
Advice: no further preg for 6mnths, oral contraceptives.
What is choriocarcinoma?
Highly aggressive malig tumour trophoblastic tissue.
Only develops after fertilisation + implantation.
Most cases preceded by: molar (2-3% go on to choriocarcinoma), miscarriage ectopic or normal preg.
Destructive growth into myometrium w/o chorionic villi
Features of choriocarcinoma?
PP vaginal bleeding, inadequate regression after delivery
Multiple theca lutein cyst
Mets: seizure, dyspnoea, haemoptysis
Investigations of choriocarcinoma?
Very ↑bHCG
Pelvic USS: mass of varying appearance (haem + necrosis), hypervascular on colour doppler.
Uterine dilation + curettage: cytotrophoblasts + synctiotrophoblasts w/o chorionic villi.
CXR: cannon ball mets
Treatment of choriocarcinoma?
Methotrexate or dactinomycin
Surgical eg hysterectomy may be indicated to stop bleeding
Monitor B-HCG for at least 12 mnths
Cure rate of 95-100%
What are reduced fetal movements?
Can indicate fetal distress, as method of fetal compensation to ↓O2 consumption as response to chronic hypoxia IU.
<10 in 2hrs indication for assessment.
Movements ↑from 18-20 wks, until 32wks when they plateau.
Link between ↓fetal movements + placental insuff.
Linked with stillbirth and fetal growth restriction
If RFM recurrent, further investigations to consider structural / genetic fetal abnormalities.
Causes of reduced fetal movements?
Posture: positional changes in fetal movement awareness gen more prominent during lying down + less when sitting/ standing
Distraction
Placental position: ant placenta <28wks may have lesser awareness of movements.
Meds: alcohol + sedative meds eg BDZ, opiates
Fetal position: ant fetal position, movements less noticeable
Obese pts less likely to feel prominent fetal movements
Amniotic fluid volume
Fetal size: SGA
Management of reduced fetal movements?
> 28wks: handheld doppler to confirm FHB, if no HB, immediate USS. If HB, CTG 20+mins, if concern remains despite normal CTG, USS within 24hrs. incl abdo circumference or estimated fetal weight + amniotic fluid measurement
24-28wks: handheld doppler to confirm FHB
<24 wks: handheld doppler if fetal movement prev felt.
If fetal movements not yet felt by 24wks, referral made to maternal fetal medicine unit.
What is polyhydramnios, and causes of it?
Too much amniotic fluid
Causes: ↑placental blood flow, renal perfusion, urine produced ↓baby’s drinking (duodenal/ oesophageal/ intestinal atresia, transoesophageal fistula). Fetal swallowing clears AF in last ½ of gestation, fetal skin highly permeable in 1st ½ of preg, keratinised 22-25 wks.
RF’s for polyhdramnios?
CNS abnormalities
↑CO of fetus
nonimmune hydrops
aneuploidy
trisomy 18/21
TT transfusion
multiple gestation.
Gestational/chronic DM (HBS in mother + baby, osmotic diuresis ↑fetal urination)
Features of polyhydramnios?
Uterine size/ fundal height higher than expected for gestational age
Difficulty palpating fetal parts.
Complications of polyhydramnios?
Preterm labour
PROM
Fetal malpresentation
Placental abruption
UC prolapse
PP uterine atony > haem
Upward diaphragm pressure > resp distress
Fetal anomalies.
Diagnosis of polyhydramnios?
Uterine USS: AFI >24cm, single deepest pocket >8cm
Fetal US + biophysical profile: detect fetal anomalies, assess fetal well-being.
Treatment of polyhydramnios?
Indomethacin: severe, fetal antidiuretic response via endogenous vasopressin production. Not recommended >31 wks risk of fetal heart problems (DA closure)
Amnioreduction (decompression amniocentesis), amniotic fluid removal
What is oligohydramnios + causes?
Too little AF for gestational age
Causes: ↓placental blood flow, urine production. ↑amniotic fluid loss. Potter’s seq (renal agenesis, pul hypoplasia, twisted skin/face, extremity malformation), GU obstruction
Features of oligohydramnios?
Smaller fundal height/ uterine size than expected for gest age
Easily palpated fetus
↓fetal movements. ↓MSK development
Complications of oligohydramnios?
Amniotic band synd: limb malformation + amputation.
Limb position defect: club foot,
Pul hypoplasia
LBW/IUGR
Meconium aspiration
fetal death
↓fluid cushioning, ↑risk UC compression
↓amniotic fluid bacteriostatic > ↑infection.
Investigations for oligohydramnios?
Uterine USS: ↓AFI, <5cm total, single deepest pocket <2cm
AFI: AF measurement in deepest pocket in each uterine quadrant, sum of each maximal vertical pocket.
Fetal US + biophysical profile
Amniotic fluid leak detection: nitrazine, fern tests,
AmniSure, sterile speculum exam
Management of oligohydramnios?
↑intrauterine-fluid volume: maternal hydration, amnioinfusion
Delivery of the fetus is close to term
Summary of rubella in pregnancy?
a viral infection caused by the togavirus
if contracted during pregnancy there is a risk of congenital rubella syndrome.
incubation period is 14-21 days and individuals are infectious from 7 days before symptoms appear to 4 days after the onset of the rash.
in first 8-10 weeks risk of damage to fetus is as high as 90%
damage is rare after 16 weeks
suspected cases should be discussed immediately with the local Health Protection Unit (HPU) as type/timing of investigations may vary
IgM antibodies are raised in women recently exposed to the virus
very difficult to distinguish rubella from parvovirus B19 clinically - so check parvovirus B19 serology as there is a 30% risk of transplacental infection, with a 5-10% risk of fetal loss
since 2016, rubella immunity is no longer routinely checked at the booking visit
if a woman is however tested at any point and no immunity is demonstrated they should be advised to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
MMR vaccines should not be administered to women known to be pregnant or attempting to become pregnant > live vaccine
Features of congenital rubella syndrome?
sensorineural deafness
congenital cataracts
congenital heart disease (e.g. patent ductus arteriosus)
growth retardation
hepatosplenomegaly
purpuric skin lesions
‘salt and pepper’ chorioretinitis
microphthalmia
cerebral palsy
Summary of chicken pox in pregnancy?
caused by primary infection with varicella-zoster virus
In pregnancy, there is a risk to both the mother and also the fetus, a syndrome now termed fetal varicella syndrome
risk to mother - 5 times greater risk of pneumonitis
Fetal varicella syndrome (FVS)
risk of FVS following maternal varicella exposure is around 1% if occurs before 20 weeks gestation
features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities
other risks to fetus - shingles in infancy, severe neonatal varicella (fatal in 20% cases)
Management of chicken pox exposure in pregnancy (i.e PEP)
if immunity doubt > maternal blood should be urgently checked for varicella antibodies
if the pregnant woman <= 20 weeks gestation is not immune to varicella she should be given varicella-zoster immunoglobulin (VZIG) as soon as possible
if the pregnant woman > 20 weeks gestation is not immune to varicella then either VZIG or antivirals (aciclovir or valaciclovir) should be given days 7 to 14 after exposure
Management of chicken pox in pregnancy?
if a pregnant woman develops chickenpox in pregnancy then specialist advice should be sought
there is an increased risk of serious chickenpox infection (i.e. maternal risk) and fetal varicella risk (i.e. fetal risk) balanced against theoretical concerns about the safety of aciclovir in pregnancy
consensus guidelines (Health Protection Authority and RCOG) suggest oral aciclovir should be given if the pregnant women is ≥ 20 weeks and she presents within 24 hours of onset of the rash
if the woman is < 20 weeks the aciclovir should be ‘considered with caution’
Summary of CMV in pregnancy?
Infected saliva/ urine of asymptomatic children
Most common congen infection
Features - Temp, aching muscles, skin rash, feeling sick, sore throat, swollen glands
Infected cells have owl eyes due to intranuclear inclusion bodies.
Summary of toxoplasmosis in pregnancy?
Contamination from cat faeces
↑risk later in preg, transplacental spread
Cerebral toxoplasmosis accounts for 50% of cerebral lesions in HIV.
Mostly asymptomatic, fever, malaise, lymphadenopathy.
Resembles infectious mononucleosis
Meningoencephalitis + myocarditis
CT: single or multiple ring enhancing lesions
No tx unless pt has severe infection of is IC
Pyrimethamine + sulphadiazine for at least 6 wks
Summary of parvovirus in pregnancy?
Spread resp route
Infectious 3-5 days before rash appears
Not infective when have rash
Non-specific Sx 1st rash (slapped cheeks) then reticular rash on limbs/ trunk (raised + pruritis) rarely involves palms + soles, may cause arthritis.
Complications - Miscarriage
Severe foteal anaemia
Hydrops fetalis
Pre-eclampsia like syndrome
Dangerous in 1st + 2nd trim, check maternal IgM + IgG
Summary of treponema pallidum infection in pregnancy?
Bacteria that causes syphilis
2-6wks after birth, blunted upper incisor teeth (Hutchninson’s teeth), rhagades, saber shins, saddle nose, keratitis, deafness
Summary of UTI in pregnancy?
Pregnant women at ↑risk
E coli
Asymptomatic bacteriuria: ↑risk of UTI.
Dysuria Suprapubic pain ↑freq, urgency Incontinence Haematuria Pyelonephritis: fever, loin or back pain, vomiting, anorexia, renal angle tenderness
Complications - Preterm delivery
LBW
Pre-eclampsia
Investigations - Routinely check urine
MC+S
Further culture as test for cure.
Trimethoprim: avoided in 1st trim, folate antagonist, NTD
7 days Abx
1st: nitrofurantoin (except 3rd trim, risk of neonatal haemolysis)
2nd: amoxicillin or cefalexin
Treat asymptomatic bacteriuria.
Summary of anaemia in pregnancy?
↑plasma vol, haemodilution, ↓Hb conc.
Sx - SOB, dizziness, fatigue, pallor
Complications - Preterm birth, LBW, PP maternal infection, PPH
Investigations - Screened at booking + 28wks
MCV: ↓(IDA), normal (physiological), ↑(B12 or folate def).
Tx - Iron: booking <11g/dl, 28 wks <10.5g/dl. Ferrous sulphate 200mg TD
B12: IM hydroxocobalamin/ oral cyanocobalamin tablets
Folate: all women 400mcg OD, if high risk/deficient 5mg OD
Causes and RF’s for VTE and PE in pregnancy?
Hypercoag. state, ↑factors 7, 8, 10 + fibrinogen, ↓protein S, uterus presses on IVC, cause venous stasis.
RF: smoking, multiparous, >35, BMI>30, >90kg, ↓mobility, paraplegia, pre-eclampsia, gross varicose veins, FHx/PMH VTE, IVF, thrombophilia, sickle cells, nephrotic disease, cardiac disease, IBD, myeloprolif disease, hyperemesis, dehydration, infection, forceps labour >12 hrs.
Investigations for VTE and PE in pregnancy?
Doppler USS: repeat if neg on day 3 + 7 if high suspicion. If present don’t need additional investigations to confirm PE.
CXR, ECG
CPTA: ↑risk maternal breast Ca
VQ: ↑risk childhood Ca
Well’s score + D-dimer not useful in preg.
