Antenatal Flashcards
What effect does progesterone have in pregnancy?
Relaxes smooth muscle:
uterus
gut- constipation + acid reflux
ureters- hydronephrosis
Raises temperature
What effect does oestrogen has in pregnancy?
Breast and nipple growth
Water retention
Protein synthesis
Why does vaginal discharge increase in pregnancy?
Cervical ectopy
Cell desquamation
Vasocongested vagina > increased mucus production
How much does plasma volume increase to in pregnancy?
3.8 Litres
What increases on the FBC are expected in pregnancy?
WCC (10.5)- neutrophilia from invading placenta ESR (x4) Cholesterol b-globulin Fibrinogen
What decreases are expected on the FBC in pregnancy?
Platelets- haemodilution + consumption
Urea
Creatinine
(small degree of hydronephrosis)
What happens to the inferior vena cava when pregnant woman lie supine?
From 20 weeks the gravid uterus compresses the ivc reducing venous return
How can ivc compression in pregnant women be reduced?
Lying in the left lateral position or wedging her tilted 15 degrees onto the left (restores venous return and thus cardiac output).
What effect does progesterone have on the lungs?
Relaxes smooth muscle of the diaphragm causing tidal volume to increase to 700mL
Why do pregnant women get breathless?
Maternal PaCO2 is set lower to allow the placenta to offload CO2 so breath more.
How soon will a pregnancy test give a positive result?
9 days after ovulation (day 23 of cycle)
How long into pregnancy is a pregnancy test positive?
20 weeks
How long does the corpus luteum produce progesterone for?
35 days
What three factors contribute to high risk pregnancies?
- Maternal age above 35
- Previous abnormal baby
- Family history of genetic condition
What does the ultrasound scan at 11-13weeks (+6 days) look for?
Nuchal translucency
Chorionicity- twins
When is the second abnormality scan?
18 weeks
What kinds of things is the ultrasound screen better or worse at identifying?
Good for:
Structural abnormalities that alter external anatomy
- anencephaly, spina bifida
Bad for:
internal structural abnormality- under 50% pick up
- heart disease, diaphragmatic hernia
What is choroid plexus cyst a soft sign for?
Trisomy 21- Down’s
Trisomy 18- Edwards
(choroid plexus is blood supply to brain)
What is echogenic bowel a soft sign for?
Trisomy 21
Cystic fibrosis- associated wit reduced bowel motility
Where is a-fetoprotein synthesised in the fetus?
the GI tract and liver
What pathologies can a high a-fetoprotein indicate?
Increased opening to amniotic sac:
Open neural tube defect
Examphalos
Tube Obstruction:
Kidney (post urethral valves) or gut abnormalities
Turner’s syndrome (XO)
(NB: not Downs which has low AFP)
What is a normal cause of high a-fetoprotein?
Twins
What can cause a low a-fetoprotein?
Chromosomal abnormalities- Down’s syndrome
Diabetic mother
When can amniocentesis be performed?
16 weeks
before then it has a 5% loss rate and may lead to talipes (club foot) or respiratory problems.
What is the advantage of amniocentesis over chorionic villus biopsy?
Amniocentesis provides a more accurate a-fetoprotein level to detect neural tube defects.
Chorionic villus biopsy can’t detect neural tube defects
What is the disadvantage of amniocentesis?
Problems detected late in pregnancy
-done at 16 weeks, cell culture for enzyme and gene probing takes 3 weeks
What is the chorionic villus biopsy loss rate?
4%
When can chorionic villus biopsies be taken up until?
20 weeks
after that use cordcentesis
What type of pregnancy is chorionic villus biopsy not recommended in?
Dichorionic multiple pregnancy
+ After 20 weeks
When is fetoscopy carried out and why?
At 18 weeks to find external abnormalities
Loss rates of all the invasive procedures for fetal abnormality?
Amniocentesis before 16 weeks- 5%
Amniocentesis after 16 weeks- 1%
Chorionic villus biopsy- 4%
Fetoscopy- 4%
What can nuchal translucency be a sign of?
Anomaly of heart and great arteries- leads to oedema in neck
Downs- more hydrophilic collagen in dermis
Turners- lymph obstruction
Nuchal translucency has a positive predictive value of 4%, what does this mean?
Out of 100 women with a positive result, 4 will have a chromosomal abnormality
What type of twins have a higher rate of false positives with nuchal translucency?
Monochorionic twins
What risk of Down’s prompts the option of invasive sampling in 1st and 2nd trimester?
1st: 1 in 150
2nd: 1 in 250
What does the combined test for Down’s entail?
nuchal translucency (high)
b-HCG (high)
pregnancy associated plasma protein (low)
woman’s age
How is risk assessed with the combined test for dichorionic fetuses?
Risk is done per fetus so use nuchal translucency of each for their own scores
What does the integrated test for Down’s entail?
Nuchal translucency
Pregnancy associated plasma protein (PrAP-A)
\+ Quadruple test (EFGHI): unconjugated Estriol maternal a-Fetoprotein free b-HCG Inhibin-A
What is the advantage and disadvantage of the integrated Down’s test over the combined test?
Advantage- better than combined test
Disadvantage- can only do the quadruple test with values from the 2nd trimester
What Down’s tests can be used in 2nd trimester?
The quadruple test:
Low:
AFP
unconjugated estriol
High: b-HCG
inhibin A
When can the quadruple test be used?
Between 15 weeks (+0 days) and 20 weeks (+0 days)
When can the combined test be used?
Between 10 weeks (+3 days) and 13 weeks (+6 days)
What are the indications for preimplantation genetic diagnosis?
Women who have repeatedly terminated pregnancy due to abnormality
Concurrent infertility
Recurrent miscarriage
+ if objections to terminations
In preimplantation genetic diagnosis how are different conditions detected?
Fluorescence in situ hybridisation- chromosomes
PCR- mongenic gene diseases
Women with 3 risk factors for thromboembolism should receive what Rx?
LMW heparin (like enoxaparin) fro 28 weeks + labour and 6 weeks after. With TED stockings given.
Lady with BMI above 40 gives birth.
What does she need after birth?
7 days of LMWH
After caesarian sections that occur whilst in labour what thromboprophylaxis should woman get?
7 days of LMWH
elective C-section is just a risk factor, of which 2 are needed to warrant post-birth LWH
What are the risk factors for thromboembolism in pregnancy?
Over 35
BMI >30 in early pregnancy
Parity >= 3
Multiple pregnancy
COAGULATION
Assisted reproduction
Ovarian hyperstimulation
Hyperemesis
Vomiting
PMH: Thromboembolism Thrombophilia Myeloproliferative disorder Sickle cell
ENDOTHELIAL INJURY Major infection- pyelonephritis, wound infection Smoker SLE Inflammatory bowel disease
Pre-eclampsia Nephrotic syndrome (hypertension, oedema, proteinuria)
FLOW
Paraplegia
Immobility for more than 2 days
pubic symphysis dysfunction
Long travel time (>3 hours)
Gross varicose veins
Flow: Labour for more than 24 hours Coag: Blood loss> 1L Transfusion >1L Endo injury: Mid-cavity forceps Elective caesarian Postpartum sterilisation
How does the LMWH regimen change if a woman has two risk factors rather than 3 in pregnancy?
3- Start LMWH straight away
2- Start LMWH after delivery
What factors should delay starting LMWH after birth?
Postpartum haemorrhage
Wait 4 hours after epidural catheter siting or removal
Wait 6 hours after traumatic epidural catheter placement
How is enoxaparin (LMWH) dosed according to weight?
For every 40kg give 20mg more SC OD, starting below 50kg.
What constitutes very high risk of VTE in pregnancy?
How should they be managed?
Recurrent VTEs
- antiphospholipid syndrome
- antithrombin deficiency
Or on long-term Warfarin
High dose of prophylaxis, giving dose BD instead of OD
or 75% of therapeutic dose (= 1mg/kg/12hrs)
What dose of LMWH do you give a pregnant woman who gets a VTE?
1mg/kg SC BD enoxaparin
What do you give a woman who gets a VTE post partum?
1.5mg/kg OD SC ENOXAPARIN
How should thromboprophylaxis regimen change as a very high risk woman for VTE onsets labour?
Go from giving it BD to OD the day before and the day of induction
A pregnant woman had a VTE in the past due to varicose veins that have since been removed. She has no other risk factors. What thromboprophylaxis should she receive?
LMWH for 6 weeks post birth
any previous VTE
What complications of sickle cell anaemia are commoner in pregnancy?
Painful crises
Prematurity
Fetal growth restriction
What factors in pregnancy could precipitate painful sickle cell crises?
Cold Hypoxia Dehydration- vomiting Over exertion Stress
Pregnant woman has chest pain and a cough
PMH: sickle cell
IHx: infiltrates on CXR
Acute Chest Syndrome
Respiratory symptoms + CXR infiltrates
How should acute chest crises in sickle cell patients be treated?
Blood transfusion
+ pneumonia antibiotics
ie Cephalosporin (cefotaxime) \+ Macrolide (Azithromycin)
What assessments do sickle cell pregnant women require?
Echocardiography- look for pulmonary hypertension
BP + urinalysis- higher risk of pre-eclampsia
U+E, LFTs- crises can damage liver or kidney function
Retinal screening- Proliferative retinopathy common
Iron levels- may need chelation due to transfusions
What prophylaxis and vaccines do hyposplenic patients need?
Daily Penicillin + Erythromycin
Vaccines: Hepatitis B Haemophilus influenza B Meningococcal H1N1 seasonal influenza Pneumococcal- every 5 years
What drug alterations should be made for sickle cell patients trying to conceive?
Stop ACEi and Angiotensin Receptor blockers
Start 5mg folic acid preconception
When can sickle cell prenatal testing be done?
8-10 weeks
For what Hb changes would transfusions be considered for sickle cell pregnant women?
If Hb falls to 6
or if Hb falls by 2g/dL from booking
What sickle cell complications in pregnancy would need an exchange transfusion?
Acute chest syndrome
Stroke
What pain relief should be used or avoided for sickle cell pregnant women with crises?
Use morphine/diamorphine
Avoid pethidine- increases risk of fits
What heparin regime should be given to sickle cell women after birth?
Heparin for 7 days if vaginal delivery
or for 6 weeks if caesarian
What is the maternal mortality associated with Eisenmenger’s syndrome and pulmonary hypertension?
30-50% so advise against pregnancy
Eisenmenger’s = right to left shunt
What thromboprophylaxis regime can be used for women with prosthetic heart valves?
Heparin IV on weeks 6-12 and 37 to term +7 days
Warfarin at other times
Why can’t Warfarin be used throughout pregnancy for women with prosthetic heart valves?
Fetal harm
What position should be avoided in labour for women with impaired cardiac function?
Avoid lithotomy position- causes dangerous rise in venous return after labour
Semi-sitting is best with short 2nd stage labour- instrumental delivery may be needed
In labour what drug should be avoided in mothers with cardiac impairment?
Ergometrine for expulsion of the placenta
use OXYTOCIN if necessary instead
Under what circumstances would a caesarian be given for a woman with cardiac impairment?
Only if she develops eclampsia should it be given. shouldn’t be done if she is in heart failure unless eclampsia occurs.
Rx for pregnant women who develop acute heart failure?
Furosemide 40mg IV slowly
Oxygen
Morphine 10mg IV
Ventilation if no improvement
Rx for pregnant woman with palpitations
ECG shows narrow complex tachycardia
Valsalva manoeuvre
Carotid massage
anaesthetise and cardiovert if unstable
IV adenosine if stable
What heart sounds can be normal in pregnancy?
Loud S1
an S3 heart sound
Ejection systolic murmur
What cardiac signs can be normal in pregnancy?
Pulsating neck veins (not raised JVP)
Oedema
Forceful apex beat
What CXR findings can be normal in pregnancy?
Slight cardiomegaly
Distention of pulmonary veins (due to increased plasma volume)
What signs are not normal in pregnancy?
A raised JVP in neck
Apex beat more than 2cm lateral to the midclavicular line
When is it best to hold off antidepressants until in pregnancy?
2nd trimester
Which antidepressants are typically prescribed in pregnancy?
Tricylics- AMITRIPTYLINE
blocks seratonin reuptake
What is the disadvantage of tricyclics in pregnancy?
Consequences of overdose are worse than SSRIs
What withdrawal symptoms of amitriptyline (TCA) are seen in neonates?
Agitation ± respiratory depression
(it’s an SNRI and 5-HT is involved in chemoreception at central respiratory centres, increases breathing rate so as conc lowers, so does breathing rate)
What withdrawal symptoms of imipramine (TCA) are seen in neonates?
(Imipramine also blocks serotonin uptake)
Colic
Spasms
Hypotension/hypertension (binds a-adrenergic Rs)
What withdrawal symptoms do neonates get from clomipramine (TCA) antidepressants?
Convulsions
What is the danger of using SSRIs in pregnancy for depression?
Persistent pulmonary hypertension of the newborn if used after 20 weeks gestation
Which SSRI in pregnancy is associated with least known risk?
Fluoxetine
Why is paroxetine SSRI contraindicated in pregnancy?
1st trimester- associated with cardiac malformations
withdrawal in neonate- convulsions
Which antidepressants have the lowest rate of transfer in breastfeeding?
Imipramine (TCA)
Nortriptyline (TCA)
Sertraline (SSRI)
Which antidepressants have the highest rate of transfer in breastfeeding?
Citalopram (SSRI)
Fluoxetine (SSRI)
What defects in the fetus is lithium therapy associated with?
Teratogenicity: Heart defects
ie Ebsteins abnormality
(displaced tricuspid valve allows back flow of blood into the R atrium)
For pregnant women who choose to stay on lithium therapy what investigation should be offered?
Fetal echocardiography at 16 weeks incase of heart defects
How should drug levels be monitored in women electing to stay on lithium during pregnancy?
Up to 36 weeks:
Measure 12hours after dose 4x a week
After 36 weeks:
Measure weekly
What lithium drug level is aimed for if continuing it in pregnancy?
As low as possible- under 0.4mmol/L
Can women taking lithium breastfeed?
No.
Can women with schizophrenia continue taking phenothiazines in pregnancy?
Yes = Dopamine 2 Receptor antagonist
What can phenothiazine use in pregnancy (for schizophrenia) cause in the newborn?
Phenothiazine = DA 2 R antagonist, causes parkinsonism symptoms in baby:
Hyperreflexia
Hypertonia
Tremor
Which antipsychotics can lead to raised prolactin levels and thus infertility?
Atypicals: Amisulpride
Sulpride
Risperidone
dopamine antagonists stop inhibition of prolactin
What can Olanzapine (anti-schizophrenic) cause in pregnancy?
Gestational diabetes due to weight gain. Atypicals are known to sometimes trigger metabolic syndrome
What side effects can anxiety medication cause in pregnancy?
Benzodiazepines- fetal malformation
Diazepam- floppy baby syndrome when withdrawal
b-blockers- retard fetal growth
What are the diagnostic indications for amniocentesis?
Prenatal genetic studies
Assess fetal lung maturity- if possibility of prematurity
Chorioamnionitis or TORCH infection (toxo, rubella, CMV, HSV, HIV)
Blood type, haemoglobinopathies
Neural tube defects
What is twin to twin transfusion syndrome?
Occurs with monochorionic pregnancies where placental vascular anastomoses cause disproportionate blood supplies.
One twin becomes anaemic- used too much oxygen
the other twin becomes plethoric and then jaundiced when red cells are destroyed at birth- used to too little oxygen
What structures need to be avoided during amniocentesis?
The umbilical cord and its insertion site.
Maternal bowel and bladder
What symptoms after amniocentesis are normal and which should be reported?
Expect: Mild cramping
Report: Vaginal bleeding/discharge, severe uterine cramping or fever
Avoid: coitus and anaerobic exercise for a day
Why might a genetic abnormality be detected in chorionic villus sampling but not in amniocentesis or fetal blood sampling?
Confined placental mosaicism- only the placenta contains the abnormality.
At inner cell mass stage, a few cells will derive the fetus and a few the placenta.
Could be only the placental precursors don’t correctly split the chromosomes (post-zygotic nondisjunction) or there’s trisomic rescue in the fetal cells (deletes extra chromosome)
What is antepartum haemorrhage defined as?
Bleeding from the genital tract after 24 weeks of pregnancy
What can cause antepartum haemorrhage?
Placental abruption- placenta separates from uterus lining
Placental praevia- placenta anchored in the lower uterine segment
Vasa praevia- fetal blood vesse;s running across uterine os
Genital tract source
What ares the dangers of anaemia in pregnancy?
Worsens postpartum haemorrhage
Predisposes to infection
Antagonises heart failure
Causes problems with postnatal malaria
Risk factors for placenta praevia
Age >40 Babies before (multiparity) Caesarian/ Previous uterine surgery Dilatation & cutterage (biopsies) Endometriosis + deficient Endometrial-manual removal of the placenta Fibroids Going smoking
What investigation best diagnoses a low lying placenta
Transvaginal ultrasound, not transabdominal
What investigation can be combined with ultrasound to diagnose vase praevia or placenta acreta?
3D Doppler USS /MRI
What is the most severe form of placenta praevia?
Major/Grade 4
Covers the internal os
How is major placenta praevia treated?
Caesarian section for delivery.
What are the different grades of placenta praevia?
- minor- placenta in lower segment, doesn’t extend to cervix
- minor- placenta extends to cervix, does not cover it
- major- placenta partially covers cervix
- major- placenta wholly covers cervix
What factors in placenta praevia would suggest caesarian is needed rather than vaginal delivery?
If placenta encroaches within 2cm of internal os
especially if it encroaches posteriorally or is thick
Why does placenta praevia predispose to postpartum haemorrhage?
Poor contractility of the uterus in the lower segment, where the placenta is lying.
If accreta suspected in a case of placenta praevia, when should the baby be delivered?
36-37 weeks with steroid cover and cross-matched blood available
Placenta weighs more than 25% of the baby and baby has proteinuria at birth and is swollen, what does this suggest?
Congenital nephrotic syndrome (HOP)
Common in Finnish population
Give 2 reasons why vasa praevia may occur?
- Velamentous cord insertion- cord inserts into chorioamniotic membranes instead of placenta, vessels are running with the cord
- Vessels may be joining an accessory lobe of the placenta to the main placental disk.
What are the issues of an anterior low-lying placenta?
During the caesarian the placenta may need to be parted to access the baby.
Also more possibility of accreta
What abdominal findings can be found with placenta praevia?
Soft uterus
High presenting part
25 year old, para 2 presents at 37 weeks
Pain at uterine fundus, fresh vaginal bleeding
Abdomen is hard and tender. Diagnosis?
- degenerating uterine fibroid
- pancreatitis
- placenta praevia
- torted ovarian cyst
- placental abruption
Placental abruption
Fundus where placenta normally is
What should be avoided with placenta praevia?
- Pervaginal examinations
2. PV intercourse
Why isn’t blood loss a good indicator of placental abruption severity?
Blood can collect behind membranes.
20 year old woman at 38 weeks gestation
Vaginal bleeding that started as membranes ruptured 20 minutes ago
CTG shows fetal bradycardia
Diagnosis?
Vasa praevia- stretching of os ruptures vessels
25 year old primip at 30 weeks
Fresh vaginal bleeding and abdominal pain
EHx: uterus is tender and irritable
Diagnosis?
Placental abruption
41 year old para 2 (caesarian sections) at 32 weeks
Heavy vaginal bleeding
Soft non tender uterus
Diagnosis?
Placenta praevia
RFs: age, babies before, caesarians
EHx typical
37 year old refugee, HIV positive
2/12 vaginal bleeding with intercourse
Diagnosis?
Cervical carcinoma
HIV increases risk
Definition of haemocrit?
Blood cells/Blood volume
22 year old primiparous woman
Vaginal spotting at 24 weeks gestation
Vulval itching and vaginal discharge
Diagnosis?
Vulvo-vaginitis (likely candida)
MCHC, mean corpuscular haemoglobin concentration
Hb concentration in a given volume of packed red cells
How does LMW heparin work?
Increases adhesion of anti-thrombin to factor Xa (10a)
What factors are involved in the intrinsic pathway of coagulation?
Factor 12, 11, 9, 8
Contact activation with damaged surface
What part of the clotting cascade does APTT measure?
The intrinsic, contact-activated pathway
Involves factors 12, 11, 9, 8
How does unfractionated heparin work differently to LMW heparin?
LMWH activates Antithrombin - inhibits factor Xa
UF heparin activates Antithrombin- inhibits factor Xa + thrombin
X > Xa
Prothrombin > Thrombin
Which proteins degrade Factor V and where is Factor V involved in the coagulation pathway?
Factor Va combines with Factor X to activate Thrombin
Protein S + Protein C degrade Factor V
Protein C resistance = factor V not degraded
Why is the Kleinhauer test used?
To determine how much fetal Hb is in the maternal blood stream and therefore whether fetal haemorrhage is the cause of fetal death
How does the Kleinhauer test work?
Acid is added to maternal blood which destroys adult Hb, leaving only the fetal Hb behind to be quantified.
Why might TSH be low in the first 20 weeks of pregnancy?
HCG suppresses it
What are the factors of hyperemesis gravidarum?
Persistent vomiting leading to:
5% of weight loss from pre-pregnancy weight
Ketosis
What are the risk factors for hyperemesis gravidarum?
Youth
Primips
Multiple
Molar pregnancy
PMH: diabetes,
hyperthyroidism,
psych illness,
eating disorder
FHx
SHx: non smokers, working women
What is thought to underlie morning sickness?
Steeply rising oestrogens
Excessively high levels of what are thought to cause hyperemesis gravidarum?
HCG
as molar and multiple pregnancy are RFs
If a woman has hyperemesis in one pregnancy, what is the likelihood of reoccurance?
15%
10% if she changes partner
How should hyperemesis gravidarum be investigated?
Urine dipstick- look for ketones
For guiding fluids: U+Es + Packed Cell Volume (FBC)
LFTs will be abnormal
TFTs- abnormality corresponds to severity of hyperemesis, indicates likely duration of hospital stay
Fluid chart, weights, BP lying and standing
USS- exclude twins or hydratidiform mole
How should Hyperemesis Gravidarum be managed?
Enoxaparin 40mg SC
Thiamine 40mg TDS (prevent Wernicke’s encephalopathy)
IV Saline + Potassium
Cyclizine 50mg TDS PO/IM for emesis
What things can help with hyperemesis?
Rest Ginger Pyridoxine- found in bananas, whole grains, avocados Dry bland food Carbonated drinks
What antiemetics are D2 antagonists
METOCLOPROMIDE
PROCHLOPERAZINE
CHLORPROMAZINE
DOMPERIDONE
Which antiemetic for pregnancy antagonises 5-HT 3 receptors?
ONDANSETRON
the only one with an S for Seratonin
Which antiemetic for pregnancy acts on antihistamine Rs?
Cyclizine
What are the potential side effects of phenothiazines like prochlorperazine or chlorpromazine (used for anti-emesis)?
Drowsiness
Extrapyramidal side effects- dystonia, parkinsonism
Oculogyric crisis- involuntary upwards looking
If someone has hyperemesis resistant to anti-emetics, what can be tried?
100mg BD Hydrocortisone
then 40mg Prednisolone OD
tapering down towards 20 weeks gestations
What do women taking steroids in pregnancy need to be monitored for?
UTIs
Gestational diabetes
What is anaemia in pregnancy defined as?
Hb below 11g/dL
How to treat iron deficiency anaemia in pregnancy?
Ferrous Sulphate 200mg OD
What can you give to anaemia patients not tolerating iron supplements?
What does it risk?
Parental (IV) iron
Anaphylaxis
After iron supplementation how long does it take for Hb levels to improve?
6 weeks
When should iron not be given for a microcytic anaemia?
When thalassaemia is suspected, iron levels will already be high.
Which thalassaemia is more severe for the fetus to have?
a thalassaemia is worse (as HbF is a2 y2)
b thalassaemia affects adult Hb (a2, b2)
How can thalassaemias be identified?
Chorionic villus sampling
What reduces risk of HIV transmission in pregnancy and peripuerium?
3 things
- Antiretroviral use
- Elective caesarian
- Bottle feeding
What should pregnant women found to be HIV +ve be tested for?
Antibodies against: Hep B + Hep C Varicella zoster measles toxoplasmosis
Genital tract infections
What vaccines should HIV +ve pregnant women be offered?
Vaccines for:
Hep B
Pneumococcus
Influenza
What are women with HIV in pregnancy more at risk of?
Infections
and thus, pre-term labour
What are women on HAART for HIV more at risk of?
Gestational diabetes
HIV +ve women taking prophylaxis against pneumocystis jirovecii (co-trimoxazole) should also take what in early pregnancy?
5mg folic acid
as trimethoprim in cotrimoxazole inhibits folate synthesis
For women who are HIV +ve not taking HAART, when should they start taking it in pregnancy?
Zidovudine from 20-28 weeks until delivered
What should you do if a HIV +ve woman’s membranes rupture earlier than 34 weeks?
Steroids- for lung development
Erythromycin
take normal HAART regime
may need zidovudine IV
Which women with HIV could have a vaginal delivery?
If viral load is below 50 copies per mL
or if on HAARt and viral load is below 400/mL
What monitoring investigation in labour should be avoided if a woman is HIV +ve?
Fetal blood sampling OBVS
What instrumentation is preferred in HIV +ve women?
Low cavity forceps
Appears to cause less fetal trauma than mid-cavity forceps or the ventouse (kiwi)
When should HIV women undergoing Caesarian have it?
At 38 weeks
unless viral load is under 50copies/mL, then 39 weeks + is fine
Which HIV +ve women should be offered caesarian?
3 reasons
- If viral load is above 50, or above 400 on HAART
- If coinfected with Hep C
- If on zidovudine monotherapy
What can be given after birth to suppress lactation in HIV mothers who can’t breastfeed?
1mg Cabergoline within 24 hours.
Dopamine agonist, acts on pituitary to suppress prolactin
What HAART regimen should new borns recieve after delivery if mum is HIV +ve?
Zidovudine BD for 4 weeks
HAART if mum is untreated/high risk
For babies at high risk of HIV transmission, what other medication should be given aside from HAART?
Co-trimoxazole to protect against pneumocystis jirovecii
What CD4 count is a contraindication for HIV +ve women to receive an MMR vaccine?
below 200/mL
as MMR is a live vaccine
What HbA1C is the aim for diabetic women before they conceive?
Below 6.1%
Avoid conception is above 10%
What supplement should diabetic women take before conception?
5mg folic acid
What diabetic medications should be stopped before pregnancy?
Oral hypoglycaemics- except metformin
Statins
ACEi/ A2R blockers
What are the maternal risks of diabetes?
Unawareness of hypoglycaemia
Hydramnios-(could be due to fetal polyuria)
Preterm labour
Stillbirth
What are the risks of diabetes to the fetus?
CVS + CNS malformation
Macrosomia- more glucose not taken up by cells
Growth restriction
Rarely sacral agenesis (no sacrum bones, bad bad)
What are the risks to the neonate when the mother is diabetic?
name 4 things
Hypoglycaemia- persistent high insulin levels with sudden loss of glucose
Low Ca2+ or Mg2+- due to low maternal levels with polyuria
Respiratory distress syndrome- high insulin interferes with steroid maturation of lungs perhaps
Polycythaemia (jaundice)- high insulin increases metabolic rate, increasing oxygen requirements and predisposing to hypoxia
What is the fasting sugar level at which you would diagnose gestational diabetes?
5.6mmol or over
What is the 2 hour glucose level that suggests gestational diabetes?
7.8mmol/L or over
What values would prompt referral of diabetic mother to nephrologist?
Creatinine above 120micromol/L
or protein excretion more than 2g/24 hours
What diabetic medication is used in pregnancy?
Metformin
Insulin
Why should maternal hyperglycaemia be avoided during labour in diabetic mothers?
High glucose leads to high insulin levels
predisposes the baby to hypoglycaemia when the glucose source suddenly dissappears
What should be aimed for in the labour of diabetic mothers?
Deliver at 38 weeks
Vaginally
Give insulin to prevent hyperglycaemia
Aim for under 12hours
What complication is increased in delivery of diabetic mother’s babies?
Shoulder dystocia
What insulin and glucose can be given to mothers electively giving birth who have diabetes?
Night before- normal insulin
On day-
1L 5% Dextrose /8 hours IV
1-2U Insulin/ hour via pump
Aim: 4.5-5.5mmol/L check hourly
How is the timing of cord clamping related to polycythaemia risk?
The cord transfers the placental reservoir of RBCs to the newborn after birth, 75% are transferred in the first minute so depending when it is clamped, more or less RBCs will be recieved by the fetus.
Which diabetic medications are allowed when breastfeeding?
Metformin- increases insulin sensitivity
Glibenclamide- acts on Katp channels in pancreatic b cells
How is gestational diabetes defined?
> 7.8mmol/L glucose on the Oral Glucose Tolerance Test
What proportion of gestational diabetics become diabetic after pregnancy?
50%
What hyperthyroid treatment is contraindicated in pregnancy?
radioactive iodine
What thyroid drug is recommended for hyperthyroidism in pregnancy and breastfeeding?
Propylthiouracil
inhibits conversion of iodide into iodine for hormone production
preferred to carbimazole, less concentrated in breast milk too
What can be done for hyperthyroidism in pregnancy if drugs don’t work?
and when?
Partial thyroidectomy in 2nd trimester
At onset of labour woman starts to become feverish, tachycardic, agitated, psychotic.
DHx propythiouracil
Whats the diagnosis?
Thyroid storm
What consequences can occur from fetuses having TSH-receptor antibodies?
Fetal hyperthyroidism- premature delivery
Craniosynostosis (skull sutures are fixed) - intellectual impairment
Goitre- polyhydramnios as fetus doesn’t swallow enough amniotic fluid
How much should levothyroxine be increased by when a woman finds out she is pregnant?
30%
What TSH should a woman with hypothyroidism aim for in pregnancy?
below 2.5mu/L
For women with gestational diabetes, how long should you trial diet and exercise before switching them onto oral hypoglycaemics?
1-2 weeks
How to Rx postpartum thyrotoxicosis?
b- blockers (symptomatic)
antithyroid drugs don’t work as the gland is releasing more due to it being attacked not because it is synthesising more
monitor for permanant hypothyroidism
What proportion of women giving birth undergo thyrotoxicosis for 4 months, which eventually resolves?
5%
90% have antiperoxidase Abs. Hyperthyroidism then hypothyroidism
5% develop permanent hypothyroidism
Mother has had Grave’s disease in past
At 37 weeks fetus’ heart rate is 170/min
Diagnosis + Rx?
Neonatal thyrotoxicosis
Mother’s TSH-R stimulating Abs cross placenta
Test thyroid function in baby
May need antithyroid drugs
What are the different antibodies associated with thyroid disease?
TSH R-stimulating antibodies: Graves’ disease
Antiperoxidase antibodies: thyroiditis
Thyroid antibodies: can occur in pregnancy
What tests should you do for a pregnant woman with jaundice?
Urine test for bile- obstructive cholestasis (alk phos high)
Serology- hepatitis
LFTs- hepatitis (massive AST, ALT increase)
Ultrasound- obstruction, fibrosis
Woman in third trimester, intractable itching. Gravida 2 para 1
Previous pregnancy, lots of itching too.
ALT 250 iU/L, AST 250iU/L, Bilirubin 3.1, yGTP= normal
Serum bile acids- 10x normal level
R upper quadrant USS= normal
Viral serology= normal
Diagnosis?
Intrahepatic (obstructive) cholestasis
Bile can’t get out of the hepatocyte
No abdo pain or fever making choledocolithiasis unlikely
No dilatation of bile duct making cholangitis unlikely
Normal yGTP- making primary biliary cirrhosis unlikely
Serology- not hepatits
What Rx can you offer a pregnant woman with intrahepatic cholestasis?
Cholestasis- bile can’t get out of hepatocyte cells
Vitamin K to woman and baby at birth
Ursodeoxycholic acid reduces pruritis and abnormal LFTs
When should pregnancy associated- obstructive cholestasis resolve?
Within days of delivery
When do pregnant women get obstructive cholestasis?
Third trimester when levels of oestrogen are highest- exact mechanism unknown
What type of contraception should women who have had pregnancy-related intrahepatic cholestasis avoid?
Oestrogen containing contraaceptive pills because it is the high levels of oestrogens thought to prompt the cholestasis in pregnancy.
Pregnant woman gravida 1 para 0 comes in with jaundice, vomiting and abdo pain.
BP is mildly raised
AST + ALT 300iU/L, WCC raised, Prothrombin Time increased
Urinanalysis- trace protein
What is diagnosis and differential?
Acute Fatty Liver of Pregnancy (1 in 10000)
Micro-droplets of fat in liver cells
Normalish BP and urinalysis make HELLP and Atypical Pre-eclampsia less likely
Coagulopathy (^PT time) + jaundice make Fatty Liver more likely
Abdo pain makes fatty liver more likely than cholestasis
What symptoms or test findings make fatty liver more likely than HELLP or atypical pre-eclampsia?
Hypoglycaemia (as liver fails to break down glycogen)
Encephalopathy
Coagulopathy
Not very raised BP or urine protein
What Rx should be offered to women with Acute Fatty Liver of Pregnancy?
Treat hypoglycaemia vigorously (protect from neonatal hypoglycaemia)
Correct clotting disorders (in preparation of birth)
Fresh frozen plasma, cryoprecipitate, RBCs, platelets PRN
Supportive treatment for liver and renal failure- fluids
Which viral hepatitis is associated with high mortality rates in pregnancy?
Hepatitis E
Under what circumstances would you offer a pregnant woman with viral hepatitis a caesarian section?
If she has HIV also
When should you check a baby for Hep C RNA if the mother is Hep C +ve?
after 2/3 months and again at 12 months
anti HCV Abs at 12-18 months
Why might someone with pre-eclampsia get jaundice?
DIC- tissue factor from high BP damage to endothelium HELLP Fatty liver (rare)
Causes of jaundice in pregnancy:
Pregnancy specific:
intrahepatic cholestasis (itchy)
acute fatty liver (low BM, clotting abnormal)
hyperemesis gravidarum- 1st trimester (ketones)
pre-eclampsia (BP, ketones)
HELLP- haemolysis, elevated LFTs, low platelets
Viral hepatitis (serology)
What does HELLP stand for?
Haemolysis, elevated LFTs, low platelets
in 16% of cases it coincides with pre-eclampsia
28 weeks pregnant woman, gravida 1 para 0 with twins
was hypertensive, prescribed methyldopa and has progressively increasing aminotransferases.
platelets are normal, urine dip: 1+ protein
hepatitis serology- autoimmune and viral is normal
differential + management?
Severe pre-eclampsia, toxicity to methyldopa, acute fatty liver.
Switch methyldopa to labetalol for her HTN
Give corticosteroids incase early delivery is needed
Monitor LFTs in hospital
28 week pregnant woman with a history of mild hypertension, urine dip: 1+ protein, raised serum aminotransferases was admitted to hospital.
platelets were normal, hepatitis serology normal.
36 hours later thrombocytopenia has arisen, BP has steadily risen and headache onset. Her ALTs + ASTs continue to climb
Diagnosis and management?
HELLP syndrome
Elevated LFTs + Low platelets
Deliver asap
Try to give steroids for lung maturation if she hasn’t already had.
What kind of ALT’s would you expect in jaundice caused by hyperemesis gravidarum in pregnant women?
Below 200iU/L
Pregnant woman presents with fever and sweating
she recently went to visit family in Malawi
Possible diagnosis and investigations?
Malaria
Thick and thin blood films
Pregnant woman with malaria is found to be unconscious
She was started on quinine a few days ago
What could have happened?
Investigations?
Hypoglycaemia or cerebral malaria
Check blood glucose, as quinine and malaria both cause low glucose.
Rx for pregnant woman with severe Falciparum malaria?
ARTESUNATE 2.4mg/kg IV
then ARTESUNATE + CLINDAMYCIN PO when possible
or
QUININE in 5% glucose
What are the possible complications to the mother of malaria in pregnancy?
HA SPR
Hypoglycaemia- especially if on quinine
Anaemia- may need packed red cells + furosemide 20mg
Sepsis
Pulmonary oedema
Renal failure
How should uncomplicated Falciparum malaria be treated in pregnancy?
Quinine 600mg
+ Clindamycin 450mg TDS
How should non-resistant vivax + ovale malaria be treated during pregnancy?
Chloroquine PO 3 days
then weekly to prevent reoccurence
3 months after delivery give
PRIMAQUINE
If mother had malaria during pregnancy, what should you do after birth to see if the baby got it?
Send placenta for histology
and bloods from the cord, placenta and baby 4x a week
Pregnant woman going to a malarial area, what should she take?
Any additional medications?
Chloroquine + Proguanil if Falciparum is sensitive
+ 5mg folic acid with Proguanil
Mefloquine if malaria is resistent
In which trimester is malarial prophylaxis an issue?
1st trimester
What is the benefit on pregnant women who live in malaria endemic areas of giving them chemoprophylaxis?
What chemoprophylaxis can you give?
Better neonate birthweight
Higher red cell mass in mum
Sulfadoxine-pyrimethamine
but increasing resistance and rarely cases of Steven Johnson syndrome occur.
What creatinine and urea values in pregnancy would prompt investigation of renal function?
Creatinine above 75umol/L
Urea above 4.5mmol/L
Pregnant woman has no symptoms
Urine dip + WCC, + nitrites on two mid-stream urines
Rx?
Asymptomatic bacteruria
Amoxicillin 250mg TDS with high fluid intake
Check for cure in 1-2 weeks
Why are pregnant women screened for asymptomatic bacteruria?
High risk of developing pyelonephritis as ureters and calyces are dilated.
Rx for pyelonephritis during pregnancy
Fluids + bed rest
Blood + urine culture then
AMPICILLIN 500mg QDS IV
for 2-3 weeks, G +ve and G-ve cover
Once a woman has had pyelonephritis in pregnancy what monitoring should be undertaken?
Mid-stream urine every 2 weeks
Ultrasound at 16 weeks postpartum can be considered if renal tract abnormality suspected
Pregnant woman has had repeated urinary tract infections, Rx?
Nitrofurantoin 100mg PO OD with food
attacks bacterial ribosomes
When is the antibiotic nitrofurantoin (for recurrent UTIs) not a good idea? In pregnancy
When GFR is below 50mL/min
(nephrotoxic)
SEs: vomiting, peripheral neuropathy, liver damage
What complications need to be looked for in pregnant women with chronic renal failure on dialysis?
Fluid overload
Hypertension
Pre-eclampsia
Polyhydramnios
Where pregnant women get acute tubular necrosis and need to be catheterised, what urine output should be the aim?
30mL/hour
What complications can arise in pregnancy for those with epilepsy?
3rd trimester vaginal bleeding- possibly related to folate deficiency from antiepileptic medications
1% convulse in labour
What do anti-epileptic drugs put foetuses at risk of?
Enzyme inducers- haemorrhagic disease of newborn
Malformation with valproate,carbamazepine or lamotrigine
depends on dose and how many anticonvulsants used
What are the features of fetal valproate syndrome?
L SOAS
L SOAS
Long thin upper lip
Small ears + nose + jaw
Organ anomalies
Autism
Shallow philtrum
Which epileptic drugs are associated with cleft lips In newborns?
Phenytoin
Phenobarbital
(also congenital heart disease)
Which epileptic drugs are associated with neural tube defects?
Valproate
Carbamazepine
screen for them
What is the antiepileptic of choice in pregnancy?
Carbamazepine
still associated with congenital malformation + neural tube defect
What non-epileptic related medication should a pregnant woman with epilepsy take?
5mg folic acid OD
20mg Vitamin K from 36 weeks if taking enzyme inducers
carbamazepine, phenytoin, phenobarbital
Which epileptic drug can cause drowsiness of baby if taking it whilst breastfeeding?
Phenobarbital
Rx of rheumatoid arthritis in pregnancy?
Give sulfasalazine + extra folate
Which rheumatoid arthritis drugs are not recommended for pregnancy?
Methotrexate is contraindicated
Azathioprine can cause growth restriction- impact on immune system, may affect spiral artery conversion
Penicillamine may weaken fetal collagen
When can NSAIDs be taken in pregnancy for rheumatoid arthritis?
Why?
1st and 2nd trimester
In 3rd trimester impact on prostaglandin levels may cause premature closure of ductus arteriosis and renal impairment
When is it feasible for women with SLE to consider pregnancy?
After 6 months of stable disease status without using cytotoxic drugs.
What drugs to treat women with SLE on during pregnancy?
azathioprine (even though it’s avoided in RA)
hydroxychloroquine
aspirin 75mg for pre-eclampsia risk
What risks does the foetus face if the mother has SLE?
Sunlight-sensitive rash (which doesn’t require treatment)
Anti-Ro/anti-La may damage heart conduction causing congenital heart block= requires a pacemaker
Mother with SLE is taking 7.5mg PREDNISOLONE daily in 2 weeks before birth. What medication does she require in labour?
Hydrocortisone 100mg per 6 hours IV
to mimic physiology of birth with rise in cortisol now that endogenous steroid production is reduced
What test findings and PMH are defining features of antiphospholipid syndrome?
lupus anticoagulant
or anticardiolipin antibodies
on 2 tests taken 8 weeks apart
± past arterial thrombosis
venous thrombosis
recurrent pregnancy loss
What is the likelihood of a live birth for women with untreated antiphospholipid syndrome?
under 20%
thromboses in the placenta lead to 1st trimester loss due to placental insufficiency and growth restriction
How can women with antiphospholipid syndrome be treated in pregnancy to reduce fetal loss?
75mg aspirin- from conception
High dose LMWH if previous VTE
Low dose LMWH if no VTE
from when fetal heart is seen at 6weeks ish to 34 weeks
What is the difference between chronic and gestational hypertension and pre-eclampsia?
Chronic HTN- predates pregnancy or 20 weeks gestation
Gestational HTN- comes on after 20 weeks, no proteinuria
Pre-eclampsia- HTN + proteinuria
What antihypertensives should be changed pre-conception for those considering pregnancy
STOP
ACE inhibitors- ramipril
Angiotensin 2 Receptor blockers- losartan
Chlorothiazide- thiazide
Which antihypertensives are okay in pregnancy?
b blockers: Atenolol + Labetalol + Metoprolol
Methyldopa
What BP should be aimed for in pregnant women with chronic hypertension without end organ damage?
BP under 150/90
What BP should be aimed for in pregnant women with chronic hypertension with end organ damage?
Under 140/90
+ diastolic above 80
When should pregnant women with chronic hypertension start aspirin?
From 12 weeks until the baby is born
How regularly should women have their blood pressure checked in labour if they have PMH of chronic hypertension?
hourly if BP is below 159/109
continuously if BP is above 160/100 mmHg
How does active management of the third stage of labour change if a woman has a history of hypertension?
Oxytocin is given alone
No ergotamines
When should a woman have her BP checked if shes just given birth and has a PMH of chronic hypertension
Day 1 + 2 + 3/4/5
What antihypertensive should be changed after delivery in women with chronic hypertension?
Methyldopa- predisposes to postnatal depression
Which classes of hypertensives are okay or not when breastfeeding?
b-blockers and ACEi = okay
diuretics = avoid
What tests need to be performed with gestational hypertension (comes on after 20 weeks gestation)?
Urine dip- proteinuria
Protein creatinine ratio
Pregnant woman at week 23 has a BP of 145/95mmHg
How should she be managed?
Weekly urine dips and BP
Pregnant woman at 25 weeks has blood pressure of 155/105
no history of hypertension before
management?
IHx: BP and urine dips twice weekly
As BP is above 150/100 give
LABETOLOL
What blood pressure with gestational hypertension would provoke admission to hospital?
A blood pressure above 160/110
Woman has gestational hypertension, BP of 161/110
Management?
Admit to hospital IHx: BP 4x a day Daily urine Weekly FBC, U+Es, AST/ALT, bilirubin Fortnightly ultrasound
In pregnancy how does hypertension affect mode of delivery?
Should there be any change to medication?
Maintain antihypertensives during labour
Monitor BP hourly or continuously (if above 169/110)
If above 160/110 consider c-section
What are the soft ultrasound signs for Downs?
Fetal nasal bone appearance Doppler velocity wave form in: the ductus venosus tricuspid regurgitation Nuchal thickening Chorioid plexus cysts Echogenic bowel
What material is analysed in preimplantation genetic diagnosis?
1st polar body of the egg
2nd extruded polar body of zygote
Blastomeres from embryos at day 5-6
Pregnant woman comes in, she’s 31 weeks pregnant
PC: sudden onset breathlessness, chest pain
Obs: T of 38 degree
CXR normal
Tests?
Any precautions regarding tests?
Could be pulmonary embolism
ABG: reduced PaO2 and PaCO2
Scan legs for venous thrombi
if none found:
V/Q scan (increases risk of cancer to fetus)
CTPA (increases risk of breast cancer in mum and fetal hypothyroidism)
fetal hypothyroidism due to iodinated contrast used.
If pregnant woman with signs of PE is found to have thrombi in legs on scanning, does she need any other tests before treatment?
No further imaging needed (VQ scan or CTPA) but should do: FBC U+Es- check hydration status (RF) coagulation screen LFTs- incase of liver failure
Rx: small- LWMH, massive- unfractionated heparin + thrombolysis
How might a massive Pulmonary Embolism present in a pregnant woman?
PC + EHx
PC: Collapse, cyanosis, chest pain
EHx: raised JVP (pulmonary hypertension
third heart sound
parasternal heave (R ventricle enlargement)
What management can be used for massive pulmonary embolism in pregnant women?
Prolonged cardiac massage
Percutaneous catheter thrombus fragmentation
Thrombolysis
Pulmonary embolectomy- clot removal (often last resort)
Pregnant woman has massive pulmonary embolism, is treated with percutaneous catheter thrombus fragmentation.
What medication should she be given after?
Post-thrombolysis- continuous IV unfractionated heparin
No thrombolysis- STAT dose first as loading dose
then LWMH
Once unfractionated heparin is given for a massive pulmonary embolism in a pregnant woman, how should it be monitored?
What is the aim value?
APTT:
(activated partial prothrombin time)
at 6 hours from loading dose
after dose changes
at 24 hours
Target APTT: 1.5-2.5
What side effects are associated with unfractionated heparin in pregnancy given at high doses to treat VTE?
maternal osteopenia (reversible)
thrombocytopenia- monitor platelets every 2 days from day 4
alopecia
How should small pulmonary emboli be treated in pregnancy.
When should it be stopped?
Enoxaparin 1mg/kg BD SC (based on early pregnancy weight)
Stop at onset of labour or 24 hours before planned delivery
Conradi-Hünermann Syndrome
what is it
what’s it caused by?
caused by Warfarin in 1st trimester pregnancy
Cataracts Optic atrophy Nasal hypoplasia Reduced IQ A bit small
After a small pulmonary embolism in pregnancy, how long should treatment be given?
Throughout pregnancy
and for 6 weeks post partum
and at least 3 months after the emboli
Pregnant woman has discomfort in L leg and some swelling. What tests?
Deep vein thrombosis
FBC: raised WCC
Compression duplex ultrasound
What findings in a suspected deep vein thrombosis would suggest it’s a iliac vein thrombosis and how would this effect management?
Back pain or entire limb swollen
changes:
IHx: MRI or contrast venography
Rx: inferior vena cava filter
If a pregnant woman is on LMWH, how long do you have to wait before giving regional anaesthesia- like a epidural?
24 hours- risk of spinal haematoma?
After a DVT and enoxaparin Rx, how soon can Rx be restarted after birth?
3 hours in caesarian
or 4 hours after epidural siting
How does therapeutic enoxaparin regimen change before and after birth?
(therapeutic = given for DVT or PE)
1mg/kg BD before birth
1.5mg/kg OD after birth
If a woman who has just given birth would prefer to have her clotting risk managed after a DVT with Warfarin, how long should you wait before commencing and is it safe to breastfeed on it?
Start warfarin 3 days postpartum
Warfarin and heparin are safe to breast feed with
If a pregnant woman has a PE/DVT during pregnancy, how long should she wear compression stockings for?
2 years
halves relative risk of post-thrombotic syndrome
What is Factor V Leiden?
What risk does it pose
Factor V is needed to combine with Factor Xa to convert
prothrombin to thrombin
= protein C resistance where factor V isn’t broken down by protein C
in 4% of population
heterozygotes have 7x risk of VTE
homozygotes have 25x risk of VTE
What impact does protein C and protein S deficiency have?
=thrombophilia
protein C and S break down factor V
Factor Va + Factor Xa turn prothrombin into thrombin
How does antithrombin deficiency have an impact?
mechanism
Thrombophilia
Antithrombin breaks down Factor Xa and Thrombin
What is acquired thrombophilia?
what are the risks?
Lupus anticoagulant ± anticardiolipin antibody
Risk of arterial and venous thrombosis, particularly in portal veins or arms
What pregnancy complications would prompt a screen for thrombophilia defects?
second trimester pregnancy loss
severe/recurrent pre-eclampsia
intrauterine growth restriction
Which thrombophilias pose an increased risk of pre-eclampsia and should be started on 75mg Aspirin from 12 weeks?
Factor V Leiden Protein C deficiency Protein S deficiency Cardiolipin antibody (acquired thrombophilia)
Maculopapular rash in pregnant woman.
What do you want to rule out?
Rubella
Parvovirus B19
Measles
Mother gets measles 6 days before birth or 6 days after birth, what Rx for the baby?
Human immune globulin 0.6mL/kg (up to 5mL) to prevent infection
Pregnant mother gets itchy chicken pox rash at week 21, Rx?
After 20 weeks, give:
oral aciclovir- if already having the rash it’s too late for IV Ig
In what circumstances of a pregnant mother getting chicken pox would you hospitalize for IV aciclovir rather than oral?
If immunosupressed, dense or haemorrhagic lesions, neuro/resp symptoms- IV aciclovir
If in contact with chickenpox, no rash yet and no varicella Ig- give IV Ig
If 20 weeks pregnant, within 24 hours of rash onset: PO aciclovir
What constitutes ‘contact’ when determining if a pregnant mother has been ‘in contact’ with someone with a rash
15 minutes around them
live in same household
face-to-face contact- conversation
Pregnant woman had a conversation with someone who turned out to have a rash, what tests should be done?
When is test not needed?
Parvovirus B19 serology
Rubella serology
Don’t test if mother has :
2 rubella Ab levels above 10iU/mL
2 rubella vaccinations
1 vaccination + 1 high Ab level
Pregnant mother has a child who contracts chicken pox, she is not sure if she has had it before.
Management?
Urgent blood test to check for VZV antibodies
if negative >
Varicella zoster immune globulin within 10 days of exposure
‘see your GP if you develop a rash’
When does rubella pose the greatest risk to the fetus?
What is the risk of fetus being affected?
1st trimester worst
55% affected in 1st trimester
5% affected in 2nd trimester infection
If suspect pregnant woman has been in contact with rubella, how is it investigated?
Look for increase in IgG antibody levels 10 days apart
and IgM antibodies 4 weeks from contact
Which infection causes more congenital retardation if contracted during pregnancy?
Cytomegalovirus
moreso than rubella
What effects can CMV have on fetal development?
ears and eyes and nose and mouth
chorioidoretinitis
deafness
microcephaly, cerebral calcification (low IQ)
hydrops (fluid in compartments ie ascites)
How can CMV transmission be determined in the fetus?
and in the baby?
Amniocentesis at 20 weeks + viral culture
Post birth:
Throat swab
urine culture
baby’s serum.
How can reactivation of CMV in pregnancy (benign) be distinguished from new infection (dangerous)?
Serology pre-pregnancy
IgG avidity indicates recent infection or previous pretty well.
Pregnant woman has high temperature, very sore throat and swollen glands.
She also has a cat.
What are you worried about?
How to test?
Toxoplasmosis
gives an glandular fever-like presentation
IHx: IgG and IgM
Toxoplasmosis Rx in pregnancyif mother is affected?
Spiramycin 1.5mg BD (macrolide)
Toxoplasmosis Rx for mum in pregnancy if fetus is affected?
Loading: Pyrimethamine 50mg BD on day 1
Ongoing until delivery:
Pyrimethamine 1mg/kg OD
+ Sulfadiazine 50mg/kg BD
+ Calcium Folinate 15mg twice weekly
Pyrimethamine interferes with dihydrofolate reductase
How to treat a neonate who has toxoplasmosis?
4-weekly course of:
pyrimethamine
sulfadiazine
calcium folinate
then 4 weeks of: spiramycin macrolide
+ Prednisolone until CNS inflammation or choroidretinitis abated
If pregnant mother found to have syphilis, what Rx can reduce chance of fetus being still born?
Procaine Penicillin 600mg OD IM for 10 days
What tests suggest a newborn has been affected by syphilis?
Nasal discharge exam: spirochetes
Xrays: perichondritis (affects cartilage)
CSF: raised monocytes and protein, serology +ve
Rx of neonate with syphilis?
Procaine penicillin 37mg/kg OD IM for 3 weeks
What foods may transmit Listeria to pregnant mothers?
Milk
Paté
Soft cheeses
Pregnant woman has had unexplained fever for 48 hours, how can Listeria be tested for?
What are the other possible PCs?
Blood culture
As commensal, swabs and serology don’t help
Myalgia Headache Sore throat, cough Vomiting, diarrhoea Vaginitis
What may be the complications of a neonate who gets Listeria?
QRS
Q- convulsions, conjuctivitis
R- respiratory distress due to pneumonia, rash
S- spleen/liver is big, small WCC
How can neonatal Listeria be tested for?
Blood, CSF, meconium and placental culture
Rx for neonate with listeria?
Gram-positive anaerobe
Ampicillin 50mg/kg QDS (gram +ve and gram -ve)
Gentamycin 3mg/kg BD
for 1 week after fever subsides
What does TORCH stand for?
Screen in pregnancy:
Toxoplasmosis Other (syphilis, cocksackie, chicken pox, leptospira, Q fever, lyme disease, malaria) Rubella CMV Herpes, HIV
When do most neonatal transmissions of Hep B occur?
During birth
although in the East it may be transplacental, hence failure of the vaccination attempts
Mother of baby is found to be HBsAg +ve during pregnancy, how should baby be managed post-birth?
Immunoglobulin 200U IM
Hep B vaccination
Baby is born to Hep B +ve mum, given IM Ig and vaccination. What signs at three months would indicate that the virus has been cleared?
HBV DNA cleared
anti-core antibodies present
anti-HBe antibodies
HBeAg and ABsAg decline at 3 months
What test should be done on a HepB exposed baby to demonstrate the child is protected after vaccination and Ig?
Serology at 12-15 months:
HBsAg -ve
anti-HBs +ve
What is the progression of HepE in pregnant women prior to death?
When do they tend to die?
After birth:
Hepatic failure
Coma
Massive post-partum haemorrhage
What can Herpes Simplex cause in the neonate?
blindness low IQ, epilepsy DIC, jaundice respiratory distress death
What are the high risk groups that should take 75mg Aspirin to prevent pre-eclampsia in pregnancy?
gestational hypertension
chronic kidney disease
autoimmune disorders such as SLE or antiphospholipid syndrome
type 1 or 2 diabetes mellitus
If a mother contracted Herpes Simplex for the first time in pregnancy, what Rx would you offer?
(note it depends on the trimester it was contracted in)
If primary infection + third trimester that she’s become infected:
Oral aciclovir/vanciclovir
± elective caesarian (if birth is in the 6 weeks after infection)
Pregnant mother ruptured membranes 4 hours before, midwife has noticed some warts around vagina.
No PMH of herpes reported
How should delivery be managed?
Caesarian section
vaginal transmission of HSV to baby is 40%
Mother with vaginal warts is adamant that she wants a vaginal delivery, despite risk of transmitting Herpes Simplex to baby. How should she be managed?
IV aciclovir in labour try to avoid: fetal blood sampling instrumental delivery scalp electrodes
high dose aciclovir to baby once born
- do PCR of baby at birth
How does a neonatal present with herpes simplex infection?
Vesicles around site of trauma or presenting part
Periocular lesions
Conjunctival lesions
Pregnant woman comes into contact with person with chicken pox, she doesn’t think she’s ever had it before?
Test and Rx?
Test: varicella antibodies
Rx: Varicella Zoster Ig
‘notify doctor if you develop a rash’
Pregnant woman exposed to chicken pox develops a rash.
Rx?
After 20 weeks gestation
Oral aciclovir 5x day
for 7 days
Mother gets chicken pox in first trimester, not thought to have been infected with it before.
How should she be followed up to see if Fetal Varicella Syndrome has occurred?
Infection between 3-28 weeks requires:
detailed ultrasound at 16-20 weeks
or 5 weeks post-infection
Neonate develops conjunctivitis on day 10 post-partum
Mother is known to have chlamydia
Rx for baby?
Rx for parents?
Baby- eye cleansing + Erythromycin 12.5mg/kg QDS
Parents- Erythromycin or Azithromycin 1g PO one dose.
How does chlamydial and gonococcal conjunctivitis present differently in the neonate?
Chlamydia: minimal inflammation, slight purulent discharge
PC on day 5-14
Gonococcal: purulent discharge, lid swelling ± corneal rupture/hazing
PC on day 4
Rx + prophylaxic Rx for neonatal gonococcal conjunctivitis?
Active infection of newborn:
Benzylpenicillin
Chloramphenical eye drops every 3 horus for 7 days
Prophylaxis if mum has active infection:
Cefotaxime 100mg/kg STAT IM
Chloramphenicol eye drops within 1hour of birth
Neonate under 21 days has purulent discharge coming from the eye, what is the differential?
Opthalmia neonatorum:
viral: Chlamydiae Herpes virus bacterial: Staphylococci Streptococci Pneumococci Gonococci E Coli
What are the indications regarding group B strep for giving a woman IV antibiotics in labour?
+ve Group B Strep swab (at 35-37 weeks)
previous baby had Group B Strep
Cultured GBS on urinalysis during pregnancy
Intrapartum fever
Culture GBS unknown + membranes ruptured longer than 18 hours
Which babies should receive a BCG after birth?
If they:
are born into households with TB
have mothers from endemic areas
will travel to TB endemic areas
(0.05mL intradermal at the deltoids)
Mother had cough, fever and not much weight gain during pregnancy, has just given birth and is found to have active TB.
How long must mum be isolated for?
Rx for baby?
Rx for mum?
Separate mum from baby whilst giving her RIPE:
Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
after 2 weeks and sputum -ve, may be reunited.
Baby Rx:
BCG vaccination
+ Isoniazid until +ve skin reaction
Woman 30 weeks pregnant:
PC: Abdominal pain, vaginal bleeding
EHx: rigid tender uterus
- diagnosis?
- differential?
- management?
- complications?
- placental abruption
- rectus sheath haemotoma- ultrasound to decide
- try to deliver baby
- if 50% of placenta affected- likely fetal demise
DIC
postpartum haemorrhage
Woman 34 weeks pregnant
PC: abdominal pain, hasn’t peed in hours
PMH: fibroids
EHx: tense uterus, difficulty catheterising
diagnosis
Uterine Torsion- very rare
often diagnosed by laparotomy
deliver with caesarian
What are the risks of appendicitis in pregnancy?
Higher mortality
Perforation
Fetal mortality (1% of time, 30% of perforations)
Similarities and differences between presentation of appendicitis in pregnancy Vs normal individual?
Similarities:
Right low quadrant pain commonest
Need to Rx with surgery- often laparoscopy in both cases
Differences:
can be subcostal or para-umbilical in pregnancy
Tenderness + guarding less obvious in pregnancy
- instead uterus becomes rigid and woody-hard
obstetrician performs surgery
patient is tilted 30 degrees to left
Why is cholecystitis more common in pregnancy?
Gallstones form with
increased biliary stasis (progesterone relaxes muscles)
and increased cholesterol in bile
(cystitis= inflammation of cystic duct containing bile)
Pregnant woman has subcostal pain, nausea and vomiting.
Tests?
Management?
Differential: appendicitis or cholecystitis
IHx: ultrasound- gallstones or appendicitis
if inconclusive- MRI
if can’t exclude appendicitis- laparoscopy
Rx: appendicitis- surgery
cholecystitis- conservative
if complicated and non-resolving cholecystitis- laparoscopic surgery
How is pancreatitis in pregnancy tested for in first trimester?
Urinary diastase
amylase may be low
How is postmaturity defined in obstetrics?
Pregnancy exceeding 42 weeks
What are the possible issues for neonates of being born after 42 weeks?
Placental insufficiency
Larger fetus
Skull more ossified and less mouldable for labour
Increased meconium passage in labour
Increased fetal distress in labour
What options can be offered to a woman at 41 weeks gestation in pregnancy to prompt initiation of labour?
- membrane sweep
- induction (vaginal prostaglandin, then oxytocin)
- if the above is declined, twice weekly CTG + USS
Mother has genital herpes during pregnancy, how does the timing of this determine whether she should be routinely offered a caesarian section or not?
Herpes in 3rd trimester- offer
Recurrent herpes at term- don’t offer
Which antibiotics should be avoided with breastfeeding?
Ciprofloxacin
Chloramphenicol
Tetracycline
Sulphonamides
What dose of folic acid should be taken as standard in pregnancy?
400micrograms
Neonate born prematurely, xray shows bilateral ground glass appearance of lungs. Diagnosis?
Respiratory distress syndrome
Abdo xray signs is baby has bowel perforation?
Air in peritoneal cavity:
Look for football sign, air under diaphragm, visible ligament of liver demarcated by air either side
Kernicterus is the build up of unconjugated or conjugated bilirubin?
Unconjugated (fat-soluble)
it’s insoluble and can cross the blood brain barrier to be deposited in the basal ganglia
How is low, very low and extremely low birth weight defined?
LBW
Why is nitrofurantoin avoided close to delivery?
May cause haemolysis of fetus
How does the fasting glucose level in recently-diagnosed gestational diabetes in pregnant woman determine initial treatment approach?
Fasting glucose 6.9 straight onto insulin
Who gets high dose folate? (5mg rather than 400 micrograms)
Obese >30 BMI
Previous neural tube defect
PMH: diabetic, sickle cell
DHx: HIV mum on co-trimoxazole or anti-epileptics
When would you give IV glucose to a neonate?
If symptomatically hypoglycaemic
If 2 blood glucose readings are under 2mmol
If a woman giving birth has a BMI over 40, what is always indicated post birth?
7 days heparin
TED stocking
What is Naegele’s rule for determining estimated due date in pregnancy?
LMP + 1year + 7 days -3 months
If irregular period +/- days difference from 28 days
How is screening different for someone with previous gestational diabetes compared to someone at high risk (FHx, BMI >30, previous baby >45kg, asian)?
Previous diabetes: OGTT at 18 ± 28 weeks
High risk: OGTT at 24 weeks
Women with what BMI should take vit D supplements in pregnancy?
Above 30
When is 500U of anti-D unlikely to be sufficient for a rhesus -ve mother?
500U is enough for 8mL of fetal blood (=4ml of fetal red cells) may be more transplacental haemorrhage in:
Manual removal or placenta
C-section
Hence Kleihauer test needed to quantify
A miscarriage after how many weeks warrants anti-D prophylaxis for a rhesus -ve mother?
12 weeks
Which diseases are associated with hyperemesis gravidarum?
Pre-existing diabetes
Hyperthyroidism
Previous eating disorders
For miscarriages and terminations, sometimes anti-D isn’t given if it is before 12 weeks, which circumstances does this not apply for?
ALWAYS give anti-D (even if pre-12 weeks) if:
Terminations with medical or surgical management
Spontaneous miscarriage with medical or surgical management
If spontaneous or threatened miscarriage with no intervention before 12 weeks, no anti-D needed
Why ask about peripheral sensation in those with hyperemesis gravidarum?
May get a polyneuritis due to low B vitamins
Which trimester is it worse to take Lithium in?
1st trimester- increased chance of heart defects (ebstein’s abnormality)
How may atypical antipsychotics impact fertility? (The mechanism)
DA antagonist = hyperprolactinaemia = infertility
Which regions are associated with a high prevelance of thalassaemia?
Mediterranean
Indian
South East Asian regions
How long does it take Hb to rise once iron supplementation is given?
6 weeks
If very anaemic late in pregnancy then blood transfusion may be needed as iron will more work in time
35 weeks pregnant, found to have Hb of 60 from iron-deficiency anaemia, due Caesarian
Rx?
Blood transfusion
Too late for Fe supplementation (takes 6 weeks to work)
How do you decide whether a woman needs HAART from 28 weeks or all the way through pregnancy?
If she needs HAART for her own health (low CD4, AIDS illnesses) = all the way through
If CD4 high, viral load low = take from 28 weeks
Mum is taking propylthiouracil but doesn’t know why and doesn’t speak much english. What abnormalities might the fetus have?
Mum has hyperthyroidism (likely Grave’s disease)
Can cause fetal hyperthyroidism as antibodies cross placenta:
Premature delivery
Craniosynostosis
Goitre (= polyhydramnios)
Tachycardia
Mother has Dubin-Johnson syndrome, what is likely to happen in pregnancy?
Inability to secrete conjugated bilirubin in liver due to a protein transporter defect (autosomal recessive)
Likely to become jaundiced, fairly benign
What is the difference between acute fatty liver of pregnancy and intra-hepatic cholestatsis of pregnancy?
In both: jaundice and after 2nd trimester
Cholestasis- itchy, mild AST + ALT rise
Acute fatty liver- pain, headache, vomiting, low BM/clotting disorder/ other liver dysfunction
Why don’t you want to give methylodopa after birth in women with hypertension?
Predisposes to post-natal depression
Jaundice in pregnancy, what conditions tend to have an abnormal ALT
A. Hyperemesis gravidarum complication
B. Intrahepatic cholestasis
C. Pre-eclampsia + HELLP
High- hepatitis
Pregnant woman comes in breathless and with pleuritic chest pain, what would make you think it was due to a pneumonia over a thromboembolism?
High fever
Purulent sputum
A pregnant woman with VTE has a CTPA, what needs to be checked in the fetus afterwards?
Neonatal hypothyroidism as iodinated contrast is used
Sleepy, poor tone, jaundice, low body temperature
What is considered a high risk thrombophilia in pregnancy and a low risk thrombophilia when determining appropriate thromboprophylaxis regime For those who have not had a VTE before?
High risk (>10x worse than general population): antithrombin deficiency homozygotes factor V leiden homozygotes G20210A Two compounding thrombophilias
Require antenatal LMWH
Low risk thrombophilia just counts as a RF like obesity etc
Primary infection of chickenpox before how many weeks predisposes a fetus to varicella zoster syndrome?
20 weeks
Skin scarring, eye cataracts and retinitis, small head low IQ
Which infections in pregnancy do you give IV Ig to the babies at birth for?
Measles (if get it 6 days before birth) Chicken pox (if get it 7 days before birth) Hepatits B (if mum is carrier)
Which infections in pregnancy would you give mum aciclovir for?
Chicken pox (if primary infection, after 20 weeks and within 24 hours of a rash) Herpes simplex (3rd trimester PO, IV if vaginal delivery- recommend C-section)
Which infections in pregnancy warrant a penicillin derivative for mum?
Syphilis- procaine pen IM
Listeria- ampicillin (+ gentamycin)
Clostridium perfringins endometritis- Benzylpenicillin
Group B Strep- penicillin (prophylaxis)
Which infections in pregnancy warrant a macrolide for mum?
Toxoplasmosis- spiramycin (+sulfadiazine, pyrimethamine + ca folinate if fetus becomes infected)
Sheep-borne infections- erythromycin
Chlamydia trachomatis- erythromycin
Imaging to differentiate cholecystitis and appendicitis in pregnancy?
USS- Stones in gallbladder = cholecystitis
Appendix is displaced upwards in pregnancy so pain is localised to RUQ often.
Laproscopy 2nd line if can’t be sure.
What number of accelerations would you expect on a CTG?
2 in 20 minutes, of an amplitude of 15bpm (unless sleeping)
How can amniotic fluid levels indicate chronic asphyxia of the fetus?
Chronic hypoxia in IUGR may lead to shunting of blood to vital organs rather than the fluid producing organs (of kidney and lungs) leading to less amniotic fluid.
If the largest pocket of fluid is less than 1cm this suggests chronic asphyxia
You suspect there is IUGR of a fetus, how can the fetal growth be monitored?
Regular scans measuring the abdominal: skull circumference ratio
In pre-eclampsia what can be tested for in blood that rises before women start getting proteinuria?
Urate (uric acid)
> 0.29 at 28 weeks
0.34 at 32 weeks
0.39 at 36 weeks
When would you admit someone for suspected pre-eclampsia?
> 160/100
140/90 + proteinuria
BP rise of >30/20 mmHg
Growth restriction
How does Rx for the mum change if she is infected by toxoplasmosis depending on whether amniocentesis shows the baby is also infected or not?
Baby not infected: mum takes spiramycin
Baby infected: mum takes sulfadiazine, pyrimethamine, calcium folinate
