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HY OBGYN - (edited) > Antenatal care > Flashcards

Antenatal care Flashcards

1
Q

What does LMP stand for?

A

Last menstural period (first day of the most recent period)

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2
Q

What does GA stand for?

A

Gestational age (duration of pregnancy from the date of the last menstrual period)

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3
Q

What does EDD stand for?

A

Estimated date of delivery (40 weeks gestation)

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4
Q

What does Gravida mean?

A

Total number of pregnancies a woman has had

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5
Q

What does multigravida stand for?

A

Patient that is pregnant for at least the second time

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6
Q

What does Para (P) mean?

A

Number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was stillborn

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7
Q

What does nulliparous (“nullip”) mean?

A

Patient that has never given birth after 24 weeks gestation

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8
Q

What does primiparous mean?

A

Patient that has given birth after 24 weeks gestation once before

Used on the labour ward to refer to a woman that is due to give birth for the first time

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9
Q

How is the gestational age described?

A

In weeks and days

5 + 0 refers to 5 weeks since LMP

13 + 6 refers to 13 weeks and 6 days gestational age

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10
Q

How to represent gravida and para for a previous miscarriage?

A

G1 P0 + 1

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11
Q

How are trimesters divided?

A

First trimester: start of pregnancy until 12 weeks gestation

Second trimester: 13 weeks until 26 weeks

Third trimester: from 27 weeks until birth

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12
Q

When do fetal movements start?

A

From 20 weeks gestation until birth

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13
Q

What are the milestones in Antenatal care?

A
  • Before 10 weeks = booking clinic (offer a baseline assessment and plan the pregnancy)
  • Between 10 and 13 + 6 = dating scan (gestational age is calculated from crown rump length CRL and multiple pregnancies are identified)
  • At 16 weeks = antenatal appointment (discuss results and plan future appointments
  • Between 18 and 20 + 6 = anomaly scan
  • 25, 28, 31, 34, 36, 38, 41, 41, 42 = Antenatal appointments (monitor pregnancy and discuss future plans)
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14
Q

When is an oral glucose tolerance test usually completed?

A

Between 24 and 28 weeks

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15
Q

When are Anti-D injections given in rhesus negative women?

A

28 and 34 weeks

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16
Q

When is an ultrasound scan done for women with placenta praevia on the anomaly scan?

A

32 weeks

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17
Q

When are serial growth scans offered?

A

When women are at an increased risk of fetal growth restriction

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18
Q

When is the symphysis-fundal height measured from?

A

24 weeks onwards

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19
Q

When is fetal presentation assessed?

A

36 weeks onwards

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20
Q

Why is a urine dipstick and blood pressure taken in pregnancy?

A

For pre-eclampsia

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21
Q

Why is a urine sample taken in pregnant women?

A

Asymptomatic bacteriuria

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22
Q

Which two vaccines are offered to all pregnant women?

A

Whooping cough (pertussis) from 16 weeks gestation

Influenza (flu) when available in autumn

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23
Q

What is some general advice all pregnant patients are given- regarding lifestyle?

A
  • Take folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
  • Take vitamin D supplement (10 mcg or 400 IU daily)
  • Avoid vitamin A supplements and eating liver or pate (vitamin A is teratogenic at high doses)
  • Don’t drink alcohol when pregnant (risk of fetal alcohol syndrome)
  • Don’t smoke (smoking has a long list of complications, see below)
  • Avoid unpasteurised dairy or blue cheese (risk of listeriosis)
  • Avoid undercooked or raw poultry (risk of salmonella)
  • Continue moderate exercise but avoid contact sports
  • Sex is safe
  • Flying increases the risk of venous thromboembolism (VTE)
  • Place car seatbelts above and below the bump (not across it)
  • Do not drink any alcohol
  • Do not smoke
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24
Q

What are the effects of alcohol in early pregnancy?

A
  • Miscarriage
  • Small for dates
  • Preterm delivery
  • Fetal alcohol syndrome
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25
Q

What are the features of fetal alcohol syndrome?

A
  • Microchephaly (small head)
  • Thin upper lip
  • Smooth flat philtrum (the midline groove in upper lip)
  • Short palpebral fissure (short horizontal distance from one side of the eye to the other)
  • Behavioural difficulties
  • Hearing and vision problems
  • Cerebral palsy
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26
Q

What are the risks of smoking in pregnancy?

A
  • Fetal growth restriction
  • Misscarriage
  • Stillbirth
  • Preterm labour and delivery
  • Placental abruption
  • Pre-eclampsia
  • Cleft lip or palete
  • Sudden infant death syndrome (SIDS)
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27
Q

When is flying ok in pregnancy?

A

Ok in uncomplicated pregnancy up to:

  • 37 weeks in a single pregnancy
  • 32 weeks in a twin pregnancy
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28
Q

At what point will airlines need a note from a midwife, GP or obstetrician to state the pregnancy is going well?

A

28 weeks gestation

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29
Q

Who conducts a booking clinic? When does this clinic occur?

A

Midwife

Occurs by 10+0 weeks gestation

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30
Q

What is discussed at a booking clinic appointment?

A
  • Ask the woman about:
    • PMH, obstetric hx, fhx
    • Mental health problems
    • Current and recent medicines, including OTC medicines, health supplements, herbal remedies
    • Allergies
    • Occupations- any risks/ concerns
    • Family and home situation
    • People involved in care of baby- partner or others
    • Contact details for partner and next of kin
    • Factors such as nutrition & diet, physical activity, smoking and tobacco use, alcohol consumption, recreational drug use
  • Other points of discussion
    • What to expect at different stages of the pregnancy
    • Plans for birth
    • Screening tests (e.g. Downs)
    • Antenatal classes
    • Breastfeeding classes
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31
Q

Outline routine blood tests that should be performed at the booking visit, and why.

A
  • Blood group
  • Antibodies and rhesus D status
  • FBC- for anaemia
  • Screening for thalassaemia (all women) and sickle cell disease (those at risk)- forward planning
  • Offered screening for infectious diseases- antibodies for HIV, hep B, syphilis - vertical transmission
  • Screening for Down’s can only be done from 11 weeks
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32
Q

What investigations are done at the booking clinic?

A
  • The woman’s height and weight- calculate BMI
  • Blood tests- FBC, blood group, rhesus D status
  • Offer infectious disease scfreening
  • Urine dip for protein and bacteria
  • Blood pressure
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33
Q

Describe the Naegele rule, and calculate the patient’s Expected Date of Delivery (EDD) using that method.

A

3 step method:

  1. First determine the first day of last menstrual period
  2. Then count back 3 months from that date
  3. Then add 1 year and 7 days to that date

This gives you an estimated date of delivery

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34
Q

At a booking clinic, a woman needs to be assessed for risk factors for other conditions and plans need to be made for these conditions- give some examples?

A
  • Rhesus negative (book anti-D prophylaxis)
  • Gestational diabetes (book oral glucose tolerance test)
  • Fetal growth restriction (book additional growth scans)
  • Venous thromboembolism (provide prophylactic LMWH if high risk)
  • Pre-eclampsia (provide aspirin if high risk)
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35
Q

What is Down’s Syndrome also known as?

A

Trisomy 21

  • Down’s syndrome is caused by 3 copies of chromosome 21
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36
Q

What is the purpose of screening for Down’s Syndrome during pregnancy?

A

To establish whether more invasive testing is needed

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37
Q

How does the screening test give a measurement of the risk of Down’s syndrome?

A

Using:

  • Measurements from the fetus using ultrasound
  • Mother’s age
  • Mother’s blood results
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38
Q

What does ultrasound measure in Down’s screening?

A

Nural translucency - thickness of the back of the neck of the fetus (greater than 6mm indicates Down’s)

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39
Q

Between 11 and 14 weeks gestation, what test can be done for Down’s syndrome?

A

Combined test

  • Ultrasound
    • Nuchal translucency- >6mm can be caused by Down’s
  • Maternal blood tests-the following results indicates a greater risk of Down’s:
    1. ↑ βHCG
    2. ↓ PAPP-A
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40
Q

Between 14 and 20 weeks gestation, what tests can be performed to assess risk of Down’s syndrome?

A

Maternal blood tests- triple test (1-3) or quadruple test (all 4) the following results indicates a greater risk of Down’s:

  1. ↑ βHCG
  2. ↓ AFP
  3. ↓ oestriol
  4. ↑ inhibin-A
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41
Q

What does the antenatal screening test for Down’s syndrome provide? Who is offered further screening and in what form?

A

A risk score - if it is greater than 1 in 150 (occuring in 5% of women) then the woman is offered amniocentesis or chorionic villus sampling

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42
Q

What does Chorionic Villus sampling involve? What are the risks associated with CVS?

A

Ultrasound-guided biopsy of the placental tissue (used earlier in pregnancy - before 15 weeks)

Risks

  • Miscarriage- 1%
  • Inadequate sample- may need to be carried out again/ do amniocentesis instead
  • Infection- 0.1%
  • Rhesus sensitisation- if mother is RhD negative but baby is Rhpositive then sensititisation can occur- baby’s blood enters mother’s bloodstream and mother produces antibodies
    • Anti-D immunoglobulin injection can be given to avoid sensitisation
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43
Q

What does amniocentesis involve for Down’s testing? What are the risks associated with it?

A

Ultrasound-guided aspiration of amniotic fluid using a needle and syringe - used later in pregnancy when there is enough amniotic fluid to make a sample

Risks- higher if carried out before 15 weeks, so amniocentesis only done after 15 weeks

Most common time is 15-18 weeks

  • Miscarriage- 1%
  • Discomfort (uterien cramping)
  • Vaginal bleeding- 2%
  • Maternal rhesus sensitisation in susceptible pregnancies
  • Amnionitis
  • Failure of cell culture if performed <12 weeks gestation
  • Anxiety for parents
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44
Q

What is non-invasive prenatal testing for Down’s?

A

New test for detecting fetal abnormalities - involves a simple blood test from the mother.

Contains fragments of DNA from the fetus which can be tested.

Used as an alternative to invasive testing (CVS and amniocentesis)

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45
Q

What can untreated hypothyroidism in pregnancy cause?

What can untreated thyrotoxicosis in pregnancy cause?

A
  • Hypothyroidism can cause-
    • Miscarriage
    • Anaemia
    • SGA
    • Pre-eclampsia
  • Thyrotoxicosis can cause-
    • Fetal loss
    • Maternal heart failure
    • Premature labour
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46
Q

What is hypothyroidism treated with and what alteration needs to be made during pregnancy & why?

In contrast, what is thyrotoxicosis treated with and what alteration needs to be made during pregnancy & why?

A

Hypothyroidism: Levothyroxine (T4)

  • Can cross placenta and provide thyroid hormone to the fetus
  • Hence dose needs to be increased by 30-50% (25-50mcg)
  • Treatment is based on the TSH level, aiming for low-normal TSH

Thyrotoxicosis (commonly caused by Graves’): Propylthiouracil / Carbimazole

  • Carbimazole can cause congenital abnormalities, so PTU is used in the 1st trimester
  • Can switch back to carbimazole in the 2nd trimester
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47
Q

If a pregnant patient has pre-existing hypertension, wht is this called?

What hypertension medications must be stopped in pregnancy & why?

A

Essential hypertension

The following medications need to be stopped

  • ACE inhibitors
  • Angiotensin receptor blockers (e.g. losartan)
  • Thiazide and thiazide-like diuretics (e.g.indapamide)

They may cause congenital abnormalities

The target BP is 135/85

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48
Q

What anti-hypertensives are allowed in pregnancy?

A
  • Labetalol (a beta-blocker - although other beta blockers may have adverse effects)
    • Not suitable to DM pts (hypos)
  • CCBs (e.g. nifedipine)
  • Alpha-blockers (e.g. doxazosin)
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49
Q

What dose of folic acid should women with epilepsy take?

A

5mg daily to reduce the risk of neural tube defects

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50
Q

Why may pregnancy increase the risk of seizures in pregnancy?

A
  • Additional stress
  • Lack of sleep
  • Hormonal changes
  • Altered medication regimes
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51
Q

Are seizures harmful to the pregnancy?

A

No, only the risk of physical injury

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52
Q

What are the safer anti-epileptic medications in pregnancy?

A
  • Levetiracetam
  • Iamotrigine
  • Carbamazepine
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53
Q

What drugs are avoided during pregnancy with epilepsy?

A
  • Sodium valporate (causes neural tube defects and developmental delay)
  • Phenytoin (causes cleft lip and palete)
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54
Q

What is Prevent (valporate pregnancy prevention programme)?

A
  • Programme to prevent pregnancy in epileptic patients on sodium valporate (due to it’s teratogenic effects)
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55
Q

How long should rheumatoid arthritis be well controlled for before becoming pregnant?

A

3 months

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56
Q

How do the symptoms of rheumatoid arthritis change during pregnancy?

A

Improve but may flare up after delivery

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57
Q

What rheumatoid arthritis drugs are contraindicated in pregnancy?

A

Methotrexate (teratogenic, causing miscarriage and congenital abnormalities)

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58
Q

What rheumatoid arthritis drugs are considered safe during pregnancy?

A
  • Hydroxychloroquine (often the first-line choice)
  • Sulfasalazine (safe during pregnancy)
  • Corticosteroids may be used during flare-ups
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59
Q

Describe what prostaglandins do in pregnancy/ delivery?

A
  • Maintaining ductus arteriosus in fetus
  • During delivery, soften cervix
  • Stimulate uterine contractions both during delivery and pregnancy
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60
Q

Why are NSAIDs avoided in general during pregnancy?

A

Avoided in the third trimester as they can cause premature closure of the ductus arteriosus in the fetus. They can also delay labour.

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61
Q

What are beta blockers commonly used for?

A
  • Hypertension
  • Cardiac conditions
  • Migraine
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62
Q

What medication is first-line for hypertension caused by pre-eclampsia?

A

Labetalol

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63
Q

What complications can beta-blockers cause in pregnancy?

A
  • Fetal growth restriction
  • Hypoglycaemia in the neonate
  • Bradycardia in the neonate
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64
Q

Name 2 complications of using ACE inhibitors and ARBs in pregnancy?

A
  • In the fetus, they affect the kidneys causing reduced production of urine (and therefore amniotic fluid)
  • Hypoclavaria (incomplete formation of the skull bones)
  • Oligohydraminos (reduced amniotic fluid)
  • Miscarriage or fetal death
  • Hypocalvaria (incomplete formation of the skull bones)
  • Renal failure in the neonate
  • Hypotension in the neonate
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65
Q

What happens to the neonate if the mother takes opiates during pregnancy? When is treatment initiated and what is it?

A

Withdrawal symptoms in the neonate after birth, called neonatal abstinence syndrome which presents between 3 - 72 hours after birth with irritability, tachypnoea (fast breathing), high temperatures and poor feeding

Treatment is usually initiated if:

  • Feeding becomes a problem and tube feeding is required;
  • There is profuse vomiting or watery diarrhoea;
  • The baby remains very unsettled after two consecutive feeds despite gentle swaddling and the use of a pacifier.

Treatment involves weaning the baby from the drug on which it is dependent- morphine can be given

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66
Q

Can warfarin be used in pregnancy?

A

No

Teratogenic; crosses the placenta, causes:

  • Fetal loss
  • Congenital malformations, particularily craniofacial problems
  • Bleeding during pregnancy, PPH, fetal harmorrhage and intracranial bleeding
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67
Q

Why can’t sodium valporate be used in pregnancy?

A
  • Neural tube defects
  • Developmental delay

Prevent programme to ensure it is avoided

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68
Q

What is lithium used for?

A

Mood stabilising agent for patients with bipolar disorder, mania, recurrent depression.

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69
Q

Can lithium be used in pregnancy?

A

Avoided in pregnant women or those planning pregnancy unless other options (i.e. antipsychotics) have failed

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70
Q

Why is lithium particularily avoided in the first trimester?

A

It’s linked with congenital cardiac abnormalities

  • Ebstein’s anomaly
    • Characterised by low insertion of the tricuspid valve resulting in a large RA and small R ventricle
    • Clinical features: cyanosis, prominent ‘a’ wave in the distended jugular venous pulse, hepatomegaly, tricupsid regurgitation, RBBB
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71
Q

What extra measures need to be taken when lithium is used in pregnancy?

A

Monitored closely (every 4 weeks, then weekly from 36 weeks) it also enters breast milk so should be avoided in breastfeeding

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72
Q

Do SSRIs cross the placenta?

A

Yes

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73
Q

What are the risks of using SSRIs in the first trimester of pregnancy?

A
  • Congenital heart defects
  • Paroxetine has stronger link with congenital malformation
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74
Q

What are the risks of using SSRIs in the third trimester?

A

Persistent pulmonary hypertension

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75
Q

What are the risks to the neonate after using SSRIs?

A

Withdrawal symptoms usually only mild and not requiring medical management

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76
Q

What is isotretinoin (roaccutane)?

A

Retinoid medication (relating to vitamin A) which is used to treat severe acne - should be prescribed and monitored by a specialist dermatologist

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77
Q

What is the risk of using isotretionoin?

A

Highly teratogenic causing miscarriage and congenital defects. Women need very reliable contraception before, during and for one month after taking isotretinoin.

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78
Q

What is Rubella also known as? Describe the clinical features of rubella infection?

A

German measles

  • Rash — typically starts on the face and neck before spreading down the body and becoming generalized — the rash is pink or light red, maculopapular and usually present for 3–5 days.
  • Lymphadenopathy (most often suboccipital, postauricular, and cervical) — may precede rash and last for 2 weeks after the rash resolves.
  • Arthritis and arthralgia — more common in adult women.
  • Non-specific symptoms such as low-grade fever, headache, malaise, nausea, mild upper respiratory tract symptoms and non-purulent conjunctivitis.
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79
Q

What is congenital rubella syndrome caused by?

A

Maternal infection with rubella virus during the first 20 weeks of pregnancy

The risk is highest before 10 weeks

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80
Q

How can women protect against congenital rubella syndrome?

A
  • Women planning on becomming pregnant should ensure that they have had the MMR vaccine, if in doubt they can be tested for rubella immunity if they do not have antibodies to rubella they can be vaccinated with two doses of the MMR three months apart
  • Pregnant women shouldn’t have the vaccine as it is a live vaccine
  • Non-immune women should be offered the vaccine after birth
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81
Q

What are the features of congenital rubella syndrome?

A
  • Congenital deafness
  • Congenital cataracts
  • Congenital heart disease (PDA and pulmonary stenosis)
  • Learning difficulty
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82
Q

What is chicken pox caused by & why is chickenpox dangerous during pregnancy?

A
  • Varicella zoster virus (VZV)
  • Causes more severe cases in the mother, such as varucella pneumonitis, hepatitis or encephalitis
  • Fetal varicella syndrome
  • Severe neonatal varicella infection (if infected around delivery)
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83
Q

How to check for immunity to chicken pox?

A

IgG levels for VZV can be tested, if positive then indicated immunity

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84
Q

What can be do to treat a pregnant woman who has been exposed to chicken pox and has no immunity?

A

Treated with IV varicella immunoglobulins as prohylaxis against developing chickenpox, given within 10 days of exposure

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85
Q

What is the treatment for a chickenpox rash in pregnancy?

A

Treament with oral aciclovir if presenting within 24 hours and more than 20 weeks gestation

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86
Q

What is congenital varicella syndrome up until what week of gestation will infection usually cause this?

A

Occurs in around 1% of chickenpox cases with infection in the first 28 weeks of gestation. Features include:

  • Fetal growth restriction
  • Microcephaly, hydrocephalus and learning difficulty
  • Scars and significant skin changes located in specific dermatomes
  • Limb hypoplasia (underdeveloped limbs)
  • Cataracts and inflammation in the eye (chorioretinitis)
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87
Q

How does the Listeria bacteria stain?

A

Gram positive

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88
Q

What infection does the listeria bacteria cause?

A

Listeriosis

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89
Q

How does infection with listeria present in the mother?

A

Asymptomatic or flu-like illness or less commonly pneumonia or meningoencephalitis

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90
Q

What is the result of listeriosis in pregnant women?

A

High rate of miscarriage or fetal death it can also cause severe neonatal infection

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91
Q

Where is listeria typically found?

A

Unpasteurised dairy products

Processed meats

Contaminated food

Advise avoid blue cheese and other high risk fods and practice good food hygiene

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92
Q

How is CMV spread?

A

Via infected saliva or urine of asymptomatic children

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93
Q

What are the features of congenital CMV?

A
  • Fetal growth restriction
  • Microcephaly
  • Hearing loss
  • Vision loss
  • Learning disability
  • Seizures
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94
Q

What is congenital toxoplasmosis caused by?

A

Caused by infection during pregnancy with the toxoplasma gondii parasite

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95
Q

How is toxoplasma gondii usually spread?

A

By contamination with faeces from a cat that is a host of the parasite

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96
Q

What is the classic triad of features in congenital toxoplasmosis?

A
  1. Intracranial calcification
  2. Hydrocephalus
  3. Chorioretinitis (inflammation of the choroid and the retina in the eye)
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97
Q

What is parvovirus B19 also known as?

A

Fifth disease, slapped cheek syndrome and erythema infectiosum.

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98
Q

How does parvovirus typically present? How is it treated?

A
  • Initally with non-specific viral symptoms
  • After 2-5 days the rash appears quite rapidly as a diffuse bright red rash on both cheeks as though they have “slapped cheeks”
  • A few days later a reticular mildly erythmatous rash affecting the trunk and limbs appears which can be raised and itchy
  • Illness is self-limiting and the rash and symptoms usually fade over 1-2 weeks
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99
Q

When are patients with Parvovirus B19 infectious?

A
  • 7-10 days before the rash appears (not infectious once the rash has appeared)
  • They are not infectious once the rash appears
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100
Q

How is parvovirus spread?

A

15 minutes in the same room or face-to-face contact with someone that has the virus

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101
Q

What are the complications of infections with parvovirus B19 during pregnancy?

A

Typically worse in 1st and 2nd trimesters

  • Miscarriage or fetal death
  • Severe fetal anaemia
    • ​Casued by parvovirus infection of erythroid progenitor cells in the fetal bone marrow & liver
    • The infection causes them to produce faulty RBCs
    • Leads to anaemia
    • Which can lead to HF
  • Hydrops fetalis (fetal heart failure)
  • Maternal pre-eclampsia-like syndrome
    • Mirror syndrome
    • Triad of hydrops fetalis, placental oedema, and oedema in mother, hypertension & proteinuria
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102
Q

How is fetal anaemia caused by parvovirus infection?

A

Infection of the erythroid progenitor cells in the fetal bone marrow and liver (the cells which produce red blood cells)

Producing faulty red blood cells which have a shorter life span - less red blood cells results in anaemia, this anaemia leads to heart failure, referred to as hydrops fetalis.

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103
Q

What is mirror syndrome?

A

Rare complication of severe fetal heart failure (hydrops fetalis) involving a triad of:

  1. Hydrops fetalis
  2. Placental oedema
  3. Oedema in the mother
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104
Q

What are the tests to order for women suspected of parvovirus infection?

A
  • IgM to parvovirus which tests for acute infection within the past 4 weeks
  • IgG to parvovirus which tests for long term immunity to the virus after a previous infection
  • Rubella antibodies (as a differential diagnosis)
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105
Q

What is the treatment for infection with parvovirus B19?

A

Supportive

Referral to fetal medicine to monitor for complications and malformations

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106
Q

How is the zika virus spread?

A

By host Aedes mosquitos in aread of the world where the virus is prevalent

Also spread by sex with someone infected

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107
Q

What are the symptoms of Zika virus infection?

A

No symptoms, minimal symptoms or mild flu-like illness

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108
Q

What is the result of congenital Zika syndrome?

A
  • Microcephaly
  • Fetal growth restrictions
  • Other intracranial abnormalities such as ventriculomegaly and cerebellar atrophy
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109
Q

What is the test for Zika virus in pregnancy?

A
  • Viral PCR
  • Antibodies to the zika virus
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110
Q

How are pregnant women with zika virus managed?

A

Referred to fetal medicine for close monitoring of the pregnacy

There is no treatment for the virus

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111
Q

Do women who are rhesus-D positive need treatment during pregnancy?

A

No additional treatment needed during pregnancy

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112
Q

What is the problem with a rhesus negative mother who gives birth to a rhesus positive baby ?

A
  • Blood from the baby will find a way into the mothers blood stream e.g. during childbirth, the baby’s RBCs display the rhesus-D antigen which the mother’s immune system will recognise as foreign and produce antibodies to the rhesus-D antigen - the mother has then become sensitised to rhesus-D antigens
  • This won’t cause problems during the 1st pregnancy
  • During subsequent pregnancies the mother’s anti-rhesus-D antibodies can cross the placenta into the fetus.
  • If the fetus is rhesus-D positive, these antibodies attach themselves to the RBC of the fetus and cause the immune system of the fetus to attack them, causing the destruction of the RBC = haemolytic disease of the newborn
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113
Q

What is the management of rhesus incompatibility?

A

Prevention of sensitisation - involves giving prophylactic intramuscular anti-D injections to rhesus-D negative women (there is no way to reverse the sensitisation process once it has occured)

  1. Offered once at 28 weeks gestation
  2. Offered at birth
  3. Also offered any other events where sensitisation may occur- eg antepartum haemorrhage, amniocentesis procedures, abdominal trauma

Given within 72 hrs of a sensititisation event

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114
Q

How does the anti-D medication work?

A

Attaches itself to the rhesus-D antigens on the fetal red blood cells in the mothers circulation causing them to be destroyed - thus preventing the mother’s immune system recognising the antigen and creating it’s own antibodies to the antigen - acts as a prevention of sensitisation

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115
Q

How soon after a sensitisation event do anti-D injections need to be given?

A

Within 72 hours

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116
Q

What is the Kleihauer test and when is it done?

A

Test to check how much fetal blood has passed into the mother’s during a sensitisation event

Done at 20 weeks

To determine whether further doses of anti-D are required

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117
Q

How is the Kleihauer test performed?

A

Involves adding acid to a sample of the mother’s blood fetal haemoglobing is more resistant to acid (so they are protected against the acidosis that occurs around childbirth)

Fetal haemoglobin persists in response to the added acid whilst the mothers Hb is destroyed - number of cells still containing the haemoglobin (remaining fetal cells) can then be calculated

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118
Q

What fetus is considered small for gestational age?

A

Fetus which measures below the 10th centile for their gestational age

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119
Q

What measurements on ultrasound are used to assess the fetal size?

A
  • Estimated fetal weight (EFW)
  • Fetal abdominal circumference (AC)
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120
Q

Customised growth charts are used to assess the size of the fetus, what are they based on?

A

Mother’s:

  • Ethnic group
  • Weight
  • Height
  • Parity
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121
Q

What is severe Small for Gestational age defined as?

A

Below the 3rd centile for their gestational age

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122
Q

What is low birth weight?

A

Birth weight less than 2500g (5.5 Ib)

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123
Q

What are the two categories of causes for causes of SGA?

A
  1. Constitutionally small (matching the mother and other’s in the family) - growing appropriately on the growth chart
  2. Fetal growth restriction also known as intrauterine growth restriction- fetus not growing as expected due to a pathology reducing the amount of nutrients & O2 being delivered to fetus via placenta
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124
Q

What are the two causes of fetal growth restriction?

A

Placenta mediated growth restriction- conditions which affect the transfer of nutrients across the placenta:

  • Idiopathic
  • Pre-eclampsia
  • Maternal smoking
  • Maternal alcohol
  • Anaemia
  • Malnutrition
  • Infection
  • Maternal health conditions

Non-placenta mediated growth restriction, where the baby is small due to a genetic or structural abnormality

  • Genetic abnormalities
  • Structural abnormalities
  • Fetal infection
  • Errors of metabolism
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125
Q

What are some signs that would indicate Fetal Growth Restriction?

A
  • Small for Gestational Age (SGA)
  • Reduced amniotic fluid volume
  • Abnormal Doppler studies
  • Reduced fetal movements
  • Abnormal CTGs
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126
Q

What are some short term complications of FGR?

A
  • Fetal death or stillbirth
  • Birth asphyxia-when a baby’s brain and other organs do not get enough oxygen and nutrients before, during or right after birth
  • Neonatal hypothermia
  • Neonatal hypoglycaemia
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127
Q

What are growth restricted babies at an increased long term risk of?

A
  • Cardiovascular disease, particularly hypertension
  • Type 2 diabetes
  • Obesity
  • Mood and behavioural problems
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128
Q

What are the risk factors of SGA?

A

Previous SGA baby

Obesity

Smoking

Diabetes

Existing hypertension

Pre-eclampsia

Older mother (over 35 years)

Multiple pregnancy

Low pregnancy‑associated plasma protein‑A (PAPPA)

Antepartum haemorrhage

Antiphospholipid syndrome

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129
Q

What do the serial ultrasound scans measure?

A

Estimated fetal weight (EFW) and abdominal circumference (AC) to determine the growth velocity

Umbilical arterial pulsatility index (UA-PI) to measure flow through the umbilical artery

Amniotic fluid volume

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130
Q

What is the general managment of SGA?

A

Identifying those at risk of SGA

  • Woman with a major risk factors- USS measurement of fetal size & assessment of wellbeing with umbilical artery doppler from 26-28 weeks
  • 3 or more minor risk factors- uterine artery Doppler at 20-24 weeks gestation

Aspirin is given to those at risk of pre-eclampsia

Treating modifiable risk factors (e.g. stop smoking)

Serial growth scans to monitor growth

Early delivery where growth is static, or there are other concerns

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131
Q

How can the underlying cause of SGA be investigated?

A
  • Blood pressure and urine dipstick for pre-eclampsia
  • Uterine artery doppler scanning
  • Detailed fetal anatomy scan by fetal medicine
  • Karyotyping for chromosomal abnormalities
  • Testing for infections (e.g. toxoplasmosis, cytomegalovirus, syphilis and malaria)
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132
Q

When would early deliery be considered for SGA?

A

Growth is static on the charts or abnormal doppler results

Reducing the risk of stillbirth

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133
Q

What is given to the woman when delivery is planned early?

A

Corticosteroids particulary when delivered by C-Section

These help the unborn baby’s lungs to develop more quickly

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134
Q

What weight of newborn classes macrosomia?

A

>4.5kg at birth (weight above 90th centile in pregnancy)

(9.92 Ib)

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135
Q

What are some causes of macrosomia?

A
  • Constitutional
  • Maternal diabetes
  • Previous macrosomia
  • Maternal obesity or rapid weight gain
  • Overdue
  • Male baby
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136
Q

What are the risks to the mother if a fetus is LGA?

A

Failure to progress

Perineal tears

Instrumental delivery or caesarean

Postpartum haemorrhage

Uterine rupture (rare)

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137
Q

What is shoulder dystocia and what are the key risk factors?

A
  • Shoulder dystocia is a complication of vaginal cephalic delivery
  • It entails the inability to deliver the body of the fetus using gentle traction, the head having already been delivered
  • It usually occurs due to impaction of the anterior fetal shoulder on the maternal pubic symphysis
  • Shoulder dystocia is a cause of both maternal and fetal morbidity
  • Key risk factors
    • Fetal macrosomia
    • High maternal BMI
    • DM
    • Prolonged labour
138
Q

What are the risks to the baby if a fetus is LGA?

A
  • Shoulder dystocia
  • Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
  • Neonatal hypoglycaemia
  • Obesity in childhood and later life
  • Type 2 diabetes in adulthood
139
Q

What are the investigations for a LGA baby?

A

Ultrasound to exclude polyhydramnios and estimate the fetal weight

Oral glucose tolerance test for gestational diabetes

140
Q

How can the risks of shoulder distocia be reduced in a macrosomia baby?

A

Delivery on a consultant lead unit

Delivery by an experienced midwife or obstetrician

Access to an obstetrician and theatre if required

Active management of the third stage (delivery of the placenta)

Early decision for caesarean section if required

Paediatrician attending the birth

Senior help should be called as soon as shoulder dystocia is identified and McRoberts’ manoeuvre should be performed:

  • This manoeuvre entails flexion and abduction of the maternal hips, bringing the mother’s thighs towards her abdomen
  • This rotation increases the relative anterior-posterior angle of the pelvis and often facilitates a successful delivery

An episiotomy will not relieve the bony obstruction but is sometimes used to allow better access for internal manoeuvres.

141
Q

What does multiple pregnancy refer to?

A

Pregnancy with more than one fetus

142
Q

Which type of twin pregnancies have the best outcomes?

A

Diamniotic, dichorionic - each fetus has their own nutrient supply

(2 separate amniotic sacs and 2 placentas)

143
Q

When is a diagnosis of multiple pregnancies made?

A

Booking ultrasound scan; USS to determine:

  • Gestational age
  • Number of placentas (chorionicity) and amnionicity
  • Risk of Down’s syndrome (as part of the combined test)
144
Q

For the different type of twin pregnancies, how do the membranes appear on ultrasound?

A

Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign

Monochorionic diamniotic twins have a membrane between the twins, with a T sign

Monochorionic monoamniotic twins have no membrane separating the twins

145
Q

What is the lambda sign or twin peak sign seen on ultrasound scan?

A

The triangular appearance, where the membrane between the twins meets the chorion as the chorion blends partially into the membrane, indicating a dichorionic twin pregnancy (2 separate placentas)

Its absence does not confidently exclude dichroionicity

146
Q

What is the T-sign seen on ultrasound scan?

A

Where the membrane between the twins abruptly meets the chorion giving a T appearance - indicating a monochorionic twin pregnancy (single placenta)

147
Q

What are the risks to the mother during multiple pregnancy?

A
  • Anaemia
  • Polyhydramnios
  • Hypertension
  • Malpresentation
  • Spontaneous preterm birth
  • Instrumental delivery or caesarean
  • Postpartum haemorrhage
148
Q

What are the risks to the fetuses and neonates in multiple pregnancies?

A
  • Miscarriage
  • Stillbirth
  • Fetal growth restriction
  • Prematurity
  • Twin-twin transfusion syndrome
  • Twin anaemia polycythaemia sequence
  • Congenital abnormalities
149
Q

What is twin-twin transfusion syndrome?

A

When fetuses share a placenta called feto-fetal transfusion syndrome in pregnancies with more than two fetuses

One fetus (the recipient) may receive the majority of the blood from the placenta whilst the other (the donor) is starved of blood

Recipent = Heart failure and polyhydraminos

Donor = Growth restriction, anaemia and oligohydraminos

Discrepancy between the size of the fetuses

150
Q

How are women with twin-twin transfusion syndrome managed?

A

Referred to a tertiary specialist fetal medicine centre

Laser treatment may be used to destroy the connection between the two blood supplies

151
Q

What is twin anaemia polycythaemia sequence?

A

Similar to twin-twin transfusion syndrome but less acute, one twin becomes anaemic whilst the other develops polycythaemia (raised Hb)

152
Q

What are women with multiple pregnancies monitored for and when?

A

Anaemia with an FBC at booking clinic, 20 weeks gestation and 28 weeks gestation

Additional USS to monitor for FGR, unequal growth and twin-twin transfusion syndrome- 2 weekly scans from 16 weeks for monochorionic twins and 4 weekly scans from 20 weeks for dichorionic twins

Planned birth is also offered

153
Q

When is planned birth offered for multiple pregnancies?

A

32 and 33 + 6 weeks for uncomplicated monochorionic monoamniotic twins

36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins

37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins

Before 35 + 6 weeks for triplets

154
Q

How are monoamniotic twins delivered?

A

Elective C-Section at between 32 and 33+6 weeks

155
Q

How and when are diamniotic twins delivered?

A

Between 37 and 37 + 6 weeks

  • Vaginal delivery is possible when the first baby has a cephalic presentation (head first)
  • Caesarean section may be required for the second baby after successful birth of the first baby
  • Elective caesarean is advised when the presenting twin is not cephalic presentation
156
Q

What are the risks of UTI in pregnancy?

A

Increased risk of preterm delivery, also increased risk of low birth weight and pre-eclampsia

157
Q

What is asymptomatic bacteriuria?

A

Bacteria present in the urine without symptoms of infection (increases risk of UTI in pregnancy)

158
Q

When are pregnant women tested for asymptomatic bacteriuria?

A

At booking and routinely throughout pregnancy involving sending urine sample to the lab for microscopy, culture and sensitivites (MC&S)

159
Q

How do lower urinaty tract infections present?

A
  • Dysuria (pain, stinging or burning when passing urine)
  • Suprapubic pain or discomfort
  • Increased frequency of urination
  • Urgency
  • Incontinence
  • Haematuria
160
Q

How does pyelonephritis present?

A
  • Fever (more prominent than in lower urinary tract infections)
  • Loin, suprapubic or back pain (this may be bilateral or unilateral)
  • Looking and feeling generally unwell
  • Vomiting
  • Loss of appetite
  • Haematuria
  • Renal angle tenderness on examination
161
Q

What may appear on dipstick for a urinary infection?

A
  • Nitrites produced by gram-negative bacteria (such as E. Coli) a breakdown produce of nitrates - a normal waste product in the urine
  • Leukocytes refer to WBCs (normally a small number anyway in the urine) - dipstick tests for leukocyte esterase which gives an indication to the number of leukocytes in the urine
162
Q

What is the best indicator of infection on urine dipstick?

A

Nitrites

163
Q

What are the common causes of UTI?

A

Escherichia coli (gram negative, anaerobic, rod-shaped bacteria which is part of the normal lower intestinal micobiome - found in faeces normally)

Klebsiella pneumoniae (gram negative anaerobic rod)

Enterococcus

Pseudomonas aeruginosa

Staphylococcus saprophyticus

Candida albicans (fungal)

164
Q

What is the management of UTI in pregnancy?

A

7 days of abx:

  • Nitrofurantoin (avoid in the third trimester- risk of neonatal haemolysis)
  • Amoxicillin (only after sensitivities are known)
  • Cefalexin
165
Q

Why should trimethoprim not be used in pregnancy?

A

Not to be used in first trimester as it works as a folate antagonist - folate is important in early pregnancy for the normal development of the fetus

Can cause congenital malformations particularly neural tube defects (i.e. spina bifida)

Not known to be harmful later in pregnancy but is generally avoided

166
Q

When are women screened for anaemia during pregnancy?

A

Usually twice during pregnancy:

  • Booking clinic
  • 28 weeks gestation
167
Q

How does the blood change in pregnancy?

A

Plasma volume increases

Causes a reduction in the Hb concentration- blood is diluted

168
Q

Why is it important to optimise the treatment of anaemia during pregnancy?

A

So the woman has reasonable reserves in case there is significant blood loss during delivery

169
Q

How does anaemia present in pregnancy?

A

Often anaemia in pregnancy is asymptomatic, symptoms include:

  • SoB
  • Fatigue
  • Dizziness
  • Pallor
170
Q

What are the normal ranges for Hb in pregnancy?

A
  • Booking bloods = > 110 g/l
  • 28 weeks gestation = > 105 g/l
  • Post partum = > 100 g/l
171
Q

What can the MCV tell you about the cause of anaemia in pregnancy?

A

Low MCV may indicate iron deficiency

Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy

Raised MCV may indicate B12 or folate deficiency

172
Q

What hamatological diseases are women screened for at booking clinic?

A

Thalassaemia (all women)

Sickle cell disease (women at higher risk)

173
Q

What is the management of anaemia in pregnancy according to cause?

A

Iron = iron replacement (e.g. ferrous sulphate 200mg three times daily) also for if they just have low ferritin

B12 = tested for pernicious anaemia (checking for intrinsic factor antibodies, advice from a haematologist RE treatment but includes: Intramuscular hydroxocobalamin injections, Oral cyanocobalamin tablets

Folate = 5mg daily if folate deficient (should already be on 400mcg daily)

Thalassaemia and sickle cell anaemia = women with haemoglobinopathy will be managed jointly with a specialist haematologist - require high dose folic acid (5mg), close monitoring and transfusions when required

174
Q

Why is pregnancy a risk for VTE?

A

Pregnancy is a hyper-coagulable state

  • Fibrin generation is increased
  • Fibrinolytic activity is reduced
  • Coagulation factors increase- II, VII, VIII, X
175
Q

When is the risk of PE highest in pregnancy?

A

Postpartum period

176
Q

What are the risk factors for VTE in pregnancy?

A
  • Smoking
  • Parity ≥ 3
  • Age > 35 years
  • BMI > 30
  • Reduced mobility
  • Multiple pregnancy
  • Pre-eclampsia
  • Gross varicose veins
  • Immobility
  • Family history of VTE
  • Thrombophilia
  • IVF pregnancy
177
Q

When should prophylaxis be started for VTE?

A

28 weeks if there are three risk factors

First trimester if there are four or more of these risk factors

178
Q

When else is prophylaxis for VTE considered in pregnancy? (Even in the absence of other risk factors)

A

Hospital admission

Surgical procedures

Previous VTE

Medical conditions such as cancer or arthritis

High-risk thrombophilias

Ovarian hyperstimulation syndrome

179
Q

When should pregnant women be assessed for their risk of VTE?

A

At booking and again after birth

(additionally if admitted to hospital, undergo a procedure or develop significant immobility)

180
Q

What is the prophylaxis for VTE in pregnancy?

When should this be started and how long for?

A

Low molecular weight heparin (e.g. enoxaparin, dalteparin and tinzaparin)

  • As soon as possible (1st trimester) in very high risk
  • From 28 weeks in high risk
  • Temporariyl stopped when woman goes into labour, can be started immediately after delivery except with PPH, spinal anaesthesia and epidurals
  • Continued throughout the antenatal period and for 6 weeks postnatally
181
Q

What are the management options for women with contraindications to LMWH?

A

Mechanical prophylaxis:

  • Intermittent pneumatic compression
  • Antiembolic compression stockings
182
Q

How does a DVT present?

A

Unilateral:

Calf or leg swelling

Dilated superficial veins

Tenderness to the calf (particularly over the deep veins)

Oedema

Colour changes to the leg

183
Q

How to examine for leg swelling in DVT?

A

Measure the circumference of the calf 10cm below the tibial tuberosity

More than 3cm difference between calves is significant

184
Q

What are the presenting features of a PE?

A

Shortness of breath

Cough with or without blood (haemoptysis)

Pleuritic chest pain

Hypoxia

Tachycardia (this can be difficult to distinguish from the normal physiological changes in pregnancy)

Raised respiratory rate

Low-grade fever

Haemodynamic instability causing hypotension

185
Q

What is the investigation of choice for a DVT?

A

Doppler ultrasound (repeated on day 3 and 7 in patients with a high index of suspicion for DVT)

186
Q

What are the investigations for women with suspected PE?

A

Definitive diagnosis: CTPA or VW scan

Also require chest X-ray and ECG

187
Q

How can a definitive diagnosis of PE be made?

A

CT pulmonary angiogram

Ventilation-perfusion scan (VQ scan)

188
Q

How does a CT pulmonary angiogram work?

A

Chest CT with IV contrast which highlights the pulmonary arteries to demonstrate any blood clots (helpful as it provides info about alternative diagnoses such as pneumonia or malignancy)

189
Q

How is a ventilation-perfusion scan performed for a PE?

A

Involves using radioactive isotopes and a gamma camera to compare the ventilation with the perfusion of the lungs

First the isotopes are inhaled to fill the lungs and a picture is taken to demonstate ventilation

Next a contrast containing isotopes is injected and a picture is taken to demonstrate perfusion

In a PE, the area of lung tissue will be ventilated but not perfused

190
Q

How is the choice between CTPA and VQ scan determined?

A

CTPA is the test for choice for patients with an abnormal chest xray

CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk)

VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk)

191
Q

If a diagnosis of DVT is established then is a VQ scan or CTPA required?

A

No as the treatment for DVT and PE are the same

192
Q

Is the Wells score or D-dimer test useful in pregnant women?

A

No as pregnancy is a cause of raised D-Dimers

193
Q

What is the management of VTE in pregnancy?

A

LMWH e.g. enoxaparin, dalteparin and tinzaparin, dose is based on the woman’s weight at the booking clinic or from early pregnancy

  • Should be started immeditately even before confirming the diagnosis
  • Treatment can be stopped when Ix exclude the diagnosis
  • When diagnosis is confirmed, LMWH is continued for remainder of pregnancy + 6 weeks post partum - option to switch to DOAC or warfarin after delivery
194
Q

What are the treatment options for a massive PE and haemodynamic compromise?

A

Unfractionated heparin

Thrombolysis

Surgical embolectomy

195
Q

What is pre-eclampsia?

A
  • New onset hypertension: >140/90 after 20 weeks of pregnancy
  • And end organ dysfunction- proteinuria or other organ dysfunction eg renal insufficiency
196
Q

What are some consequences of the spiral arteries of the placenta malforming?

A
  • Recurrent 1st/2nd trimester losses
  • Fetal growth restriction (FGR)
  • Early onset pre-eclampsia
  • Spontaneous pre-term labour
  • Pre-term premature rupture of the membranes
197
Q

When does pre-eclampsia occur?

A

After 20 weeks gestation, when the spiral arteries of the placenta form abnormally leading to a high vascular resistance in these vessels

198
Q

What are some severe complications of pre-eclampsia?

A
  • Maternal organ damage
  • FGR
  • Seizures (eclampsia)
  • Early labour
  • Death
  • Cerebral haemorrhage
  • Renal failure
  • Placental abruption
  • HELLP syndrome
199
Q

What is the triad in pre-eclampsia?

A
  1. Hypertension
  2. Proteinuria
  3. Oedema
200
Q

What is eclampsia?

A

When seizures occur as a result of pre-eclampsia

201
Q

What is the pathophysiology of pre-eclampsia?

A

Pathophysiology is poorly understood, by simplified:

  • When the blastocyst implants on the endometrium , the outermost later called the syncytiotrophoblast grows into the endometrium forming finger-like projections called chorionic villi, these villi contain fetal blood vessels
  • Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance making them more fragile, blood flow to these areas increases and eventually they break down forming pools of blood called lacunae
  • Maternal blood flows from the uterine arteries into the lacunae and back out through the uterine veins- these form at around 20 weeks gestation
  • When the process of forming lacunae is inadequate then the woman can develop pre-eclampsia
  • Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta causing oxidative stress in the placenta and the release of inflammatory chemicals into the systemic circulation leadind to a systemic inflammation and impaired endothelial function in the blood vessels
202
Q

What are the high risk factors for pre-eclampsia?

A
  • Pre-existing hypertension
  • Previous hypertension in pregnancy
  • Existing autoimmune conditions (e.g. systemic lupus erythematosus)
  • Diabetes
  • Chronic kidney disease​
203
Q

What are the moderate risk factors for pre-eclampsia?

A
  • Older than 40
  • BMI > 35
  • More than 10 years since previous pregnancy
  • Multiple pregnancy
  • First pregnancy
  • Family history of pre-eclampsia
204
Q

Who is offered prophylactic aspirin for pre-eclampsia?

A

Women with one high-risk factor or more than one moderate risk factor from 12 weeks gestation until birth

205
Q

What are the symptoms of pre-eclampsia?

A

Headache

Visual disturbance or blurriness

Nausea and vomiting

Upper abdominal or epigastric pain (this is due to liver swelling)

Oedema

Reduced urine output

Brisk reflexes

206
Q

How is a diagnosis of pre-eclampsia made?

A

Systolic blood pressure above 140 mmHg

Diastolic blood pressure above 90 mmHg

PLUS

Proteinuria (1+ or more on urine dipstick)

Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)

Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)

207
Q

How can proteinuria be qualtified on testing?

A

Urine albumin:creatinine ratio (above 30mg/mmol is significant)

Urine protein:creatinine ratio (above 8mg/mmol is significant)

208
Q

How can placental growth factor testing be used for pre-eclampsia?

A

Recommended for use on one occasion during pregnancy in women suspected of having pre-eclampsia

Placental growth factor is a protein released by the placenta which functions to stimulate the development of new blood vessels.

In pre-eclampsia the levels of PIGF are low

NICE recommends using PIGF between 20 and 35 weeks gestation to rule out pre-eclampsia

209
Q

How is pre-eclampsia monitored for at antenatal appts?

A

Blood pressure

Symptoms

Urine dipstick for proteinuria

210
Q

What is the general management for gestational hypertension (without proteinuria)?

A

Treating to aim for a blood pressure below 135/85 mmHg

Admission for women with a blood pressure above 160/110 mmHg

Urine dipstick testing at least weekly

Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)

Monitoring fetal growth by serial growth scans

PlGF testing on one occasion

211
Q

What is the managment of pre-eclampsia?

A

Outpatient mx

  • Appropriate if:
    • BP < 160 systolic and <110 diastolic and can be controlled
    • No or low proteinuria
    • Asymptomatic
  • Difficult to distinguish from gestational htn
    • Warn about development of symptoms
    • 1-2 weekly review of BP and urine
    • Weekly review of bloods
    • Monitoring fetal growth 2 weekly

Mild-moderate pre-eclampsia

  • BP <160 systolic and <110 diastolic with significant proteinuria and no maternal complications
  • Once significant proteinuria occurs, admission is advised
    • ≥2+ protein
    • >300mg proteinuria/24h
    • A split protein:creatinine ratio can be a useful screening test for proteinuria—check with your lab for their normal values, but in general >30 equates to >300mg proteinuria/24h.
  • 4 hourly BP
  • 24 hour urine collection for protein
  • Daily urinalysis
  • Daily fetal assessment with CTG
  • Regular blood tests every 2-3 days unless signs/ symptoms worsen
  • Regular USS

Severe pre-eclampsia mx

  • Defined as the occurrence of BP ≥160 systolic or ≥110 diastolic in the presence of significant proteinuria (≥1g/24h or≥2+ on dipstick), or if maternal complications occur.
  • Senior obstetric, anaesthetic, and midwifery staff should be informed and involved in the management of a woman with severe pre-eclampsia
  • The only treatment is delivery, but this can sometimes be delayed with intensive monitoring if <34wks
  • Pre-eclampsia often worsens for 24h after delivery

Management

  • Labetalol is first line
  • Offer nifedipine if labetalol not suitable
  • Offer methyldopa if nidepine and labetalol both not suitable
  • Strict fluid balance- consider catheter
  • CTG monitoring of fetus until condition status
  • USS fetus, assess if IUGR, assess condition using fetal and umbilical artery doppler
  • If <34 weeks give steroids
212
Q

What is the medical management of pre-eclampsia?

A

Labetolol is first-line as an antihypertensive

Nifedipine (modified-release) is commonly used second-line

Methyldopa is used third-line (needs to be stopped within two days of birth)

Intravenous hydralazine may be used as an antihypertensive in critical care in severe pre-eclampsia or eclampsia

IV magnesium sulphate is given during labour and in the 24 hours afterwards to prevent seizures

Fluid restriction is used during labour in severe pre-eclampsia or eclampsia, to avoid fluid overload

213
Q

When may planned early birth be necessary for pre-eclampsia?

A

Blood pressure cannot be controlled or complications occur

Indications for immediate delivery

  • Worsening thrombocytopaenia or coagulopathy.
  • Worsening liver or renal function.
  • Severe maternal symptoms, especially epigastric pain with abnormal LFTs.
  • HELLP syndrome or eclampsia.
  • Fetal reasons such as abnormal CTG or reversed umbilical artery end diastolic flow.
214
Q

What is the treatment for pre-eclampsia after delivery?

A

Enalapril (first-line)

Nifedipine or amlodipine (first-line in black African or Caribbean patients)

Labetolol or atenolol (third-line)

215
Q

What is eclampsia?

A

The seizures associated with pre-eclampsia IV magnesium sulphate is used to help manage the seizures

  • IV bolus 4g over 5-10 mins
  • Followed by IV infusion 1g/hour
  • Monitor UO, reflexes, RR, O2 sats
    • Respiratory depression can occur- calcium gluconate is first-line for magnesium sulphate induced respiratory depression
216
Q

What is HELLP syndrome?

A

Combination of features with occur as a complication of pre-eclampsia:

Haemolysis

Elevated Liver enzymes

Low Platelets

217
Q

What is gestational diabetes?

A

Diabetes triggered by birth, caused by reduced insulin sensitivity during pregnancy and resolves after birth

218
Q

What is the most significant complication of gestational diabetes?

A

Large for dates fetus and macrosomia leading to shoulder dystocia

Long term risk- women are at a higher risk of developing type 2 diabetes after pregnancy

219
Q

How to screen for gestational diabetes?

A

Oral glucose tolerance test at 24-28 weeks gestation

Used for pts with risk factors for gestational diabete and also when there are features suggestive of gestational diabetes such as

  • Large for dates fetus
  • Polyhydramnios
  • Glucose on urine dipstick
220
Q

What are the risk factors for gestational diabetes?

A

Previous gestational diabetes

Previous macrosomic baby (≥ 4.5kg)

BMI > 30

Ethnic origin (black Caribbean, Middle Eastern and South Asian)

Family history of diabetes (first-degree relative)

221
Q

How should an OGTT be performed?

A

Performed in the morning after a fast (they can drink plain water)

Patient drinks a 75g glucose drink at the start of the test

Blood sugar level is measured before the sugar drink (fasting) and then at 2 hours

222
Q

What are the normal results for an OGTT?

A

Fasting: < 5.6 mmol/l

At 2 hours: < 7.8 mmol/l

(5, 6, 7, 8)

223
Q

What is the initial management of gestational diabetes as suggested by NICE?

A

Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin

Fasting glucose above 7 mmol/l: start insulin ± metformin

Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin

224
Q

What medication can be used as an alternative in those who declin insulin or cannot tolerate metformin

A

Glibenclamide (a sulfonylurea)

225
Q

What are the target levels for blood sugar in gestational diabetes?

A
  • Fasting: 5.3 mmol/l
  • 1 hour post-meal: 7.8 mmol/l
  • 2 hours post-meal: 6.4 mmol/l
  • Avoiding levels of 4 mmol/l or below
226
Q

What should women with pre-existing diabetes take before becoming pregnant?

A

They should take 5mg folic acid from preconception until 12 weeks gestation

227
Q

How are women with type 2 diabetes managed during pregnancy?

A

Using metformin and insulin (other oral diabetic medications should be stopped)

228
Q

When should retinopathy screening be performed antenatally in pre-existing diabetics?

A

Shortly after booking and at 28 weeks gestation in pregnancy

Involves referral to an ophthalmologist to check for diabetic retinopathy

229
Q

When should delivery be planned for in pre-existing diabetes?

A

Planned delivery between 37 and 38 + 6 weeks

230
Q

When should women with gestational diabetes give birth?

A

Up to 40+6

231
Q

How are patients with type 1 diabetes managed during labour?

A

Sliding-scale insulin regime

A dextrose and insulin infusion is titrated to blood sugar levels according to the local protocol. Also considered for women with poorly controlled blood sugars with gestational or type 2 diabetes

232
Q

When can women with gestational diabetes stop their diabetic medication?

A

Immediately after birth with follow up testing for their fasting glucose at least 6 weeks after

233
Q

How to women with pre-existing diabetes be managed postnatally?

A

Lower their insulin dose and be wary of hypoglycaemia in the postnatal period - insulin sensitivity will increase after birth and with breast feeding

234
Q

What are babies of mothers with diabetes at risk of?

A
  • Neonatal hypoglycaemia
  • Polycythaemia (raised haemoglobin)
  • Jaundice (raised bilirubin)
  • Congenital heart disease
  • Cardiomyopathy
235
Q

What is the main neonatal complication of gestational diabetes?

A

Neonatal hypoglycaemia - babies have been accustomed to a large supply of glucose during the pregnancy

Neonates need close monitoring for this with regular blood glucose checks and frequent feeds aiming to maintain thier blood sugar above 2 mmol/l and if it falls they may need IV dextrose or nasogastric feeding

236
Q

What is obstetric cholestasis characterised by?

A

Reduced outflow of bile acids from the liver - resolving after delivery of the baby

Result of Increased oestrogen and progesterone levels

237
Q

What ethnicity is obstetric cholestatsis most common in?

A

South asian ethnicity

238
Q

What are the symptoms of cholestasis?

A
  • Itching (pruritis) on the palms of the hands and soles of the feet
  • Fatigue
  • Dark urine
  • Pale, greasy stools
  • Jaundice (indicating obstruction of the common bile duct)

More acute cholecystitis-

  • Signs of systemic infection (fever, tachycardia)
  • N&V
  • Murphy’s sign positive
  • Colicky epigastric/ RUQ pain
239
Q

Is there a rash associated with obstetric cholestasis?

A

No rash, if this is present then an alternative diagnosis should be considered e.g. polymorphic eruption of pregnancy pr pemphigoid gestationis

240
Q

What are some differentials for pruritis and deranged LFTs?

A
  • Obstetric chilestasis
  • Gallstones
  • Acute Fatty liver
  • Autoimmune hepatitis
241
Q

What are some investigations of obstetric cholestasis?

A

LFTs (deranged ALT, AST and GGT) (WCC and alkaline phosphatase are ↑ in pregnancy; a rise of ALP with normal LFTs may be ALP production from placenta)

↑ Bilirubin (identify patients with concomitant biliary tree obstruction)

Bile acids (raised)

USS biliary tract (may demonstate calculi or a dilated biliary tree)

242
Q

What is the management of obstetric cholestasis?

A
  • Ursodeoxycholic acid - improves LFTs, bile acids and symptoms
  • Emollients (i.e. calamine lotion) to soothe the skin
  • Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)
  • Vit K supplementation if clotting (prothrombin time) is deranged
  • Monitor LFTs during pregnancy weekly and for 10 days after pregnancy to ensure condition doesn’t woren & resolves after birth
  • induction of labour at 37-38 weeks is common practice but may not be evidence based
243
Q

What is acute fatty liver of pregnancy?

A

Rare condition which occurs in the third trimester of pregnancy with rapid accumulation of fat within the liver cells (hepatocytes) causing acute hepatitis

High risk of liver failure and mortality for both the mother and fetus

244
Q

What is acute fatty liver of pregnancy caused by?

A

Impaired processing of fatty acids in the placenta result of a genetric condition in the fetus which impairs fatty acid metabolism

Most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus which is an autosomal recessive condition

The LCHAD enzyme is important in fatty acid oxidation breaking down fatty acids to be used as fuel

Fatty acids then enter maternal circulation and accumulate in the liver causing inflammation and failure

245
Q

How does acute fatty liver of pregnancy present?

A

Vague symptoms associated with hepatitis:

General malaise and fatigue

Nausea and vomiting

Jaundice

Abdominal pain

Anorexia (lack of appetite)

Ascites

Headache

Hypoglycaemia

Severe disease may result in pre-eclampsia

246
Q

What do the blood show in acute fatty liver of pregnancy?

A
  • Elevated ALT and AST (liver enzymes)
  • Raised bilirubin
  • Raised WBC
  • Deranged clotting (raised prothrombin time and INR)
  • Low platelets
247
Q

How is acute fatty liver of pregnancy managed?

A

Obstetric emergency which requires prompt admission and delivery of the baby - most patients recover after delivery

248
Q

What are the possible long term complications of acute fatty liver of pregnancy?

A

Acute liver failure - consider liver transplant

249
Q

What is polymorphic eruption of pregnancy?

A

Itchy rash which tends to start in the 3rd trimester

  • Also known as pruritic and urticarial papulaes and plaques of pregnancy
  • Usually begins of abdomen and particularly assocuated with stretch marks (striae)

Characterised by:

  • Urticarial papules (raised itchy lumps)
  • Wheals (raised itchy areas of skin)
  • Plaques (larger inflamed areas of skin)
250
Q

What are some pregnancy-related skin changes/ rashes that can occur?

A
  • Polymorphic eruption of pregnancy
    • Pruritic condition associated with 3rd trimester
    • Lesions often appear in abdominal striae first
    • Periumbilical area often spared
  • Atopic eruption of pregnancy
    • Commonest skin disorder found in pregnancy
    • Eczemaotus, itchy, red rash
    • No specific treatment required
  • Pemphigoid gestationis
    • Pruritis blistering lesions
    • Often peri-umbilical reigon, later spreads to trunk, back, buttocks and arms
    • Usually 2nd and 3rd trimester
    • Oral corticosteroids usually required
  • Melasma
    • Increased pigmentation to patches of skin on the face, symmetrical and flat, on sun-exposed areas
  • Pyogenic granuloma
    • Sites: head, neck, upper trunk, hands
    • Lesions in oral mucosa during pregnancy
    • Initially small red/ brown spot, rapidly progresses within days to weeks forming raised, red brown lesions which are spherical in shape, lesions may bleed profusely or ulcerate
    • Resolve spontaneously post-partum
251
Q

How is polymorphic eruption of pregnancy managed?

A

Control the symptoms:

Topical emollients

Topical steroids

Oral antihistamines

Oral steroids may be used in severe cases

252
Q

What are the two types of atopic eruption of pregnancy?

A

E-type or eczema type with eczematous inflamed, red and itchy skin, inside of elbows and knees, face and chest

P-type or prurigo-type intesely itchy papules (spots) typically affecting the abdomen, back and limbs

253
Q

How is atopic eruption of pregnancy managed?

A

Topical emollients

Topical steroids

Phototherapy with ultraviolet light (UVB) may be used in severe cases

Oral steroids may be used in severe cases

254
Q

What is melasma characterised by?

A

Increased pigmentation to patched of the skin on the face - usually symmetrical and flat, affecting sun-exposed areas

255
Q

What is melasma associated with?

A

Increased female sex hormones associated with pregnancy

Also occurs with the COCP and HRT

Associated also with sun exposure, contraceptive pill and HRT

256
Q

What is the management of melasma?

A

No active management if the appearance is acceptable to the woman, otherwise:

Avoiding sun exposure and using suncream

Makeup (camouflage)

Skin lightening cream (e.g. hydroquinone or retinoid creams), although not in pregnancy and only under specialist care

Procedures such as chemical peels or laser treatment (not usually on the NHS)

257
Q

What is pyogenic granuloma?

A

Benign rapidly growing tumour of capillaries

258
Q

How does pyogenic granuloma present?

A

Discrete lump with a red / dark appearace

Occuring more often in pregnancy can also be associated with hormonal contraceptives, minor trauma or infection

259
Q

Where does pyogenic granuloma appear?

A

Rapidly growing lump which develops over days up to 1-2cm in size (but can be larger)

Often occur on the fingers or on the upper chest, back, neck or head.

May cause profuse bleeding and ulceration if injured

260
Q

What is the management of pyogenic granuloma?

A

Usually resolve in pregnancy without any further treatment after delivery

Treatment is with surgical removal with histology to confirm the diagnosis

261
Q

What is pemphigoid gestationis?

A

Rare autoimmune skin condition in pregnancy

Autoantibodies are created with damage the connection between the epidermis and dermis creating a space with can fill with fluid, resulting in large fluid-filled blisters (bullae)

262
Q

How does pemphigois gestationis usually present?

A

Itchy, red, papular or blistering rash around the umbilicus that then spreads to other parts of the body - over weeks large fluid filled blisters form

263
Q

How is pemphigoid gestationis managed?

A

Rash usually resolves without treatment after delivery, blisters heal without scarring, treatment can be:

Topical emollients

Topical steroids

Oral steroids may be required in severe cases

Immunosuppressants may be required where steroids are inadequate

Antibiotics may be necessary if infection occurs

264
Q

What risks does pemphigoid gestationis pose to the baby?

A

Fetal growth restriction

Preterm delivery

Blistering rash after delivery (as the maternal antibodies pass to the baby)

265
Q

What is placenta praevia?

A

The palcenta is attached in the lower portion of the uterus, lower than presenting part of fetus

  • Over the internal cervical os

Low lying placenta = the placenta is within 20mm of the cervical os

266
Q

What are some causes of spotting in pregnancy?

A

Cervical ectropion

Infection

Vaginal abrasions from intercourse

267
Q

What are the risks associated with placenta praevia?

A
  • Antepartum haemorrhage
  • Emergency caesarean section
  • Emergency hysterectomy
  • Maternal anaemia and transfusions
  • Preterm birth and low birth weight
  • Stillbirth
268
Q

What are the traditional four grades of placenta praevia? (system is outdated, now used low lying and placenta praevia)

A

Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os

Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os

Partial praevia, or grade III – the placenta is partially covering the internal cervical os

Complete praevia, or grade IV – the placenta is completely covering the internal cervical os

269
Q

What are the risk factors for placenta praevia?

A

Previous caesarean sections

Previous placenta praevia

Older maternal age

Maternal smoking

Structural uterine abnormalities (e.g. fibroids)

Assisted reproduction (e.g. IVF)

270
Q

When is the position of the placenta assessed?

A

20 week anomaly scan

271
Q

What are the signs and symptoms of placenta praevia?

A

Usually asymptomatic

Painless vaginal bleeding (around 36 weeks)

Malpresentation of fetus

Normal uterine tone- unlike abruption- fetal parts easy to palpate

272
Q

What is the management of a low-lying placenta/placenta praevia?

A

When antepartum haemorrhage of any type occurs, suspect placenta praevia, admit to hospital

  • IV access
  • Fluid resuscitation
  • Take bloods for FBC and cross match
  • CTG to determine fetal status
  • Cause for bleeding sought from USS
    • Up to 50% no cause may be seen
  • Emergency C-Section required with premature labout or antenatal bleeding
  • Anti D immunoglobulin if Rh negative mother

Conservative mx of placenta praevia where there is non-life-threatening bleeding and pre-term lady

  • Keep in hospital with cross-matched blood until fetal maturity is adequate
  • Oral iron or iron infusion where necessary to maintain adequate Hb
  • Repeat scans at 32 weeks and 36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
  • Corticosteroids given between 34 and 35+6 gestation to mature the fetal lungs
  • Planned delivery between 36 and 37 weeeks to reduce the risk of spontaneous labour and bleeding
  • Planned C-Section is required with placenta praevia and low-lying placenta
  • Ultrasound around the time of procedure to locate placenta
273
Q

What is the main complication of placenta praevia?

A

Haemorrhage before, during and after delivery

274
Q

What is the management of haemorrhage in placenta praevia?

A
  • Emergency caesarean section
  • Blood transfusions
  • Intrauterine balloon tamponade
  • Uterine artery occlusion
  • Emergency hysterectomy
275
Q

What is vasa praevia?

A

Condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes- surround amniotic cavity & developing fetus) and travel across the internal cervical os

The fetal vessels = 2 umbilical arteries and single umbilical vein

The fetal vessels are places over the internal cervical os, before the fetus - exposed, outside the protection of the umbilical cord or placenta - prone to bleeding, particularly when the membranes are ruptured during labour and at birth

276
Q

What are the two types of vasa praevia?

A

Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord

Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental lobe

277
Q

What are the risk factors for vasa praevia?

A

Low lying placenta

IVF pregnancy

Multiple pregnancy

278
Q

How may vasa praevia present?

A

Maybe diagnosed by ultrasound during pregnancy (allowing planned C-Section to reduce risk of haemorrhage)

Antepartum haemorrhage with bleeding during 2nd or 3rd trimester of pregnancy

Maybe detected on vaginal examintation during labour when pulsatiling vessels are seen in the membranes

Maybe detected during labour when fetal distress and dark-red bleeding occur following rupture of the membranes carries a very high fetal mortality

279
Q

What is the management of vasa praevia?

A

For asymptomatic patients:

  • Corticosteroids from week 32 gestation
  • Elective c-section planned for 34 to 36 weeks gestation

In antepartum haemorrhage:

  • Emergency C-Section is required to deliver fetus
280
Q

What is placental abruption?

A

When the placenta separates from the walls of the uterus during pregnancy (site of attachment can bleed extensively after the placenta separates - significant cause of antepartum haemorrhage)

281
Q

What are some risk factors for placental abruption?

A

Previous placental abruption

Pre-eclampsia

Bleeding early in pregnancy

Trauma (consider domestic violence)

Multiple pregnancy

Fetal growth restriction

Multigravida

Increased maternal age

Smoking

Cocaine or amphetamine use

282
Q

How does placental abruption present?

A

Sudden onset severe abdominal pain that is continuous

Vaginal bleeding (antepartum haemorrhage)

Shock (hypotension and tachycardia)

Abnormalities on the CTG indicating fetal distress

Characteristic “woody” abdomen on palpation, suggesting a large haemorrhage

Unlike placenta praevia, placental abruption presents with pain, vaginal bleeding of variable amounts and increased uterine activity.

283
Q

How is the severtity of antepartum haemorrhage estimated?

A

Spotting: spots of blood noticed on underwear

Minor haemorrhage: less than 50ml blood loss

Major haemorrhage: 50 – 1000ml blood loss

Massive haemorrhage: more than 1000 ml blood loss, or signs of shock

284
Q

What is a concealed abruption?

A

Cervical os remains closed, and any bleeding that occurs remains within the uterine cavity. The severity of bleeding can be significantly underestimated with concealed haemorrhage.

285
Q

What is a revealed abruption?

A

Where blood loss is observed via the vagina

286
Q

How is placental abruption diagnosed?

A

No reliable test, clinical diagnosis

287
Q

Is placental abruption an emergency?

A

Obstetric emergency - urgency depends on the amount of fetal separation, extent of bleedin, haemodynamic stability of the mother and condition of the fetus (important to consider concealed haemorrhage where vaginal bleeding may be disproportionate to uterine bleeding)

288
Q

What are the management steps of placental abruption?

A
  • Urgent involvement of a senior obstetrician, midwife and anaesthetist
  • 2 x grey cannula
  • Bloods include FBC, UE, LFT and coagulation studies
  • Crossmatch 4 units of blood
  • Fluid and blood resuscitation as required
  • CTG monitoring of the fetus
  • Close monitoring of the mother

Fetus alive and < 36 weeks

  • fetal distress: immediate caesarean
  • no fetal distress: observe closely, steroids, no tocolysis, threshold to deliver depends on gestation

Fetus alive and > 36 weeks

  • fetal distress: immediate caesarean
  • no fetal distress: deliver vaginally

Fetus dead

  • induce vaginal delivery
289
Q

In the antenatal period what is the management for placental abruption?

A

Ultrasound to exclude placenta praevia as a cause for antepartum haemorrhage (not good for diagnosing abruption)

Antenatal steroids between 24 and 34 + 6 weeks gestation

Rhesus-D negative women require anti-D prophylaxis when bleeding occurs - a Kleihauer test is used to quantify how much fetal blood is mixed with maternal blood to determine dose

Emergency C-Section if mother is unstable or there is fetal distress

Increased risk of postpartum haemorrhage after delivery in women with placental abruption - active management of the third stage is recommended

290
Q

What is placenta accreta?

A

When the placenta implants deeper, through and past the endometrium - then difficult to separate the placenta after delivery of the baby

291
Q

What are the three layers to the uterine wall?

A

Endometrium, the inner layer that contains connective tissue (stroma), epithelial cells and blood vessels

Myometrium, the middle layer that contains smooth muscle

Perimetrium, the outer layer, which is a serous membrane similar to the peritoneum (also known as serosa)

292
Q

Where does the placenta usually attach to?

A

The endometrium

293
Q

Where does the placenta embed in placenta accreta?

A

Past the endometrium into the myometrium and beyond

294
Q

Why may placenta accreta occur?

A

Previous uterine surgery e.g. C-Section or curettage procedure

295
Q

What is the adverse outcome in placenta accreta?

A

Difficult for the placenta to separate suring delivery, leading to extensive bleeding (post-partum haemorrhage)

296
Q

What are the other definitions of placenta accreta (based on the depth of insertion)?

A

Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond

Placenta increta is where the placenta attaches deeply into the myometrium

Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder

297
Q

What are the risk factors for placenta accreta?

A

Previous placenta accreta

Previous endometrial curettage procedures (e.g. for miscarriage or abortion)

Previous caesarean section

Multigravida

Increased maternal age

Low-lying placenta or placenta praevia

298
Q

How does placenta accreta present?

A

Doesnt usually cause symptoms in pregnancy

Can present with antepartum haemorrhage in the third trimester

May be diagnosed on antenatal ultrasound scans with particular attention fiven to women with previous placenta accreta or caesarean during scanning

May be diagnosed at birth when it is difficult to deliver the placenta

299
Q

How are patients with placenta accreta ideally diagnosed?

A

Antenatally by ultrasound - allowing planning for birth

300
Q

What can be used to assess the depth and width of invasion in placenta accreta?

A

MRI scans

301
Q

How are patients with placenta accreta managed?

A

May need additional management at birth due to the risk of bleeding:

Complex uterine surgery

Blood transfusions

Intensive care for the mother

Neonatal intensive care

302
Q

When is delivery planned for in placental accreta?

A

Between 35 to 36+6 weeks gestation to reduce the risk of spontaneous labour and delivery (antenatal steroids given to mature the fetal lungs before delivery)

303
Q

What are the options during caesarean delivery for treating placenta accreta?

A

Hysterectomy with the placenta remaining in the uterus (recommended)

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

304
Q

How to manage unexpected placenta accreta during delivery?

A
  • During an elective C-section the abdo can be closed and delayed whilst services are put in place
  • If discovered after delivery of baby then a hysterectomy is recommended
305
Q

What is breech presentation?

A

Presenting part of the fetus is the legs and bottom

306
Q

How often does breech presentation occur?

A

Less than 5% of pregnancies by 37 weeks gestation

307
Q

What are the different types of breech presentation?

A

Complete breech, where the legs are fully flexed at the hips and knees

Incomplete breech, with one leg flexed at the hip and extended at the knee

Extended breech, also known as frank breech, with both legs flexed at the hip and extended at the knee

Footling breech, with a foot is presenting through the cervix with the leg extended

308
Q

What is the management of breech babies?

A

Before 36 weeks often turn spontaneously

After 37 weeks external cephalic version can be used to attempt to turn the fetus

If this fails then women are given a choice between vaginal delivery and elective CS

  • VD needs to involve senior midwives and access to emergency theatres if CS required
  • When the first baby in a twin pregnancy is breech CS is required
309
Q

What is given before ECV is attempted? What does it do?

A

Tocolysis to relax the uterus: subcutaneous terbutaline- A beta-agonist similar to salbutamol (reduces the contractility of the myometrium)

310
Q

What is a stillbirth?

A

Birth of a dead fetus after 24 weeks gestation (result of intrauterine fetal death) occurs in approx 1 in 200 pregnancies

311
Q

What are the causes of stillbirth?

A

Unexplained (around 50%)

Pre-eclampsia

Placental abruption

Vasa praevia

Cord prolapse or wrapped around the fetal neck

Obstetric cholestasis

Diabetes

Thyroid disease

Infections, such as rubella, parvovirus and listeria

Genetic abnormalities or congenital malformations

312
Q

What are the factors which increase the risk of stillbirth?

A

Fetal growth restriction

Smoking

Alcohol

Increased maternal age

Maternal obesity

Twins

Sleeping on the back (as opposed to either side)

313
Q

How is stillbirth prevented?

A

Risk assesment for SGA / FGR is performed on all pregnant women

Those at risk have serial growth scans (maybe planned early delivery when the growth is static or other concerns)

Risk assessment for pre-eclampsia and given aspirin

Modifiable risk factors for stillbirth are treated e.g. stopping smoking, avoiding alcohol, effective control for diabetes

Sleeping on the side is recommended

314
Q

What are the three key symptoms to always ask during pregnancy?

A

Reduced fetal movements

Abdo pain

Vaginal bleeding

315
Q

How is intrauterine fetal death diagnosed?

A

Ultrasound scan to visualise the fetal heatbeat

Passive fetal movements are still possible so a repeat scan is offered to confirm situation

316
Q

How are patients with IUFD managed?

A

Vaginal birth is first line (choice of induction of labour or expectant management - provided there is no sepsis, pre-eclampsia or haemorrhage)

Expectant managment needs close monitoring - condition of fetus will deteriorate with time

Induction of laboue involves use of oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue)

Dopamine agonists (e.g. cabergoline) can be used to suppress lactation after stillbirth

317
Q

How can the cause of stillbirth be determined?

A

With parental consent, testing is carried our after stillbirth:

Genetic testing of the fetus and placenta

Postmortem examination of the fetus (including xrays)

Testing for maternal and fetal infection

Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia

318
Q

What are the causes of cardiac arrest?

A
  1. Thrombosis (i.e. PE or MI)
  2. Tension pneumothorax
  3. Toxins
  4. Tamponade (cardiac)
  5. Hypoxia
  6. Hypovolaemia
  7. Hypothermia
  8. Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities
319
Q

What are the other causes of cardiac arrest in pregnancy?

A

Eclampsia

Intracranial haemorrhage

Obstetric haemorrhage

Pulmonary embolism

Sepsis leading to metabolic acidosis and septic shock

320
Q

What are the causes of massive obstetric haemorrhage?

A

Ectopic pregnancy (early pregnancy)

Placental abruption (including concealed haemorrhage)

Placenta praevia

Placenta accreta

Uterine rupture

321
Q

What is aorto-caval compression?

A

Pregnant woman lies on her back - the mass of the uterus compresses the IVC and aorta (compression on the IVC is most significant as it lowers cardiac output leading to hypotension) can lead to cardiac arrest

322
Q

How to prevent aortocaval compression?

A

Place the pt in the left lateral position, lying on her left side

323
Q

What factors make resuscitation in pregnancy more difficult?

A

Aortocaval compression

Increased oxygen requirements

Splinting of the diaphragm by the pregnant abdomen

Difficulty with intubation

Increased risk of aspiration

Ongoing obstetric haemorrhage

324
Q

How is resuscitation performed in pregnancy?

A

A 15 degree tilt to the left side for CPR, to relieve compression of the inferior vena cava and aorta

Early intubation to protect the airway

Early supplementary oxygen

Aggressive fluid resuscitation (caution in pre-eclampsia)

Delivery of the baby after 4 minutes, and within 5 minutes of starting CPR

325
Q

When is immediate caesarean section performed in a pregnant woman?

A

There is no response after 4 minutes to CPR when performed correctly

CPR continues for more than 4 minutes in a woman more than 20 weeks gestation

326
Q

How quickly after CPR should a baby be delivered?

A

Within 5 minutes of starting CPR - performed at the site of the arrest e.g. A&E resus or on the ward

327
Q

What is the primary reason for the immediate delivery of the baby during CPR?

A

Improves survival of the mother improving the venous return to the heart, improving cardiac output and reducing oxygen consumption - also helps with ventilation and chest compressions (also increases the chances of the baby surviving, although this is secondary to the survival of the mother)

328
Q

Describe some characteristic changes in the cervix during pregnancy?

A
  • Increased vascularity
  • Hypertrophy of cervical glands producing the appearance of a cervical erosion; an increase in mucous secretory tissue in the cervix during pregnancy leads to a thick mucus discharge and the development of an antibacterial plug of mucus in the cervix
  • Reduced collagen in the cervix in the third trimester and the accumulation of glycosaminoglycans and water, leading to the characteristic changes of cervical ripening
    • The lower section shortens as the upper section expands, while during labour there is further stretching and dilatation of the cervix
329
Q

What is polyhydramnios and how does it present?

A
  • Polyhydramnios is the presence of too much amniotic fluid in the uterus.
  • Polyhydramnios may present with a uterus which feels tense or large for dates and it may be difficult to feel the foetal parts on palpation of the abdomen. In many cases of polyhydramnios there is no identifiable cause.
330
Q

What can cause polyhydramnios?

A

Causes of polyhydramnios can be due to excessive production of amniotic fluid or insufficient removal of amniotic fluid.

Excess production can be due to increased foetal urination:

  • Maternal diabetes mellitus
  • Foetal renal disorders
  • Foetal anaemia
  • Twin-to-twin transfusion syndrome

Insufficient removal can be due to reduced foetal swallowing:

  • Oesophageal or duodenal atresia
  • Diaphragmatic hernia
  • Anencephaly
  • Chromosomal disorders
331
Q

What are the complications and mx of polyhydramnios?

A

Complications of polyhydramnios can be divided into maternal and foetal.

Maternal complications

  • Maternal respiratory compromise due to increased pressure on the diaphragm
  • Increased risk of urinary tract infections due to increased pressure on the urinary system
  • Worsening of other symptoms associated with pregnancy such as gastro-oesophageal reflux, constipation, peripheral oedema and stretch marks
  • Increased incidence of caesarean section delivery
  • Increased risk of amniotic fluid embolism (although this is rare)

Foetal complications

  • Pre-term labour and delivery
  • Premature rupture of membranes
  • Placental abruption
  • Malpresentation of the foetus (the foetus has more space to “move” within the uterus)
  • Umbilical cord prolapse (polyhydramnios can prevent the foetus from engaging with the pelvis, thus leaving room for the cord to prolapse out of the uterus before the presenting part)

Management

  • Treatment includes management of any underlying causes (e.g. in maternal diabetes) and amnio-reduction in severe cases.
332
Q

What bloods need to be done for pts with severe pre-eclampsia and how often?

A

U&E, FBC, transaminases and bilirubin three times per week to anticipate if a pt will develop HELLP syndrome

333
Q

Define antepartum haemorrhage?

A

WHO definition- haemorrhage from vagina after 24 weeks gestation

The factors that cause antepartum haemorrhage may be present before 20 weeks, but the distinction between a threatened miscarriage and an antepartum haemorrhage is based on whether the fetus is considered potentially viable at the time of the bleed

334
Q

What is gestational hypertension?

A

Gestational hypertension is characterized by the new onset of hypertension without any features of pre-eclampsia after 20 weeks of pregnancy or within the first 24 hours postpartum. Although by definition the blood pressure should return to normal by 12 weeks after pregnancy; it usually returns to normal within 10 days after delivery.

335
Q

Causes of antepartum haemorrhage?

A

Vaginal bleeding may be due to:

  • haemorrhage from the placental site and uterus: placenta praevia, placental abruption, uterine rupture
  • lesions of the lower genital tract: heavy show/onset of labour (bleed from cervical epithelium), cervical ectropion/carcinoma, cervicitis, polyps, vulval varices, trauma and infection
  • bleeding from fetal vessels, including vasa praevia (very rare)
336
Q

What are some causes of a breech presentation?

A
  • Gestational age
  • Placental location
  • Uterine anomalies
  • Multiple pregnancy
  • Neurological impairment of the fetal limbs
337
Q

What are the folic acid requirements for pregnant women?

A

400mcg daily from before pregnancy till 12 weeks

Take 5mg if any of the following apply:

  • BMI > 30
  • Sickle cell disease
  • Diabetes
  • Thalassemia trait
  • Personal/ family hx of neural tube defects (NTD)
  • Coeliac disease
  • On AEDs
338
Q

When should fetal movements be estabilished by?

A

24 weeks gestation

339
Q

What are some risk factors for reduced fetal movements?

A
  • Posture
    • There can be positional changes in fetal movement awareness, generally being more prominent during lying down and less when sitting and standing
  • Distraction
    • Awareness of fetal movements can be distractable, and if a woman is busy or concentrating on something else, these can be less prominent
  • Placental position
    • Patient with anterior placentas prior to 28 weeks gestation may have lesser awareness of fetal movements
  • Medication
    • Both alcohol and sedative medications like opiates or benzodiazepines can temporarily cause reduced fetal movements
  • Fetal position
    • Anterior fetal position means movements are less noticeable
  • Body habitus
    • Obese patients are less likely to feel prominent fetal movements
  • Amniotic fluid volume
    • Both oligohydramnios and polyhydramnios can cause reduction in fetal movements
  • Fetal size
    • Up to 29% of women presenting with RFM have a SGA fetus
340
Q

Why does smoking decrease the risk of hyperemesis gravidarum?

A

Hyperemesis gravidarum is believed to occur due to rapidly rising levels of human chorionic gonadotropin (HCG) and oestrogen. Any condition which increases these hormone levels (or is associated with higher hormone levels) will lead to an increased risk of hyperemesis. Smoking is considered to be anti-oestrogenic and has been found to decrease the risk of hyperemesis gravidarum.

341
Q

List 4 complications of placental abruption to the mother

A
  • Shock
  • DIC- Disseminated intravascular coagulation
  • Renal failure
  • PPH
342
Q

List some complications to the fetus of placental abruption

A

IUGR

Hypoxia

Premature birth

Death

HY OBGYN - (edited) (10 decks)

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