Antenatal Care Flashcards
Primigravida vs. multigravida
Primigravida refers to a patient that is pregnant for the first time
Multigravida refers to a patient that is pregnant for at least the second time
para vs gravida
Para (P) refers to the number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn
Gravida (G) is the total number of pregnancies a woman has had
Nulliparous (“nullip”) vs primiparous (primip) vs Multiparous (“multip”)
Nulliparous (“nullip”) refers to a patient that has never given birth after 24 weeks gestation
Primiparous technically refers to a patient that has given birth after 24 weeks gestation once before - but often used to refer to W who has never given birth before
Multiparous (“multip”) refers to a patient that has given birth after 24 weeks gestation two or more times
Gravidity and Parity
A non-pregnant woman with a previous stillbirth (after 24 weeks gestation):
G1 P1
Gravidity and Parity
A pregnant woman with three previous deliveries at term
G4 P3
Gravidity and Parity
A non-pregnant woman with a previous birth of healthy twins:
G1 P1
Gravidity and Parity
A non-pregnant woman with a previous miscarriage:
G1 P0+1
trimester weeks
1-12, 13-26, 27-40
When do fetal movements start?
week 20, continue until birth
who needs anti-D injections
rhesus Negative women
6 things that happen at routine antenatal appointments
Discuss plans for the remainder of the pregnancy and delivery
Symphysis-fundal height measurement from 24 weeks onwards
Fetal presentation assessment from 36 weeks onwards
Urine dipstick for protein for pre-eclampsia
Blood pressure for pre-eclampsia
Urine for microscopy and culture for asymptomatic bacteriuria
what 2 vaccines are offered to all pregnant women?
Whooping cough (pertussis) from 16 weeks gestation Influenza (flu) when available in autumn or winter
Live vaccines, such as the MMR vaccine, are avoided in pregnancy.
Signs of fetal alcohol syndrome
Microcephaly (small head) Thin upper lip Smooth flat philtrum (the groove between the nose and upper lip) Short palpebral fissure (short horizontal distance from one side of the eye to the other) Learning disability Behavioural difficulties Hearing and vision problems Cerebral palsy
what does Smoking in pregnancy increases the risk of?
Fetal growth restriction (FGR)!!
Miscarriage Stillbirth Preterm labour and delivery Placental abruption Pre-eclampsia Cleft lip or palate
Sudden infant death syndrome (SIDS)!!
what GA is ok to fly in pregnancy?
The RCOG advises flying is generally ok in uncomplicated healthy pregnancies up to:
37 weeks in a single pregnancy
32 weeks in a twin pregnancy
What are the booking bloods?
A set of booking bloods are taken for:
- Blood group, antibodies and rhesus D status
- FBC for anaemia
- Screening for thalassaemia (all women) and sickle cell disease(women at higher risk)
Patients are also offered screening for infectious diseases, by testing antibodies for:
HIV
Hepatitis B
Syphilis
What is the combined test?
tests for down syndrome
1st line and most accurate screening test
do it GA 11-14
combine US and maternal blood test results
US - nuchal translucency (>6mm)
blood - B-hCG (higher inc risk), PAPPA (lower inc risk)
what is the difference between triple and quadruple test?
screen for Down's GA 14-20 only maternal blood (no US) - b-hCG (high inc risk) -AFP (low inc risk) -serum oesteriol (low inc risk)
quadruple - same but also test serum inhibit-A (high inc risk)
what is the risk score needed to offer amniocentesis or chorionic villus sampling to investigate Downs?
> 1 in 150 (occurs in 5% of tested W)
take fetal cells and perform karyotyping
CVS <15 weeks GA
amnio > 15 weeks GA
difference btw CVS and amniocentesis
Chorionic villus sampling (CVS) involves an ultrasound-guided biopsy of the placental tissue. This is used when testing is done earlier in pregnancy (before 15 weeks).
Amniocentesis involves ultrasound-guided aspiration of amniotic fluid using a needle and syringe. This is used later in pregnancy once there is enough amniotic fluid to make it safer to take a sample.
what is alternative screening test for Downs not currently available on NHS?
Non-invasive prenatal testing (NIPT)
- blood test from the mother. The blood will contain fragments of DNA, some of which will come from the placental tissue and represent the fetal DNA.
These fragments can be analysed to detect conditions such as Down’s.
NIPT is not a definitive test, but it does give a very good indication of whether the fetus is affected
Possible consequences of untreated hypothyroidism in pregnancy?
miscarriage, anaemia, small for gestational age and pre-eclampsia.
management of hypothyroidism in pregnancy?
Levothyroxine T4
- crosses placenta
- -> inc dose by 25-50 mcg (30-50%)
titrate according to TSH level, aim for low-normal TSH
what meds for HT must be stopped when pregnant?
Medications that should be stopped as they may cause congenital abnormalities:
ACE inhibitors (e.g. ramipril)
Angiotensin receptor blockers (e.g. losartan)
Thiazide and thiazide-like diuretics (e.g. indapamide)
what antihypertensives can be used in pregnancy?
Labetalol (a beta-blocker - although other beta-blockers may have adverse effects)
Calcium channel blockers (e.g. nifedipine)
Alpha-blockers (e.g. doxazosin)
how do you manage epilepsy in pregnancy?
inc folic acid to 5mg
inc risk of seizures
ideally use 1 drug before become pregnant
Levetiracetam, lamotrigine and carbamazepine are the safer anti-epileptic medication in pregnancy
Sodium valproate - teratogenic, do not start childbearing age W on it —> causes neural tube defects and developmental delay
Phenytoin is avoided as it causes cleft lip and palate
management of RA in pregnancy?
well controlled for ≥3 months pre pregnant
symptoms improve in pregnancy, flare up after delivery
Methotrexate is contraindicated, and is teratogenic, causing miscarriage and congenital abnormalities
Hydroxychloroquine is considered safe during pregnancy and is often the first-line choice
Sulfasalazine is considered safe during pregnancy
Corticosteroids may be used during flare-ups
Up to What GA can get congenital rubella syndrome?
aka German measles
rubella virus infection during 1st 20 weeks of pregnancy
high risk <10 weeks GA
how do you prevent congenital rubella syndrome?
planning to have baby
- have MMR vaccine
- if ?, check rubella immunity
- if no antibodies to rubella –> vaccinate w/ 2x doses MMR, 3 months apart
pregnant
- no MMR vaccine bc live
- if non-immune, MMR vaccine after birth
4 features of congenital rubella syndrome
Congenital deafness
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
3 dangers of chickenpox in pregnancy
Chickenpox is caused by the varicella zoster virus (VZV).
can lead to:
More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis
Fetal varicella syndrome
Severe neonatal varicella infection (if infected around delivery)
Management of chickenpox exposure in pregnancy
if had CP = safe
if unsure - check VZV IgG, if + safe
if no immune –> tx with IV varicella IG as prophylaxis within 10 days of exposure to CP
Management of chickenpox rash in pregnancy
if present within 24 hours exposure and >20 weeks GA –> oral aciclovir
5 features of Congenital varicella syndrome
occurs in 1% CP cases, when inf in 1st 28 weeks GA
Fetal growth restriction
Microcephaly, hydrocephalus and learning disability
Scars and significant skin changes located in specific dermatomes
Limb hypoplasia (underdeveloped limbs)
Cataracts and inflammation in the eye (chorioretinitis)
what gram + infection is more likely when pregnant?
listeria –> causes listeriosis
Infection in the mother may be asymptomatic, cause a flu-like illness, or less commonly cause pneumonia or meningoencephalitis.
risk of Listeriosis in pregnant women
inc rate of:
miscarriage or fetal death.
It can also cause severe neonatal infection.
how do you get listeriosis?
Listeria is typically transmitted by unpasteurised dairy products, processed meats and contaminated foods.
Pregnant women are advised to avoid high-risk foods (e.g. blue cheese) and practice good food hygiene.
how is CMV spread?
from infected saliva or urine of asymptomatic kids
features of congenital CMV
Most cases of CMV in pregnancy do not cause congenital CMV.
Fetal growth restriction Microcephaly Hearing loss Vision loss Learning disability Seizures
what is Congenital Toxoplasmosis?
Toxoplasma gondii parasite infection
It is usually asymptomatic.
It is primarily spread by contamination with faeces from a cat that is a host of the parasite. When infection occurs during pregnancy, it can lead to congenital toxoplasmosis. The risk is higher later in the pregnancy.
Triad of congenital toxoplasmosis
- Intracranial calcification
- Hydrocephalus
- Chorioretinitis (inflammation of the choroid and retina in the eye)
3 other names for parvovirus B19 infection
fifth disease, slapped cheek syndrome and erythema infectiosum
parvovirus infection signs
cause: parvovirus B19 virus
illness is self-limiting, and the rash and symptoms usually fade over 1 - 2 weeks.
starts 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 (net like) mildly erythematous rash affecting the trunk and limbs appears, which can be raised and itchy.
incubation period of parvovirus
infection 7-10 days before rash appears
not infectious once have rash
what time means significant exposure to parvovirus?
15 minutes in the same room, or face-to-face contact, with someone that has the virus.
complications of parvovirus
Particularly in the first and second trimesters.
Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)
Maternal pre-eclampsia-like syndrome
how does parvovirus cause fetal anaemia?
- inc of euthyroid progenitor cells in fetal bone marrow and liver
- those cells make RBC –> inf causes faulty RBC production with shorter t1/2
- -> heart failure = hydrops fetalis
Cause and triad of maternal pre-eclampsia syndrome?
Parvovirus infection
aka mirror syndrome
rare comp of severe fetal heart failure (hydrops fetalis)
triad 1. hydrops fetalis 2. placental oedema 3. oedema in mom \+ Ht and proteinuria
investigations for parvovirus infection in the pregnant woman
- IgM to parvovirus –> acute infection within the past 4 weeks
- IgG to parvovirus —> long term immunity to the virus after a previous infection
- Rubella antibodies (as a differential diagnosis)
supportive tx, refer to fetal medicine
features of congenital Zika syndrome,
Microcephaly
Fetal growth restriction
Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
management of congenital Zika syndrome
Pregnant women that may have contracted the Zika virus should be tested with viral PCR and antibodies to the Zika virus.
if + –> fetal medicine for close monitoring of the pregnancy.
There is no treatment for the virus.
who needs anti-D antibodies in pregnancy?
no tx if rhesusD ++++ (+ for antigen)
if rhesus D –
- -> child may be RhD+
- fetal blood into mom (delivery)
- baby’s RBC display RhD ANTIGEN
- mom immune system sees antigen as foreign –> make antibodies to antigen –> becomes sensitised
management - PREVENT SENSITISATION
why is sensitisation to rhesus-D antigens bad?
no probs in 1st pregnancy
later pregs
- mom anti-D antibodies cross placenta in fetus
–> if foetus rh +, antibodies attack foetus RBC to cause haemolysis
= haemolytic disease of newborn
management of Rhesus Incompatibility in Pregnancy
PREVENT SENSITISATION
–> give IM anti-D injections to rhesus D — W (i.e. no antigens)
no way to reverse sensitisation so prophylaxis essential
anti-D
- attaches to rhesusD antigens on fetal RBC in moms circulation –> destroys them
- -> prevents mom IS recognising antigen and creating own antibodies against it
when is anti-D routinely given?
28 weeks gestation
birth (if foetus rhesus ++)
when sensitisation may occur
- Antepartum haemorrhage
- Amniocentesis procedures
- Abdominal trauma
–> give with 72 hours of event
when and why do you perform the Kleihauer test?
after 20 weeks gestation
- see how much fetal blood has passed to mom
- -> determine if need further doses of anti-D
What is the Kleinhauer test?
The Kleihauer test checks how much fetal blood has passed into the mother’s blood during a sensitisation event. This test is used after any sensitising event past 20 weeks gestation, to assess whether further doses of anti-D is required.
- add acid to moms blood
- Fetal hb is naturally more resistant to acid –> protected against the acidosis that occurs around childbirth.
–> fetal hb persists in response to the added acid, while the mothers hb is destroyed.
The number of cells still containing haemoglobin (the remaining fetal cells) can then be calculated.
Define small for GA and 2 measurements used on US
fetus that measures below the 10th centile for their GA
on US
- Estimated fetal weight (EFW)
- Fetal abdominal circumference (AC)
how care growth charts customised to assess size of fetus?
based on the mother’s:
Ethnic group
Weight
Height
Parity
what is severe SGA
fetus below 3rd centile for CA
causes of SGA
The causes of SGA can be divided into two categories:
Constitutionally small, matching the mother and others in the family, and growing appropriately on the growth chart
–> stay on same centile, grows appropriately
Fetal growth restriction (FGR), aka intrauterine growth restriction (IUGR)
= small fetus (or fetus not growing as expected) due to pathology dec amount of nutrients + O2 delivered via placenta –> drop down centiles
difference btw SGA and FGR
Small for gestational age simply means that the baby is small for the dates, without stating why.
The fetus may be constitutionally small, growing appropriately, and not at increased risk of complications.
Alternatively, the fetus may be small for gestational age due to pathology (i.e. FGR), with a higher risk of morbidity and mortality.
–> drops centiles
2 categories of FGR
The causes of fetal growth restriction can be divided into two categories:
Placenta mediated growth restriction
Non-placenta mediated growth restriction,
- baby is small due to a genetic or structural abnormality
Placenta mediated growth restriction causes for FGR
= conditions that 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 causes for FGR
= refers to pathology of the fetus, such as:
Genetic abnormalities
Structural abnormalities
Fetal infection
Errors of metabolism
signs indicating FGR (aka IUGR)
SGA (main finding)
Reduced amniotic fluid volume
Abnormal Doppler studies
Reduced fetal movements
Abnormal CTGs
Short term complications of fetal growth restriction
Fetal death or stillbirth
Birth asphyxia
Neonatal hypothermia
Neonatal hypoglycaemia
Long term complications of fetal growth restriction
Cardiovascular disease, particularly hypertension
Type 2 diabetes
Obesity
Mood and behavioural problems
risk factors of SGA
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
how do you monitor low risk W for SGA?
at booking clinic –> low or high risk
if low –> monitor SFH from 24 weeks
- plot on customised growth chart
if SFH <10th centile
–> book for serial growth scans with umbilical artery doppler
3 reasons why Women are booked for serial growth scans with umbilical artery doppler to assess for SGA
Three or more minor risk factors
One or more major risk factors
Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)
how do you monitor high risk W for SGA?
serial ultrasound scans measuring:
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
mebs scan every 4 weeks, inc with dec growth velocity or probs with umbilical flow
management of SGA
The critical management steps are:
Identifying those at risk of SGA
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
how to investigate cause of SGA
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)
Early delivery - considered when growth is static on the growth charts, or other problems are identified (e.g. abnormal Doppler results)
–> to dec risk of stillbirth. Corticosteroids are given when delivery is planned early, particularly when delivered by caesarean section. Paediatricians should be involved at birth to help with neonatal resuscitation and management if required.
define large for gestational age (aka macrosomia)
weight of the newborn is more than 4.5kg at birth.
During pregnancy, an estimated fetal weight above the 90th centile is considered large for gestational age.
Causes of Macrosomia
Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby
risks of macrosomia
The risks to the mother include:
Shoulder dystocia Failure to progress Perineal tears Instrumental delivery or caesarean Postpartum haemorrhage Uterine rupture (rare)
The risks to the baby include:
Birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
Neonatal hypoglycaemia
Obesity in childhood and later life
Type 2 diabetes in adulthood
management for large for gestational age baby
Ultrasound to exclude polyhydramnios and estimate the fetal weight
Oral glucose tolerance test for gestational diabetes
macrosomia is not reason to induce, most have SNVD
how to reduce risk of shoulder dystocia of large for GA baby at delivery
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
diff types of twins
Monozygotic: identical twins (from a single zygote)
Dizygotic: non-identical (from two different zygotes)
Monoamniotic: single amniotic sac
Diamniotic: two separate amniotic sacs
Monochorionic: share a single placenta
Dichorionic: two separate placentas
The best outcomes are with diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply.
what signs determine type of twins on US?
Dichorionic diamniotic twins - membrane between the twins
- lambda sign or twin peak sign = triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane –> indicates dichorionic
Monochorionic diamniotic twins
- membrane between the twins
- T sign –> membrane between the twins abruptly meets the chorion, giving a T appearance –> indicates monochorionic
Monochorionic monoamniotic twins
- no membrane separating the twins
complications of multiple pregnancy
Risks to the mother:
Anaemia Polyhydramnios Hypertension Malpresentation Spontaneous preterm birth Instrumental delivery or caesarean Postpartum haemorrhage
Risks to the fetuses and neonates:
Miscarriage Stillbirth Fetal growth restriction Prematurity Twin-twin transfusion syndrome Twin anaemia polycythaemia sequence Congenital abnormalities
what is Twin-Twin Transfusion Syndrome?
occurs when
- fetuses share a placenta
>2 fetuses
When there is a connection between the blood supplies of the two fetuses, one fetus (the recipient) may receive the majority of the blood from the placenta, while the other fetus (the donor) is starved of blood. The recipient gets the majority of the blood, and can become fluid overloaded, with heart failure and polyhydramnios. The donor has growth restriction, anaemia and oligohydramnios. There will be a discrepancy between the size of the fetuses.
Women with twin-twin transfusion syndrome need to be referred to a tertiary specialist fetal medicine centre. In severe cases, laser treatment may be used to destroy the connection between the two blood supplies.
what is Twin Anaemia Polycythaemia Sequence
similar to twin-twin transfusion syndrome, but less acute.
One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).
antenatal care for multiple pregnancy
Require additional monitoring for anaemia - FBC
Booking clinic
20 weeks gestation
28 weeks gestation
Additional ultrasound scans for FGR, unequal growth and twin-twin transfusion syndrome:
2 weekly scans from 16 weeks for monochorionic twins
4 weekly scans from 20 weeks for dichorionic twins
Planned birth is offered between:
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
Waiting beyond these dates is associated with an increased risk of fetal death. The timing of birth when there are complications is assessed on an individual basis. Corticosteroids are given before delivery to help mature the lungs.
delivery for multiple pregnancies
Monoamniotic twins require elective caesarean section at between 32 and 33 + 6 weeks.
Diamniotic twins (aim to deliver 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
risk of UTI in pregnancy
PTB
maybe also LBW and PET
are pregnant women treated for asymptomatic bacteriuria?
yes with antibiotics
risk of PTB if UTI
most common causes of UTI in pregnancy
MC -E.coli
gram -, anaerobic, rod found in faeces
Other causes:
Klebsiella pneumoniae (gram-negative anaerobic rod) Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans (fungal)
management of UTI in pregnancy
7 days of antibiotics.
The antibiotic options are:
Nitrofurantoin (avoid in the third trimester)
Amoxicillin (only after sensitivities are known)
Cefalexin
No Nitrofurantoin in 3rd T –> risk of neonatal haemolysis
No trimethoprim in 1st T –> folate antagonist –> congenital malformations, NTD (i.e. spina bifida). It is not known to be harmful later in pregnancy, but is generally avoided unless necessary.
when do you screen for anaemia
booking clinic
28 weeks GA
anaemia bc plasma vol inc
normal hb in pregnancy
Booking bloods
> 110 g/l
28 weeks gestation
> 105 g/l
Post partum
> 100 g/l
MCV in physiological anaemia
normal - inc plasma volume
management of anaemia
anaemia –> ferrous sulphate 200mg TDS
no anaemia but low ferritin –> supplementary iron
if low B12 –> check pernicious anaemia (intrinsic factor ab) –> IM hydroxocobalamin, oral cyanocobalamin
folate - 400mcg or 5mg
VTE risk factors in pregnancy
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
prophylaxis of VTE
–> LMWH (enoxaparin, dalteparin, tinzaparin)
starting prophylaxis from:
28 weeks if there are 3 risk factors
First trimester if there are ≥4 of these risk factors
–> continue until 6 weeks postpartum (highest risk)
There are additional scenarios where prophylaxis is considered, even in the absence of other risk factors:
Hospital admission Surgical procedures Previous VTE Medical conditions such as cancer or arthritis High-risk thrombophilias Ovarian hyperstimulation syndrome
how do you examine calf for DVT?
To examine for leg swelling measure the circumference of the calf 10cm below the tibial tuberosity.
> 3cm difference between calves is significant.
investigation of VTE in pregnancy
if ? DVT –> doppler ultrasound
(if neg –> repeat 3/7 7/7)
if ?PE –> CXR + ECG
When considering the choice between CTPA and VQ scan:
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)
if DUS + –> no VQ or CTPA needed, treat VTE
no Well’s score
management of VTE in pregnancy
LMWH
- dose based on weight at booking
- start ASAP when suspect, stop if dx excluded
- if VTW –> LMWH for remainder of pregnancy + 6 weeks postnatal
can switch to oral anticoagulation (warfarin or DOAC) PP
if massive PE + shock –> UFH, thrombolysis, surgical embolectomy
pre-eclampsia triad
HT
proteinuria (end-organ dysfunction)
oedema
cause of pre-eclampsia
It occurs after 20 weeks gestation, when spiral arteries form abnormally
inadequate formation of lacunae –> high vascular resistance in spiral arteries of the placenta and so poor placenta perfusion –> oxidative stress in placenta, release of inflammatory chemicals –> systemic inflammation and impaired endothelial function
risk factors for pre-eclampsia
Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease
Moderate-risk factors are:
Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia
–> aspirin from 12 weeks gestation until birth if they have:
1 high-risk factor or
> 1 moderate-risk factors.
symptoms of pre-eclampsia
Pre-eclampsia has symptoms of the complications:
Headache Visual disturbance or blurriness Nausea and vomiting Upper abdominal or epigastric pain (this is due to liver swelling, stretching of capsule) Oedema Reduced urine output Brisk reflexes
diagnosis of pre-eclampsia
systolic BP >140
diastolic >90
with any:
- Proteinuria
- ≥ 1+ on urine dipstick
- U P:C >30 mg/mmol
- U A:C >8 mg/mmol - Organ dysfunction
- e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia - Placental dysfunction
- e.g. FGR or abnormal Doppler studies
what is the use of testing placental growth factor (PlGF)?
test on 1 occasion btw GA 20-35 if ? PET
PlGF = protein released from placenta that functions to stimulate the development of new blood vessels.
management of gestational HT
Treating to aim for a blood pressure< 135/85 mmHg
Admission for women with a blood pressure >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
management of pre-eclampsia
Scoring systems are used to determine whether to admit the woman (fullPIERS or PREP‑S)
BP is monitored closely (at least every 48 hours)
Urine dipstick testing is not routinely necessary (the diagnosis is already made)
Ultrasound monitoring of the fetus, amniotic fluid and dopplers is performed two weekly
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
Planned early birth may be necessary if the blood pressure cannot be controlled or complications occur. Corticosteroids should be given to women having a premature birth to help mature the fetal lungs.
Blood pressure is monitored closely after delivery. Blood pressure will return to normal over time once the placenta is removed.
For medical treatment, NICE recommend after delivery switching to one or a combination of:
Enalapril (first-line)
Nifedipine or amlodipine (first-line in black African or Caribbean patients)
Labetolol or atenolol (third-line)
management of eclampsia
IV magnesium sulphate
what is HELLP syndrome?
combination of features that occurs as a complication of pre-eclampsia and eclampsia. It is an acronym for the key characteristics:
Haemolysis
Elevated Liver enzymes
Low Platelets
cause of GDM
dec insulin sensitivity
GDM risk factors
The NICE guidelines (2015) list the risk factors that warrant testing for gestational diabetes (OGTT 24-28 weeks)
Previous GDM
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative)
management of GDM
GA 28-34
4 weekly US –> monitor the fetal growth and amniotic fluid volume
The initial management:
FPG <7 –> trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
FPG > 7 mmol/l: start insulin ± metformin
FPG >6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
Glibenclamide (a sulfonylurea) is suggested as an option for women who decline insulin or cannot tolerate metformin.
what must you screen for if pregnant women with pre-exisiting DM?
diabetic retinopathy
- do after booking and 28 weeks
What are babies of mothers with diabetes at risk of?
Neonatal hypoglycaemia
- become accustomed to lots of glucose, struggle to maintain supply used to with oral feeding
- -> may need IV dextrose or NG feeding
Polycythaemia (raised haemoglobin)
Jaundice (raised bilirubin)
Congenital heart disease
Cardiomyopathy
what is Obstetric cholestasis?
AKA Intrahepatic cholestasis of pregnancy.
= Reduced outflow of bile acids from the liver (so builds up in blood), resolves after delivery
itchy, iinc risk stillbirth
presentation of Obstetric cholestasis
in 3rd trimester > 28 weeks
Pruritis is the main symptom, particularly affecting the palms of the hands and soles of the feet.
Other symptoms are related to cholestasis and outflow obstruction in the bile ducts: Fatigue Dark urine Pale, greasy stools Jaundice
no rash!
–> if rash, ?polymorphic eruption of pregnancy or pemphigoid gestationis.
differentials for rash in pregnancy
?polymorphic eruption of pregnancy or pemphigoid gestationis.
differentials for Obstetric cholestasis
exclude Gallstones Acute fatty liver Autoimmune hepatitis Viral hepatitis
investigations for Obstetric cholestasis
pruritis –> LFTs and bile acids
OC –> abn ALT, AST, GGT (ALP raised in pregnancy form placenta producing ALP)
–> raised bile acids
management for Obstetric cholestasis
1st - ursodeoxycholic acid
–> improves LFTs and symptoms
symptoms:
- Emollients (i.e. calamine lotion) to soothe the skin
- Antihistamines (e.g. chlorphenamine) can help sleeping (but does not improve itching)
water-soluble vit K if PTT deranged
- vit K is fat soluble
- lack of bile acids –> vit K deficiency
aim for early delivery to dec risk of stillbirth
what is Acute fatty liver of pregnancy?
rare
in 3rd T
Rapid accumulation of fat within hepatocytes –> acute hepatitis
High risk of liver failure and mortality, for both the mother and fetus.
pathophysiology and MC cause of Acute fatty liver of pregnancy
- impaired processing of fatty acids in placenta
- -> bc genetic condition in fetus that impairs FA metabolism
mc cause: long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, = autosomal recessive
LCHAD enzyme –> used in fatty acid oxidation. Fetus and placenta Can’t break down FA –> enter maternal circulation, accumulate in liver –> inflam and death
presentation of Acute fatty liver of pregnancy
vague symptoms associated with hepatitis :
General malaise and fatigue Nausea and vomiting Jaundice Abdominal pain Anorexia (lack of appetite) Ascites
investigations in Acute fatty liver of pregnancy
LFTs - inc ALT and AST
Other bloods may be deranged, with:
Raised bilirubin
Raised WBC count
Deranged clotting (raised prothrombin time and INR)
Low platelets
TOM TIP: In your exams, elevated liver enzymes and low platelets should make you think of HELLP syndrome rather than acute fatty liver of pregnancy. HELLP syndrome is much more common, but keep acute fatty liver of pregnancy in mind as a differential.
management of Acute fatty liver of pregnancy
obstetric emergency and requires prompt admission and delivery of the baby. Most patients will recover after delivery.
Management also involves treatment of acute liver failure if it occurs, including consideration of liver transplant.
what is Polymorphic Eruption of Pregnancy?
AKA pruritic and urticarial papules and plaques of pregnancy.
= itchy rash, starts in 3rd T
- starts on abdo, assoc with striae
It is characterised by:
- Urticarial papules (raised itchy lumps)
- Wheals (raised itchy areas of skin)
- Plaques (larger inflamed areas of skin)
The condition will get better towards the end of pregnancy and after delivery
management of Polymorphic Eruption of Pregnancy
Management is to control the symptoms, with:
Topical emollients
Topical steroids
Oral antihistamines
Oral steroids may be used in severe cases
what is Atopic Eruption of Pregnancy?
= eczema that flares up in pregnancy
–> W with no hx eczema and W with pre-existing eczema
presents in 1st and 2nd T
what are the 2 types of Atopic Eruption of Pregnancy?
E-type, or eczema-type: with eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of knees, neck, face and chest.
P-type, or prurigo-type: with intensely itchy papules (spots) typically affecting the abdomen, back and limbs.
management of Atopic Eruption of Pregnancy
The condition will usually get better after delivery. Management is with:
Topical emollients
Topical steroids
Phototherapy with ultraviolet light (UVB) may be used in severe cases
Oral steroids may be used in severe cases
what is melasma (in pregnancy)
aka Mask of pregnancy
= inc pigmentation to patches of the skin on the face.
- symmetrical and flat, affecting sun-exposed areas.
cause - think related to the increased female sex hormones associated with pregnancy.
- –> It can also occur with COCP and HRT
- -> + associated with sun exposure, thyroid disease and family history.
management of melasma
No active treatment is required if the appearance is acceptable to the woman. Management is with:
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)
what is Pyogenic Granuloma?
AKA lobular capillary haemangioma.
= benign, rapidly growing tumour of capillaries.
presents: discrete lump with a red or dark appearance
- develops over days up to 1-2cm
- often on fingers!, also upper chest, back, neck or head.
- They may cause profuse bleeding and ulceration if injured.
- occur more often in pregnancy, and can also be associated with hormonal contraceptives.
- triggered by minor trauma or infection.
management of Pyogenic Granuloma
Other differentials, such as malignancy, need to be excluded (particularly nodular melanoma).
When they occur in pregnancy, they usually resolve without treatment after delivery.
Treatment is with surgical removal with histology to confirm the diagnosis.
what is pemphigoid gestationis?
rare AI skin condition that occurs in pregnancy
- autoantibodies –> damage the connection between the epidermis and the dermis
- W develop AB in response to placental tissue –> epidermis and dermis separates –> makes space that can fill with fluid, resulting in large fluid-filled blisters (bullae).
in 2nd or 3rd T
Presentation: Initially itchy red papular or blistering rash around the umbilicus, that then spreads to other parts of the body. Over several weeks, large fluid-filled blisters form.
management of Pemphigoid Gestationis
The rash usually resolves without treatment after delivery.
It may go through stages of improvement and worsening during pregnancy and after birth. The blisters heal without scarring.
Treatment is with:
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
Pemphigoid Gestationis risks to baby
Fetal growth restriction
Preterm delivery
Blistering rash after delivery (as the maternal antibodies pass to the baby)
What is placenta praevia?
placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus.
in 1% of pregnancies, cause of antepartum haemorrhage
diffence btw placenta praevia and low lying placenta
Low-lying placenta is used when the placenta is within 20mm of the internal cervical os
Placenta praevia is used only when the placenta is over the internal cervical os
risks associated with placenta praevia
Antepartum haemorrhage Emergency caesarean section Emergency hysterectomy Maternal anaemia and transfusions Preterm birth and low birth weight Stillbirth
risk factors of placenta praevia
Previous caesarean sections Previous placenta praevia Older maternal age Maternal smoking Structural uterine abnormalities (e.g. fibroids) Assisted reproduction (e.g. IVF)
how can placenta praevia present
on 20 week anomaly scan
- asymptomatic
or painless vaginal bleeding in pregnancy, usually >36 weeks
management of low lying placenta and placenta praevia if diagnosed at anomaly scan
- repeat TVUS at:
32 weeks and 36 weeks –> guide delivery - corticosteroids 34-36W as inc risk PTB
- elective C-section btw 36-37 W –> dec risk of spontaneous labour and bleeding
- may need vertical incision, use US to locate placenta to avoid cutting it
- emergency C-section is PTB or APH
management of placenta praevia haemorrhage
haemorrhage before, during and after delivery.
Emergency caesarean section Blood transfusions Intrauterine balloon tamponade Uterine artery occlusion Emergency hysterectomy
what is vasa praevia?
a condition where the fetal vessels are within the fetal membranes (chorioamniotic membranes) and travel across the internal cervical os.
The fetal membranes surround the amniotic cavity and developing fetus.
The fetal vessels consist of the two umbilical arteries and single umbilical vein.
–> prone to bleeding so can lead to fetal blood loss and death at delivery
pathophysiology of vasa praevia
umbilical cord has umbilical arteries and vein (fetal vessels)
- -> protected by UC or placenta
- -> cord has Wharton’s jelly to protect
in VP fetal vessels exposed outside protection of UC or placenta –> prone to bleeding, esp when membranes ruptured during labour and birth
–> can lead to fetal blood loss and death
risk factors for vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
presentation of vasa praevia
US diagnosis –> plan C-section
often not able to see tho
- APH in T2 or 3
- Vaginal exam in labour, pulsating fetal vessels seen in membranes through dilated cervix
- labour, fetal distress and dark red bleeding with ROM
management of vasa praevia
asymptomatic:
- steroids from W32
- Elective CS 34-36W
APH –> emergency CS
if stillborn or fetal compromise in delivery, examine placenta for vasa praevia
what is Placental abruption
placenta separates from the wall of the uterus during pregnancy.
The site of attachment can bleed extensively –> significant cause of antepartum haemorrhage.
risk factors for placental abruption
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
typical presentation of placental abruption
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
Severity of Antepartum Haemorrhage
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
whats the difference btw Concealed and revealed abruption
concealed abruption
- cervical os remains closed, and any bleeding that occurs remains within the uterine cavity.
- The severity of bleeding can be significantly underestimated
revealed abruption,
- where the blood loss is observed via the vagina.
how do you diagnose placenta abruption?
clinical diagnosis
emergency
how do you initially manage major or massive haemorrhage
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
what is Placenta accreta
when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby.
It is referred to as placenta accreta spectrum, as there is a spectrum of severity in how deep and broad the abnormal implantation extends.
what are the 3 layers of uterine wall? where does placenta attach to?
There are three layers to the uterine wall:
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)
Usually the placenta attaches to the endometrium.
where does the placenta embed in Placenta accreta
beyond endometrium, into myometrium (and more - perimetrium)
risk factors for Placenta accreta
if defect in endometrium
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
how does Placenta accreta present
- difficult to deliver placenta –> PPH
or on antenatal US or APH in T3
management of placenta accreta
need C-section
if see PA when open for elective CS –> can close and expectant management
if see PA at delivery –> hysterectomy (with placenta remaining in uterus)
4 types of breech presentation
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
when can you use External Cephalic Version
After 36 weeks for nulliparous women
After 37 weeks in women that have given birth previously
give tocolysis before (SC terbutaline)–> relax uterus, makes it easier to baby to turn
anti-D prophylaxis
define stillbirth
birth of a dead fetus after 24 weeks gestation. Stillbirth is the result of intrauterine fetal death (IUFD). It occurs in approximately 1 in 200 pregnancies.
causes of stillbirth
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
Factors that increase the risk of stillbirth
Fetal growth restriction Smoking Alcohol Increased maternal age Maternal obesity Twins Sleeping on the back (as opposed to either side)
management of stillbirth
US dx
vaginal birth 1st line
Induction of labour
- oral mifepristone (anti-progesterone) and vaginal or oral misoprostol (prostaglandin analogue).
Dopamine agonists (e.g. cabergoline) can be used to suppress lactation after stillbirth.
4Ts and 4Hs of reversible cardiac arrest in adults. what else do you add in pregnancy?
4 Ts: Thrombosis (i.e. PE or MI) Tension pneumothorax Toxins Tamponade (cardiac)
4 Hs: Hypoxia Hypovolaemia Hypothermia Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities
Eclampsia
Intracranial haemorrhage
three major causes of cardiac arrest in pregnancy
Obstetric haemorrhage
Pulmonary embolism
Sepsis leading to metabolic acidosis and septic shock
causes of obstetric haemorrhage as cause of cardiac arrest
–> severe Hypovolaemia
Ectopic pregnancy (early pregnancy) Placental abruption (including concealed haemorrhage) Placenta praevia Placenta accreta Uterine rupture
how should a woman lie >20 weeks gestation and why
left lateral position
IVC on right side, relieve compression by uterus on IVC to improve venous return and cardiac output.
what factors make resuscitation more complicated in pregnancy
Aortocaval compression Increased oxygen requirements Splinting of the diaphragm by the pregnant abdomen Difficulty with intubation Increased risk of aspiration Ongoing obstetric haemorrhage
how do the principles of resus differ in pregnancy
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
when do you perform immediate C-section
- There is no response after 4 minutes to CPR performed correctly
- CPR continues for more than 4 minutes in a woman more than 20 weeks gestation
aim: delivery baby and placenta wihtin 5 mins of CPR starting, perform at site of arrest
reason: improve survival of mother –> inc venous return to heart, improve CO and dec o2 consumption
