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3- Reproduction > Antenatal care > Flashcards

Antenatal care Flashcards

1
Q

hypothyroid management in pregnancy

A

levothyroxine dose needs to be increased (30-50%)

Treatment is titrated based on TSH level, aiming for low-normal TSH level.

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2
Q

hypertension medication to be stopped during pregnancy

A

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

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3
Q

epilepsy in pregnancy

A

Folic acid 5mg daily from 3months prior conception.

Safe anti-epileptic medication
- Lamotrigine, carbamazepine, levetiracetam

Medications to avoid

  • Sodium valproate (neural tube defects & developmental delay)
  • Phenytoin (cleft lip and palate)
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4
Q

rheumatoid arthritis in pregnancy

A

Ideally, well-controlled for at least 3 month prior to becoming pregnant

Contraindicated
- Methotrexate (miscarriage & congenital abnormalities)

Safe

  • Hydroxychloroquine (1st line)
  • sulfasalazine
  • corticoteroids can be used during flare-ups
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5
Q

gestational diabetes suggestive features

A

large for date fetus
Polyhydramnios
Glucose on urine dipstick

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6
Q

Screening test for Gestational Diabetes

A

Oral Glucose Tolerance Test

  • Fasting >5.6
  • 2 hours >7.8
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7
Q

Management of gestational diabetes

A

Fasting glucose <7
- diet and exercise for 1-2 weeks then metformin then insulin

fasting glucose >7
- start insulin +/- metformin

Monitor blood sugar levels

4 weekly US from 28-36 weeks

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8
Q

Complications of Gestational diabetes

A 
shoulder dystocia 
neonatal hypoglycaemia 
polycythaemia 
jundice
congenital heart disease
cardiomyopathy
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9
Q

features of congenital rubella syndrome

A

congenital deafness
congenital cataracts
congenital heart disease
learning disability

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10
Q

pregnancy and rubella

A

women planning to become pregnant should ensure they have had MMR vaccine

Vaccine not given during pregnancy as it is live

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11
Q

Chickenpox in pregnancy complications

A

more severe cases in mother: varicella pneumonitis, hepatitis, or encephalitis

Fetal varicella syndrome

Severe neonatal varicella infection

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12
Q

Exposure to chickenpox in pregnancy

A

Previous exposure: safe

Not immune
- IV varicella Immunoglobulins (given within 10 days of exposure)

Chickenpox rash
- oral acyclovir if present within 24 hours and >20 weeks gestation

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13
Q

listeria in pregnancy

A

high rate of miscarriage or foetal death

Avoid high-risk foods (e.g. blue cheese) and practice good food hygiene

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14
Q

congenital cytomegalovirus features

A 
Fetal growth restriction 
microcephaly
hering loss
vision loss
learning disability
seizures

note; most cases of CMV in pregnancy do not cause congenital CMV

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15
Q

parvovirus B12

A

‘slapped-cheek’ syndrome

Supportive treatment in pregnancy
need referral to fetal medicine to monitor for complications and malformations

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16
Q

complications of parvovirus b12 infection in pregnancy

A

miscarriage or fetal death
severe fetal anaemia
hydros fettles
Maternal pre-eclampsia-like syndrome

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17
Q

small for gestational age

A

fetus that measures below 10th centime for gestational age.

Measures on US used to assess

  • estimated fetal weight
  • fetal abdominal circumference
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18
Q

Fetal Growth restriction aetiology

A

Placenta mediated

  • idiopathic
  • pre-eclampsia
  • maternal smoking & alcohol
  • anaemia
  • malnutrition
  • infection

Non-placenta mediated

  • genetic abnormaltiies
  • structural abnormalities
  • fetal infection
  • errors of metabolism
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19
Q

signs of fetal growth restriction

A

reduced amniotic fluid volume
abnormal doppler studies
reduced fetal movements
abnormal CTGs

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20
Q

large for gestational age

A

macrosomia
Weight of newborn >4.5 kg at birth
During pregnancy, estimated fetal weight above 90th percentile

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21
Q

aetiology of macrosomia

A 
constitutional 
maternal diabetes
previous macrosomia pregnancy
maternal obesity or rapid weight gain 
overdue
male baby
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22
Q

risks of macrosomia

A

Risks to mother

  • shoulder dystocia
  • failure to progress
  • perineal tears
  • intrumental delivery or caesarean
  • postpartum haemorrhage
  • uterine rupture (rare0

Risks to baby

  • birth injury (Erbs palsy, clavicular fracture, fetal distress and hypoxia)
  • neonatal hypoglycaemia
  • obesity in childhood & later life
  • T2DM in adulthood
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23
Q

NAIDs in pregnancy

A

e.g. ibuprofen and naproxen

Generally avoided in pregnancy

3rd trimester: premature closure of ductus arteriosus
Can delay labour

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24
Q

Beta-blockers in pregnancy

A

labetalol

- 1st line for high BP caused by pre-eclampsia

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25
Q

ACE-inhibitors and ARBs in pregnancy

A

Can cross the placenta and enter fetus
- in fetus mainly affect kidneys and reduce production of urine

Possible complications

  • oligohydramnios
  • miscarriage/ fetal death
  • hypocalvaria
  • renal failure in neonate
  • hypotension in neonate
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26
Q

neonatal abstinence syndrome

A

caused by use of opiates in pregnancy

Presents 3-72 hours after birth 
Irritability
Tachypnoae
High temperatures
Poor feeding
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27
Q

Warfarin in pregnancy

A

Avoid in pregnancy
Teratogenic and can cross the placenta

possible complications

  • fetal loss
  • congenital malformations
  • bleeding during pregnancy
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28
Q

sodium valproate

A

Avoid in pregnancy

can cause neural tube defects and developmental delay

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29
Q

lithium in pregnancy

A

avoid in pregnancy and when breastfeeding

Possible complications
-congenital cardiac abnormalities (Ebsteins anomaly) a

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30
Q

SSRIs in pregnancy

A

Can cross placenta into fetus.

Risks need to be balanced against benefits of treatment.

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31
Q

Isotretinoin (roaccutane) in pregnancy.

A

highly teratogenic
Causes miscarriage and congenital defects.
Women need very reliable conception before, during and for one month after taking isotretinoin

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32
Q

twin-twin transfusion syndrome

A

Occurs when foetuses share a placenta.

Connection between blood supplies of the two foetuses. One fetus may receive majority of blood from the placenta while the other is starved of blood.

Recipient: fluid overloaded -> heart failure & polyhydramnios

Donor: growth restriction, anaemia and oligohydramnios

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33
Q

placenta accrete

A

placenta implants deeper, through and past endometrium making it difficult to separate the placenta after delivery of the baby

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34
Q

types of placenta accrete

A

superficial placenta accreta
- placenta implants in surface of myometrium

placenta increta
- attaches deeply into myometrium

placenta percreta
-invade past myometrium and perimetric

35
Q

placenta accrete management

A

ideally diagnosed antenatally by US to allow for planning of birth.

Delivery

  • planned between 35 and 36+6 weeks gestation to reduce risk of spontaneous labour and delivery
  • antenatal steroids to mature fetal lungs

Caesarean
-hysterectomy with placenta remaining in uterus

36
Q

placenta previa

A

placenta is arched in lower portion of the uterus, lower than presenting part of fetus.
Placenta is over internal cervical os

37
Q

placenta previa presentation

A

20 week anomaly scan

38
Q

management of placenta previa

A

repeat Transvaginal US

  • 32 weeks
  • 36 weeks (guide decisions about delivery)

Planned delivery 36-37 weeks gestation.
-planned caesarean

39
Q

low lying placenta

A

placenta within 20mm of internal cervical os

40
Q

placental abruption

A

placenta separates from wall of uterus during pregnancy.
Site of attachment can bleed extensively after placenta separates.
Significant cause of antepartum haemorrhage

41
Q

placental abruption presentation

A

sudden onset severe abdo pain
vaginal bleeding
shock (hypotension & tachycardia)
Abnormalities on CTG

characteristic ‘woody’ abdomen on palpation

42
Q

severity of antepartum haemorrhage

A

minor: <50ml
major: 50-1000 ml
masive >1000ml or signs of thick

43
Q

concealed abruption

A

cervical os remains closed and any bleeding that occurs remains within uterine cavity.
Severity of bleeding can be significantly underestimated with concealed haemorrhage.

44
Q

placental abruption management

A

EMERGENCY

bloods
Crossmatch 4 units of blood
fluid and blood rests as required
CTG monitoring of foetus 
Close monitoring of mother

Antenatal steroid offered between 24 and 34 + 6 weeks gestation

anti-d prophylaxis

45
Q

kleihaur test

A

used to quantify how much fetal blood is mixed with maternal blood, to determine dose of anti-D required.

46
Q

pre-eclampsia

A

new high BP in pregnancy with end-organ dysfunction, notably proteinuria

Triad of features: hypertension, proteinuria, oedema

47
Q

symptoms of pre-eclampsia

A 
headache
visual disturbacne
nausea and vomiting 
upper abdo or epigastric pain 
oedema
reduced urine output
brisk reflexes
48
Q

diagnosis of pre-eclampsia

A

High BP (>140/90)

PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction
- raised creatinine, elevated liver enzymes, seizures, thrombocytopenia, haemolytic anaemia)
Placental dysfunction
-fetal growth restriction/ abnormal doppler studies

Placental Growth Factor Testing
-Low in pre-eclampsia

49
Q

management of pre-eclampsia

A

anti-hypertensive: labetalol

IV magnesium sulphate: during and 24hours after labour to prevent seizures

Fluid restriction: during labour if severe pre-eclampsia to avoid fluid overload

50
Q

eclampsia

A

seizures associated with pre-eclampsia

Management: IV magnesium sulphate

51
Q

HELLP syndrome

A

Complication of pre-eclampsia

Haemolysis
Elevated liver enzymes
Low platelets

52
Q

pregnancy-related rashes

A 
polymorphic eruption of pregnancy 
atopic eruption of pregnancy
melasma 
Pyogenic granuloma 
pemphigoid gestations
53
Q

polymorphic eruption of pregnancy

A

itchy rash that tends to start in third trimester.
Usually begins on abdomen

Characteristics: urticarial papules. wheals and plaques

54
Q

polymorphic eruption of pregnancy management

A

control symptoms
topical emollients
oral antihistamines
Topical steroids

55
Q

atopic eruption of pregnancy

A

eczema that flares up during pregnancy

Presents in first and second trimester.

56
Q

melasma

A

mask of pregnancy

Increased pigmentation to patches of the skin on the face.

57
Q

Pyogenic granuloma

A

lobular capillary haemangioma
Benign, rapidly growing tumour of capillaries.

discrete lump that develops over days up to 1-2 cm in size.
Often occurs on fingers, upper chest, back, neck or head

58
Q

Pemphigoid gestations

A

rare autoimmune skin condition that occurs in pregnancy
typically 2nd to 3rd trimester
itchy red popular or blistering rash around the umbilicus, that then spreads to other parts of the body.
Over several weeks, large fluid-filled blisters form.

59
Q

stillbirth

A

birth of a dead fetus after 24 weeks

Result of intrauterine fetal death

60
Q

management of stillbirth

A

US: investigation of choice for diagnosis

Rhesus-D negative require Anti-D prophylaxis

Vaginal birth
- induction of labour or expectant management

Induction of labour: mifepristone + misoprostol

Dopamine agonists

  • e.g. cabergoline
  • suppress lactation after birth
61
Q

UTI in pregnancy

A

Pregnancy women at higher risk of developing lower UTI and pyelonephritis.
UTIs in pregnancy increase risk of preterm delivery

62
Q

presentation of UTI

A

Lower UTI

  • dysuria
  • suprapubic pain or discomfort
  • increassed frequency of urination
  • urgancy
  • incontinence
  • haematuria

pyelonephritis

  • fever
  • loin, suprapubic pain or back pain
  • generally unwell
  • vomiting
  • losss. of appetitie
  • haematuria
  • renal angle tenderness on exam
63
Q

investigation of UTI

A

urine dipstick

  • nitrites produce by gram -ve bacteria (e.g. E.coli)
  • leukocyte esterase
64
Q

Causes of UTI

A

Most common: E. coli

Klebsiella pneumoniae
Enterococcus
Pseudomonas aeruginosa
Sstaph. aprophyticus

65
Q

Management of UTI in pregnancy

A

7 days of ABx
- Nitrofurantoin (avoided in 3rd trimester)
Amoxicillin (once sensitivities known
-Cefalexin

66
Q

Nitrofurantoin in pregnancy

A

needs to be avoided in 3rd trimester

-Risk of neonatal haemolytic

67
Q

Trimethoprim in pregnancy

A

needs to be avoided in 1st trimester
- works as a folate antagonist.
Can cause congenital malformations, particularly neural tube defects

Generally avoided throughout pregnancy

68
Q

vasa praevia

A

foetal vessels placed over internal cervical os before the foetus

Fetal vessels: 2 umbilical arteries & single umbilical vein

type I: fetal vessels are exposed s a velamentous umbilical cord

Type II: fetal vessels exposed as they travel to an accessory placental lobe

69
Q

risk factors for vasa praaevia

A

low-lying placenta
IVF pregnancy
Multiple pregnancy

70
Q

Presentation of vasa praevia

A

May be diagnosed by US during pregnancy

antepartum haemorrhage during 2nd or 3rd trimester

may be detected by vaginal exam during labour
-pulsating fetal vessels are seen in membranes through dilated cervix

71
Q

management of vasa praevia

A

asymptomatic

  • corticosteroids from 32 weeks
  • elective c-section: 34-36 weeks

Antepartum haemorrhage
-emergency c-section

72
Q

screening for anaemia in pregnancy

A

Booking clinic
28 week gestation

Haemoglobinopathy screening offered at booking clinic
- identify thalassaemia and sickle cell disease

Additional investigations
-ferritin, B12, folate

73
Q

posible causes of anaemia (& indicative MCV)

A

Low MCV
- iron deficiency

Normal MCV
- physiological anaemia due to increased plasma volume of pregnancy

Raised MCV
- B12 or folate deficiency

74
Q

Management of anaemia in pregnancy

A

Iron
- Ferrou sulphate 200mg 3x daily

B12

  • Low B12: test for pernicious anaemia (check for intrinsic factor antibodies)
  • Intramuscular hydroxycobalamin injections

Folate

  • All women: folic acid 400mcg per day
  • Deficiency: 5mg daily
75
Q

acute fatty liver disease of pregnancy

A

rare condition that occurs in 3rd trimester of pregnancy

Rapid accumulation of fat within liver cells (hepatocytes) causing acute hepatitis.

76
Q

aetiology acute fatty liver disease of pregnancy

A

impaired processing of fatty acids in placenta

LCHAD deficiency in fetus
Autosomal recessive condition

77
Q

presentation acute fatty liver disease of pregnancy

A 
general malaise and fatigue
nausea and vomiting
jaundice
abdo pain 
anorexia 
ascites
78
Q

bloods in acute fatty liver disease of pregnancy

A 
LFTs: elevated liver enzymes (ALT &AST) 
raised bilirubin 
raised WBC count 
Deranged clotting 
- raised prothrombin time and INR 
low platelets
79
Q

management acute fatty liver disease of pregnancy

A

obstetric emergence
Prompt admission & delivery of baby
Most recover after delivery

80
Q

obstetric cholestasis

A

intrahepatic cholestasis of pregnancy

Reduced outflow of bile acids from the liver.
Associated with increased risk of stillbirth

81
Q

pathophysiology obstetric cholestasis

A

Result of increased oestrogen and progesterone.

Bile acids are produced in the liver from the breakdown of cholesterol. Bile acids flow from liver to hepatic ducts, past the gallbladder and out of bile duct to intestines.

In obstetric cholestasis: outflow of bile acid is reduced, causing them to build up in the blood, resulting in itching

82
Q

presentation of obstetric cholestasis

A

usually develops later. in pregnancy (~28 weeks)

itching: affects palms of hands and soles of feet 
Ftigue
Dark urine 
Pale-greasy stools 
jaundice
83
Q

investigations of obstetric cholestasis

A

liver function tests
-Abnormal: ALT, AAST and GGT

(Note: normal for ALP to increase in pregnancy as its produced by placenta)

Raised bile acids

84
Q

Management of obstetric cholestasis

A

Urseodeoxycholic Acid

Symptoms of itching
-Emollients to soothe skin

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