Antenatal care Flashcards
hypothyroid management in pregnancy
levothyroxine dose needs to be increased (30-50%)
Treatment is titrated based on TSH level, aiming for low-normal TSH level.
hypertension medication to be stopped during pregnancy
ACE-inhibitors (ramipril)
Angiotensin receptor blockers (e.g losartan)
Thiazide and thiazide-like diuretics (e.g. indapamide)
epilepsy in pregnancy
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)
rheumatoid arthritis in pregnancy
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
gestational diabetes suggestive features
large for date fetus
Polyhydramnios
Glucose on urine dipstick
Screening test for Gestational Diabetes
Oral Glucose Tolerance Test
- Fasting >5.6
- 2 hours >7.8
Management of gestational diabetes
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
Complications of Gestational diabetes
shoulder dystocia neonatal hypoglycaemia polycythaemia jundice congenital heart disease cardiomyopathy
features of congenital rubella syndrome
congenital deafness
congenital cataracts
congenital heart disease
learning disability
pregnancy and rubella
women planning to become pregnant should ensure they have had MMR vaccine
Vaccine not given during pregnancy as it is live
Chickenpox in pregnancy complications
more severe cases in mother: varicella pneumonitis, hepatitis, or encephalitis
Fetal varicella syndrome
Severe neonatal varicella infection
Exposure to chickenpox in pregnancy
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
listeria in pregnancy
high rate of miscarriage or foetal death
Avoid high-risk foods (e.g. blue cheese) and practice good food hygiene
congenital cytomegalovirus features
Fetal growth restriction microcephaly hering loss vision loss learning disability seizures
note; most cases of CMV in pregnancy do not cause congenital CMV
parvovirus B12
‘slapped-cheek’ syndrome
Supportive treatment in pregnancy
need referral to fetal medicine to monitor for complications and malformations
complications of parvovirus b12 infection in pregnancy
miscarriage or fetal death
severe fetal anaemia
hydros fettles
Maternal pre-eclampsia-like syndrome
small for gestational age
fetus that measures below 10th centime for gestational age.
Measures on US used to assess
- estimated fetal weight
- fetal abdominal circumference
Fetal Growth restriction aetiology
Placenta mediated
- idiopathic
- pre-eclampsia
- maternal smoking & alcohol
- anaemia
- malnutrition
- infection
Non-placenta mediated
- genetic abnormaltiies
- structural abnormalities
- fetal infection
- errors of metabolism
signs of fetal growth restriction
reduced amniotic fluid volume
abnormal doppler studies
reduced fetal movements
abnormal CTGs
large for gestational age
macrosomia
Weight of newborn >4.5 kg at birth
During pregnancy, estimated fetal weight above 90th percentile
aetiology of macrosomia
constitutional maternal diabetes previous macrosomia pregnancy maternal obesity or rapid weight gain overdue male baby
risks of macrosomia
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
NAIDs in pregnancy
e.g. ibuprofen and naproxen
Generally avoided in pregnancy
3rd trimester: premature closure of ductus arteriosus
Can delay labour
Beta-blockers in pregnancy
labetalol
- 1st line for high BP caused by pre-eclampsia
ACE-inhibitors and ARBs in pregnancy
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
neonatal abstinence syndrome
caused by use of opiates in pregnancy
Presents 3-72 hours after birth Irritability Tachypnoae High temperatures Poor feeding
Warfarin in pregnancy
Avoid in pregnancy
Teratogenic and can cross the placenta
possible complications
- fetal loss
- congenital malformations
- bleeding during pregnancy
sodium valproate
Avoid in pregnancy
can cause neural tube defects and developmental delay
lithium in pregnancy
avoid in pregnancy and when breastfeeding
Possible complications
-congenital cardiac abnormalities (Ebsteins anomaly) a
SSRIs in pregnancy
Can cross placenta into fetus.
Risks need to be balanced against benefits of treatment.
Isotretinoin (roaccutane) in pregnancy.
highly teratogenic
Causes miscarriage and congenital defects.
Women need very reliable conception before, during and for one month after taking isotretinoin
twin-twin transfusion syndrome
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
placenta accrete
placenta implants deeper, through and past endometrium making it difficult to separate the placenta after delivery of the baby
types of placenta accrete
superficial placenta accreta
- placenta implants in surface of myometrium
placenta increta
- attaches deeply into myometrium
placenta percreta
-invade past myometrium and perimetric
placenta accrete management
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
placenta previa
placenta is arched in lower portion of the uterus, lower than presenting part of fetus.
Placenta is over internal cervical os
placenta previa presentation
20 week anomaly scan
management of placenta previa
repeat Transvaginal US
- 32 weeks
- 36 weeks (guide decisions about delivery)
Planned delivery 36-37 weeks gestation.
-planned caesarean
low lying placenta
placenta within 20mm of internal cervical os
placental abruption
placenta separates from wall of uterus during pregnancy.
Site of attachment can bleed extensively after placenta separates.
Significant cause of antepartum haemorrhage
placental abruption presentation
sudden onset severe abdo pain
vaginal bleeding
shock (hypotension & tachycardia)
Abnormalities on CTG
characteristic ‘woody’ abdomen on palpation
severity of antepartum haemorrhage
minor: <50ml
major: 50-1000 ml
masive >1000ml or signs of thick
concealed abruption
cervical os remains closed and any bleeding that occurs remains within uterine cavity.
Severity of bleeding can be significantly underestimated with concealed haemorrhage.
placental abruption management
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
kleihaur test
used to quantify how much fetal blood is mixed with maternal blood, to determine dose of anti-D required.
pre-eclampsia
new high BP in pregnancy with end-organ dysfunction, notably proteinuria
Triad of features: hypertension, proteinuria, oedema
symptoms of pre-eclampsia
headache visual disturbacne nausea and vomiting upper abdo or epigastric pain oedema reduced urine output brisk reflexes
diagnosis of pre-eclampsia
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
management of pre-eclampsia
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
eclampsia
seizures associated with pre-eclampsia
Management: IV magnesium sulphate
HELLP syndrome
Complication of pre-eclampsia
Haemolysis
Elevated liver enzymes
Low platelets
pregnancy-related rashes
polymorphic eruption of pregnancy atopic eruption of pregnancy melasma Pyogenic granuloma pemphigoid gestations
polymorphic eruption of pregnancy
itchy rash that tends to start in third trimester.
Usually begins on abdomen
Characteristics: urticarial papules. wheals and plaques
polymorphic eruption of pregnancy management
control symptoms
topical emollients
oral antihistamines
Topical steroids
atopic eruption of pregnancy
eczema that flares up during pregnancy
Presents in first and second trimester.
melasma
mask of pregnancy
Increased pigmentation to patches of the skin on the face.
Pyogenic granuloma
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
Pemphigoid gestations
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.
stillbirth
birth of a dead fetus after 24 weeks
Result of intrauterine fetal death
management of stillbirth
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
UTI in pregnancy
Pregnancy women at higher risk of developing lower UTI and pyelonephritis.
UTIs in pregnancy increase risk of preterm delivery
presentation of UTI
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
investigation of UTI
urine dipstick
- nitrites produce by gram -ve bacteria (e.g. E.coli)
- leukocyte esterase
Causes of UTI
Most common: E. coli
Klebsiella pneumoniae
Enterococcus
Pseudomonas aeruginosa
Sstaph. aprophyticus
Management of UTI in pregnancy
7 days of ABx
- Nitrofurantoin (avoided in 3rd trimester)
Amoxicillin (once sensitivities known
-Cefalexin
Nitrofurantoin in pregnancy
needs to be avoided in 3rd trimester
-Risk of neonatal haemolytic
Trimethoprim in pregnancy
needs to be avoided in 1st trimester
- works as a folate antagonist.
Can cause congenital malformations, particularly neural tube defects
Generally avoided throughout pregnancy
vasa praevia
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
risk factors for vasa praaevia
low-lying placenta
IVF pregnancy
Multiple pregnancy
Presentation of vasa praevia
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
management of vasa praevia
asymptomatic
- corticosteroids from 32 weeks
- elective c-section: 34-36 weeks
Antepartum haemorrhage
-emergency c-section
screening for anaemia in pregnancy
Booking clinic
28 week gestation
Haemoglobinopathy screening offered at booking clinic
- identify thalassaemia and sickle cell disease
Additional investigations
-ferritin, B12, folate
posible causes of anaemia (& indicative MCV)
Low MCV
- iron deficiency
Normal MCV
- physiological anaemia due to increased plasma volume of pregnancy
Raised MCV
- B12 or folate deficiency
Management of anaemia in pregnancy
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
acute fatty liver disease of pregnancy
rare condition that occurs in 3rd trimester of pregnancy
Rapid accumulation of fat within liver cells (hepatocytes) causing acute hepatitis.
aetiology acute fatty liver disease of pregnancy
impaired processing of fatty acids in placenta
LCHAD deficiency in fetus
Autosomal recessive condition
presentation acute fatty liver disease of pregnancy
general malaise and fatigue nausea and vomiting jaundice abdo pain anorexia ascites
bloods in acute fatty liver disease of pregnancy
LFTs: elevated liver enzymes (ALT &AST) raised bilirubin raised WBC count Deranged clotting - raised prothrombin time and INR low platelets
management acute fatty liver disease of pregnancy
obstetric emergence
Prompt admission & delivery of baby
Most recover after delivery
obstetric cholestasis
intrahepatic cholestasis of pregnancy
Reduced outflow of bile acids from the liver.
Associated with increased risk of stillbirth
pathophysiology obstetric cholestasis
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
presentation of obstetric cholestasis
usually develops later. in pregnancy (~28 weeks)
itching: affects palms of hands and soles of feet Ftigue Dark urine Pale-greasy stools jaundice
investigations of obstetric cholestasis
liver function tests
-Abnormal: ALT, AAST and GGT
(Note: normal for ALP to increase in pregnancy as its produced by placenta)
Raised bile acids
Management of obstetric cholestasis
Urseodeoxycholic Acid
Symptoms of itching
-Emollients to soothe skin
