Antenatal care Flashcards

1
Q

What is gestational age?

A

duration of the pregnancy starting from the date of the last menstrual period

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2
Q

What is gravida?

A

total number of pregnancies a woman has had

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3
Q

What is primigravida?

A

patient that is pregnant for the first time

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4
Q

What is multigravida?

A

patient that is pregnancy for at least the second time

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5
Q

What is para?

A

number of times the woman has given birth after 24 weeks gestation, regardless of whether the foetus was alive or stillborn

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6
Q

What does nuliparous mean?

A

patient that has never given birth after 24 weeks gestation

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7
Q

What does primiparous mean?

A

patient that has given birth after 24 weeks gestation once before

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8
Q

What does multiparous mean?

A

patient that has given birth after 24 weeks gestation two or more times

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9
Q

When is the first trimester?

A

start of pregnancy until 12 weeks gestation

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10
Q

When is the second trimester?

A

13-26 weeks gestation

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11
Q

When is the third trimester?

A

27 weeks gestation to birth

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12
Q

When do foetal movements start?

A

20 weeks

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13
Q

When is the booking clinic?

A

before 10 weeks

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14
Q

What happens at the booking clinic?

A

baseline assessment
plan the pregnancy

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15
Q

When is the dating scan?

A

10 - 13+6

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16
Q

What happens at the dating scan?

A

accurate gestational age is calculated from the crown rump length
multiple pregnancies are identified

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17
Q

When is the anomaly scan?

A

18 - 20+6

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18
Q

When are antenatal appointments?

A

weeks:
16
25
28
31
34
36
38
40
41
42

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19
Q

When is the oral glucose tolerance test carried out in people at risk of gestational diabetes?

A

24-28 weeks
and at booking if previous gestational diabetes

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20
Q

When are anti-D injections administered to rhesus negative pregnant people?

A

28-34 weeks

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21
Q

What vaccines are offered to all pregnant people?

A

whooping cough (pertussis) from 16 weeks gestation
influenza (Flu) in autumn or winter

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22
Q

What supplements should pregnant people take?

A

folic acid 400mcg from before pregnancy to 12 weeks (reduces neural tube defects)
vitamin D

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23
Q

What vitamin supplement should pregnant people avoid?

A

vitamin A (teratogenic at high doses)

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24
Q

What foods should pregnant people avoid?

A

liver or pate (high in vitamin A)
unpasteurised diary or blue cheese (risk of listeriosis)
undercooked or raw poultry (risk of salmonella)

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25
What are the effects of alcohol in pregnancy?
miscarriage small for dates preterm delivery foetal alcohol syndrome
26
What are the features of foetal alcohol syndrome?
microcephaly (small head) thin upper lip smooth flat philtrum (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
27
What does smoking during pregnancy increase the risk of?
foetal growth restriction miscarriage stillbirth preterm labour and delivery placental abruption pre-eclampsia cleft lip or palate sudden infant death syndrome (SIDS)
28
What are the recommendations around flying in pregnancy?
safe in uncomplicated healthy pregnancies up to: 37 weeks in a single pregnancy 32 weeks in a twin pregnancy
29
What forms the antenatal screening programme for Down's syndrome?
11-14 weeks = combined test 14-20 weeks = triple test 14-20 weeks = quadruple test
30
What is involved in the combined screening test for Down's syndrome?
US to measure nuchal translucency (thickness of the back of the neck) maternal blood tests: beta-HCG pregnancy-associated plasma protein-A (PAPA)
31
What is involved in the triple screening test for Down's syndrome?
maternal blood tests: beta-HCG alpha-fetoprotein (AFP) serum oestriol
32
What is involved in the quadruple screening test for Down's syndrome?
triple test plus maternal blood testing for inhibin-A
33
When is antenatal testing for Down's syndrome offered?
risk of Down's greater than 1 in 150 (occurs in around 5% of tested pregnant people)
34
What are the antenatal tests for Down's syndrome?
before 15 weeks = chorionic villus sampling (US-guided biopsy of the placental tissue) after 15 weeks = amniocentesis (US guided aspiration of amniotic fluid using a needle and syringe) non-invasive prenatal testing (not definitive but less invasive)
35
How is hypothyroidism managed during pregnancy?
increased levothyroxine dose aim for a low-normal TSH level
36
What hypertension medications should be stopped during pregnancy as they cause congenital abnormalities?
ACE inhibitors (e.g. ramipril) ARBs (e.g. losartan) thiazide and thiazide-like diuretics (e.g. indapamide)
37
What medications can be used to manage hypertension during pregnancy?
labetalol (other beta-blockers may have adverse effects) CCBs (e.g. nifedipine) alpha-blockers (e.g. doxazosin)
38
What anti-epileptic drugs are safe in pregnancy?
levetiracetam lamotrigine carbamazepine
39
What anti-epileptic drugs should be avoided in pregnancy and why?
sodium valproate - causes neural tube defects and developmental delay phenytoin - causes cleft lip and palate
40
What DMARDs are safe during pregnancy?
hydroxychloroquine (first-line) sulfasalazine
41
What DMARD should be avoided during pregnancy?
methotrexate
42
Why should NSAIDs be avoided during pregnancy unless absolutely necessary?
premature closure of the ductus arteriosus in the fetus delay labour (block prostaglandins - maintain the ductus arteriosus, soften the cervix, stimulate uterine contractions)
43
What can use of beta blockers during pregnancy cause?
foetal growth restriction hypoglycaemia in the neonate bradycardia in the neonate
44
What can the use of ACE inhibitors and ARBs in pregnancy cause?
oligohydraminos (reduced amniotic fluid) miscarriage or foetal death hypocalvaria (incomplete formation of the skull bones) renal failure in the neonate hypotension in the neonate
45
What can the use of opiates during pregnancy cause?
neonatal abstinence syndrome
46
What is the presentation of neonatal abstinence syndrome?
3-72 hours after birth with: irritability tachypnoea high temperatures poor feeding
47
What can the use of warfarin during pregnancy cause?
foetal loss congenital malformations - particularly craniofacial problems bleeding during pregnancy, postpartum haemorrhage, foetal haemorrhage, intracranial bleeding
48
Why should lithium be avoided during pregnancy unless other options have failed?
congenital cardiac abnormalities - particularly Ebstein's (tricuspid valve is set lower on the right side of the heart, causing a bigger right atrium and a smaller right ventricle)
49
What are the potential risk of SSRIs during pregnancy?
first-trimester = congenital heart defects, paroxetine has a stronger link with congenital malformations third-trimester = persistent pulmonary hypertension in the neonate neonates can experience withdrawal (usually mild)
50
What causes congenital rubella syndrome?
maternal infection with the rubella virus during the first 20 weeks of pregnancy
51
What are the features of congenital rubella syndrome?
congenital deafness congenital cataracts congenital heart disease learning disability
52
Why is chickenpox dangerous in pregnancy?
more severe in the mother (e.g. varicella pneumonitis, hepatitis, encephalitis) foetal varicella syndrome severe neonatal varicella infection (if infected around delivery)
53
What is done when a pregnant person is exposed to chickenpox?
check blood for antibodies if non-immune = IV varicella immunoglobulins within 10 days of exposure
54
What is the treatment of chickenpox during pregnancy?
oral aciclovir within 24 hours of onset of rash in a patient that is more than 20 weeks gestation
55
What are the features of congenital varicella syndrome?
foetal growth restriction microcephaly, hydrocephalus and learning disabilities scars and significant skin changes located in specific dermatomes limb hypoplasia (underdeveloped limbs) cataracts and inflammation in the eye (chorioretinitis)
56
What can listeriosis in a pregnant person cause?
miscarriage foetal death severe neonatal infection
57
What are the features of congenital CMV?
foetal growth restriction microcephaly hearing loss vision loss learning disability seizures
58
How is toxoplasmosis spread?
faeces from a cat that is a host of the parasite Toxoplasma gondii
59
What are the features of congenital toxoplasmosis?
classic triad of: intracranial calcification hydrocephalus chorioretinitis (inflammation of the choroid and retina in the eye)
60
What are the complications of parvovirus B19 infection during pregnancy?
miscarriage or foetal death severe foetal anaemia hydrops fetalis (foetal heart failure) maternal pre-eclampsia-like syndrome
61
How is the Zika virus spread?
Aedes mosquitos sex with someone infected with the virus
62
What are the features of congenital Zika syndrome?
microcephaly foetal growth restriction other intracranial abnormalities such as ventriculomegaly and cerebellar atrophy
63
What can happen if a rhesus-D negative person becomes pregnant with a rhesus positive child?
likely at some point, that the blood from the baby will cross into the mother's bloodstream mother's immune system will recognise the rhesus-D antigen as foreign and produce antibodies to it - mother has become sensitised to rhesus-D antigens during subsequent pregnancies, the mother's anti-rhesus-D antibodies can cross the placenta if the foetus is rhesus-D positive, this can result in haemolytic disease of the newborn
64
When are anti-D injections given to rhesus-D negative pregnant patients?
routinely at: 28 weeks gestation birth - if the baby's blood group is found to be rhesus-positive within 72 hours of a sensitisation event - e.g. antepartum haemorrhage, amniocentesis procedures, abdominal trauma
65
What is the Kleihauer test used for?
assess how much foetal blood has passed into the mother's blood during a sensitisation event after 20 weeks used to assess whether further doses of anti-D is required
66
How is the Kleihauer test performed?
adding acid to a sample of the mother's blood foetal haemoglobin is naturally more resistant to acid foetal haemoglobin persists in response to the added acid, whilst the mother's haemoglobin is destroyed number of cells still containing haemoglobin (remaining foetal cells) can then be calculated
67
What is the definition of small for gestational age?
foetus measures below the 10th centile for their gestational age
68
What are the two US measurements used to assess foetal size?
estimated foetal weight (EFW) foetal abdominal circumference (AC)
69
What is the defined as severe small for gestational age?
below the 3rd centile for their gestational age
70
What is low birth weight defined as?
birth weight of less than 2500g
71
What are the two categories of causes of small for gestational age?
constitutionally small (matching the mother and others in the family and growing appropriately on the growth chart) foetal growth restriction/intrauterine growth restriction
72
What are the two categories of causes of foetal growth restriction?
placenta mediated growth restriction non-placenta mediated growth restriction
73
What are the causes of placenta mediated growth restriction?
idiopathic pre-eclampsia maternal smoking maternal alcohol anaemia malnutrition infection maternal health conditions
74
What are the causes of non-placenta medicated growth restriction?
genetic abnormalities structural abnormalities foetal infection errors of metabolism
75
What signs may indicate foetal growth restriction other than the foetus being SGA?
reduced amniotic fluid volume abnormal doppler studies reduced foetal movements abnormal CTGs
76
What are the short term complications of foetal growth restriction?
foetal death or stillbirth birth asphyxia neonatal hypothermia neonatal hypoglycaemia
77
What are the long term complications of foetal growth restriction?
increased risk of: cardiovascular disease, particularly hypertension T2DM obesity mood and behavioural problems
78
What are the risk factors for small for gestational age?
previous SGA baby obesity smoking diabetes existing hypertension pre-eclampsia older mother (>35 years) multiple pregnancy low pregnancy-associated plasma protein-A (PAPPA) antepartum haemorrhage antiphospholipid syndrome
79
What is the management of pregnant people at low risk of SGA?
monitoring of symphysis fundal height at every antenatal appointment from 24 weeks onwards
80
What is the criteria for a pregnant person to have serial growth scans with umbilical artery doppler?
three or more minor risk factors one or more major risk factors issues with measuring the symphysis fundal height (e.g. large fibroids, BMI>35) symphysis fundal height <10th centile
81
What is the management of pregnant people with SGA?
monitored closely with serial US measuring: estimated foetal weight and abdominal circumference to determine growth velocity umbilical arterial pulsatility index amniotic fluid volume treat modifiable risk factors (E.g. smoking) early delivery where growth is static or there are other concerns identify underlying cause: blood pressure and urine dipstick for pre-eclampsia uterine artery doppler scanning detailed foetal anatomy scan by foetal medicine karyotyping for chromosomal abnormalities testing for infections
82
What is defined as being large for gestational age/macrosomia?
estimated foetal weight >90th centile
83
What is a high birthweight?
>4500g
84
What are the causes of macrosomia?
constitutional maternal diabetes previous macrosomia maternal obesity or rapid weight gain overdue male baby
85
What are the risks to the mother of macrosomia?
shoulder dystocia failure to progress perineal tears instrumental delivery or caesarean postpartum haemorrhage uterine rupture (rare)
86
What are the risks to the foetus of macrosomia?
birth injury neonatal hypoglycaemia obesity in childhood and later life T2DM in adulthood
87
What investigations are done in macrosomia?
US to exclude polyhydramnios and estimate the foetal weight oral glucose tolerance test for gestational diabetes
88
How can the risks surrounding delivery in macrosomia be reduced?
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 early decision for caesarean section if required paediatrician attending the birth
89
What is monozygotic?
identical twins from a single zygote
90
What is dizygotic?
non-identical twins from two different zygotes
91
What is monoamniotic?
single amniotic sac
92
What is diamniotic?
two separate amniotic sacs
93
What is monochorionic?
share a single placenta
94
What is dichorionic?
two separate placentas
95
What type of twin pregnancy has the best outcome?
diamniotic, dichorionic (each foetus has their own nutrient supply)
96
How can the type of twin pregnancy be determined on US?
dichorionic diamniotic twins = membrane between the twins with a lambda sign or twin peak sign monochorionic diamniotic twins = membrane between the twins with a T sign monochorionic monoamniotic twins = no membrane
97
What are the risks to the pregnant person with a twin pregnancy?
anaemia polyhydramnios hypertension malpresentation spontaneous preterm birth instrumental delivery or caesarean postpartum haemorrhage
98
What are the risks to the foetuses and neonates of a twin pregnancy?
miscarriage stillbirth foetal growth restriction prematurity twin-twin transfusion syndrome twin anaemia polycythaemia sequence congenital abnormalities
99
What is the pathophysiology of twin-twin transfusion syndrome?
foetuses share a placenta and there is a connection between the blood supplies of the foetuses one foetus (the recipient) may receive the majority of the blood while the other foetus (the donor) is starved of blood
100
What are the complications of twin-twin transfusion syndrome?
recipient = fluid overloaded - heart failure, polyhydramnios donor = growth restriction, anaemia, oligohydramnios
101
What is the management of twin-twin transfusion syndrome?
referred to a tertiary specialist foetal medicine centre
102
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)
103
What additional US scans are required in twin pregnancy?
monochorionic = 2 weekly scans from 16 weeks dichorionic = 4 weekly scans from 20 weeks
104
When is planned birth offered for twin pregnancies?
uncomplicated monochorionic monoamniotic twins = 32-33+6 weeks uncomplicated monochorionic diamniotic twins = 36-36+6 weeks uncomplicated dichorionic diamniotic twins = 37-37+6 weeks triplets = before 35+6 weeks (waiting beyond these dates is associated with an increased risk of foetal death, corticosteroids given before delivery to help mature the lungs)
105
How are twin pregnancies delivered?
monoamniotic twins = elective caesarean section diamniotic twins: vaginal delivery is possible when the first baby has a cephalic presentation 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
106
What can UTIs increase the risk of in pregnant people?
pre-term delivery low birth weight pre-eclampsia
107
What is the management of UTIs during pregnancy?
7 days of antibiotics antibiotic options: nitrofurantoin (avoid in the third trimester - risk of neonatal haemolysis) amoxicillin (only after sensitivities are known) cefalexin (avoid trimethoprim as it is a folate antagonist)
108
What are the risk factors for VTE during pregnancy?
smoking parity ≥3 age >35 BMI >30 reduced mobility multiple pregnancy pre-eclampsia gross varicose veins immobility FMHx of VTE thrombophilia IVF pregnancy
109
When should prophylaxis for VTE in pregnancy start?
28 weeks if there are three risk factors first trimester if there are four or more risk factors hospital admission surgical procedures previous VTE medical conditions such as cancer or arthritis high-risk thrombophilias ovarian hyperstimulation syndrome
110
What are the options for VTE prophylaxis during pregnancy?
LMWH (e.g. enoxaparin, dalteparin, tinzaparin) unless contraindicated contraindications to LMWH consider mechanical prophylaxis: intermittent pneumatic compression anti-embolic compression stockings
111
When does pre-eclampsia occur?
after 20 weeks gestation
112
What are the features of pre-eclampsia?
triad of: hypertension proteinuria oedema
113
What is chronic hypertension?
high blood pressure that exists before 20 weeks gestation and is longstanding
114
What is pregnancy-induced/gestational hypertension?
hypertension occurring after 20 weeks gestation without proteinuria
115
What is pre-eclampsia?
pregnancy-induced hypertension associated with organ damage, notably proteinuria
116
What is eclampsia?
seizures occurring as a result of pre-eclampsia
117
What is the pathophysiology of pre-eclampsia?
process of forming lacunae is inadequate high vascular resistance in the spiral arteries and poor perfusion of the placenta causes oxidative stress in the placenta and release of inflammatory chemicals into the systemic circulation leads to systemic inflammation and impaired endothelial function in the blood vessels
118
What are the high-risk factors for pre-eclampsia?
pre-existing hypertension previous hypertension in pregnancy existing autoimmune conditions diabetes CKD
119
What are the moderate-risk factors for pre-eclampsia?
older than 40 BMI >35 more than 10 years since previous pregnancy multiple pregnancy first pregnancy FMHx of pre-eclampsia
120
What are the symptoms of pre-eclampsia?
headache visual disturbance or blurriness nausea and vomiting upper abdominal or epigastric pain (due to liver swelling) oedema reduced urine output brisk reflexes
121
How is pre-eclampsia diagnosed?
systolic BP >140 OR diastolic BP >90 PLUS any of: proteinuria (1+ or more on urine dipstick) organ dysfunction (e.g. raised creatinine, elevated liver enzymes, thrombocytopenia, haemolytic anaemia) placental dysfunction (e.g. foetal growth restriction or abnormal Doppler studies)
122
What pregnant people are given aspirin as prophylaxis against the development of pre-eclampsia?
single high-risk factor two or more moderate risk factors
123
What is the management of gestational hypertension?
aim for BP <135/85 admit if BP >160/110 weekly urine dipstick monitoring of blood tests weekly - FBC, LFTs, renal profile monitoring foetal growth by serial growth scans placental growth factor (PIGF) testing between 20-35 weeks gestation to rule out pre-eclampsia (low levels in pre-eclampsia)
124
What is the management of pre-eclampsia?
scoring system to determine need for admission - fullPIERS or PREP-S 48hrly blood pressure two weekly US medical management: 1st line = labetolol 2nd line = modified release nifedipine 3rd line = methyldopa (needs to be stopped within 2 days of birth) severe = IV hydralazine during labour and 24 hrs afterwards = IV magnesium sulfate (to prevent seizures)
125
What is the treatment of pre-eclampsia post birth?
BP monitoring - will return to normal once placenta is removed medical: first line = enalapril second line or first line in black African or Caribbean patients = nifedipine or amlodipine 3rd line = labetolol or atenolol
126
What is used to manage seizures associated with eclampsia?
IV magnesium sulfate
127
What is HELLP syndrome?
complication of pre-eclampsia
128
What are the features of HELLP syndrome?
Haemolysis Elevated Liver enzymes Low Platelets
129
What are the risks of gestational diabetes?
large for dates foetus/macrosomia - increased risk of shoulder dystocia higher risk of developing T2DM after pregnancy
130
What are the risk factors that warrant testing for gestational diabetes?
previous gestational diabetes previous macrosomic baby (>4.5kg) BMI >30 ethnic origin FMHx of diabetes (first degree relative) large for dates foetus polyhydramnios (increased amniotic fluid) glucose on urine dipstick
131
What are the normal results of an oral glucose tolerance test in pregnancy?
fasting <5.6 mmol/l at 2 hours <7.8 mmol/l (5-6-7-8)
132
What is the initial management of gestational diabetes?
fasting glucose <7: 1st line = 1-2 week trial of diet and exercise 2nd line = metformin 3rd line = insulin fasting glucose >7 = insulin +/- metformin fasting glucose >6 + macrosomia or other complications = insulin +/- metformin glibenclamide is an option for women who decline insulin or cannot tolerate metformin
133
What are the target blood sugar levels for diabetes during pregnancy?
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
134
When should retinopathy screening in patients with diabetes be performed during pregnancy?
booking 28 weeks gestation
135
When should patients with pre-existing diabetes deliver their baby?
37-38+6 weeks
136
What are the risks to the baby of a patient with diabetes?
neonatal hypoglycaemia polycythaemia (raised haemoglobin) jaundice (raised bilirubin) congenital heart disease cardiomyopathy
137
When does obstetric cholestasis usually develop?
after 28 weeks
138
What patients is obstetric cholestasis most common in?
South Asian
139
What is the main risk of obstetric cholestasis?
increased risk of stillbirth
140
What is the presentation of obstetric cholestasis?
main symptom = pruritis - particularly of the palms and soles other symptoms = fatigue, dark urine, pale, greasy stools, jaundice
141
What are the differential diagnoses of obstetric cholestasis?
gallstones acute fatty liver autoimmune hepatitis viral hepatitis
142
What is the management of obstetric cholestasis?
ursodexoycholic acid symptoms of itching = emollients water-soluble vitamin K if prothrombin time deranged weekly LFT monitoring
143
When does acute fatty liver of pregnancy occur?
third trimester
144
What is the pathophysiology of acute fatty liver of pregnancy?
impaired processing of fatty acids in the placenta fatty acids enter the maternal circulation and accummulate in the liver
145
What is the pathophysiology of acute fatty liver of pregnancy?
impaired processing of fatty acids in the placenta fatty acids enter the maternal circulation and accumulate in the liver
146
What causes acute fatty liver of pregnancy?
genetic condition in the foetus - most commonly LCHAD deficiency (autosomal recessive)
147
What is the presentation of acute fatty liver of pregnancy?
general malaise and fatigue nausea and vomiting jaundice abdominal pain anorexia ascites
148
What is the management of acute fatty liver of pregnancy?
obstetric emergency - prompt admission and delivery of baby
149
When does polymorphic eruption of pregnancy occur?
third trimester
150
Where does polymorphic eruption of pregnancy typically begin?
abdomen - particularly associated with stretch marks (striae)
151
When does atopic eruption of pregnancy typically occur?
first and second timester
152
When does atopic eruption of pregnancy typically occur?
first and second trimester
153
What are the two types of atopic eruption of pregnancy?
E-type/eczema type = eczematous, inflamed, red and itchy skin, typically affecting the insides of the elbows, back of the knees, neck, face and chest P-type/prurigo type = intensely itchy papules affecting the abdomen, back and limbs
154
What are the symptoms of melasma?
increased pigmentation to patches of sun-exposed skin
155
What can cause melasma?
pregnancy COCP HRT thyroid disease
156
What is the management of melasma?
avoiding sun exposure and using suncream makeup
157
When does pemphigoid gestationis occur?
second or third trimester
158
What is the presentation of pemphigoid gestationis?
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
159
What is a low-lying placenta?
placenta is within 20mm of the internal cervical os
160
What is placenta praevia?
placenta is over the internal cervical os
161
What are the risks associated with placenta praevia?
antepartum haemorrhage emergency C section emergency hysterectomy maternal anaemia and transfusions preterm birth and low birth weight stillbirth
162
What are the risk factors for placenta praevia?
previous C section previous placenta praevia older maternal age maternal smoking structural uterine abnormalities (e.g. fibroids) assisted reproduction (e.g. IVF)
163
When is placenta praevia diagnosed?
20 week anomaly scan
164
What are the symptoms of placenta praevia?
asymptomatic may present with painless vaginal bleeding (antepartum haemorrhage) late in pregnancy (after 36 weeks(
165
What is the management of a low-lying placenta or placenta praevia?
repeat transvaginal US at 32 weeks and 36 weeks corticosteroids between 34-35+6 weeks to mature foetal lungs due to the risk of preterm delivery planned delivery between 36-37 weeks via elective C section
166
What is vasa praevia?
foetal vessels travel across the internal cervical os
167
What are the two causes of vasa praevia?
type 1 = foetal vessels are exposed as a velamentous umbilical cord type 2 = foetal vessels are exposed as the travel to an accessory placental lobe
168
What are the risk factors for vasa praevia?
low lying placenta IVF pregnancy multiple pregnancy
169
How can vasa praevia be diagnosed?
US during pregnancy antepartum haemorrhage vaginal examination during labour - pulsating foetal vessels are seen in the membranes through the dilated cervix foetal distress and dark-red bleeding following rupture of the membranes
170
What is the management of vasa praevia?
corticosteroids from 32 weeks to mature the foetal lungs elective C section planned for 34-36 weeks gestation
171
What are the risk factors for placental abruption?
previous placental abruption pre-eclampsia bleeding early in pregnancy trauma (consider domestic violence) multiple pregnancy foetal growth restriction multigravida increased maternal age smoking cocaine or amphetamine use
172
What is the presentation of placental abruption?
sudden onset severe abdominal pain in third trimester vaginal bleeding (antepartum haemorrhage) shock (hypotension and tachycardia) CTG abnormalities indicating foetal distress woody abdomen on palpation
173
What are the causes of antepartum haemorrhage?
placenta praevia placental abruption vasa praevia
174
How is the severity of an antepartum haemorrhage defined?
spotting = spots of blood noticed on underwear minor haemorrhage = <50ml blood loss major haemorrhage = 50-1000ml blood loss massive haemorrhage = >1000ml blood loss or signs of shock
175
What is a concealed placental abruption?
cervical os remains closed so blood remains within the uterine cavity
176
What are the risk factors for placenta accreta?
previous placenta accreta previous endometrial curettage procedures (e.g. for miscarriage or abortion) previous C section multigravida increased maternal age low-lying placenta or placenta praevia
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What are the management options for placenta praevi during a C section?
hysterectomy (recommended) uterus preserving surgery expectant management (leaving the placenta in place to be reabsorbed over time)
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What is a complete breech presentation?
legs are fully flexed at the hips and knees
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What is an incomplete breech presentation?
one leg flexed at the hip and extended at the knee
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What is an extended/frank breech presentation?
both legs flexed at the hip and extended at the knee
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What is a footling breech presentation?
foot presenting through the cervix with the leg extended
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What is the management of breech presentation?
<36 weeks = no intervention as they often turn spontaneously 37 weeks = external cephalic version choice of elective C section or vaginal delivery with access to emergency theatre
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What is used to relax the uterus for ECV?
subcutaneous terbutaline (beta-agonist)
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What is a stillbirth?
birth of a dead foetus after 24 weeks gestation
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What are the causes of stillbirth?
unexplained (50%) pre-eclampsia placental abruption vasa praevia cord prolapse or wrapped around the foetal neck obstetric cholestasis diabetes thyroid disease infections - e.g. rubella, parvovirus, listeria genetic or congenital abnormalities
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What factors increase the risk of stillbirth?
foetal growth restriction smoking alcohol increased maternal age maternal obesity twins sleeping on the back
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What are the key symptoms of an intrauterine foetal death?
reduced foetal movements abdominal pain vaginal bleeding
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How is an intrauterine foetal death diagnosed?
US to visual foetal heartbeat
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What is the management of intra-uterine foetal death?
1st line = vaginal birth - induction or expectant management dopamine agonists (e.g. cabergoline) to suppress lactation testing to determine cause
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What are the three major causes of cardiac arrest in pregnancy?
obstetric haemorrhage PE sepsis
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What are the causes of a massive obstetric haemorrhage?
ectopic pregnancy placental abruption (may be concealed) placenta praevia placenta accreta uterine rupture
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Why should a pregnant person be positioned in the left lateral position?
prevent the uterus from compressing the IVC and preventing venous return to the heart (aotrocaval compression)
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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
194
What are the key differences with resuscitation in pregnancy?
15 degree tilt to the left side for CPR (relive aortocaval compression) early supplementary oxygen and intubation aggressive fluid resuscitation (caution in pre-eclampsia) delivery of the baby via immediate C section after 4 minutes and within 5 minutes of starting CPR - improves maternal survival
195
What women should take 5mg of folic acid instead of 400mcg?
either partner has a neural tube defect previous pregnancy affected by a neural tube defect FMHx of neural tube defect woman is taking antiepileptic drugs woman has coeliac disease, diabetes or thalassaemia trait woman is obese (BMI >30)
196
What are the causes of oligohydraminos?
premature rupture of membranes Potter sequence (bilateral renal agenesis + pulmonary hypoplasia) intrauterine growth restriction post-term gestation pre-eclampsia
197
What are the causes of increased nuchal translucency on US in pregnancy?
Down's syndrome congenital heart defects abdominal wall defects
198
What are the causes of hyperechogenic bowel on US in pregnancy?
cystic fibrosis Down's syndrome CMV infection
199
When should pregnant people receive oral iron?
first trimester = Hb <110 second/third trimester = Hb <105 postpartum = Hb <100
200
What should be monitored during treatment with magnesium sulphate?
urine output reflexes respiratory rate oxygen saturations
201
What is the treatment for magnesium sulphate induced respiratory depression?
calcium gluconate
202
What are the physiological blood pressure changes in a normal pregnancy?
blood pressure falls in the first trimester (particularly the diastolic) and continues to fall until 20-24 weeks after this time, the blood pressure usually increases to pre-pregnancy levels by term
203
What are the results of the quadruple test in Down's syndrome?
low AFP low unconjugated oestriol high HCG high inhibin A
204
What are the results of the quadruple test in Edward's syndrome?
low AFP low unconjugated oestriol low HCG normal inhibin A
205
What are the results of the quadruple test in neural tube defects?
high AFP normal unconjugated oestriol normal HCG normal inhibin A
206
What is the most common cause of early onset severe infection in the neonatal period?
group B Strep (20-40% of mothers have GBS in their bowel flora and infants may be exposed to it during labour)
207
What are the risk factors for neonatal GBS infection?
prematurity prolonged rupture of membranes previous sibling GBS infection maternal pyrexia
208
When should GBS be tested for?
35-37 weeks or 3-5 weeks prior to anticipated delivery
209
Who is offered testing for GBS?
women who've had GBS detected in a previous pregnancy
210
What women get intrapartum antibiotic prophylaxis for GBS?
tested positive previous baby had GBS (and women wasn't tested this pregnancy) preterm labour regardless of their GBS status pyrexia during labour regardless of GBS status
211
What is used for GBS prophylaxis?
benzylpenicillin
212
What are the glucose targets for diabetes during pregnancy?
fasting = 5.3 mmol/l 1 hr after meals = 7.8 mmol/l 2 hrs after meals = 6.4 mmol/l
213
How does the location of appendicitis pain change during pregnancy?
first trimester = RLQ second = umbilicus third = RUQ
214
What are the investigations for reduced foetal movements?
initial = handheld Doppler to confirm foetal heartbeat if no foetal heartbeat = US if foetal heartbeat = CTG for at least 20 minutes
215
What is placenta accreta?
chorionic villi attach to the myometrium, rather than being restricted within the decidua basalis
216
What is placenta increta?
chorionic villi invade into the myometrium
217
What is placenta percreta?
chorionic villi invade through the perimetrium
218
What is the management of migraine during pregnancy?
1st line = paracetamol 2nd line = NSAIDs in the first and second trimester
219
Why is gestational thrombocytopenia relatively common?
combination of dilution, decreased production and increased destruction of platelets
220
What are the differentials for bleeding in the first trimester?
spontaneous abortion ectopic pregnancy hydatidiform mole non-pregnancy causes - e.g. STIs, cervical polyps
221
What are the differentials for bleeding in the second trimester?
spontaneous abortion hydatidiform mole placental abruption non-pregnancy causes - e.g. STIs, cervical polyps
222
What are the differentials for bleeding in the third trimester?
bloody show placental abruption placenta praevia vasa praevia non-pregnancy causes - e.g. STIs, cervical polyps
223
What is gastroschisis?
congenital defect in the anterior abdominal wall just lateral to the umbilical cord
224
What is the management of gastroschisis?
vaginal delivery may be attempted newborns should go to theatre asap after delivery
225
What is exomphalos/omphalocoele?
abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum
226
What is exomphalos/omphalocoele associated with?
Beckwith-Wiedemann syndrome Down's syndrome cardiac and kidney malformations
227
What is the management of exomphalos/omphalocoele?
C section to reduce the risk of sac rupture staged repair