Antenatal care Flashcards
prophylaxis for neutral tube defects
5mg in first trimester
ideally begun 3 months before pregnancy
which conditions increased risk of neural tube defects
Epilepsy
Previous baby with neural tube defects
Obesity with BMI over 35
Diabetes (Type 1 and 2)
Sickle cell disease
Thalassemia
Malabsorption disorders (e.g. Crohn’s disease)
Those taking folate antagonist drugs (HIV anti-retroviral drugs, methotrexate, sulphonamides
reduce risk of rickets and when higher dose
vit d
if darker skin/BAME group or BMI>30 higher dose
what check for in maternal blood
maternal blood grouping and rhesus
how assess foetal growth
symphysis fundal height
indications for regular USS as unsuitable for SFH measurements
Multiple pregnancy
BMI >35
Large or multiple fibroids
how reduce incidence of foetal growth restrictions
low dose aspirin
lifestyle advice
-food
-exercise
-smoking
- alcohol
- recreational drugs
- travel
food -avoid raw meat, fish, eggs, unpasteurised milk or cheese, pate and shellfish
fruit and veg washed (reduce toxoplasmosis)
exercise - not vigorous (risk of small baby), avoid high contact
smoking - cessation
alcohol - avoid
recreational drugs - cocaine (spontaneous abortion, placental abruption, growth restriction, sudden infant death syndrome). if opiate addicted - methadone programme
travel - counsel about increased risk of VTE…compression stockings
reduced foetal movements advice
no change to pattern of movements after 28 weeks
if change - lie on left side and focus on movements for 2 hours, if less than 10 contact maternity unit
N+V advice
4th and 7th week
should settle by week 20
ginger and acupuncutre to help. ir prolonged and severe - tx for hyperemesis gravidarum
heartburn advice
sitting up for meal
avoid fat and spice
smaller portions
consider gaviscon or omeprazole
constipation advice
fibre and oral fluids
small for gestational age definition
an infant with a birth weight <10th centile for its gestational age.
Severe SGA – a birth weight < 3rd centile.
foetal SGA definition
an estimated fetal weight (EFW), or abdominal circumference (AC) <10th centile.
Severe fetal SGA – an EFW or AC <3rd centile.
foetal growth restriction definition
when a pathological process has restricted genetic growth potential. This can present with features of fetal compromise including reduced liquor volume (LV) or abnormal doppler studies.
low birth weight
<2500g
types of small for gestationages ages
normal - growth follows normal centiles
placenta mediated growth restriction - foetal growth restriction….placental insuffiency from substance abuse, DM, renal disease etc
non placenta mediated growth restriction - foetal factors such as chromosomal or structural anomaly
minor risk factors for SGA
maternal age same or more 35
smoker 1-10/day
nullparity
BMI<20 OR 25-34.9
IVF singleton
previous pre eclampsia
preg interval <6or >60 months
low fruit intake pre preg
major risk factors for SGA
maternal age >40
smoker>11
previous SGA baby
maternal/paternal SGA
previous stillbirth
cocaine use
daily vigorous exercise
maternal disease
heavy bleeding
low PAPP-A
how diagnosed SGA
USS
ratio of head circumference and AC (if assymetric - placental insufficiency)
doppler studies
reduced amnotic fluid vol
other - Detailed fetal anatomical survey
Uterine artery Doppler (UAD)
Karyotyping
Screening for infections including congenital cytomegalovirus, toxoplasmosis, syphilis and malaria
mx of SGA
prevention - smoking cessation etc, high risk of pre eclampsia - 75mg of aspirin
UAD suveillance or SFH
antenatal steroids if early delivery considered
neonatal complications SGA
birth asphyxia
meconium aspiration
hypothermia
hypo/hyperglycaemia
polycythaemia
retinopathy of prematurity
persistent pulmonary HTN
pulmonary haemorrhage
necrotising entercolitis
long term complications SGA
cerebral palsy
type 2 DM
obesity
HTN
precocious puberty
behavioural problems
depression
alzheimers
cancer
post term pregnancy definition
a pregnancy extending past 42 weeks gestation (term refers to the 37-42 week gestation period)
post dates pregnancy definition
a pregnancy extending past the estimated delivery date (EDD), also known as due date at 40 weeks gestation
risk factors for prolonged pregnancy
Nulliparity
Maternal age >40
Previous prolonged pregnancy
High body mass index (BMI)
Family history of prolonged pregnancies
primary concern of prolonged pregnancy
stillbirth
clinical fx of prolonged pregnancy
Static growth or potentially macrosomia
Oligohydramnios
Reduced fetal movements
Presence of meconium
Signs of meconium staining e.g. on nails
Dry / flaky skin with reduced vernix
ddx of prolonged pregnancy
inaccurate dating
ix of prolonged pregnancy
dating in first trimester scan
USS scan
mx of prolonged pregnancy
Membrane sweeps – can be offered from 40+0 weeks in nulliparous and 41+0 weeks in parous women.
Induction of labour – usually offered between 41+0 and 42+0 weeks gestation
patho red cell isoimmunisation
maternal antibodies are formed in response to surface antigens on fetal erythrocytes. It occurs when the fetal cells enter the maternal circulation via a ‘sensitising event‘ – such as an antepartum haemorrhage or abdominal trauma. It can also occur during delivery.
in subsequent pregnancies, maternal antibodies can cross the placenta and attack the fetal red blood cells (if they carry the same surface antigen). This leads to haemolysis and subsequent fetal anaemia.
examples of surface antigens in maternal isoimmunisation
rhesus D blood group
rhesus D positive scenario
A woman is RhD-, and her partner is RhD+. She becomes pregnant with a fetus that is also RhD+. During childbirth, she comes into contact with the fetal (RhD+) blood, and antibodies are produced (known as anti-D antibodies).
She later becomes pregnant with a second child that is also RhD+.
The woman’s anti-D antibodies cross the placenta during this pregnancy and enter the fetal circulation, which contains RhD+ blood. They bind to the fetus’ RhD antigens on its erythrocyte surface membranes.
This causes the fetal immune system to attack and destroy its own RBCs, leading to fetal anaemia. This is termed haemolytic disease of the newborn
anti-d immunoglobulin when given
rhesus d negative women in any sensitising event such as invasive obstetric testing, antepartum haemorrhage, ectopic preg, miscarriage, fall, intrauterine death, termination of preg, delivery etc
ix rhesus D-ve women
maternal blood group and antibody screen
deto-maternal haemorrhage test
LMP
to the date of the first day of the most recent menstrual period
Gestational age
to the duration of the pregnancy starting from the date of the last menstrual period
Estimated delivery date def
to the estimated date of delivery (40 weeks gestation)
primigravida
a patient that is pregnant for the first time
multigravida
a patient that is pregnant for at least the second time
Para
refers to the number of times the woman has given birth after 24 weeks gestation, regardless of whether the fetus was alive or stillborn
nulliparous
refers to a patient that has never given birth after 24 weeks gestation
primiparous
refers to a patient that has given birth after 24 weeks gestation once before
multiparous
refers to a patient that has given birth after 24 weeks gestation two or more times
gestation age described
gestational age is described in weeks and days. For example:
5 + 0 refers to 5 weeks gestational age (since the LMP)
13 + 6 refers to 13 weeks and 6 days gestational age
gravidity and parity description
A pregnant woman with three previous deliveries at term: G4 P3
A non-pregnant woman with a previous birth of healthy twins: G1 P1
A non-pregnant woman with a previous miscarriage: G1 P0 + 1
A non-pregnant woman with a previous stillbirth (after 24 weeks gestation): G1 P1
trimesters
The first trimester is from the start of pregnancy until 12 weeks gestation.
The second trimester is from 13 weeks until 26 weeks gestation.
The third trimester is from 27 weeks gestation until birth.
when foetal movements
20 weejs
milestone <10 weeks
booking clinic
baseline assessment and plan
10 and 13+6 key milestone
dating scan
An accurate gestational age is calculated from the crown rump length (CRL), and multiple pregnancies are identified
16 weeks key milestone
antenatal appointment
discuss results
18 to 20+6 key milestone
anomaly scan
25, 28, 31, 34, 36, 38, 40, 41 and 42 weeks key milestones
monitor
additional investigations/appointments indications
Additional appointments for higher risk or complicated pregnancies
Oral glucose tolerance test in women at risk of gestational diabetes (between 24 – 28 weeks)
Anti-D injections in rhesus negative women (at 28 and 34 weeks)
Ultrasound scan at 32 weeks for women with placenta praevia on the anomaly scan
Serial growth scans are offered to women at increased risk of fetal growth restriction
what covered 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
which vaccines pregnant women
Whooping cough (pertussis) from 16 weeks gestation
Influenza (flu) when available in autumn or winter
live vaccines c/i
what is discussed in the booking clinic (initial appointment)
What to expect at different stages of pregnancy
Lifestyle advice in pregnancy (e.g. not smoking)
Supplements (e.g. folic acid and vitamin D)
Plans for birth
Screening tests (e.g. Downs screening)
Antenatal classes
Breastfeeding classes
Discuss mental health
bloods in booking clinic
Blood group, antibodies and rhesus D status
Full blood count for anaemia
Screening for thalassaemia (all women) and sickle cell disease (women at higher risk)
HIV
Hepatitis B
Syphilis
booking clinic risk assessment
Rhesus negative (book anti-D prophylaxis)
Gestational diabetes (book oral glucose tolerance test)
Fetal growth restriction (book additional growth scans)
Venous thromboembolism (provide prophylactic LMWH if high risk)
Pre-eclampsia (provide aspirin if high risk)
1st line antenatal screening for down’s
combined test - USS and maternal blood tests
combined test results
beta-hcg (higher result..greater risk)
pregnancy associated plasma protein A (lower result…increased risk)
triple test
between 14 and 20 weeks gestation. It only involves maternal blood tests:
Beta-HCG – a higher result indicates greater risk
Alpha-fetoprotein (AFP) – a lower result indicates a greater risk
Serum oestriol (female sex hormone) – a lower result indicates a greater risk
quadruple test
between 14 and 20 weeks gestation. It is identical to the triple test, but also includes maternal blood testing for inhibin-A. A higher inhibin-A indicates a greater risk
when offered further testing after screening
greater than 1 in 150…then iffered amniocentesis or chronic villus sampling
what tests involve to confirm down’s
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.
other non invasive prenatal testing
Non-invasive prenatal testing (NIPT) is a relatively new test for detecting abnormalities in the fetus during pregnancy. It involves a simple blood test from the mother. The blood will contain fragments of DNA
how hypothyroidism treated in pregnancy
levothyroxine dose increased by 25-50 mcg
tx titrated based on TSH, aim for low-normal TSH level
untreated hypothyroidism complications
miscarriage, anaemia, small for gestational age and pre-eclampsia
anti-HTN drugs stopped during pregnancy
ACE inhibitors (e.g. ramipril)
Angiotensin receptor blockers (e.g. losartan)
Thiazide and thiazide-like diuretics (e.g. indapamide)
anti-HTN drugs that consider stopping 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 epilepsy managed in pregnancy
folic acid 5mg daily from before conception to reduce the risk of neural tube defects.
Pregnancy may worsen seizure control due to the additional stress, lack of sleep, hormonal changes and altered medication regimes.
avoid sodium valporate
avoid phenytoin
anti-epileptics program pregnancy
Prevent (valproate pregnancy prevention programme)
RA during pregnancy
should be well controlled for at least three months before becoming pregnant. Often the symptoms of rheumatoid arthritis will improve during pregnancy, and may flare up after delivery
methotrexate c/i
steroids can be used in flare ups
hydroxychloroquine and sulfasalazine safe
NSAIDS pregnancy
NSAIDS are generally avoided in pregnancy unless really necessary (e.g. in rheumatoid arthritis). They are particularly avoided in the third trimester, as they can cause premature closure of the ductus arteriosus in the fetus. They can also delay labour.
beta blockers risks to unborn child
Fetal growth restriction
Hypoglycaemia in the neonate
Bradycardia in the neonate
ACEi and ARB risk to unborn baby
Oligohydramnios (reduced amniotic fluid)
Miscarriage or fetal death
Hypocalvaria (incomplete formation of the skull bones)
Renal failure in the neonate
Hypotension in the neonate
opiates risk to unborn baby
withdrawal sx after birth…neonatal abstinence syndrome…3-72 hours after birth with irritability, tachypnoea and high temp, poor feeding
warfarin risk to unborn baby
Fetal loss
Congenital malformations, particularly craniofacial problems
Bleeding during pregnancy, postpartum haemorrhage, fetal haemorrhage and intracranial bleeding
sodium valporate risk to unborn baby
neural tube defects
developmental delay
lithium risks to unborn baby
first trimester - ebstein’s anomaly (tricuspid valve lower on right side of heart…bigger RA and smaller RV)
monitor levels during pregnancy…in breastmilk is toxic to infant
SSRI risks to unborn baby
First-trimester use has a link with congenital heart defects
First-trimester use of paroxetine has a stronger link with congenital malformations
Third-trimester use has a link with persistent pulmonary hypertension in the neonate
Neonates can experience withdrawal symptoms, usually only mild and not requiring medical management
isotretinoin risks to unborn baby
highly teratogenic…miscarriage and congential defects
congenital rubella syndrome caused by
maternal infection with the rubella virus during the first 20 weeks of pregnancy
how avoid congenital rubella syndrome
planning to get pregnant - MMR vaccine and/or tested for rubella immunity
when can not give MMR vaccine
live vaccine so not during pregnancy…can have before or after
so if non immune - offered after giving birth
fx of congenital rubella syndrome
Congenital deafness
Congenital cataracts
Congenital heart disease (PDA and pulmonary stenosis)
Learning disability
chickenpox in pregnancy risks
varicella pneumonitis, hepatitis or encephalitis- in mother
Fetal varicella syndrome
Severe neonatal varicella infection (if infected around delivery)
how reduce risk chicken pox pregnancy
if had chickenpox - safe
can check IgG levels for VZV
if not immune - vaccine before or after pregnancy
can also be given IV varicella immunoglobulins as prophylaxis..within 10 days of exposure
fx of congenital varicella syndrome
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)
listeria pregnancy risks
listeriosis in mother - asx, flu like or can cause pneumonia or meningoencephalitis….then cause miscarriage or foetal death or severe infection
how listeria transmitted
unpasteurised dairy products, processed meat and contaminated foods…so avoid high risk foods and good hygeine
CMV infection risk to baby
congenital cytomegalovirus infection -
Fetal growth restriction
Microcephaly
Hearing loss
Vision loss
Learning disability
Seizures
how CMV spread
infected saliva or urine of asx children
toxoplasmosis risk to baby
congenital toxoplasmosis -
Intracranial calcification
Hydrocephalus
Chorioretinitis
how toxoplasma gondii spread
contamination with faeces from a cat that is a host of the parasite
parvovirus B19 infection during pregnancy risks
Miscarriage or fetal death
Severe fetal anaemia
Hydrops fetalis (fetal heart failure)
Maternal pre-eclampsia-like syndrome(aka mirror syndrome)
if suspect parvovirus infection, what tests
IgM to parvovirus, which tests for acute infection within the past four weeks
IgG to parvovirus, which tests for long term immunity to the virus after a previous infection
Rubella antibodies (as a differential diagnosis)
how mx parvovirus b19 infection in pregnancy
referral to fetal medicine to monitor
zika virus how spread
aedes mosquito
zika virus - risk to baby
congenital zika syndrome-
Microcephaly
Fetal growth restriction
Other intracranial abnormalities, such as ventriculomegaly and cerebellar atrophy
congenital zika syndrome mx
tested with viral PCR and antibodies to the Zika virus. Women with a positive result should be referred to fetal medicine for close monitoring of the pregnancy. There is no treatment for the virus.
types of twins definition
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
best outcome types of twins
diamniotic, dichorionic twin pregnancies, as each fetus has their own nutrient supply
how diagnose twins
booking USS scan:
Number of placentas (chorionicity) and amniotic sacs (amnionicity)
how to determine type of twins with USS
Dichorionic diamniotic twins have a membrane between the twins, with a lambda sign or twin peak sign
Monochorionic diamniotic twins have a membrane between the twins, with a T sign
Monochorionic monoamniotic twins have no membrane separating the twins
signs explained
The lambda sign, or twin peak sign, refers to a triangular appearance where the membrane between the twins meets the chorion, as the chorion blends partially into the membrane.
The T sign refers to where the membrane between the twins abruptly meets the chorion, giving a T appearance.
complications of twins - mother
Anaemia
Polyhydramnios
Hypertension
Malpresentation
Spontaneous preterm birth
Instrumental delivery or caesarean
Postpartum haemorrhage
complications of twins - foetus
Miscarriage
Stillbirth
Fetal growth restriction
Prematurity
Twin-twin transfusion syndrome
Twin anaemia polycythaemia sequence
Congenital abnormalities
twin-twin transfusion syndrome patho
share a placenta so 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.
how mx twin twin tranfusion syndrome
referral to tertiary specialist fetal medicine centre
laser tx can be used to destroy connection between two blood supplies
twin anaemia polycythaemia sequence
One twin becomes anaemic whilst the other develops polycythaemia (raised haemoglobin).
what monitor for additionally in scans for twins
women need blood tests for anaemia
additional USS to monitor for foetal growth resticition, unequal growth, twin twin transfusion syndrome
planning delivery for twins
planned birth-
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
steroids before delivery to mature lungs
how delivery twins
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
UTI in pregnancy increased risk
preterm delivery
low birth weight
pre-eclampsia
how screened for UTI’s in pregnancy
Pregnant women are tested for asymptomatic bacteriuria at booking and routinely throughout pregnancy. This involves sending a urine sample to the lab for microscopy, culture and sensitivities (MC&S).
more accurate indication of infection in urine dip
nitrites
causes of UTI in pregnant women
E.coli
Klebsiella pneumoniae (gram-negative anaerobic rod)
Enterococcus
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Candida albicans (fungal)
mx of UTI in pregnant women
Nitrofurantoin (avoid in the third trimester due to neonatal haemolysis)
Amoxicillin (only after sensitivities are known)
Cefalexin
AVOID TRIMETHOPRIM as folate antagonist
when women screened for anaemia
booking clinic
28 week gestation
normal ranges for Hb during pregnancy
booking bloods - >110
28 week gestation - >105
post partum- >100
possible causes of anaemia in preg - MCV and other ix
Low MCV may indicate iron deficiency
Normal MCV may indicate a physiological anaemia due to the increased plasma volume of pregnancy
Raised MCV may indicate B12 or folate deficiency
haemoglobinopathy screening for thalassaemia and sickle cell
ferritin, B12 and folate
how tx anaemia
iron - iron supplements
b12 - test for intrinsic factor antibodies…IM hydroxocobalamin or oral cyanocobalamin
folate - folic acid 5mg daily
thalassaemia - specialist haematologist, higher dose of folic acid, monitor, tranfusions
risk fx for VTE 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
guidlines for VTE prophylaxis
start if -
28 weeks if there are three risk factors
First trimester if there are four or more of these risk factors
or if any of:
Hospital admission
Surgical procedures
Previous VTE
Medical conditions such as cancer or arthritis
High-risk thrombophilias
Ovarian hyperstimulation syndrome
which prophylaxis VTE pregnancy
LMWH - ASAP in very high risk pts and at 28 weeks in those at high risk
continued through antenatal period and for 6 weeks postnatally
prophylaxis stopped when woman goes into labour and started immediately after delivery
what prophylaxis for vte in pregnancy if c/i LMWH
intermittent pneumatic compression
atni embolic compression stockings
how to examine for DVT
measure the circumference of the calf 10cm below the tibial tuberosity. More than 3cm difference between calves is significant.
ix for VTE in pregnancy
doppler USS for DVT (if positive, not need further scans)
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)
considerations for vte ix in pregnancy
The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.
massive PE and haemodynamic compromise tx pregnancy
Unfractionated heparin
Thrombolysis
Surgical embolectomy
when occur pre eclampsia
after 20 weeks - when the spiral arteries of the placenta form abnormally, leading to a high vascular resistance in these vessels.
triad of pre eclampsia
Hypertension
Proteinuria
Oedema
chronic hypertension definition
high blood pressure that exists before 20 weeks gestation and is longstanding. This is not caused by dysfunction in the placenta and is not classed as pre-eclampsia.
pregnancy induced HTN definition
hypertension occurring after 20 weeks gestation, without proteinuria.
pre eclampsia definition
pregnancy-induced hypertension associated with organ damage, notably proteinuria.
eclampsia definition
when seizures occur as a result of pre-eclampsia.
pathophysiology pre eclampsia
When the blastocyst implants on the endometrium, the outermost layer, called the syncytiotrophoblast, grows into the endometrium. It forms finger-like projections called chorionic villi. The chorionic villi contain fetal blood vessels.
Trophoblast invasion of the endometrium sends signals to the spiral arteries in that area of the endometrium, reducing their vascular resistance and making them more fragile. The blood flow to these arteries increases, and eventually they break down, leaving pools of blood called lacunae (lakes). Maternal blood flows from the uterine arteries, into these lacunae, and back out through the uterine veins. Lacunae form at around 20 weeks gestation.
When the process of forming lacunae is inadequate, the woman can develop pre-eclampsia. Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.
high risk fx for pre eclampsia
Pre-existing hypertension
Previous hypertension in pregnancy
Existing autoimmune conditions (e.g. systemic lupus erythematosus)
Diabetes
Chronic kidney disease
moderate risk fx for pre eclampsia
Older than 40
BMI > 35
More than 10 years since previous pregnancy
Multiple pregnancy
First pregnancy
Family history of pre-eclampsia
when offered prophylaxis for pre eclampsia
Women are offered aspirin from 12 weeks gestation until birth if they have one high-risk factor or more than one moderate-risk factors.
when suspect pre eclampsia
Headache
Visual disturbance or blurriness
Nausea and vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
diagnosis pre eclampsia
Systolic blood pressure above 140 mmHg
Diastolic blood pressure above 90 mmHg
PLUS any of:
Proteinuria (1+ or more on urine dipstick)
Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia)
Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies)
proteinuria classification
Urine protein:creatinine ratio (above 30mg/mmol is significant)
Urine albumin:creatinine ratio (above 8mg/mmol is significant)
NICE guidelines for PIGF
NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.
how monitor for pre eclampsia
Blood pressure
Symptoms
Urine dipstick for proteinuria
general mx for pre eclampsia (besides aspirin)
Treating to aim for a blood pressure below 135/85 mmHg
Admission for women with a blood pressure above 160/110 mmHg
Urine dipstick testing at least weekly
Monitoring of blood tests weekly (full blood count, liver enzymes and renal profile)
Monitoring fetal growth by serial growth scans
PlGF testing on one occasion
when admit woman with pre eclampsia
fullPIERS or PREP-S - scoring systems
medical mx for pre eclampsia
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
after delivery medical tx of pre eclampsia
Enalapril (first-line)
Nifedipine or amlodipine (first-line in black African or Caribbean patients)
Labetolol or atenolol (third-line)
eclampsia definition and medical mx
the seizures associated with pre-eclampsia. IV magnesium sulphate is used to manage
HELLP syndrome definition and fx
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
most significant immediate complication of gestational diabetes
a large for dates fetus and macrosomia….shoulder dystocia
complication of women post pregnancy with gestational diabetes
type 2 DM
risk fx for gestational diabetes
Previous gestational diabetes
Previous macrosomic baby (≥ 4.5kg)
BMI > 30
Ethnic origin (black Caribbean, Middle Eastern and South Asian)
Family history of diabetes (first-degree relative)
screening test of choice for gestational diabetes
OGTT
indications for gestational diabetes screening
risk fx present
fx present ->
Large for dates fetus
Polyhydramnios (increased amniotic fluid)
Glucose on urine dipstick
how perform OGTT
in the morning after a fast (they can drink plain water). The patient drinks a 75g glucose drink at the start of the test. The blood sugar level is measured before the sugar drink (fasting) and then at 2 hours.
OGTT normal results
Fasting: < 5.6 mmol/l
At 2 hours: < 7.8 mmol/l
(5,6,7,8)
mx of gestational diabetes
Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin
Fasting glucose above 7 mmol/l: start insulin ± metformin
Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin
if decline insulin or cannot tolerate metformin - glibenclamide can be offered (a sulfonylurea)
target levels for monitoring blood sugar in gestational diabetes
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
type 2 DM medications pre pregnancy
stop all except metformin and insulin
screening pre diabetes and pregnancy
retinopathy screening after booking and at 28 weeks gestation
delivery pre existing diabetes
planned delivery between 37 and 38 + 6 weeks for women with pre-existing diabetes. (Women with gestational diabetes can give birth up to 40 + 6).
sliding scale if type 1 DM
postnatal care gestational diabetes
stop meds after birth
follow up fasting glucose for at least 6 weeks
post natal care pre existing diabetes
lower insulin doses as risk of hypoglycaemia as sensitivity increases
babies of mothers with diabetes are at risk of
Neonatal hypoglycaemia
Polycythaemia (raised haemoglobin)
Jaundice (raised bilirubin)
Congenital heart disease
Cardiomyopathy
obstetric cholestasis definition
intrahepatic cholestasis of pregnancy. Chole- relates to the bile and bile ducts. Stasis refers to inactivity. Obstetric cholestasis is characterised by the reduced outflow of bile acids from the liver
cause of obstetric cholestasis
increased oestrogen and progesterone
genetic
risk fx of obstetric cholestaisis
south asian ethnicity
associations of obstetric cholestasis
stillbirth
presentation obstetric cholestasis
3rd trimester
itching of palms of hands and soles of feet
Fatigue
Dark urine
Pale, greasy stools
Jaundice
if rash present when suspect obstetric cholestasis, then consider
polymorphic eruption of pregnancy
pemphigoid gestationis
ddx for obstetric cholestasis
Gallstones
Acute fatty liver
Autoimmune hepatitis
Viral hepatitis
ix for obstetric cholestasis
LFT
bile acicds
increased ALP in pregnancy
NORMAL - placenta produces ALP
mx of obstetric cholestasis
ursodeoxycholic acid
sx of itching - emollients and antihistamines
water soluble vit K can be given if PT derranged
pathophysiology of acute fatty liver of pregnancy
mpaired processing of fatty acids in the placenta. This is the result of a genetic condition in the fetus that impairs fatty acid metabolism. The most common cause is long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency in the fetus, which is an autosomal recessive
LCHAD enzyme is important in fatty acid oxidation, breaking down fatty acids to be used as fuel. The fetus and placenta are unable to break down fatty acids. These fatty acids enter the maternal circulation, and accumulate in the liver. The mother’s defective copy of the gene may also contribute to the accumulation of fatty acids. The accumulation of fatty acids in the mother’s liver leads to inflammation and liver failure.
clinical fx of acute fatty liver of pregnancy
General malaise and fatigue
Nausea and vomiting
Jaundice
Abdominal pain
Anorexia (lack of appetite)
Ascites
ix for acute fatty liver of pregnancy
raised WCC
raised bilirubin
derranged clotting
low platelets
elevated liver enzymes and low platelets in pregnancy….
HELLP syndrome or acute fatty liver of pregnancy
mx of acute fatty liver of pregnancy
OBSTETRIC EMERGENCY - must deliver
tx of acute liver failure if occurs and consider transplant
rashes that occur during pregnancy
SEE DERM
polymorphic eruption of preg
atopic eruption of preg
melasma
pyogenic granuloma
pemiphigoid gestationis
atopic eruption of preg
eczema that flares up during preg - never had before or pre existing
in 1st or 2nd trimester
atopic eruption of preg types
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 limb
atopic eruption of preg mx
Topical emollients
Topical steroids
Phototherapy with ultraviolet light (UVB) may be used in severe cases
Oral steroids may be used in severe cases
melasma definition
y increased pigmentation to patches of the skin on the face. This is usually symmetrical and flat, affecting sun-exposed areas
associations of melasma
COCP and HRT
sun exposure
thyroid disease
family hx
melasma tx
none required
avoid sun
make up
skin lightening cream (not in preg)
chemical peels or laser tx
risks to baby pemphigoid gestationis
Fetal growth restriction
Preterm delivery
Blistering rash after delivery (as the maternal antibodies pass to the baby)
placenta praevia patho
where the placenta is attached in the lower portion of the uterus, lower than the presenting part of the fetus. Praevia directly translates from Latin as “going before”.
placenta praevia definition
when the placenta is over the internal cervical os
low lying placenta definition
when the placenta is within 20mm of the internal cervical os
3 causes of antepartum haemorrhages
placenta praevia, placental abruption and vasa praevia
causes of spotting/minor bleeding in preg
cervical ectropion, infection and vaginal abrasions from intercourse or procedure
risks of placenta praevia
Antepartum haemorrhage
Emergency caesarean section
Emergency hysterectomy
Maternal anaemia and transfusions
Preterm birth and low birth weight
Stillbirth
grades placenta praevia
Minor praevia, or grade I – the placenta is in the lower uterus but not reaching the internal cervical os
Marginal praevia, or grade II – the placenta is reaching, but not covering, the internal cervical os
Partial praevia, or grade III – the placenta is partially covering the internal cervical os
Complete praevia, or grade IV – the placenta is completely covering the internal cervical os
OUTDATED THO (BASIC JUST LOW LYING PLACENTA V PLACENTA PRAEVIA)
risk fx 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)
diagnosis placenta praevia
20 week anomaly scan as can be asx
mx of placenta praevia
repeat transvaginal ultrasound scan at:
32 weeks gestation
36 weeks gestation (if present on the 32-week scan, to guide decisions about delivery)
steroids given
planned delivery between 36 and 37 weeks with casarean
if premature labour - casarean
complication of placenta praevia
haemorrhage before, during or after delivery
how to reduce risk of mortality in haemorrhage from placenta praevia
Emergency caesarean section
Blood transfusions
Intrauterine balloon tamponade
Uterine artery occlusion
Emergency hysterectomy
vasa praevia patho
In vasa praevia, the fetal vessels are exposed, outside the protection of the umbilical cord or the placenta. The fetal vessels travel through the chorioamniotic membranes, and pass across the internal cervical os (the inner opening of the cervix). These exposed vessels are prone to bleeding, particularly when the membranes are ruptured during labour and at birth. This can lead to dramatic fetal blood loss and death.
types of vasa praevia
Type I vasa praevia – the fetal vessels are exposed as a velamentous umbilical cord
Type II vasa praevia – the fetal vessels are exposed as they travel to an accessory placental loberi
risk fx of vasa praevia
Low lying placenta
IVF pregnancy
Multiple pregnancy
diagnosis of vasa praevia
USS
can be detected by vaginal exam during labour - pulsating fetal vessels seen in membranes
during labour - fetal distress and dark red bleeding after rupture of membranes
presentation of vasa praevia
antepartum haemorrhage, with bleeding during the second or third trimester of pregnancy.
mx of vasa praevia
if asx - Corticosteroids, given from 32 weeks gestation to mature the fetal lungs
Elective caesarean section, planned for 34 – 36 weeks gestation
if haemorrhages - emergency caesarean
placental abruption def
when the placenta separates from the wall of the uterus during pregnancy. The site of attachment can bleed extensively after the placenta separates. Placental abruption is a significant cause of antepartum haemorrhage.
risk fx 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
clinical fx 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 scored
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
haemorrhage types
concealed abruption - cervical os remains closed so bleeding remains in uterine cavity
revealed abruption - observed blood loss through vagina
initial mx of placental abruption
OBSTETRIC EMERGENCY
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
definitive mx of placental abruption
USS to exclude placenta praevia
anti-D prophylaxis
emergency caesarean
active mx for haemorrhage
placenta accreta definition
when the placenta implants deeper, through and past the endometrium, making it difficult to separate the placenta after delivery of the baby.
placenta accreta patho
the placenta embeds past the endometrium, into the myometrium and beyond. This may happen due to a defect in the endometrium…so not separate during delivery…bleeding
types of placenta accreta
Superficial placenta accreta is where the placenta implants in the surface of the myometrium, but not beyond
Placenta increta is where the placenta attaches deeply into the myometrium
Placenta percreta is where the placenta invades past the myometrium and perimetrium, potentially reaching other organs such as the bladder
risk fx for placenta accreta
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
placenta accreta presentation
antepartum haemorrhage in 3rd timester
asx so diagnsoed on USS or at birth
placenta accreta mx
diagnosed byUSS
MRI for depth and width
specialist mx - Complex uterine surgery
Blood transfusions
Intensive care for the mother
Neonatal intensive care
definitive mx placenta accreta
caesarean then during which options are:
Hysterectomy with the placenta remaining in the uterus (recommended)
Uterus preserving surgery, with resection of part of the myometrium along with the placenta
Expectant management, leaving the placenta in place to be reabsorbed over time
definition breech
refers to when the presenting part of the fetus (the lowest part) is the legs and bottom. This is opposed to cephalic presentation, where the head is the presenting part
types of breech
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
mx of breech
if before <36 weeks no intervention as usually turn spontaneously, ECV can be used to at term to attempt to turn foetus
Where ECV fails, women are given a choice between vaginal delivery and elective caesarean section
When the first baby in a twin pregnancy is breech, caesarean section is required.
when ECV used
After 36 weeks for nulliparous women (women that have not previously given birth)
After 37 weeks in women that have given birth previously
how ECV procedure work
Women are given tocolysis to relax the uterus before the procedure. Tocolysis is with subcutaneous terbutaline. Terbutaline is a beta-agonist similar to salbutamol. It reduces the contractility of the myometrium, making it easier for the baby to turn.
+anti-D prophylaxis
kleihauer test
used to quantify how much fetal blood is mixed with the maternal blood, to determine the dose of anti-D that is required.
stillbirth definition
the birth of a dead fetus after 24 weeks gestation. Stillbirth is the result of intrauterine fetal death (IUFD)
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 risk of stillbirth
Fetal growth restriction
Smoking
Alcohol
Increased maternal age
Maternal obesity
Twins
Sleeping on the back (as opposed to either side)
prevention of stillbirth
SGA or FGR = monitored with serial growth scans
pre-eclampsia = given aspirin
modifiable risk fx = stop smoking, avoid alcohol, control DM, sleeping on side
3 key sx of stillbirth
Reduced fetal movements
Abdominal pain
Vaginal bleeding
ix of choice for stillbirth
USS - foetal heartbeat
mx of stillbirth
repeat scan
anti d prophylaxis
vaginal birth 1st line either via induction (oral mifepristone and vaginal/oral misoprostol) or expectant mx
dopamine agonist to suppress lactation after
testing to determine cause if consent given
testing after stillbirth
Genetic testing of the fetus and placenta
Postmortem examination of the fetus (including xrays)
Testing for maternal and fetal infection
Testing the mother for conditions associated with stillbirth, such as diabetes, thyroid disease and thrombophilia
reversible causes of adult cardiac arrest
4T’S
4H’S
4 T’s
Thrombosis (i.e. PE or MI)
Tension pneumothorax
Toxins
Tamponade (cardiac)
4 H’s
Hypoxia
Hypovolaemia
Hypothermia
Hyperkalaemia, hypoglycaemia, and other metabolic abnormalities
RCOG guidlines for additional causes of cardiac arrest
eclampsia
IC haemorrhage
3 major causes of cardiac arrest in pregnancy
Obstetric haemorrhage
Pulmonary embolism
Sepsis leading to metabolic acidosis and septic shock
causes of massive obstetric haemorrhage
Ectopic pregnancy (early pregnancy)
Placental abruption (including concealed haemorrhage)
Placenta praevia
Placenta accreta
Uterine rupture
pathophysio of aortocaval compression
After 20 weeks gestation, the uterus is a significant size. When a pregnant woman lies on her back (supine), the mass of the uterus can compress the inferior vena cava and aorta. The compression on the vena cava is most significant, as it reduces the blood returning to the heart (venous return). This reduces the cardiac output, leading to hypotension. In some instances, this can be enough to lead to the loss of cardiac output and cardiac arrest.
The vena cava is slightly to the right side of the body. The solution to aortocaval compression is to place the woman in the left lateral position, lying on her left side, with the pregnant uterus positioned away from the inferior vena cava. This should relieve the compression on the inferior vena cava and improve venous return and cardiac output.
difficulties with resuscitiation 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
principles of adult life support for pregnancy differences
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
delivery cardiac arrest
immediate caesarean if no response after 4mins of correct CPR or CPR is continued for more than 4mins in woman more than 20 weeks gestation
aim of delivery with cardiac arrest
within 5 mins of CPR commencing..caesarean on ward or wherever
to improve the survival of the mother. Delivery improves the venous return to the heart, improves cardiac output and reduces oxygen consumption. It also helps with ventilation and chest compressions
when quadruple test
15-20 weeks
when combined test
combined test is now standard
these tests should be done between 11 - 13+6 weeks
