Antenatal Care 4 Flashcards
What is USS used for in the first trimester?
- exclusion of ectopic
- assess pregnancy viability
- detect retained products of conception after miscarriage
- estimate gestational age
- detect multiple pregnancy and chorionicity
- screen for chromosomal abnormalities
- diagnose structural abnormalities
What is USS used for in the second trimester?
- diagnose structural abnormalities
- screen chromosomal abnormalities
- aid amniocentesis or transfusion
- Doppler for fetal assessment or of uterine arteries
What is USS used for in the third trimester?
- assess fetal growth
- diagnose placenta praevia
- determine presentation in difficult cases
- Doppler for fetal assessment
What is the definition of maternal death?
death of woman during pregnancy or within 42 days of its cessation, from
any cause related to or aggravated by pregnancy or its management, but nor from accidental or incidental causes
What are the causes of maternal morbidity?
- Infection causing sepsis
- Venous thromboembolic disease
- Haemorrhage
- Hypertensive disorders
- Cardiac disease
- Ectopic pregnancy + abortion
- Neurological disease
- Psychiatric disease + suicide
What is the definition of a stillbirth?
fetus delivered at 24 completed weeks gestation showing no signs of life
What are the causes of perinatal mortality?
Unexplained antepartum stillbirth IUGR Prematurity Congenital anomalies Intrapartum stillbirth – mostly hypoxia, but also infection + inflammation, trauma + fetal exsanguination Antepartum haemorrhage Pre-eclampsia – preterm delivery + IUGR, and term
What are the two types of pregnancy induced HTN?
pre-eclampsia
gestational HTN
What is pre-eclampsia?
hypertension and proteinuria appear in second half of pregnancy, often with oedema
What is gestational hypertension?
new hypertension presenting after 20 weeks without proteinuria
What is pre-existing or chronic hypertension?
Present when BP >140/90mmHg before pregnancy or before 20 weeks’ gestation, or
woman already on antihypertensive medication
How common is HTN in pregnancy?
commonest complication
What are the risk factors for developing pre eclampsia?
Nulliparity Previous history FHx Older maternal age Chronic HTN Diabetes Twin preganancies Autoimmune disease Renal disease Obesity
What is the pathophysiology of pre-eclampsia?
Stage 1 – before 20 weeks, no symptoms, trophoblastic invasion of spiral arterioles
incomplete (poss caused by altered immune responses) resulting in decreased
uteroplacental blood flow
- Stage 2 – ischaemic placenta induces exaggerated maternal inflammatory response,
induces widespread endothelial cell damage, causing vasoconstriction, increased
vascular permeability + clotting dysfunction
How does pre-eclampsia present?
HTN Proteinuria IUGR - reduced placental flow Eclampsia (occurrence of epileptiform seizures) - reduced cerebral perfusion
What investigations should be carried out if pre eclampsia is suspected?
urine dipstick - exclude infection and protein
24hr urine collection
monitor maternal complications - do bloods
monitor fetal complications - USS to monitor weight
What are the maternal complications of pre-eclampsia?
Eclampsia Cerebrovascular accident (CVA) Haemolysis, elevated liver enzymes + low platelet count (HELLP) Disseminated intravascular coagulation Liver failure Renal failure Pulmonary oedema
What are the fetal complications of pre-eclampsia?
IUGR
Preterm birth
Placental abruption
Hypoxia
How is pre-eclampsia managed?
investigate if BP >140/90
Admit if: confirmed pre-eclampsia (>0.3g/24hr) + BP 160/110mmHg
Antihypertensives if: BP >150/110mmHg
Steroids if: moderate/severe <34 weeks
Delivery: mild by 37 weeks, moderate-severe by 34-36 weeks (if maternal
complications then deliver regardless of gestation)
Magnesium sulphate if: eclampsia (consider prophylactic use in severe disease)
Postnatally watch BP, urine output, FBC UEs LFTs + follow up
How is pre-existing hypertension managed in pregnancy?
medication changed pre-pregnancy (ACEI teratogenic, affecting urine production), labetalol normally used
may not be needed in second trimester due to physiological fall in BP
risk of pre-eclampsia - use uterine artery Doppler and have additional antenatal visits
What is gestational diabetes?
glucose levels rise temporarily to diabetic level
3.5-16% prevalence
What are the risk factors for gestational diabetes?
Family or previous history Polycystic ovary syndrome (PCOS) Previous large baby/unexplained stillbirth BMI >30 Persistent glycosuria Polyhydramnios
What investigations should be carried out for gestational diabetes?
if high risk - screen at 28 weeks using GTT
if prev gestational diabetes - screen at 18 weeks
What are the fetal complications of gestational diabetes?
congenital abnormalities, preterm labour, birthweight increased (increased urine
output + polyhydramnios), shoulder dystocia + birth trauma, fetal death
What are the maternal complications of gestational diabetes?
increased insulin requirements, hypoglycaemia, worsening retinopathy, pre-
eclampsia, infections, operative delivery, ketoacidosis (rare)
How is gestational diabetes managed?
Abnormal GTT – dietary + exercise advice, monitor glucose levels at home
If after 2 weeks, inadequate control, then oral hypoglycaemic drugs (e.g. metformin)
If after 2 weeks, inadequate control, then insulin + management as for pre-existing
diabetes
Discontinue insulin postnatally but glucose tolerance test at 3 months
How is pre-existing diabetes managed in pregnancy?
Preconceptual glucose stabilization, patient education/involvement
Assessment of maternal diabetic complications
Low-dose aspirin from 12 weeks to prevent pre-eclampsia
Patient education + team involvement
Glucose monitoring + insulin adjustment
Anomaly + cardiac ultrasound + fetal surveillance
Induction/lower segment C-section by 39 weeks
