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Obstetrics > Antenatal Care > Flashcards

Antenatal Care Flashcards

1
Q

You are seeing a 28 year old woman in the GP clinic. She is planning to get pregnant and would like to know how she can optimise her health for her baby. She has no significant PMH and is not taking any medicines. BMI normal, BP normal. Please counsel her.

A
  • Diet advice: eat a healthy diet with fruits/veg, whole foods and high fibre. Do not ‘eat for two’.
  • Exercise: good to maintain fitness, with aerobic exercise and strength. Pelvic floor exercises can be useful to decrease the risk of incontinence after delivery.
  • Substances: stop smoking, no/little alcohol, no drugs
  • Pregnancy multivitamins: from Boots/etc. Make sure folic acid at least.
  • Refer to info: NHS website, Start4Life
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2
Q

A 29 year old woman attends antenatal clinic for her booking visit at 8 weeks. After a history and examination, what investigations would you like to do?

A
  • Urine dip and MC&S (looking for asymptomatic bacteriuria, proteinuria, glycosuria)
  • Bloods including FBC (anaemia, low platelets), serology for HIV, HBV, syphilis, G+S (ABO and RhD)
  • USS between 10+0 and 13+6 weeks for dating
  • Combined screening for Down’s syndrome
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3
Q

What are the two different screening methods for Down’s syndrome? What results are suggestive of Down’s syndrome?

A

1) Combined test: nuchal translucency, PAPP-A, BhCG
2) Quadruple test: BhCG, AFP, inhibin A, unconjugated oestriol
A high bhCG and inhibin A, as well as low PAPP-A, AFP, and oestriol indicate possible Down’s syndrome.

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4
Q

What are the risks to the mother and fetus of a high maternal BMI?

A

Mum: GDM, hypertension including pre-eclampsia, VTE, increased risk of operative delivery, increased complications after delivery.
Fetus: macrosomia and FGR, congenital malformations, stillbirth + miscarriage, childhood obesity.

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5
Q

You are seeing a woman after her booking visits to give her the results of her screening tests. She is HBV +. Please counsel her.

A
  • Tell her diagnosis and check understanding
  • Explain: viral infection affecting liver. Transmitted sexually and through blood products. Can be lifelong, or in some adults the body can clear the virus.
  • Referral to GUM and hepatology for further tests and information
  • For the pregnancy, this means there is an increased risk to the baby of getting the virus from the mum, though this doesn’t always happen
  • Baby will need vaccination at birth and 2 more at 1 month and 6 months. Will also give baby antibodies, which will help the baby’s immune system to fight the virus.
  • Check for understanding and questions. Give leaflets
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6
Q

What are the risk factors for pre-eclampsia? When and how would you prevent pre-eclampsia?

A

High risk: previous hypertensive disease in pregnancy, CKD, autoimmune disease like SLE, DM, existing hypertension
Moderate risk: primiparity, multiple gestation, age >40, BMI >35, FHx, 10 years between pregnancies
Prevention with 75-150mg aspirin in women with 1 high risk factor or 2+ moderate.

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7
Q

What are the risk factors for GDM? Who should be screened and how?

A

RFs: previous GDM or macrosomia, FHx of DM, ethnic origin, obesity.
In women with previous GDM, screen with 2 hour OGTT at 16-18 weeks and again at 24-28 weeks. In other women with RFs, only screen at 24-28 weeks.

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8
Q

What results in an OGTT diagnose GDM?

A

Fasting glucose >/=5.6mmol/L or 2 hour postprandial of >/= 7.8

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9
Q

What is the difference between exomphalos and gastroschisis? When are they abnormal?

A

Exomphalos: covered by membranes, umbilical cord inserts into apex of sac, associated polyhydramnios, high incidence of congenital abnormalities
Gastroschisis: free floating abdo contents (rough outline on USS), umbilical cord inserts laterally, associated oligohydramnios.
Herniation into the umbilicus eg. in exomphalos is normal from 5/6 weeks until 12 weeks. Diagnosis cannot be made before then.

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10
Q

What are the 2 main categories of prenatal testing? What do they include?

A

Non-invasive: USS, serology, cffDNA

Invasive: chorionic villus sampling, amniocentesis, cordocentesis

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11
Q

When can you do CVS and amniocentesis? What do they test? What are the complications?

A

CVS from 10 weeks, samples fetal trophoblast cells in placental villi. Amnio from 15 weeks, samples amniotic fluid to isolate fetal cells.
Risk of miscarriage- 2% in CVS, 1% in amnio. Pain, infection eg. chorioamnionitis, RhD alloimmunisation

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12
Q

What are the ways for monitoring fetal growth? Which is routinely used?

A

Symphisis-fundal height measurement and USS. SFH is measured at each antenatal visit, and USS used if there are any suspicions of abnormal growth eg. SFH large/small for dates, or to monitor high-risk pregnancies eg. GDM

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13
Q

What are the definitions of SGA and macrosomia?

A

SGA: below the 10th centile for age
Macrosomia: above the 90th centile

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14
Q

What are the complications of FGR?

A

Intrauterine: hypoxia, HIE, organ damage
Neonatal: NEC, hypothermia, hypoglycaemia, infection
Adulthood: chronic hypertension, DM, CVD

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15
Q

Describe the fetal circulation.

A

Oxygenated blood from the placenta is carried by the umbilical veins to the liver, then passes by the ductus venosus into the IVC and right atrium. From there, it goes through the foramen ovale into the left atrium, then LV, then out the aorta and to the head and neck.
Deoxygenated blood from the head and neck enters the RA, then to RV and into pulmonary artery. It is then shunted into the aorta by the ductus arteriosus, causing the blood travelling in the aorta to be less oxygenated. The umbilical arteries stem from the aorta and bring blood back to the placenta.

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16
Q

What is the purpose of amniotic fluid? How much is normal?

A
  1. Protects the fetus mechanically
  2. Allows movements
  3. Prevents adhesions
  4. Helps lung development
    30 ml by 10 weeks, 300ml by 20 weeks, 1000ml by 38 weeks.
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17
Q

List 5-10 uses of USS in pregnancy.

A 
Confirmation of viability
Dating
Growth monitoring
Diagnosing multiple pregnancy 
Detecting fetal anomalies
Assessing amniotic fluid volume
Fetal wellbeing
Estimating cervical length
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18
Q

What are the early signs of pregnancy on USS?

A

Gestational sac: 4-5weeks
Yolk sac: 5 weeks
Embryo: 5-6 weeks
Fetal heartbeat: 6 weeks

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19
Q

How can fetal size/growth be measured on USS?

A

Crown-rump length up to 14 weeks
Head circumference 14-20 weeks
Also biparietal diameter, femur length, abdo circumference used for monitoring

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20
Q

You are reviewing the combined screening of a mother at 12 weeks gestation. The fetus has a nuchal translucency of 5mm and the mother has low PAPP-A. Should you refer to a fetal medicine unit? Justify.

A

No. Referral should be made if the NT >6mm or there are 2+ soft markers.

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21
Q

How is amniotic fluid assessed? What is normal?

A

Split the uterus into 4 quadrants. Then determine the maximum vertical pool and amniotic fluid index (add deepest pool in each).
Maximum vertical pool should be 2-8cm.
AFI should be 5-25cm in the 3rd trimester.

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22
Q

What can cause oligohydramnios? Polyhydramnios?

A

Oligo: Fetal urinary tract abnormalities eg. renal agenesis. FGR/placental insufficiency, NSAIDs, post-dates
Poly: congenital abnormalities affecting swallowing eg. duodenal atresia, cleft palate. Fetal anaemia, DM, multiple pregnancy

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23
Q

A woman is referred to the obstetric unit for a large SFH at 30 weeks gestation. On USS, the baby appears normal but there is a maximum vertical pool of 9cm. What are the next steps?

A

OGTT, maternal antibodies, Doppler USS of fetal MCA, consider offering amniocentesis and karytype (especially in cases of mod/severe poly eg. 12cm+)

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24
Q

What gestation is the fetal anomy scan done at?

A

18+0 to 20+6

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25
Q

What gestation is the combined screening test done at?

A

Combined test is 10+0 to 13+6, USS at 11+0 to 13+6

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26
Q

Which examinations/investigations should be done at every antenatal appointment?

A
  • BP
  • SFH
  • Urine dip
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27
Q

Name some factors that would affect fetal growth.

A
  • Maternal factors: age, parity, weight + height, ethnicity, medical conditions, obstetric complications, substance use
  • Placental factors: pre-eclampsia, abruption, insufficiency
  • Fetal factors: multiple pregnancy, congenital infection
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28
Q

T/F. Any women with low-lying placenta on the anomaly scan should be monitored for placenta praevia

A
  • False

- Only if the placenta is covering the os at the anomaly scan should have a repeat scan at 32 weeks

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29
Q

How is chorionicity established?

A
  • Intertwin septum thickness (thick –> dichorionic)

- Lambda sign, twin peaks at 9-10 weeks (dichorionic)

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30
Q

Why are musculoskeletal problems common in pregnancy?

A

Increased relaxin levels lead to softening of the ligaments and tendons, increased weight in the abdo causes strain on the back, etc –> backache, headache, neck pain, pubic symphysis pain

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31
Q

Why is constipation common in pregnancy? What treatment should be used?

A
  • Progesterone causes decreased peristalsis and gastric emptying
  • Conservative with high-fibre diet, hydration
  • Lactulose if needed
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32
Q

What are the complications of hyperemesis gravidarum?

A
  • Electrolyte disturbance
  • Severe dehydration
  • Vitamin deficiency
  • Preterm labour
  • LBW baby
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33
Q

How should hyperemesis gravidarum be managed?

A

-Assess severity with Pregnancy-Unique Quantification of Emesis (PUQE)
Mild: oral antiemetics (promethazine, cyclizine)
Moderate (can’t keep down antiemetics, complications): admit, IV fluids, Pabrinex, antiemetics IV or PR, LMWH

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34
Q

How should GORD in pregnancy be managed?

A
  • Conservative: small meals more frequently, elevation at night
  • Medical: antacids, PPIs, antihistamines
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35
Q

How are haemorrhoids in pregnancy managed?

A

Conservative: high fibre diet, hydration (reduce straining)
Medical: creams

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36
Q

What is obstetric cholestasis? What is the management?

A
  • Increased bile salts, causing itching and raised LFTs in the later half of pregnancy
  • Ursodeoxycholic acid can reduce itching, but will not affect fetal outcome
  • Delivery at 37 weeks offered to reduce risk to fetus (perinatal mortality)
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37
Q

How are varicose veins managed in pregnancy?

A
  • Support stockings

- Avoid long periods of standing

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38
Q

When is oedema more worrying in pregnancy?

A
  • Oedema in the feet and ankles is very common and normal in pregnancy
  • When the oedema is elsewhere eg. hands, face, that is worrying and suggests possible pre-eclampsia
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39
Q

What are the complications of fibroids in pregnancy?

A
  • Obstruction of the cervix during labour
  • Red degeneration (fibroid enlarges and becomes ischaemic –> acute pain, tenderness, vomiting), can lead to preterm labour/miscarriage
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40
Q

A retroverted uterus can cause which problem in early pregnancy?

A

Urinary retention if it does not flip –> compresses the urethra

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41
Q

How does UTI present in pregnancy?

A
  • Can be with classical symptoms
  • Or often with back pain/loin pain with overall feeling unwell
  • Tachycardia, pyrexia, dehydration
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42
Q

What is the management of UTI in pregnancy?

A
  • Urine dip and MC&S important
  • Encourage fluid intake
  • Oral amoxicillin or cephalosporins are first line
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43
Q

What is the management of pyelonephritis in pregnancy?

A
  • A-E
  • Take bloods including FBC, CRP, U+Es
  • IV fluids
  • Analgesia
  • IV antibiotics (cephalosporins or gentamicin)
  • CTG to monitor baby
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44
Q

Name some risk factors for VTE in pregnancy

A
  • Pre-existing: older age, obesity, smoking, thrombophilia, FHx of VTE
  • Pregnancy-related: multiples, pre-eclampsia, C section, hyperemesis, sepsis
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45
Q

What is antiphospholipid syndrome? How is it diagnosed?

A
  • Recurrent miscarriage/pregnancy loss and/or thrombosis with persistence of antibodies
  • Lupus anticoagulant +/- anticardiolipin
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46
Q

Describe the investigation of VTE in pregnancy

A

-Symptoms of DVT (leg pain, unilateral swelling) -> USS, consider venography if indicated
Symptoms of PE (inspiratory chest pain, SOB) ->
-ECG and CXR in all. ABG if unwell
-if DVT symptoms, do USS and treat PE
-CTPA or V/Q scan (CTPA if CXR abnormal)

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47
Q

How is VTE treated in pregnancy?

A
  • LMWH for the remainder of pregnancy, can switch to warfarin after or stay on LMWH for 6 weeks PN
  • **If very unstable/massive PE with CVS compromise –> IV unfractionated heparin, monitor APTT
  • Compression stockings
  • Can consider IVC filter in large DVT
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48
Q

What are the considerations in the use of LMWH in pregnancy in terms of delivery?

A
  • If planned delivery -> stop 24 hours prior
  • When labour starts -> stop injecting
  • Wait 4 hours after regional anaesthetic before restarting
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49
Q

Describe the guidelines for VTE prophylaxis during pregnancy.

A

1) If previous history of VTE not related to major surgery -> HIGH RISK: antenatal prophylaxis
2) Admission, predisposing medical condition, OHSS, surgery while pregnant -> MED RISK: consider prophylaxis

3) Obesity, older age, smoker, multiparity, multiple pregnancy, immobility, PET, FHx, IVF –>
- 4+ RFs -> prophylaxis from 1st trimester
- 3 RFs -> prophylaxis from 28 weeks
- <3 RFs -> mobilisation, hydration

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50
Q

Describe the guidelines for VTE prophylaxis after pregnancy (postpartum)

A

1) If needed antenatal prophylaxis or thrombophilia Hx –> continue 6 weeks
2) EMCS section, medical problems –> 10 days prophylaxis

3) ELCS, all the other RFs ->
- 2+ RFs: 10 days prophylaxis
- <2 RFs: early mobilisation, hydration

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51
Q

T/F. Alcohol use in pregnancy causes fetal alcohol syndrome

A

False.

  • Small amounts of alcohol are probably OK
  • > 1 pint can cause growth restriction
  • Binging can sometimes cause fetal alcohol syndrome, though not always
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52
Q

What are the complications of smoking in pregnancy?

A
  • Fetal growth restriction
  • Placental abruption
  • Increased perinatal mortality
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53
Q

You are the F2 in GP. A 32 year old woman comes to see you because she has had a positive urine pregnancy test. On questioning, she reports smoking 1 pack of cigarettes per day. Please counsel her.

A
  • Want to know her thoughts/intentions towards stopping, if she has tried before and why it wasn’t successful
  • Increased risk to both mum and baby of smoking
  • But if stop smoking before 15 weeks, risks are the same as if never smoked
  • We are here to help with smoking cessation
  • Give information
  • Refer to NHS Stop Smoking Services who can help with advice, regular support and counselling if you would like, and also prescribe medicines (nicotine patches, gums, etc)
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54
Q

Define oligohydramnios and polyhydramnious.

A
  • Oligo: AFI <5th centile for GA or AFI <5cm

- Poly: AFI >95th centile for GA or AFI >25cm

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55
Q

Describe the types of malpresentation.

A
  • Breech: frank/extended (legs straight up), complete/flexed (legs tucked), footling
  • Transverse
  • Oblique
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56
Q

What are the risk factors for breech presentation?

A
  • Polyhydramnios
  • Uterine abnormality, fibroids
  • Multiple pregnancy
  • Preterm delivery, SGA
  • Placenta praevia
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57
Q

A woman is seen at her routine antenatal clinic appointment with the midwife at 36 weeks. On abdominal palpation, the baby is in the breech position. What is the management? How would you counsel her?

A
  • Confirm breech presentation with USS
  • 3 management options
    1) External cephalic version (ECV)
    2) Vaginal breech delivery
    3) Elective C section
  • Explain the diagnosis of breech presentation, that this means we need to have a discussion about delivery because there are more risks involved
  • Explain available options as appropriate, what they involve and the risks
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58
Q

Describe external cephalic version, pros + cons, complications, contraindications

A
  • Manual re-orientation of the fetus from breech to cephalic presentation. Done at 37 weeks. Give tocolytic.
  • Quick, safe, 50% effective, can be uncomfortable to the mum
  • Contraindications: placenta praevia, oligo/polyhydramnios, multiple pregnancy, previous C section
  • Complications: abruption, PROM, cord accident, haemorrhage, fetal bradycardia
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59
Q

What is the best management of a breech presentation at term? What are the risks?

A

Elective C section. This has more risks to mum than a vaginal breech delivery, but there is a high risk (40%) of needing an emergency section which is much more risky than elective.
-Risks of ELCS: pain, bleeding, infection. Future uterine rupture, future placenta accreta/percreta in the scar, future difficulties in planned CS

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60
Q

Which manouvres are used to deliver a vaginal breech?

A
  • Pinards: to deliver legs if extended/frank breech
  • Lovesets: to deliver the arms
  • Mauriceau-Smellie-Veit: to deliver head
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61
Q

What are the risks of transverse/oblique presentation?

A
  • Cord prolapse during SROM

- Failure to progress in labour –> death

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62
Q

How is transverse/oblique presentation managed?

A
  • Version to make cephalic
  • If version fails, admit to antenatal ward for monitoring due to risk of cord prolapse
  • If still abnormal lie in early labour/SROM -> C section
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63
Q

Define post-term pregnancy. How common is it?

A

Pregnancy at or beyond 42 weeks. 10% of pregnancies

64
Q

What are the risks of post-term pregnancy? What is the management?

A
  • Risks of perinatal mortality, prolonged labour, C section because placenta starts to fail, amniotic fluid decreases
  • Want to monitor with USS (amniotic fluid, fetal growth etc) and CTG
  • Induction of labour
65
Q

What are the indications for immediate induction of labour in post-term pregnancy?

A
  • Abnormal amniotic fluid
  • Baby growth restricted or reduced movements
  • Not perfect CTG
66
Q

Which are the clinically important Rhesus antibodies?

A

C, D, and E. Encoded on Chromosome 1

Only D and C causes haemolytic disease of the fetus and newborn (HDFN)

67
Q

How does haemolytic disease of the fetus + newborn develop?

A
  • Rh -ve mum conceives a Rh +ve fetus (Rh +ve dad)
  • Sensitisation occurs when fetal blood and maternal blood meet, mum forms antibodies to RhD
  • In future pregnancies, antibodies can cross the placenta and cause haemolysis in the fetus, leading to severe anaemia + hydrops
68
Q

Name some sensitising events (RhD). What is the management in these situations?

A

-Miscarriage managed surgically
-Termination of pregnancy (surgical Mx)
-Ectopic pregnancy, molar pregnancy
-ECV
-Delivery
-APH
-Invasive prenatal testing
Give all Rh -ve women IM anti-D Ig within 72 hours of the event to prevent isoimmunisation

69
Q

Describe antenatal RhD prophylaxis

A

All Rh -ve women should receive routine anti-D at 28 weeks +/- again at 34 weeks

70
Q

What does the Kleihauer test show?

A

Kleihauer test is used to see the amount of fetal blood in the maternal blood, to calculate the amount of anti-D needed following a sensitising event

71
Q

How much anti-D should be given after sensitising events?

A
  • In the 1st trimester: 250 IU
  • 12-20 weeks: 250 IU and Kleihauer test
  • > 20 weeks: 500 IU and Kleihauer test
72
Q

Describe the management of a sensitised RhD -ve woman during pregnancy.

A
  • Monitor antibody levels through pregnancy
  • If antibodies rising, monitor baby with USS + Doppler
  • Consider delivery or transfusion if indicated
73
Q

Is ABO incompatibility serious? Why/why not?

A

Usually not. This is because A and B antibodies are IgM and therefore do not cross the placenta. If there are any complications, this might be a mild haemolysis.

74
Q

How comon are multiple pregnancies?

A

3% of all live births

75
Q

Describe the classification of multiple pregnancy and how they arise.

A

Multiple pregnancies can be either dizygotic (2 eggs) or monozygotic (1 egg divides).
Dizygotic pregnancies will always be dichorionic, diamniotic.
Monozygotic pregnancies can be DCDA, MCDA, or MCMA, depending on when the zygote divides.
-If the zygote divides early, this will be a DCDA pregnancy
-Division on day 4-8: MCDA
-Division on day 8-12: MCMA
-Division later than day 13: conjoined

76
Q

How does antenatal care differ in multiple pregnancy?

A
  • Under obstetric care
  • Check maternal FBC at 20 (+ normal 28 weeks) for anaemia
  • More frequent monitoring of fetal growth and blood flow (depending on the type eg. 4 weekly from 20 weeks for DCDA, 2 weekly from 16 weeks for MCDA)
  • MCMA twins should be cared for at a tertiary centre
77
Q

What are the complications of multiple pregnancy?

A

Maternal: increased symptoms (heartburn, nausea, etc), vitamin deficiency + anaemia, prolonged labour, C section, hypertension, VTE

Fetal: PRETERM BIRTH, growth restriction, anaemia, perinatal mortality, cord entaglement + congenital abnormalities (MCMA)

78
Q

How common is preterm delivery in multiple pregnancies?

A
  • 60% of DCDA born before 37 weeks

- Increased in MC twins and triplets

79
Q

What are some complications of multiple pregnancy specific to monochorionic twins? Describe them.

A
  • Twin-twin transfusion syndrome (TTTS): a condition caused by the shunting of blood preferentially to one fetus. Caused by unbalanced vascular anastomoses.
  • Twin anaemia-polycythaemia sequence (TAPS): a rare chronic form of TTTS in which there is haemodynamic compensation to slow blood exchange-> unequal Hb with equal amniotic fluid
80
Q

When and how is TTTS diagnosed?

A

TTTS usually presents around 16-26 weeks. This is one reason why monochorionic twin pregnancies are routinely scanned every 2 weeks from 16 weeks-delivery.
The key factor in diagnosis is discordance in amniotic fluid in the 2 sacs (1 oligo <2, 1 poly >8). There can also be discordant bladder appearance and haemodynamic or cardiovascular compromise.

81
Q

How is TAPS diagnosed?

A

TAPS can be diagnosed when there is significant discordance in fetal Hb as seen by low MCA PI in one twin and high MCA PI in the other twin. There also cannot be discordance in the amniotic fluid volume.

82
Q

What is Quintero staging for? What are the different stages?

A

Quintero staging is used to grade the severity of TTTS
Stage 1: Oligo/polyhydramnios, normal bladder and USS
2: oligo/poly, abnormal bladder, normal Doppler
3: oligo/poly, abnormal bladder + Doppler
4: Hydrops
5: Death

83
Q

What is hydrops fetalis?

A

Accumulation of fluid in 2+ body areas (eg. skin oedema, liver oedema, ascites, pleural effusion)

84
Q

On routine USS of MCDA twins at 22 weeks, it is reported that the amniotic fluid in the sac of twin 1 is 9cm and 1.8cm in that of twin 2. The bladders of both twins appear normal, and there are no abnormalities on the Doppler scan. What is the diagnosis?

A

This is Quintero stage 1 TTTS (abnormal amniotic fluid, normal bladder, normal Doppler)

85
Q

Describe the management of TTTS

A
  • Refer to tertiary fetal medicine unit
  • Fetoscopic laser ablation is usually first line especially if presenting early
  • Amnioreduction
  • Delivery if there is concern about fetal wellbeing eg. reversed end diastolic volume in the umbilical arteries, reversed a waves in the DV
86
Q

What is the estimated fetal weight discordance and why is that monitored in multiple pregnancies?

A
  • The degree of difference between the weight of the babies
  • (Heavier twin - lighter twin) / heavier twin
  • If this is >20%, they need weekly monitoring, if >25% they should be seen in a tertiary centre
87
Q

What are the considerations for delivery in multiple pregnancies?

A
  • Site of delivery (labour ward, with a good NICU on site)
  • Likelihood of preterm delivery and need for NICU
  • Mode of delivery: vaginal delivery possible if not contradindicated, C section may be needed if any problems arise during pregnancy/labour
  • Need close monitoring of the babies during labour
  • 2 of everything! Including doctors
  • Often use and epidural, because twin 2 may need internal podalic version
88
Q

What are the hypertensive disorders of pregnancy?

A
  • Pregnancy-induced hypertension
  • Pre-eclampsia
  • Chronic hypertension (in pregnancy)
89
Q

Define pregnancy-induced hypertension

A

Hypertension arising for the first time during the 2nd half of pregnancy.
Usually fine but can progress to pre-eclampsia in 1/3 of women.

90
Q

Define the severity of hypertension

A

Mild: 140-149/90-99
Moderate: 150-159/100-109
Severe: >160/110

91
Q

Define pre-eclampsia

A

Hypertension (BP >140/90) arising after the 20th week of pregnancy, with proteinuria OR systemic complications eg. raised liver enzymes, low Plts, neuro, renal impairment

92
Q

What are the risk factors for pre-eclampsia?

A
  • High risk: Previous hypertension, previous pre-eclampsia, FHx of pre-eclampsia, CKD, DM, SLE and other autoimmune diseases
  • Mod risk: first pregnancy, nulliparity, obesity, older age, multiple pregnancy, pregnancy interval
93
Q

Describe the pathophysiology of pre-eclampsia including effects in the kidneys, liver, blood, and brain

A

Abnormal placentation: abnormal trophoblast invasion leading to malformation of the spiral arteries and systemic inflammation

  • In response to the abnormal placentation there is maternal vasoconstriction, leading to hypertension and oedema.
  • Renal: inflammation leads to glomeruloendotheliosis, causing protein loss (proteinuria + oedema)
  • Haem: platelet activation and consumption (low Plt)
  • Liver: small vessel damage -> inflammation (elevated enzymes, haemolysis, liver capsule inflammation)
  • Brain: cerebral oedema (headache, visual changes)
94
Q

Define HELLP syndrome

A
  • A severe form of pre-eclampsia, characterised by haemolysis, elevated liver enzymes, and low platelets
  • May occur in the absence of a raised BP
95
Q

Define eclampsia

A

New onset seizures on the background of pre-eclampsia

96
Q

Describe the signs and symptoms of pre-eclampsia

A
  • Headache, visual changes, swelling, RUQ pain, N+V, difficulty breathing
  • Signs: oedema, abdo tenderness, clonus + hyper-reflexia
97
Q

A 32 year old G1 at 30 weeks gestation attends MAS with a new onset headache for the past 2 days, generalised oedema, and some RUQ pain. What would you want to know from her history?

A
  • Characterise symptoms, including onset. Ask about visual changes, N+V, seizures
  • Ask about baby: fluids, contractions, bleeding, movements
  • Obs Hx: how this pregnancy has been, any problems diagnosed, BP + urine dip abnormalities
  • Not relevant here but in multip ask about prev. PET
  • PMH of HTN, CKD, DM, autoimmune disease
  • Meds + allergies
  • FHx of HTN, PET
98
Q

A 32 year old G1 at 30 weeks gestation attends MAS with a new onset headache for the past 2 days, generalised oedema, and some RUQ pain. What would you want to do next after taking a history?

A
  • Examination: general, look for oedema, clonus+hyperreflexia, pregnant abdo exam
  • Observations (BP, HR, RR, temp, oxygen sats)
  • Bedside tests: urine dip, CTG
  • Blood tests: FBC, U+Es, LFTs, clotting
  • Additional: urine PCR or ACR/24hr urine collection
99
Q

A 32 year old G1 at 30 weeks gestation attends MAS with a new onset headache for the past 2 days, generalised oedema, and some RUQ pain. On examination, abdo SNT with BP 155/105, repeated again 151/102. Urine dip is 2+ proteins. What would you like to do now?

A
  • She meets criteria for a diagnosis of PET (high BP and proteinuria)
  • As BP is >140/90, she should start treatment with an antihypertensive, specifically labetalol (nifedipine if contraindicated)
  • Want to keep on MAS for observation (repeat BP in 30 minutes) and review.
  • Do PET bloods and CTG
  • Can send home if BP is falling/stable and baby is well, return in 24 hours for review. Safety net.
100
Q

Define proteinuria.

A

Urine collection >300mg/24 hour (0.3g/24hours)

or PCR >30mg/mol

101
Q

How should antenatal care change if a woman is diagnosed with pre-eclampsia?

A

If mild-mod:

  • BP at home at minimum of every 48 hours
  • 2x weekly blood tests and fetal HB
  • USS every 2 weeks to monitor fetal growth

If severe:

  • Admission until BP falls
  • BP every few hours
  • Blood every 2 days
  • USS every 2 weeks
102
Q

What medication should be given to women who have an eclamptic fit? What are the other indications for its use?

A

Mg Sulphate

-Use if severely hypertensive and risk of eclampsia

103
Q

Which test can be used in 20-34 weeks to rule out pre-eclampsia?

A

Placental growth factor

104
Q

Describe the postpartum management of pre-eclampsia

A
  • Monitor BP on first day regularly, then every 2 days until normal
  • If on medication antenatally, reduce when BP falls to normal
  • GP review at 2 weeks if on meds, 6-8 weeks if not
105
Q

A G2 woman is seen at her booking visit at 10 weeks. On questioning, she says she had mild PET in her last pregnancy that was diagnosed at 32 weeks, for which she took labetalol. What should you do?

A
  • Inform of the risks of recurrence in this pregnancy, give lifestyle advice as normal
  • Urine dip and BP in clinic
  • Prescribe 75mg aspirin from 12 weeks until delivery
  • Ensure regular antenatal appointment attendance to monitor BP and urine
106
Q

Which women should receive aspirin antenatally to prevent pre-eclampsia?

A

Any woman with high risk features:

  • Prev hypertension in pregnancy
  • CKD
  • Chronic HTN
  • DM, SLE and other autoimmune disease

Any woman with 1+ risk factors:

  • Nulliparity
  • Age >40
  • Obesity
  • Multiple pregnancy
  • Pregnancy interval >10 years
  • Family Hx
107
Q

How should women with chronic hypertension be managed in pregnancy?

A
  • Stop ACEi/ARBs/atenolol before conception or as early as possible due to risks to fetus, switch to pregnancy safe medication
  • Aspirin 75mg from 12 weeks
  • Monitor renal function as well as urine dip + BP during pregnancy
  • More frequent monitoring of baby with USS if poorly controlled BP
  • Monitor after delivery and GP review to switch medications
108
Q

How should women with gestational hypertension be managed antenatally?

A
  • Want to monitor BP frequently (eg. every day/2 days)
  • Treat if sustained >140/90
  • Regular urine dip 2x/week, blood tests 1x/week to monitor for PET onset
  • Consider PlGF test between 20-34 weeks if suspicious of PET
109
Q

Describe antenatal care for women with CKD or other renal disease

A
  • Prepregnancy counselling important on risks to mum (worsening renal function, PET) and baby (preterm, IUGR)
  • Obstetric care, MDT approach with renal medicine
  • Change antihypertensives to labetalol/nifedipine
  • Start 75mg aspirin from 12 weeks
  • Monitor renal function, urine dip, BP, FBC, fetal growth with USS
  • Early discussion about plans for delivery
110
Q

Describe antenatal care for women with DM

A
  • Prepregnancy counselling on importance of good glycaemic control
  • Explain risks to mum (PET, C section, worsening diabetes eg. DKA/hypos, organ damage) and baby (malformation, miscarriage, stillbirth, IUGR/macrosomia, preterm)
  • Obstetric care, specialist in maternal DM
  • High dose folic acid- 5mg, change antihypertensives, stop statins
  • 75 mg aspirin from 12 weeks
  • Monitor BP, urine dip, U+Es, retinal screening at booking and at 28 weeks, fetal growth scans at 28,32,36 weeks
  • Discussion of plan for labour, neonatal monitoring
111
Q

Which congenital abnormalities are associated with maternal diabetes?

A

Neural tube defects, cardiac abnormalities

112
Q

What are the risk factors for GDM?

A

Previous GDM, FHx of DM/GDM, obesity, ethnicity, previous LGA fetus

113
Q

Describe the guidelines for GDM screening

A
  • All women with previous GDM should be screened at booking and again between 24-28 weeks
  • Any woman with a FHx, previous LGA, obesity or ethnic background should be screened between 24-28 weeks only
114
Q

How is GDM diagnosed?

A

Should only be diagnosed using the OGTT with fasting glucose and 1 + 2 hour postprandial glucose after a 75g sugar drink. Diagnosis is made if either:

  • > 5.6mmol/L fasting
  • > 7.8mmol/L 2 hour postprandial
115
Q

Describe the management of GDM.

A
  • All women should be educated on the diagnosis, including risks, monitoring and management
  • Refer to dietician
  • Blood sugar monitoring daily (morning, 1 hour before and after eating and bedtime). Aim for 5.3 before meals, 7.8 after meals
  • Diet + exercise first line if fasting <7
  • Metformin if diet + exercise not effective in 1 week
  • Insulin if fasting >7, plus diet + exercise
  • Screen for T2DM 6-13 weeks postpartum
116
Q

Describe the complications of GDM

A

Risks to mum: increased risk of T2DM in later life, C section/instrumental/tearing due to big baby,
Risks to baby: macrosomia, shoulder dystocia, neonatal hypoglycaemia

117
Q

Describe antenatal care for women with heart disease

A
  • Prepregnancy counselling of risks to mum (worsening heart disease, C section) and baby (preterm delivery, IUGR)
  • Obstetric care, MDT with cardio
  • Monitor symptoms of heart failure (SOB, fatigue, heart rhythm)
  • Echo at booking and at 28 weeks
  • Discussion about plan for delivery early (vaginal is likely but may recommend epidural/instrumental)
118
Q

T/F. Asthma medications should be reviewed and changed to pregnancy safe alternatives at booking

A

False. Asthma medications are safe in pregnancy

119
Q

Describe antenatal care for women with CF

A
  • Prepregnancy counselling: genetic counselling, risks to mum and baby
  • Obstetric care with MDT
  • Important to ensure good nutrition
  • Monitor fetal growth
120
Q

Describe antenatal care for women with epilepsy

A
  • Prepregnancy counselling: explain risks to mum and baby (congenital abnormalities), reduce medications, aim for monotherapy, no valproate, high dose folic acid preconception
  • MDT approach with neuro
121
Q

Describe antenatal care for women with sickle cell disease

A
  • Prepregnancy counselling: genetic counselling, risks to mum (increased crises, miscarriage, VTE) and baby (preterm, PET, IUGR)
  • High dose folic acid
  • 75mg aspirin
  • Lifestyle measures to avoid crises
122
Q

Explain the causes of low platelets in pregnancy

A
  • Most common is gestational thrombocytopenia (normal reduction in platelets), usually just <150
  • Can also be caused by PET
  • Also immune thrombocytopenic purpura (ITP) if severely low
  • Microangiopathic syndromes (HELLP, APS, HUS, DIC)
123
Q

What are the distinguishing features of gestational thrombocytopenia and ITP?

A
  • No tests can differentiate them

- Usually, gestational TP will be >100, and occurs in the third trimester

124
Q

What are the important considerations in maternal thrombocytopenia?

A
  • Planning for delivery
  • Increased risk of bleeding is the main worry
  • Regional anaesthetic usually not available if Plt <80
  • Consider treatment if Plts <50 with corticosteroids if ITP or IV Ig
125
Q

Describe antenatal care for women with SLE

A
  • Prepregnancy counselling on risks to mum (increased flares, PET, miscarriage) and baby (PET, preterm, IUGR)
  • 75mg aspirin from 12 weeks
  • Monitoring of BP, urine dip, U+Es, fetal growth
  • Check baby after birth
126
Q

Name 4 specific derm conditions of pregnancy

A
  • Pruritic folliculitis: acne-like spots on trunk
  • Polymorphic eruption of pregnancy (PEP): thighs + abdo, confluent rash
  • Pemphigoid gestationis: blistering lesions
  • Prurigo of pregnancy: papules
127
Q

Describe the management of confirmed rubella infection in pregnancy

A
  • If not already referred, refer to health protection team
  • Advise to avoid pregnant women and children
  • Counsel mum on the risks to baby (high if <8 weeks, nothing if >20 weeks)
  • Scan and offer termination if infected before 16 weeks
  • Vaccinate after pregnancy
128
Q

T/F. Most women with rubella infection in pregnancy will be symptomatic

A

False. Only 20-50% are symptomatic. That is why vaccination is so important!

129
Q

Describe the course of syphilis infection

A

1˚ syphilis: painless chancre (ulcer) 3-6 weeks after unprotected sex
2˚: rash on palms and soles weeks-months after infection
3˚: organ involvement eg. CVS, neurosyphilis. Years later

130
Q

What are the risks to baby of congenital syphilis infection?

A

-IUGR, preterm, stillbirth, congenital syphilis
-Congenital syphilis can present at birth with rash/LBW
OR late syphilis with Hutchinson’s teeth, interstitial keratitis, deafness, etc.

131
Q

Which test is used for syphilis screening in pregnancy?

A

Enzyme immunoassay (EIA), a type of treponemal test. This is better than non-treponemal tests

132
Q

Describe the management of syphilis infection in pregnancy

A
  • Refer to GUM
  • Treatment with IM benzylpenicillin
  • Admit to monitor for Jarisch-Herxheimer reaction (worse before better when treated)
133
Q

How can toxoplasmosis be avoided?

A
  • Avoid cat faeces (eg. wear gloves while cleaning litterbox, don’t let cat sit on furniture)
  • Avoid soil with bare hands
  • Wash fruit + veg
  • No raw meat
134
Q

What are the effects to the baby of toxoplasmosis?

A
  • Chorioretinitis
  • Intracranial calcifications
  • Microcephaly
135
Q

How is toxoplasmosis diagnosed in pregnancy?

A
  • Sabin Feldman dye test (serology)

- Can consider amniocentesis for PCR to diagnose congenital toxoplasmosis

136
Q

How is toxoplasmosis treated in pregnancy?

A

PO spiramycin 2-3g/day for 3 weeks. Consider TOP if early infection due to risk of fetal malformation

137
Q

How is CMV infection in pregnancy diagnosed and treated?

A
  • Diagnosis: new IgM in serology

- Management: No treatment. Consider TOP if fetal malformation, consider amniocentesis to diagnose congenital infection.

138
Q

What are the complications of VZV infection in pregnancy?

A
  • Maternal pneumonia, encephalitis, hepatitis

- Congenital VZV infection

139
Q

What is the treatment of chickenpox in pregnancy? Who should receive treatment?

A
  • PO aciclovir 800mg 5x/day for 7 days

- Women who are >20 weeks gestation, within 24hours of onset of the rash

140
Q

A 33 year old P1 attends MAS with regular, painful contractions at 38 weeks. She reports feeling a gush of fluids this morning. She is currently being treated for chickenpox, after developing a rash 3 days ago. How would you like to manage this case?

A
  • Because labour is within 7 days of the onset of a rash, baby needs VZV Ig after birth and neonates should be called
  • Monitor baby for 28 days from onset of the mums rash
141
Q

What are the complications of parvovirus infection in pregnancy?

A
  • Most babies will not be affected

- Severe aplastic anaemia, fetal hydrops, death

142
Q

At what gestation are fetuses most vulnerable to parvovirus infection?

A

During the 2nd trimester

143
Q

What can be done in pregnancy to avoid Listeria infection?

A

-Avoid uncooked prepared meals and foods eg. pate, mayonnaise, unpasteurised milk + cheese

144
Q

What are the complications of Listeria infection in pregnancy? What is the treatment?

A
  • Can cause preterm delivery, miscarriage + stillbirth
  • Neonatal meningitis, sepsis, RDS
  • Give IV antibiotics (amoxicillin 2g QDS for 2 weeks)
145
Q

Describe the risks to mum and baby of malaria in pregnancy

A
  • Maternal: anaemia, pulmonary oedema, jaundice, death, hypoglycaemia
  • Fetus: stillbirth, preterm, IUGR
146
Q

At what gestation are fetuses most vulnerable to HSV infection?

A

During delivery. Active HSV lesions during labour is a contra-indication to vaginal delivery due to the risk of neonatal HSV
-Offer prophylactic aciclovir around term to women with previous genital HSV infection

147
Q

A 26 year old P1 presents to MAS at 36 weeks with regular painful contractions. Her cervix is 4cm dilated. On her notes you see she was diagnosed with primary genital HSV1 3 weeks ago and received aciclovir 400mg TDS for 2 weeks. She has no obvious lesions on examination. Can this woman have a vaginal delivery?

A

She should be informed that vaginal delivery is risky and C section is preferred, as she has had primary HSV within 6 weeks of delivery.
However, if she insists on vaginal delivery after counselling, she should be given intrapartum IV aciclovir and neonates should be involved in the assessment + care of the baby.

148
Q

Which organism is a type of Group B Strep?

A

Streptococcus agalactiae

149
Q

A 33 year old P2 is seen in antenatal clinic at 28 weeks. She was told that a urine MC+S done earlier in pregnancy had isolated GBS, and wants to know what that means for her and the pregnancy. Please explain.

A
  • GBS is a very common bacteria that is found in the genital tract of 1/5 of women. It is a normal part of the vaginal flora and does not cause symptoms
  • Usually this is completely fine and does not cause any problems for the pregnancy
  • In a small number of cases, babies born to women with GBS can go on to develop infections in the first week of life, because they pick up the bacteria as they move through the birth canal
  • Because we know that you have GBS in your urine, we will give you antibiotics during labour to clear it out of the birth canal before the baby comes
150
Q

When should pregnant women receive treatment for GBS infection? What is the treatment?

A
  • Treatment is indicated if there is: maternal pyrexia in labour, prolonged ROM (>18 hours), preterm delivery, GBS isolated in swab/urine, previous GBS infant
  • Give IV benzylpenicillin 3g STAT, followed by 1.5g every 4 hours in labour
  • Monitor baby for first 12 hours of life
151
Q

What is the treatment for chlamydia infection in pregnancy? What are the complications of untreated infection?

A

Azithromycin or erythromycin. Tetracyclines are contraindicated in pregnancy!
-Preterm delivery, LBW, conjunctivitis or pneumonia

152
Q

How should HIV in pregnancy be managed?

A
  • New diagnosis: refer to GUM/HIV to start antiretroviral treatment and monitor viral load
  • Plan for delivery (C section if viral load >50 copies/ml or HCV coinfection, otherwise vaginal)
  • Counsel on the risks of transmission during breastfeeding
  • Discuss giving ART to baby for 4-6 weeks of life to prevent infection, test with HIV PCR at birth, 3 weeks, 6 weeks, 6 months
153
Q

What are the complications of smoking in pregnancy?

A 
Miscarriage, stillbirth
Placental abruption
**LBW** and prematurity
Facial defects
Illness in childhood 
Behavioural problems and poor school performance
154
Q

What are the complications of cocaine use in pregnancy?

A 
Maternal cardiovascular disease + death 
Placental abruption
Miscarriage
Preterm labour
LBW
155
Q

What are the complications of heroin use in pregnancy?

A

Neonatal abstinence syndrome (possibly death)

Obstetrics (4 decks)

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